Current research projects

At the moment, KSYOS has research projects under way for telemedicine services in ophthalmology, dermatology, pulmonology and ear/nose/throat. These studies are partly carried out by our doctoral candidates and interns. Below is a brief description of each study.

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TeleOphthalmology Examination at the optometrist

Patients are often referred to the ophthalmologist in the hospital for a range of eye disorders (e.g. retinopathy, cataracts, macular degeneration, glaucoma). The growing pressure on healthcare means that solutions must be sought outside the hospital walls. Optometrists are trained paramedics who already perform a large percentage of the fundus screenings for patients with diabetes mellitus [Healthcare standard DRP screening; NOG 2006]. This allows many DM patients to remain in primary care and improves triage towards the ophthalmologist. [Van der Heijden, JP & Schepers I; Teledermatology and other successful teleconsultation services in day-to-day general medical practice [Teledermatologie en andere succesvolle teleconsultatie diensten in de dagelijkse huisartsenpraktijk]; Bijblijven 2011] [Van der Heijden JP et al.; Teledermatological consultation by the general practitioner: better care at a lower cost [Teledermatologisch consult door de huisarts: betere zorg tegen lagere kosten]; NTvG 2012] Optometrists may be able to perform this screening function for other eye conditions as well.

In this study with KSYOS, optometrists can perform a TeleOphthalmology Examination in cooperation with regional general practitioners and ophthalmologists. The TeleOphthalmology Examination can be used for patients who are at risk for retinopathy (non-DRP), cataracts, macular degeneration, glaucoma, eye redness, dry eyes and allergies.

Purpose of the study

Primary objective:

Determine the inter-rater reliability of the optometric diagnosis and advice between optometrists and ophthalmologists when assessing a TeleOphthalmology Examination.

Secondary objective:

  • Identify patient groups that are eligible for a TeleOphthalmology Examination.
  • Report performance indicators in relation to efficiency (preventing physical referrals to the ophthalmologist) and quality (usability and learning effect).


Quality of image acquisition for TeleDermatoscopy

Dermatoscopy, also called ‘epiluminescence microscopy’, is a non-invasive technique often used to assess pigmented skin lesions. Dermatoscopy enables a dermatologist to look not only at, but also into superficial skin structures. Using a simple contact lens that provides magnification of 10 times, the epidermis is made transparent with the application of oil, making various other criteria available for diagnostics. Alongside oil application, another method has been developed over the past few years whereby the reflection from the skin is avoided by using polarised light in the dermatoscope.

Dermatoscopy increases sensitivity to approximately 90% and specificity is also about 90% with experienced use.[i] The number of benign pigmented skin deviations removed unnecessarily can be reduced by 50% with dermatoscopy.[ii] According to the Oncology working group of the Dutch Association for Dermatology and Venereology, this technique deserves a permanent place in the clinical diagnostics of pigmented skin deviations. Before using it, inexperienced doctors are strongly advised to become trained in this technique.[iii]

The incidence of skin tumours has been rising in general medical practice for a number of years, increasingly in combination with requests for (cosmetic) removal.[iv] But according to Poelman et al., the diagnostics of skin tumours in primary care is underemphasised and they argue for structurally increasing dermatological knowledge among general practitioners and trainee general practitioners. Use of the dermatoscope in general medical practice could improve clinical assessment, on condition that users are properly trained in its use.[v][vi]

TeleDermatoScopy, the combination of TeleDermatology and dermatoscopy, therefore offers opportunities for applying dermatoscopy in general medical practice under the supervision of the dermatologist.

This requires that the dermatoscopic images be digitised and that these digital images can be easily taken by a general practitioner, resulting in a high-quality dermatoscopic image that lends itself for assessment. A recent study suggests that the quality of the images greatly influences the extent to which they can be assessed and as such the usefulness of teledermatoscopy.[vii]

Purpose of the study

Primary objective:

To determine the most appropriate digital dermatoscope for taking digital dermatoscopic images in primary care for remote assessment (teledermatoscopy).

Secondary objective:

  • What digital dermatoscope delivers the best quality dermatoscopic photos?
  • What digital dermatoscope is the most user-friendly?

