Dr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\\n\\n
Seeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\\n\\n
Over these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\\n\\n
We are excited about the present, and we look forward to sharing many more successes in the future.
\\n\\n
Thank you all for being part of the journey. 5,000 times thank you!
\\n\\n
Now with 5,000 titles available Open Access, which one will you read next?
Preparation of Space Experiments edited by international leading expert Dr. Vladimir Pletser, Director of Space Training Operations at Blue Abyss is the 5,000th Open Access book published by IntechOpen and our milestone publication!
\n\n
"This book presents some of the current trends in space microgravity research. The eleven chapters introduce various facets of space research in physical sciences, human physiology and technology developed using the microgravity environment not only to improve our fundamental understanding in these domains but also to adapt this new knowledge for application on earth." says the editor. Listen what else Dr. Pletser has to say...
\n\n\n\n
Dr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\n\n
Seeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\n\n
Over these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\n\n
We are excited about the present, and we look forward to sharing many more successes in the future.
\n\n
Thank you all for being part of the journey. 5,000 times thank you!
\n\n
Now with 5,000 titles available Open Access, which one will you read next?
\n'}],latestNews:[{slug:"stanford-university-identifies-top-2-scientists-over-1-000-are-intechopen-authors-and-editors-20210122",title:"Stanford University Identifies Top 2% Scientists, Over 1,000 are IntechOpen Authors and Editors"},{slug:"intechopen-authors-included-in-the-highly-cited-researchers-list-for-2020-20210121",title:"IntechOpen Authors Included in the Highly Cited Researchers List for 2020"},{slug:"intechopen-maintains-position-as-the-world-s-largest-oa-book-publisher-20201218",title:"IntechOpen Maintains Position as the World’s Largest OA Book Publisher"},{slug:"all-intechopen-books-available-on-perlego-20201215",title:"All IntechOpen Books Available on Perlego"},{slug:"oiv-awards-recognizes-intechopen-s-editors-20201127",title:"OIV Awards Recognizes IntechOpen's Editors"},{slug:"intechopen-joins-crossref-s-initiative-for-open-abstracts-i4oa-to-boost-the-discovery-of-research-20201005",title:"IntechOpen joins Crossref's Initiative for Open Abstracts (I4OA) to Boost the Discovery of Research"},{slug:"intechopen-hits-milestone-5-000-open-access-books-published-20200908",title:"IntechOpen hits milestone: 5,000 Open Access books published!"},{slug:"intechopen-books-hosted-on-the-mathworks-book-program-20200819",title:"IntechOpen Books Hosted on the MathWorks Book Program"}]},book:{item:{type:"book",id:"217",leadTitle:null,fullTitle:"Recent Trends in Processing and Degradation of Aluminium Alloys",title:"Recent Trends in Processing and Degradation of Aluminium Alloys",subtitle:null,reviewType:"peer-reviewed",abstract:"In the recent decade a quantum leap has been made in production of aluminum alloys and new techniques of casting, forming, welding and surface modification have been evolved to improve the structural integrity of aluminum alloys. \nThis book covers the essential need for the industrial and academic communities for update information. It would also be useful for entrepreneurs technocrats and all those interested in the production and the application of aluminum alloys and strategic structures. It would also help the instructors at senior and graduate level to support their text.",isbn:null,printIsbn:"978-953-307-734-5",pdfIsbn:"978-953-51-6077-9",doi:"10.5772/741",price:159,priceEur:175,priceUsd:205,slug:"recent-trends-in-processing-and-degradation-of-aluminium-alloys",numberOfPages:530,isOpenForSubmission:!1,isInWos:1,hash:"6b334709c43320a6e92eb9c574a8d44d",bookSignature:"Zaki Ahmad",publishedDate:"November 21st 2011",coverURL:"https://cdn.intechopen.com/books/images_new/217.jpg",numberOfDownloads:114699,numberOfWosCitations:106,numberOfCrossrefCitations:32,numberOfDimensionsCitations:109,hasAltmetrics:0,numberOfTotalCitations:247,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 20th 2010",dateEndSecondStepPublish:"November 17th 2010",dateEndThirdStepPublish:"March 24th 2011",dateEndFourthStepPublish:"April 23rd 2011",dateEndFifthStepPublish:"June 22nd 2011",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6,7",editedByType:"Edited by",kuFlag:!1,editors:[{id:"52898",title:"Prof.",name:"Zaki",middleName:null,surname:"Ahmad",slug:"zaki-ahmad",fullName:"Zaki Ahmad",profilePictureURL:"https://mts.intechopen.com/storage/users/52898/images/1942_n.jpg",biography:"Professor Dr. Zaki Ahmad worked at King Fahd University of Petroleum and Minerals for thirty years in rendered distinguished services in teaching and research. He obtained his PhD from LEEDS University, UK. He was a chartered metallurgical engineer (C.Eng) from engineering council UK. He was a fellow of the institute of Materials, Minerals and Mining(FIMMM). He was a member of the European federation of corrosion and a fellow of institute of Metal Finishing. He substantially contributed to the founding activities in material science, corrosion engineering and nanotechnology at KFUPM and in Iran. He