Dr. Massone, please tell me little about yourself and how you ended up in Graz?

Thank you Bob for your nice comparison with Antonio Salieri, but first of all he was a great composer and conductor, I am only a young physician. While Salieri was born in Legnano, I come from Genoa on the East Italian coast, where I graduated in 1997 and arrived in Graz as a fellow in 2001. I chose Graz because I wanted to improve my knowledge of dermatopathology, especially in the field of cutaneous lymphoma and melanoma. Helmut Kerl, H. Peter Soyer and Lorenzo Cerroni are famous and experienced dermatopathologists and the Dermatopathology Section of the Department of Dermatology of Graz is one of the biggest in Europe. I thought that this could have an impact on my studies. After my certification in dermatology in 2002, I simply did not want to leave, so here I am.

Where did the idea of telederm.org come from?

The heart and soul of telederm.org is H. Peter Soyer. He is a pioneer in teledermatology and teledermoscopy. In 2001 he conceived the idea to found a global online community in dermatology and together with Rainer Hofmann-Wellenhof, a dermatooncologist, and Gerald Gabler, who did the informatics' work, they created telederm.org. The idea was, and still is, as simple as it is fascinating: to create a user-friendly Web application, whereby physicians create user-generated content and in addition seek a second opinion for a given dermatologic case. In short, our vision is to promote with telederm.org Open Access Teleconsultation in Dermatology using the multi-hub facilities of the Internet.

How has telederm.org developed from there?

The first application, a prototype, was launched in May 2002. Remarkably, until today there are still no similar experiences in teledermatology. Of course, it was not easy to develop the project. Moreover, 2 years ago it was not even clear how to build up the community and how to run it. For example, in the beginning the users of telederm.org were divided into Clients (who can only send requests) and Experts (who can send and also answer requests), but this generated confusion. Moreover, criteria for acceptance as Experts were never really established. The discussion forum was also not organized in a user-friendly way and needed a moderator. Therefore, Peter invited me to join the group. He gave me a couple of articles on the moderation of Online Discussion Forums and let me do the job. Now, after more than two years of work, our ideas are becoming clearer and our community is increasing constantly. In the last two months we have worked on a new version of the application that should be much more immediate. There will only be Users, and no Clients or Experts anymore. A restyling of the Web design is already planned as well as additional facilities.

How is telederm.org supported, both logistically and financially?

Telederm.org is currently a non-profit project and a joint venture between the Department of Dermatology, Medical University of Graz, in Graz, Austria, and e-derm-consult GmbH, a small spin-off company from the Medical University of Graz. H. Peter Soyer, who is currently a Professor of Dermatology for the Department of Dermatology, is also the CEO for Medicine of e-derm-consult GmbH. At this moment, there is intentionally no sponsoring requested from the pharmaceutical industry in order to be independent.

What technology is used to drive telederm.org, and who supports the technology you use?

This time the system is built on Microsoft technology using a Windows server with a SQLServer database and Active Server Pages generating the front-end. The application itself has been developed by e-derm-consult GmbH (edc) and exactly fits the demands of our customers. We are currently working on a new and extended version using the Dot Net technology. The hardware is a standard dual processor server with RAID technology to guard against drive failures, and it is working on a leased line. Using standard technologies and components we think the support will be global in the near future.

How do you scan and store images?

The idea of Open Access Teleconsultation in Dermatology is that users generate the content themselves by sharing their challenging and unusual cases with the DermOnline Community. So, basically every colleague prepares their own .JPG image files. We only perform a quality check before finally accepting a consultation case. For the discussion cases most of the images we use belong to the Department of Dermatology, Medical University of Graz. To scan our histopathologic images in Graz we have 2 different systems. First, a classic Nikon E-1000 microscope with a Nikon DM100 camera stores images in .JPG format. Second, the new robotic Imstar Pathfinder? system, composed of a Nikon E400 microscope and a Morphoscan? robotic platform connected to a high resolution Hamamatsu C4749-95 digital camera, allows us to perform a high-resolution acquisition in .TIFF format.

Who are the primary users telederm.org?

Telederm.org users are mainly dermatologists with a special interest in using the Internet for discussing challenging dermatologic cases. Although 95% of telederm.org users are dermatologists, some general practitioners, pathologists, pediatrics and gynecologists subscribe to telederm.org. I would divide the typology of our users into two categories- active and non-active. We have users that like to enter our discussion forum, answer the online cases, send cases and stimulate the discussion. In the first two years more than 800 hundred requests by these active users have been answered by the community. Then there are users that visit telederm.org regularly, but do not play an active role. They just look at the cases and read the comments. So, our community, like all other Internet communities, is made up both typologies, and both are welcome!

How many users subscribe to telederm.org?

Today, more than 400 physicians subscribed to telederm.org, coming from 45 different countries. The number of users and the average log on numbers per day are still low due to the fact that we were not very visible to the Web. Actually, these first two years have been quite a challenge and a trial at the same time. Now, the experimental phase is almost finished. As I said, we worked a lot in the last few months to prepare the new application. We will be soon linked to DermIS, one of the biggest Atlases on Dermatology on the Web.

What role does telederm.org play in the medical school training for interns, residents and fellows?