[i] Kittler H, Pehamberger H, Wolff K, Binder M. Diagnostic accuracy of dermoscopy. Lancet Oncol 2002;3:159-65.

[ii] MacKie RM, Fleming C, McMahon AD, Jarrett P. The use of the dermatoscope to identify yearly melanoma using the three-colour test. Br J Dermatol 2002;146:481-4.

[iii] Bergman W. Dermatoscopy: an asset for the clinical assessment of pigmented deviations [Dermatoscopie: een aanwinst voor de klinische beoordeling van gepigmenteerde afwijkingen]. Ned Tijdschr Geneeskd 2002; 146:1574-8.

[iv] De Jong J, Visser MR, Mohrs J, Wieringa-de Waard M. Opening the black box: the patient mix of GP trainees. Br J Gen Pract. 2011;61:e650-7

[v] Argenziano G, Puig S, Zalaudek I, Sera F, Corona R, Alsina M, et al. Dermoscopy improves accuracy of primary care physicians to triage lesions suggestive of skin cancer. J Clin Oncol. 2006;24:1877-82

[vi] Westerhoff K, McCarthy WH, Menzies SW. Increase in the sensitivity for melanoma diagnosis by primary care physicians using skin surface microscopy. Br J Dermatol. 2000;143:1016-20

[vii] van der Heijden JP, Thijssing L, Witkamp L et al.
Evaluation of accuracy and reliability of teledermoscopy with images taken by general practitioners during regular surgery. J.Telemed.Telecare 2013; in press.

TeleMonitoring, TeleDiagnostics and TeleConsultation for COPD & Asthma

Chronic Obstructive Pulmonary Disease (COPD) is the fourth leading cause of death in the world at the moment. The reported prevalence of COPD in the Netherlands is 1.7%. Various studies suggest however that the actual prevalence is much higher. COPD often goes undiagnosed or is misdiagnosed. One of the reasons for this is that the taking and interpretation of spirograms in primary care has proven difficult. The study by Thijssing et al. showed that general practitioners can be supported in this by pneumonologists by means of TelePulmonology. The use of TelePulmonology emerged to increase the quality of care and prevent unnecessary physical referrals. [Thijssing, L. et al.; Telepulmonology: effect on quality and efficiency of care, Respir Med 2014]

In another study, patients with an increased risk of COPD and asthma based on data in the GP Information System will be tracked down. These patients will then be called up to take a spirometry test at the general practitioner. The general practitioner will be supported by a pneumonologist in interpreting the results of this test and in diagnosing the patient via TelePulmonology.

If patients are diagnosed with COPD, it is important that they change their health habits because these have a major impact on improving the prognosis for COPD patients. Health habit modification is an important goal of COPD self-management programmes. Self-management programmes are therefore increasingly used to help patients get their illness better under control. Online self-management programmes can teach COPD patients to better cope with their illness. Like every other eHealth intervention, however, these programmes can only be effective if they are actually used by the envisioned end users. That is why the determinants of patients’ acceptance of an online self-management programme are being investigated in this study. In another study the effect of this self-management programme on self-management, self-efficacy and patient activation is being studied.

TeleMedicine in ENT medicine

More than 5% of the world’s population has trouble with debilitating hearing loss. This makes ENT-related disease an important contributor to the worldwide burden of disease[i]. Hearing loss and otitis media in children can have significant detrimental effects on their academic performance, language development and social well-being[ii], [iii]. It has been demonstrated that in adults, hearing loss can cause isolation, which results in poor social participation and less opportunity on the labour market[iv].

Because of the high incidence of ear, nose, throat pathology in rural areas and the poor access to specialist medical care, telemedicine is increasingly being used in these areas[v]. A systematic review will describe the status of teleconsultation applications in ENT medicine over time, whereby publications will be systematically categorised in terms of outcome measures and the way in which teleconsultation took place.

TeleConsultation in ENT medicine can also be applicable in areas where distance is not the factor limiting access to specialist medical care. The ageing of the population in the Netherlands will put pressure on healthcare and is expected to cause costs to increase exponentially[vi]. Knowing that approximately one third of people over 65 struggle with hearing loss ii calls for a redesign of care processes in which the use of teleconsultation could present the answer.