worked on international projects on aluminum with Aluminum, Ranshofen, Austria and Forschungzentrum, Geethscht, Germany and with Metallgesselscheft, Germany. He worked on international projects with Ministry of Technology, Germany. He was a founder contributor of center of excellence in corrosion at KFUPM, Dhahran, Saudi Arabia. He worked on the foundation and development of nanotechnology in Saudi Arabia in 2004. He was the author of “Principles of Corrosion Engineering and Corrosion Control” published by Elsevier in 2006. He has written over 95 research papers and international journals and over forty papers in international research conferences. His research activities included development of Al/SC alloys, Nanostructured superhydrophrobic surfaces, Nanocoatings and self-healing techniques. He was nominated for best researcher award in the Middle East by Energy Exchange in 2011. He was a consultant of several research organizations.",institutionString:null,position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"5",totalChapterViews:"0",totalEditedBooks:"4",institution:{name:"COMSATS University Islamabad",institutionURL:null,country:{name:"Pakistan"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"944",title:"Metallurgy",slug:"metals-and-nonmetals-metallurgy"}],chapters:[{id:"24031",title:"Aluminium Countergravity Casting – Potentials and Challenges",doi:"10.5772/17690",slug:"aluminium-countergravity-casting-potentials-and-challenges",totalDownloads:6625,totalCrossrefCites:1,totalDimensionsCites:2,signatures:"Bolaji Aremo and Mosobalaje O. 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This requires extensive analysis of developing trends in scientific research in order to offer our readers relevant content. Creating the book catalogue is also based on keeping track of the most read, downloaded and highly cited chapters and books and relaunching similar topics. I am also responsible for consulting with our Scientific Advisors on which book topics to add to our catalogue and sending possible book proposal topics to them for evaluation. Once the catalogue is complete, I contact leading researchers in their respective fields and ask them to become possible Academic Editors for each book project. Once an editor is appointed, I prepare all necessary information required for them to begin their work, as well as guide them through the editorship process. I also assist editors in inviting suitable authors to contribute to a specific book project and each year, I identify and invite exceptional editors to join IntechOpen as Scientific Advisors. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"314",title:"Regenerative Medicine and Tissue Engineering",subtitle:"Cells and Biomaterials",isOpenForSubmission:!1,hash:"bb67e80e480c86bb8315458012d65686",slug:"regenerative-medicine-and-tissue-engineering-cells-and-biomaterials",bookSignature:"Daniel Eberli",coverURL:"https://cdn.intechopen.com/books/images_new/314.jpg",editedByType:"Edited by",editors:[{id:"6495",title:"Dr.",name:"Daniel",surname:"Eberli",slug:"daniel-eberli",fullName:"Daniel Eberli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"57",title:"Physics and Applications of Graphene",subtitle:"Experiments",isOpenForSubmission:!1,hash:"0e6622a71cf4f02f45bfdd5691e1189a",slug:"physics-and-applications-of-graphene-experiments",bookSignature:"Sergey Mikhailov",coverURL:"https://cdn.intechopen.com/books/images_new/57.jpg",editedByType:"Edited by",editors:[{id:"16042",title:"Dr.",name:"Sergey",surname:"Mikhailov",slug:"sergey-mikhailov",fullName:"Sergey Mikhailov"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1373",title:"Ionic Liquids",subtitle:"Applications and Perspectives",isOpenForSubmission:!1,hash:"5e9ae5ae9167cde4b344e499a792c41c",slug:"ionic-liquids-applications-and-perspectives",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/1373.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"2270",title:"Fourier Transform",subtitle:"Materials Analysis",isOpenForSubmission:!1,hash:"5e094b066da527193e878e160b4772af",slug:"fourier-transform-materials-analysis",bookSignature:"Salih Mohammed Salih",coverURL:"https://cdn.intechopen.com/books/images_new/2270.jpg",editedByType:"Edited by",editors:[{id:"111691",title:"Dr.Ing.",name:"Salih",surname:"Salih",slug:"salih-salih",fullName:"Salih Salih"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"16890",title:"Teledermatology: Outcomes and Economic Considerations",doi:"10.5772/18774",slug:"teledermatology-outcomes-and-economic-considerations",body:'\n\t\t
\n\t\t\t
1. Introduction
\n\t\t\t
Teledermatology is defined as the provision of dermatologic care through the use of communications technology (Goldyne & Armstrong, 2010). It offers many benefits that include increased access to dermatologic services and potential reduction in costs associated with care. Teledermatology is traditionally categorized into two different models based on the technology that is employed: store-and-forward (S&F) teledermatology, and live, interactive (LI) teledermatology (Goldyne & Armstrong, 2010). While hybrid models (a combination of S&F and LI technology) are practiced at selected institutions, this chapter focuses primarily on S&F and LI models. We will present operational flows of these two technology-enabled modalities, common outcomes measures used for evaluation of teledermatology quality metrics, and economic analyses.
