DOI: 10.1089/tmj.2008.0001 © MARY ANN LIEBERT, INC. • VOL. 14 NO. 9 • NOVEMBER 2008 TELEMEDICINE and e-HEALTH 889 Karen E. Edison, M.D., 1 Dana S. Ward, M.D., 1 Jonathan A. Dyer, M.D., 1 Whitney Lane, M.D., 2 Louanne Chance, R.N., C.C.R.C., 1 and Lanis L. Hicks, Ph.D. 3 1 Department of Dermatology, University of Missouri, Columbia, Missouri. 2 Mecklenburg Medical Group, Charlotte, North Carolina. 3 Department of Health Management and Informatics, University of Missouri, Columbia, Missouri. Abstract Teledermatology studies have examined diagnostic concordance between live-interactive (LI) and in-person examinations (IP); and between store-and-forward (SF) and IP examinations. However, no studies have looked simultaneously across all three care delivery modalities, and few have measured management concordance and diagnostic confidence of the dermatologist. The purpose of this study was to compare LI and SF modalities with IP with respect to diag- nostic and management concordance and to compare physician diag- nostic confidence across the three modalities. Four dermatologists, in random rotation among all three care modalities, examined 110 new patients. Confidence was rated on a Likert scale from 1 to 5 (5 = total confidence; 1 = no confidence). Identical diagnoses were given to the patient by examiners from all three examination modalities in 70/110 patients (64%). More identical diagnoses were given for IP and LI examinations than for IP and SF examinations (80% vs. 73%); however, the difference was not statistically significant (p = 0.13). The highest self-reported confidence rating was given for 87% of IP examinations, 59% for LI, and 54% for SF. Diagnostic confidence ratings for SF and LI were not significantly different from each other (p = 0.50); however, diagnostic confidence ratings for LI and SF were both statistically lower than IP (p < 0.0001). Dermatologists were more confident with IP examination than either form of teledermatol- ogy. The percent of diagnostic and management agreement among IP, LI, and SF modalities was high. Key words: teledermatology; live interactive; store-and-forward; in- person examination Introduction he use of teledermatology, both live-interactive (LI) and store- and-forward (SF) modalities, has increased steadily in the United States over the past decade. 1 This expansion has coin- cided with dramatic improvements in the technology available and marked reductions in its cost. Patients’ lack of access, resulting from both workforce shortage and a mal-distribution of dermatolo- gists, 2,3 has also encouraged the use of teledermatology. The University of Missouri is a land-grant institution with a mission to serve the rural and underserved. We have provided teledermatology in weekly patient care clinics to rural Missouri since 1995; the University Dermatology Department has served 788 patients in the last year in this manner. 4 In spite of the absence of standards for teledermatology, we have noted reports of diagnostic concordance in the literature 5,6 but felt compelled to compare concordance across three modalities and to examine pro- vider confidence across those same modalities. While most teledermatology studies have examined diagnostic concordance between both LI and in-person examination (IP), or ORIGINAL RESEARCH Diagnosis, Diagnostic Confidence, and Management Concordance in Live-Interactive and Store-and-Forward Teledermatology Compared to In-Person Examination T