A scientific study is attempting to demonstrate the potential impact on the quality and efficiency of the care if an audiologist (after taking a medical history and performing otoscopic and audiometric testing in the shop) consults the ENT specialist via a teleconsultation instead of physically referring the patient to the ENT specialist. Another study will look into the quality and expertise of the audiologist in relation to performing and assessing otoscopic and audiometric testing.

A study will also evaluate what digital video otoscope is the most user-friendly when used by a general practitioner with minimal training in the use of the equipment. Secondly, an evaluation is being held to figure out which digital video otoscope is the most suitable for taking digital otoscopic videos for remote assessment. Finally it is being determined which otoscope is the most user-friendly and how potential patients view the prospect of physical consultations being replaced with teleconsultations.


[ii] Ear Hear. 2007 Dec;28(6):740-53. Current state of knowledge: language and literacy of children with hearing impairment. Moeller MP, Tomblin JB, Yoshinaga-Itano C, Connor CM, Jerger S.

[iii] Pediatrics. 1998 Nov;102(5):1161-71. Language of early- and later-identified children with hearing loss. Yoshinaga-Itano C, Sedey AL, Coulter DK, Mehl AL.

[iv] JAMA. 2006 Jul 26;296(4):441-4. Reducing the burden of communication disorders in the developing world: an opportunity for the millennium development project. Olusanya BO, Ruben RJ, Parving A

[v] World J Surg 2006;30:1128–1134. Telemedicine and electronic health information for clinical continuity in a mobile surgery program. Mora F, Cone S, Rodas E, Merrell RC.

[vi] 88E6BBF2CBE8/0/2013c156puberr.pdf

Patient experiences with TeleConsultation; CQ index

Since the introduction of the new Healthcare Insurance Act on 1 January 2006, a great deal of importance has been attached to measuring the quality of care. The aim of the new healthcare insurance act was to transform the healthcare system from a supply-driven to a demand-driven system. The patient’s wishes and expectations are the focus in this. The patient should choose the healthcare provider by whom he/she is treated. This makes the quality, efficiency and delivery of the care according to standards increasingly important. The Consumer Quality (CQ) Index is a standardised method of measuring, analysing and reporting on client experiences in healthcare. [i],[ii]

Various Consumer Quality Index questionnaires have already been developed as a general standard for measuring the quality of healthcare. This study is aimed at figuring out the quality aspects of TeleConsultation as delivered healthcare, from a patient’s perspective. This is being carried out with reference to a guide presented by the Centre for Client Healthcare Experiences.[iii]

Setting up a CG Index comprises 3 phases. The first phase involves figuring out what quality aspects are important for the patient in a TeleConsultation. In the second phase of the research a draft CQ index questionnaire is developed based on the results from the first phase. This draft is presented to a number of patients. The aim of this is to investigate whether the questionnaire is comprehensible, relevant and unambiguous. After this the questionnaire is validated in the final phase. This is done with reference to statistical analyses of the reliability and internal cohesion of questions.

The KSYOS TeleMedical Centre carries out this research together with the Clinical Information Science department of the AMC. The TeleConsultations included in this research are: TeleDermatology, TeleCardiology and TelePulmonology.

Purpose of the study

Primary objective:

To set up the CQ index for TeleConsultation.

Secondary objective:

  1. What quality aspects are important for the patient in a TeleConsultation?
  2. How important is each quality aspect for the patient?

[i] Council for Public Health and Health Care. Towards more demand-driven care [Naar een meer vraaggerichte zorg]. 1998

[ii] Gabel JR, Sasso ATL, Rice T. Consumer-Driven Health Plans: Are They More Than Talk Now? Health Aff (Millwood) [Internet]. 2002 Nov 20

[iii] Koopman L, Sixma H, Hendriks M, Boer D de, Delnoij D. Handbook for CQI development: guidelines for developing a CQI measuring instrument [Handboek CQI ontwikkeling: richtlijnen voor de ontwikkeling van een CQI meetinstrument]. Utrecht: Centre for Client Healthcare Experience, 2011