\n\t\t\t
At the end of the chapter (in section 5), we will consider a novel, technology-independent framework for categorizing teledermatology models as well. This system relies on classification of teledermatology based on healthcare delivery models, and serves as an alternative way to organize and evaluate the provision of teledermatologic care.
\n\t\t
\n\t\t
\n\t\t\t
2. Store-and-forward teledermatology
\n\t\t\t
Store-and-forward teledermatology is an asynchronous means for providing dermatologic care, as it relies on the asynchronous transmission of static digital images, patient histories, and specialist recommendations rather than real-time interaction between the specialist and the patient (Goldyne & Armstrong, 2010).
\n\t\t\t
In the S&F model, a medical staff personnel at the referral site typically takes images of the relevant skin condition and obtains medical history. This information is then sent to a dermatologist via a secure internet connection. The dermatologist evaluates the patient’s condition asynchronously and transmits the recommendations back to the primary care provider at the referral site (Pak et al., 2009).
\n\t\t\t
\n\t\t\t\t
2.1. Outcomes measures of store-and-forward teledermatology
\n\t\t\t\t
Teledermatology studies have assessed numerous outcomes measures, including learning effects, length of consultation, and technical aspects (Eminovic et al., 2007). We will focus this discussion on four extensively used outcomes measures: diagnostic accuracy, diagnostic reliability, clinical outcomes, and satisfaction.
\n\t\t\t\t
\n\t\t\t\t\t
2.1.1. Diagnostic accuracy of store-and-forward teledermatology
\n\t\t\t\t\t
Diagnostic accuracy refers to whether or not a diagnosis is correct, based on comparison to a gold standard reference test. While histopathological review or other laboratory tests are often used as the gold standard for diagnosis, results of these types of gold standards are not always available in clinical practice in dermatology. Furthermore, it is difficult to generate cumulative data regarding accuracy, because different studies use different methodologies and standards.
Different findings on diagnostic accuracy may be attributable to several factors. First, the “gold standard” used among the studies differ from in-person evaluations to pathologic evaluation. Second, patient populations and types of skin lesions differ among the various practices that were examined. Future studies can focus on tools or interventions to increase diagnostic accuracy of S&F teledermatology, such as routine incorporation of dermoscopy (Warshaw et al., 2010a).
\n\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t\t
2.1.2. Diagnostic reliability of store-and-forward teledermatology
\n\t\t\t\t\t
Diagnostic reliability is a measure of concurrence in diagnosis. It may refer to intraobserver reliability (whether one examiner makes the same diagnosis in two different examinations), or interobserver reliability (whether two different examiners make the same diagnosis). These measures of reliability may evaluate either complete agreement, which refers to comparison of the most likely diagnosis, or partial agreement, which accounts for differential diagnoses.
\n\t\t\t\t\t
Studies of intraobserver reliability between S&F teledermatology and in-person consultation found that agreement ranges between 31-88% for complete diagnostic agreement, and between 50-95% for partial diagnostic agreement (Table 1).
\n\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Reference
\n\t\t\t\t\t\t\t\t
Complete Diagnostic Agreement
\n\t\t\t\t\t\t\t\t
Partial Diagnostic Agreement
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Romero et al., 2010)
\n\t\t\t\t\t\t\t\t
.85
\n\t\t\t\t\t\t\t\t
.92
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Tan et al., 2010)
\n\t\t\t\t\t\t\t\t
.74
\n\t\t\t\t\t\t\t\t
.88
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Heffner et al., 2009)
\n\t\t\t\t\t\t\t\t
.82
\n\t\t\t\t\t\t\t\t
-
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Ebner et al., 2008)
\n\t\t\t\t\t\t\t\t
.74
\n\t\t\t\t\t\t\t\t
.90
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Pak et al., 2003)
\n\t\t\t\t\t\t\t\t
.70
\n\t\t\t\t\t\t\t\t
.91
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Lim et al., 2001)
\n\t\t\t\t\t\t\t\t
.88
\n\t\t\t\t\t\t\t\t
.95
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Taylor et al., 2001)
\n\t\t\t\t\t\t\t\t
.31-.64
\n\t\t\t\t\t\t\t\t
.50-.70
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Krupinski et al., 1999)
\n\t\t\t\t\t\t\t\t
-
\n\t\t\t\t\t\t\t\t
.76-.90
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t
Table 1.
Intraobserver Reliability for S&F Teledermatology and Conventional Care
\n\t\t\t\t\t
Studies have found that interobserver reliability ranges between 41-92% for complete diagnostic agreement and between 51-100% for partial diagnostic agreement (Table 2). A review of studies between 1997 and 2005 revealed that the aggregate complete diagnostic agreement was 60%, and partial diagnostic agreement was 80% (Romero et al., 2008).
