Teledermatology is an important subspecialty of telemedicine that continues to evolve with advances in telecommunication and mobile phone technology. A 19-week primary care quality improvement project collected baseline data and tested three change ideas, using the Model for Improvement method, with primary and secondary aims: to increase the weekly percentage of remote dermatological consultations with supporting images that were successfully concluded remotely to greater than 80% and to reduce the weekly percentage of dermatological face-to-face consultations to less than 50%. We hypothesised that by improving the quality of patient images and the confidence of reception staff in triaging skin complaints, there would be a decrease in the weekly number of face-to-face dermatological appointments, thereby decreasing the risk of COVID-19 transmission within the practice and community. Two change ideas focused on supporting patients to improve image quality by introducing ‘4 Key Instructions’ and a patient information leaflet (PIL). The third focused on increasing reception staff confidence in triaging skin complaints by introducing a triage pathway guidance tool. A total of 253 dermatological consultations were analysed: 170 of these were telephone consultations with 308 supporting images. Process measures showed clear improvements in the quality of images provided by patients which likely contributed to an increase in completed remote consultation. Our primary outcome measure was achieved. Our secondary outcome measure suggested that in the absence of high-quality images, it might not be possible to reduce dermatological face-to-face consultations much below 50% in primary care. Process measures showed clear improvements in the quality of images provided by patients which likely contributed to the increase in remote consultation. The implications of these findings for the theory of change are discussed.

IntroductionTestosterone replacement therapy (TRT) is the treatment of choice for male hypogonadism. British Society for Sexual Medicine (BSSM) guidelines on adult testosterone deficiency recommend that TRT patients undergo annual monitoring of their testosterone levels and potential complications of treatment; though evidence suggests that substantial numbers of men on TRT are not monitored adequately.MethodsReview of the electronic patient record from a single general practice in southwest Scotland revealed that only 1 of 26 (4%) TRT patients had been monitored as per BSSM guidelines in the previous 12 months. Additionally, when monitoring was undertaken there was inconsistency in the blood tests requested. The use of quality improvement (QI) tools including process mapping and cause-and-effect diagram identified staff and patient knowledge of monitoring requirements and the lack of an effective recall system as areas for improvement. We tested three change ideas: the utilisation of an existing recall system for long-term therapies; a TRT Ordercomms blood group template (OBGT) to standardise monitoring; and a patient information leaflet (PIL) to improve patient education. The aim of this project was to achieve 60% annual monitoring rate.ResultsThe percentage of patients monitored for testosterone levels and potential TRT complications increased from 4% (1/26) to 65% (17/26) over a 7-week test period. The utilisation of the existing recall system was a particularly effective intervention, leading to an increase from 4% (1/26) to 31% (8/26) in the first 2 weeks.ConclusionThe use of QI tools was associated with over 60% of male TRT patients receiving comprehensive annual monitoring, as per BSSM guidelines. Our findings support the hypothesis that a patient recall system, combined with an OBGT and a PIL led to this increase.

Alexander and Shearer discuss how utilising Quality Improvement (QI) tools when planning and prioritising curriculum processes may reduce evaluation fatigue and increase stakeholders' sense of ownership in QI.