Telederm.org offers the possibility to our students to study clinical cases in dermatology, their histopathologic counterparts and their management. We teach our students how to use the application and we introduce them to telemedicine in general. I think that using telederm.org is a good and easy way to learn dermatology, especially for those who are familiar with the Internet. Moreover, we also use telederm.org for clinical research. For research projects in dermatopathology, for example, we developed a special application with a Webscope (see http://telederm.org/research/dermatopath). In another research project, we are studying the clinical use of wireless technology in dermatology, and again telederm.org is the Web application in use. Together with the Graz Hospital IT administration, the telederm.org team is running a project to connect dermatologists and general practitioners of Styria with the Department of Dermatology in Graz, integrating the telederm.org application in the already existing information system (MEDOCS) of all Styrian hospitals. Telederm.org can then be used on a daily basis by our residents and fellows and will be connected with all relevant patient data.

What are you doing in terms of distance education and continuing medical education?

One year ago we started a trial educational program. We inserted weekly clinical cases correlating the clinical images with the histopathologic ones. We strongly encouraged colleagues to discuss these cases in the discussion forum and to give us their personal opinion. In the beginning the interest was low but after few months the discussion grew. One of our aims in the coming years is to start a well structured continuing medical education program on telederm.org under the auspices of the Postgraduate School of the Medical University of Graz.

If someone were to live in a remote area in Northern Italy or parts of Austria and doesn't have access to a dermatologist, could he or she ask for a consult from telederm.org? How would that work?

This is a crucial point. According to the current law in Austria and Italy, a physician is not yet allowed to perform an 'e-visit'. A physician always has to be in between the patient and the virtual consultant. This is also the reason why at this moment only physicians are allowed to subscribe to telederm.org. So, if you are a patient, you have to ask for a teleconsult through your general practitioner, for example. However, despite the actual legal situation in Austria, we are in the process of starting an end of the year a pilot project with an exclusive teleconsultation service for patients in collaboration with www.netdoktor.at. We will answer the requests of patients based on clinical images of the affected skin in association with a detailed personal case history and give general comments on diagnosis and treatment.

If you are a physician, it is easy. Teleconsulting to telederm.org can be achieved into two completely different ways, private or non-private. For the private method the physician interacts only with the chosen teleconsultant. The non-private way is the discussion forum. We have users that regularly send requests to other users, always staying in a private field, and users that use the discussion forum to seek more opinions on difficult cases. For example, in July a colleague from India seeking diagnostic and therapeutic advice sent to the discussion forum clinical pictures of a woman complaining of an unusual chemosis. Colleagues answered both in the discussion forum and personally to him. We also involved an ophthalmologist from our University, and just few days ago this colleague gave us his feedback. The patient improved and he found the advice he got very useful. This is also an example of how telemedicine can be helpful in daily practice.

Do you have the capacity to do live chat on telederm.org, and are you doing Grand Rounds?

The current system is not intended to do live chat. It is designed as a store-and-forward system in an asynchronous manner. Due to our multicultural user community it would not be easy to synchronize users. Actually, our discussion forum is a Grand Round, maybe in an unconventional and more global view.

What would you like telederm.org to do next?

Well, there are still many things to do. First of all, our application has to be restructured and then we will ask for HON certification. The general design, particularly the usability, has to be improved. Then we will start an ambitious project that I would like to mention. This October the Web site of the newly founded International Society of Teledermatology will be launched and telederm.org will become the DermOnline Community of the Society. Using the platform of the International Society of Teledermatology our vision to promote Open Access Teleconsultation in Dermatology will soon become reality. In addition, we are continuing our cooperation projects on teledermatology with China and are initiating a pilot project in Uganda.

David Balch, who recently retired from the Advanced Telemedicine Training Center at Eastern Carolina University, told me that he thought telemedicine as we know it would disappear, and that telemedicine would become so common on our desktop that we take it for granted. What do you think?

Telemedicine is the future of medicine, that's clear. And in this spirit David Balch is absolutely correct - teledermatology is just dermatology. I do not know if one day in the future there will really be someone like Dr. Spock (I think the first 'teleconsultant'), able to treat his patients directly from the Enterprise. This would be the extreme point, but I can only see an exponential growth of telemedicine in general.

Where do see telederm.org in one, five, and ten years from now?

I will answer in numbers. In 1 year I would be really happy to see 1000 users subscribed to telederm.org, in 5 years 5000 users. Our goal is to develop a free teleconsulting system for dermatology where physicians and health workers from all over the world interact using the multi-hub facilities of the Internet and exchange experience and expertise. To develop telederm.org to become the first and largest global online community in dermatology is our scope. I think we have to work hard, but we are on the right path. We are convinced that teleconsulting in dermatology will grow more and more and become an everyday reality and other projects similar to telederm.org will be initiated. But I do not have any doubts that telederm.org will be among the leaders in this field in 10 years.

What would you say to your colleagues around the world about the use of telemedicine and how can we continue to promote it?

Promotion should be done in the traditional way- at congresses and meetings, or just by talking to colleagues. At the next Italian National Congress of Dermatology in Genoa 2005 we will organize a Workshop on Teledermatology in order to make Italian dermatologists more confident with these new facilities. I am personally convinced that colleagues all around the world will soon discover the big opportunity that telemedicine is giving to all of us: learning and teaching, exchange of ideas, courses, communication, new technologies and, in my personal view, an improvement of the entire performance in medicine. In short, telemedicine matters.