\n\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Reference
\n\t\t\t\t\t\t\t\t
Complete Diagnostic Agreement
\n\t\t\t\t\t\t\t\t
Partial Diagnostic Agreement
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Tan et al., 2010)
\n\t\t\t\t\t\t\t\t
.75-.82
\n\t\t\t\t\t\t\t\t
.83-.89
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Heffner et al., 2009)
\n\t\t\t\t\t\t\t\t
.69
\n\t\t\t\t\t\t\t\t
-
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Silva et al., 2009)
\n\t\t\t\t\t\t\t\t
.87-.92
\n\t\t\t\t\t\t\t\t
.96-1.0
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Edison et al., 2008)
\n\t\t\t\t\t\t\t\t
.73
\n\t\t\t\t\t\t\t\t
-
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Ebner et al., 2008)
\n\t\t\t\t\t\t\t\t
.71-.76
\n\t\t\t\t\t\t\t\t
.90-.97
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Bowns et al., 2006)
\n\t\t\t\t\t\t\t\t
.55
\n\t\t\t\t\t\t\t\t
-
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Oakley et al., 2006)
\n\t\t\t\t\t\t\t\t
.53
\n\t\t\t\t\t\t\t\t
.64
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Tucker & Lewis, 2005)
\n\t\t\t\t\t\t\t\t
.56
\n\t\t\t\t\t\t\t\t
.68
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Baba et al., 2005)
\n\t\t\t\t\t\t\t\t
.75
\n\t\t\t\t\t\t\t\t
-
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Mahendran et al., 2005)
\n\t\t\t\t\t\t\t\t
.44-.48
\n\t\t\t\t\t\t\t\t
.64-.65
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Du Moulin et al., 2003)
\n\t\t\t\t\t\t\t\t
.54
\n\t\t\t\t\t\t\t\t
.63
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Eminovic et al., 2003)
\n\t\t\t\t\t\t\t\t
.41
\n\t\t\t\t\t\t\t\t
.51
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Lim et al., 2001)
\n\t\t\t\t\t\t\t\t
.73-.85
\n\t\t\t\t\t\t\t\t
.83-.89
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Taylor et al., 2001)
\n\t\t\t\t\t\t\t\t
.44-.51
\n\t\t\t\t\t\t\t\t
.57-.61
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(High et al., 2000)
\n\t\t\t\t\t\t\t\t
.64-.77
\n\t\t\t\t\t\t\t\t
.81-.89
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Whited et al., 1999)
\n\t\t\t\t\t\t\t\t
.41-.55
\n\t\t\t\t\t\t\t\t
.79-.95
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Lyon & Harrison, 1997)
\n\t\t\t\t\t\t\t\t
.89
\n\t\t\t\t\t\t\t\t
-
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Zelickson & Homan, 1997)
\n\t\t\t\t\t\t\t\t
.88
\n\t\t\t\t\t\t\t\t
-
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Kvedar et al., 1997)
\n\t\t\t\t\t\t\t\t
.61-.64
\n\t\t\t\t\t\t\t\t
.67-.70
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t
Table 2.
Interobserver Reliability for S&F Teledermatology and Conventional Care
\n\t\t\t\t\t
Based on this data on diagnostic reliability, it appears that S&F teledermatology is a functional and reasonably reliable tool for diagnosis of skin disorders.
\n\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t\t
2.1.3. Clinical outcomes for store-and-forward teledermatology
\n\t\t\t\t\t
To date, two studies have evaluated clinical outcomes of S&F teledermatology compared to conventional care, and both studies found similar outcomes for each of the two treatment modalities (Krupinski et al., 2004; Pak et al., 2007). Specifically, Pak et al. conducted a randomized controlled trial with patients randomly assigned to either conventional face-to-face care or teledermatology. Another dermatologist, blinded to the randomization, evaluated the clinical outcomes between baseline data and after four months (Table 3). The results suggest that teledermatology and conventional care result in similar outcomes (Pak et al., 2007).
\n\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Clinical Course Rating
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Improved
\n\t\t\t\t\t\t\t\t
No change
\n\t\t\t\t\t\t\t\t
Worse
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Assigned Group
\n\t\t\t\t\t\t\t\t
Teledermatology
\n\t\t\t\t\t\t\t\t
64%
\n\t\t\t\t\t\t\t\t
33%
\n\t\t\t\t\t\t\t\t
4%
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Conventional Care
\n\t\t\t\t\t\t\t\t
65%
\n\t\t\t\t\t\t\t\t
32%
\n\t\t\t\t\t\t\t\t
3%
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t
Table 3.
Reported Clinical Outcomes from Pak et al
\n\t\t\t\t\t
We may also consider intermediate clinical outcomes, such as (1) time-to-intervention and (2) preventable clinic visits. Time-to-intervention is usually defined as the wait time prior to being seen by a specialist after a referral has been placed. Preventable clinic visits refers to the percentage of dermatology clinic visits that could be avoided through use of teledermatology.
\n\t\t\t\t\t
The literature suggests that the use of S&F teledermatology may considerably reduce time-to-intervention. Researchers in Spain found that surgical patients managed through S&F teledermatology had a mean waiting interval 34.47 days shorter than those patients managed through conventional care (Ferrandiz et al., 2007). A similar study found that patients at primary care centers managed through teledermatology waited on average 76.31 days less than those with conventional referrals (Moreno-Ramirez et al., 2007). A study of patients at the Durham VA Medical Center found that those that received a S&F teledermatology consultation were seen on average 86 days sooner than those in the conventional system (Whited et al., 2002).
\n\t\t\t\t\t
The reduced time-to-intervention may be partially due to the fact that teledermatology can help prevent unnecessary clinic visits. Indeed, studies have found that S&F teledermatology could prevent 13-58% of dermatology clinic visits (Whited, 2010).
\n\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t\t
2.1.4. Satisfaction with store-and-forward teledermatology
\n\t\t\t\t\t
Satisfaction assessments may be subdivided into three categories: patient satisfaction, referring provider satisfaction, and specialist satisfaction. Studies suggest that patients were generally satisfied with receiving care through S&F teledermatology, and typically had no preference between teledermatology and usual care (Warshaw et al., 2010b). One study found that 76% of patients preferred being treated through teledermatology in order to avoid the wait time associated with a face-to-face clinic visit (Bowns et al., 2006). A common patient complaint during the S&F teledermatology process was the length of time between the consultation and being informed of the results by the primary care providers (Whited, 2010).
\n\t\t\t\t\t
When referring providers were asked about their satisfaction with S&F teledermatology, referring providers provided varied feedback (Bowns et al., 2006; Collins et al., 2004; Weinstock et al., 2002; Whited et al., 2004). Many referring providers report that they improved their therapeutic and diagnostic ability due to regular feedback and interactions with the dermatologist (van den Akker et al., 2001). From the referring providers’ perspective, some dissatisfaction with the S&F teledermatology process stemmed from the additional time and effort required for relaying the diagnoses to patients, prescribing the medications, or performing procedures (Bowns et al., 2006; Collins et al., 2004; Kvedar et al., 1999).
\n\t\t\t\t\t
Fewer studies have evaluated satisfaction of dermatologists who practice teledermatology. While most dermatologists practicing teledermatology reported increased satisfaction (Whited, 2010), many report reduced confidence in their diagnoses (Bowns et al., 2006; Pak et al., 1999; Whited et al., 2004).
\n\t\t\t\t
\n\t\t\t
\n\t\t\t
\n\t\t\t\t
2.2. Economic considerations of store-and-forward teledermatology
\n\t\t\t\t
We begin discussion of the economic aspects of S&F teledermatology with a brief review of common types of economic analysis. Three commonly used methods are cost minimization analysis, cost-effectiveness analysis, and cost-benefit analysis (Davalos et al., 2009). Cost-minimization analysis is a type of cost analysis that evaluates two systems that produce equivalent outcomes. Cost-effectiveness analysis compares monetary costs (cost) in the context of outcomes (effectiveness). However, this type of analysis generally considers only one outcomes measure. In comparison, cost-benefit analysis considers multiple economic costs as well as varied benefits within a system, and it generally includes multiple outcomes measures. Cost-benefit analyses are generally considered the most comprehensive type of economic analyses. Further information regarding economic evaluation metrics may be found in Davalos et al. (Davalos et al., 2009).
\n\t\t\t\t
Literature shows that S&F teledermatology is generally economically viable (Table 3). While studies differed in their economic perspective and modality of S&F teledermatology delivery (e.g. triage, consultation, versus provision of care), analyses have generally established that S&F teledermatology offers a cost-effective means of providing dermatologic care especially for those living in geographically isolated communities or medically underserved communities (Pak et al., 2009; Whited et al., 2003). For example, in a cost-minimization analysis that adopted the perspective of the U.S. Department of Defense, Pak et al. concluded that the use of teleconsultations through S&F technology reduced overall costs compared to conventional care (Pak et al., 2009).
\n\t\t\t\t
Similarly, Whited et al. performed a cost analysis of a consultative model using S&F technology from the perspective of the U.S. Department of Veterans Affairs (Whited et al., 2003). The authors found that teleconsultations are $15 more costly per patient compared to face-to-face consultation. In this study, effectiveness was defined as time-to-specialist evaluation. They found that having teledermatology consultations resulted in shorter time-to-specialist evaluation and was overall more cost-effective. Further analyses showed that, from a societal perspective, S&F teleconsultations would be even less costly after accounting for patients’ travel time and productivity lost through face-to-face care (Whited et al., 2003).
\n\t\t\t\t
When S&F teledermatology was used as a primary method for triaging cases appropriate face-to-face encounters, researchers found that this was an economically viable means for prioritizing patients requiring dermatologic care (Ferrandiz et al., 2008; Moreno-Ramirez et al., 2009). By comparing S&F teledermatology and conventional referrals to a skin cancer clinic in Spain, Moreno-Ramirez et al. conducted a cost-identification and cost-effectiveness analysis from a societal perspective (Moreno-Ramirez et al., 2009). The investigators assessed costs associated with travel, lost-productivity, and healthcare delivery. Effectiveness was defined as the wait-time to in-person consultation after the referral. The authors found that teledermatology triage was more cost-effective; specifically, teledermatology yielded cost-savings of €49.59 per patient compared with conventional face-to-face care (Moreno-Ramirez et al., 2009). These findings were corroborated by another cost-effectiveness study in Spain, where the investigators found that the use of teledermatology saved €122.02 compared to conventional care (Ferrandiz et al., 2008).
\n\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
Reference
\n\t\t\t\t\t\t\t
Type of Analysis
\n\t\t\t\t\t\t\t
Teleconsultation
\n\t\t\t\t\t\t\t
Conventional
\n\t\t\t\t\t\t\t
Perspective
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
Provision of Care
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
(Pak et al., 2009)
\n\t\t\t\t\t\t\t
Cost-minimization
\n\t\t\t\t\t\t\t
$340 / patient
\n\t\t\t\t\t\t\t
$372 / patient
\n\t\t\t\t\t\t\t
Department of Defense
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
(Whited et al., 2003)
\n\t\t\t\t\t\t\t
Cost / Cost-effectiveness
\n\t\t\t\t\t\t\t
$36.40 / patient
\n\t\t\t\t\t\t\t
$21.40 / patient
\n\t\t\t\t\t\t\t
Department of Veterans Affairs
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
Triage
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
(Moreno-Ramirez et al., 2009)
\n\t\t\t\t\t\t\t
Cost-identification / Cost-effectiveness
\n\t\t\t\t\t\t\t
€79.78 / patient
\n\t\t\t\t\t\t\t
€129.37 / patient
\n\t\t\t\t\t\t\t
Societal
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
(Ferrandiz et al., 2008)
\n\t\t\t\t\t\t\t
Cost / Cost-effectiveness
\n\t\t\t\t\t\t\t
€156.40 / patient
\n\t\t\t\t\t\t\t
€278.42 / patient
\n\t\t\t\t\t\t\t
Societal
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
$ - US dollars; € - euros
\n\t\t\t\t\t\t
\n\t\t\t\t\t
Table 4.
Economic Analyses of Store-and-Forward Teledermatology
\n\t\t\t
\n\t\t
\n\t\t
\n\t\t\t
3. Live, Interactive Teledermatology
\n\t\t\t
Live, interactive teledermatology involves synchronous interaction between the specialist and patient (Goldyne & Armstrong, 2010). Via videoconferencing or web-conferencing, the specialist obtains a clinical history, examines the patient in real-time, and communicates recommendations to the patient and the primary care provider (Wootton et al., 2000).
\n\t\t\t
\n\t\t\t\t
3.1. Outcomes measures of Live, Interactive Teledermatology
\n\t\t\t\t
We will consider the same outcomes measures for LI teledermatology as we did for S&F teledermatology: diagnostic accuracy, diagnostic reliability, clinical outcomes, and satisfaction.
\n\t\t\t\t
\n\t\t\t\t\t
3.1.1. Diagnostic accuracy of LI Teledermatology
\n\t\t\t\t\t
Studies comparing diagnostic accuracy of LI teledermatology to pathologic diagnosis are not currently available. Studies comparing diagnoses between LI teledermatology and in-person consultation generally show diagnostic agreement, and will be discussed further under diagnostic reliability.
\n\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t\t
3.1.2. Diagnostic reliability of Live, Interactive Teledermatology
\n\t\t\t\t\t
Studies of intraobserver reliability between LI teledermatology and in-person consultation show complete diagnostic agreement in 59-75% of cases, and partial agreement in 76-87% of cases (Table 5).
\n\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Reference
\n\t\t\t\t\t\t\t\t
Complete Diagnostic Agreement
\n\t\t\t\t\t\t\t\t
Partial Diagnostic Agreement
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Loane et al., 1998b)
\n\t\t\t\t\t\t\t\t
.71
\n\t\t\t\t\t\t\t\t
.87
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Gilmour et al., 1998)
\n\t\t\t\t\t\t\t\t
.59
\n\t\t\t\t\t\t\t\t
.76
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Oakley et al., 1997)
\n\t\t\t\t\t\t\t\t
.75
\n\t\t\t\t\t\t\t\t
.82
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t
Table 5.
Intraobserver Reliability for LI Teledermatology
\n\t\t\t\t\t
Interobserver reliability between LI teledermatology and in-person consultation ranges from 54-80% for complete diagnostic agreement, and 79-99% for partial agreement (Table 6). A review of aggregate data indicates that complete diagnostic agreement is 70%, while partial diagnostic agreement is 84% (Romero et al., 2008).
\n\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
Reference
\n\t\t\t\t\t\t\t\t
Complete Diagnostic Agreement
\n\t\t\t\t\t\t\t\t
Partial Diagnostic Agreement
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Nordal et al., 2001)
\n\t\t\t\t\t\t\t\t
.72
\n\t\t\t\t\t\t\t\t
.86
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Phillips et al., 1998)
\n\t\t\t\t\t\t\t\t
.59
\n\t\t\t\t\t\t\t\t
-
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Loane et al., 1998b)
\n\t\t\t\t\t\t\t\t
.60
\n\t\t\t\t\t\t\t\t
.76
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Lowitt et al., 1998)
\n\t\t\t\t\t\t\t\t
.80
\n\t\t\t\t\t\t\t\t
-
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Gilmour et al., 1998)
\n\t\t\t\t\t\t\t\t
.54
\n\t\t\t\t\t\t\t\t
.80
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Lesher et al., 1998)
\n\t\t\t\t\t\t\t\t
.78
\n\t\t\t\t\t\t\t\t
.99
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t
(Phillips et al., 1997)
\n\t\t\t\t\t\t\t\t
.77
\n\t\t\t\t\t\t\t\t
-
\n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t
Table 6.
Interobserver Reliability for LI Teledermatology
\n\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t\t
3.1.3. Clinical outcomes for LI Teledermatology
\n\t\t\t\t\t
One study evaluated clinical outcomes for LI teledermatology compared to conventional care. In a retrospective analysis of patients who had two or more teledermatology consultations, Marcin et al. found that diagnosis, treatment, and patient improvement data for the teledermatology patients were consistent with existing literature regarding conventional care (Marcin et al., 2005).
\n\t\t\t\t\t
Intermediate outcomes measures include (1) preventable clinic visits and (2) time for completion of consultation. Similar to the S&F modality, LI teledermatology can prevent unnecessary clinic visits. Studies found that 44.4-82% of clinic visits could be avoided through the use of LI teledermatology (Whited, 2010).
\n\t\t\t\t\t
LI teledermatology can decrease total time necessary to complete a consultation visit from the patient’s perspective. For example, researchers in New Zealand found that, compared to a clinic visit, the use of LI teledermatology saved patients an average of 3.45 hours of time, primarily due to reduced traveling time (Oakley et al., 2000). However, LI teledermatology does not necessarily reduce consult time for the dermatologist (Loane et al., 1999, 2001b; Oakley et al., 2000).
\n\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t\t
3.1.4. Satisfaction with Live, Interactive Teledermatology
\n\t\t\t\t\t
As stated previously, satisfaction in teledermatology is categorized into patient satisfaction, referring provider satisfaction, and dermatologist satisfaction. Patients reported that they were equally satisfied with LI teledermatology and conventional care and had no strong preference for one modality over another (Whited, 2010). Some patients reported initial discomfort due to the presence of camera (Gilmour et al., 1998; Loane et al., 1998a).
\n\t\t\t\t\t
Relatively few studies evaluated referring provider satisfaction in LI teledermatology. While there was some dissatisfaction associated with technical difficulties, most referring providers report being satisfied with the LI teledermatology (Gilmour et al., 1998; Jones et al., 1996).
\n\t\t\t\t\t
Similar to dermatologists who practice S&F teledermatology, dermatologists who practice LI teledermatology report being satisfied with practicing LI teledermatology. However, when compared to in-person consultation, dermatologists expressed lower confidence in their diagnoses (Artiles Sanchez et al., 2004; Lowitt et al., 1998).
\n\t\t\t\t
\n\t\t\t
\n\t\t\t
\n\t\t\t\t
3.2. Economic considerations of Live, Interactive Teledermatology
\n\t\t\t\t
Economic analyses of LI teledermatology yielded mixed conclusions regarding its economic sustainability. While some studies have shown LI teledermatology to be cost-effective, others suggested that it may be more costly than conventional care. In a cost-minimization analysis from a societal perspective, authors from New Zealand found that teledermatology consultations using LI technology appeared less costly than that of face-to-face care, especially when patients have longer travel distances (Loane et al., 2001b). In another cost-minimization study of LI teledermatology in the U.S., investigators found that consultative teledermatology using LI technology also appears to be less costly than face-to-face care from a provider perspective (Armstrong et al., 2007).
\n\t\t\t\t
In a cost-benefit analysis from the societal perspective, Wootton et al. found that a LI teleconsultation system in the United Kingdom was more costly than face-to-face care. Sensitivity analyses showed that LI teledermatology consultations could be a less costly alternative if patients travelled longer distances for in-person consultations and incurred greater lost-productivity costs (Wootton et al., 2000).
\n\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
Reference
\n\t\t\t\t\t\t\t
Type of Analysis
\n\t\t\t\t\t\t\t
Teleconsultation
\n\t\t\t\t\t\t\t
Conventional
\n\t\t\t\t\t\t\t
Perspective
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
(Dekio et al., 2010)
\n\t\t\t\t\t\t\t
Cost-effectiveness
\n\t\t\t\t\t\t\t
¥26,040 / week
\n\t\t\t\t\t\t\t
¥60,500 / week
\n\t\t\t\t\t\t\t
Societal
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
(Armstrong et al., 2007)
\n\t\t\t\t\t\t\t
Cost-minimization
\n\t\t\t\t\t\t\t
$274 / hour
\n\t\t\t\t\t\t\t
$346 / hour
\n\t\t\t\t\t\t\t
Healthcare provider
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
(Loane et al., 2001b)
\n\t\t\t\t\t\t\t
Cost-minimization
\n\t\t\t\t\t\t\t
NZ$279.23 / patient
\n\t\t\t\t\t\t\t
NZ$283.79 / patient
\n\t\t\t\t\t\t\t
Societal
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
(Loane et al., 2001a)
\n\t\t\t\t\t\t\t
Cost-benefit
\n\t\t\t\t\t\t\t
£146.48 / patient
\n\t\t\t\t\t\t\t
£47.13 / patient
\n\t\t\t\t\t\t\t
Urban Societal
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
(Loane et al., 2001a)
\n\t\t\t\t\t\t\t
Cost-benefit
\n\t\t\t\t\t\t\t
£180.22 / patient
\n\t\t\t\t\t\t\t
£48.77 / patient
\n\t\t\t\t\t\t\t
Rural Societal
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
(Wootton et al., 2000)
\n\t\t\t\t\t\t\t
Cost-benefit
\n\t\t\t\t\t\t\t
£132.10 / patient
\n\t\t\t\t\t\t\t
£48.73 / patient
\n\t\t\t\t\t\t\t
Societal
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
(Lamminen et al., 2000)
\n\t\t\t\t\t\t\t
Cost
\n\t\t\t\t\t\t\t
FM 18,627 (total cost)
\n\t\t\t\t\t\t\t
FM 18,034 (total cost)
\n\t\t\t\t\t\t\t
Societal
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
(Bergmo, 2000)
\n\t\t\t\t\t\t\t
Cost-minimization
\n\t\t\t\t\t\t\t
NKr 470,780 (total cost)
\n\t\t\t\t\t\t\t
NKr 1,635,075 (total cost)
\n\t\t\t\t\t\t\t
Healthcare provider
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
(Chan et al., 2000)
\n\t\t\t\t\t\t\t
Cost / Cost-effectiveness
\n\t\t\t\t\t\t\t
HK$57.7 / patient
\n\t\t\t\t\t\t\t
HK$322.8 / patient
\n\t\t\t\t\t\t\t
Healthcare provider
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
(Burgiss et al., 1997)
\n\t\t\t\t\t\t\t
Cost
\n\t\t\t\t\t\t\t
$141 / patient
\n\t\t\t\t\t\t\t
$294 / patient
\n\t\t\t\t\t\t\t
Societal
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
¥ - yen; € - euros; $ - US dollars; NZ$ - New Zealand dollars; £ - pounds; FM – Finnish marks; NKr – Norwegian kroners; HK$ - Hong Kong dollars
\n\t\t\t\t\t\t
\n\t\t\t\t\t
Table 7.
Economic Analyses of Live, Interactive Teledermatology
\n\t\t\t
\n\t\t
\n\t\t
\n\t\t\t
4. Comparison of store-and-forward and Live, Interactive Teledermatology
S&F and LI teledermatology present distinct advantages. S&F teledermatology appears to be very cost-effective. Specifically, compared to LI teledermatology, S&F teledermatology requires less equipment or technology costs (Pak, 2008; Watson, 2009). The requirements for administrative support and overhead also appear to be less for S&F teledermatology. Finally, the asynchronous nature of S&F modality affords greater scheduling flexibility for patients and dermatologists since coordinated appointments with specialists are not required (Finch et al., 2007; Watson, 2009). LI teledermatology, on the other hand, more closely mirrors a conventional face-to-face consultation because the specialist can interact with patients and a referring provider in real-time.
\n\t\t\t
S&F and LI teledermatology have their respective disadvantages as well. In S&F teledermatology, because the ability of the dermatologist to diagnose and provide useful recommendations depends solely on the quality of images and clinical history, suboptimal images or incomplete clinical history can be frustrating for the dermatologist. Furthermore, S&F teledermatology does not allow the development of a patient-dermatologist relationship compared to LI teledermatology (Grenier et al., 2009; Onor & Misan, 2005). LI teledermatology presents alternative challenges in terms of scheduling, coordination, and costs.
\n\t\t\t
Given the unique benefits that each modality offers, some providers have recently started to employ a hybrid model. In the hybrid model, the clinical encounters are conducted via videoconferencing or webconferencing, and the dermatologist reviews static digital images that were acquired by a digital camera prior to the encounter and sent to them during the encounter. Current research efforts are investigating the relative effectiveness of such hybrid systems (Baba et al., 2005; Romero et al., 2010). For example, Baba et al. found that a hybrid modality increased diagnostic accuracy by 7-9%, compared to S&F teledermatology alone (Baba et al., 2005).
\n\t\t
\n\t\t
\n\t\t\t
5. Novel classification teledermatology based on healthcare delivery models
\n\t\t\t
To date, teledermatology has been categorized by the technology it uses--S&F and LI technology. An alternative model to frame teledermatology is based on the type of healthcare delivery. Specifically, independent of the type of technology employed, we can arrange teledermatology delivery into (1) triage, (2) consultative, and (3) direct-care models. This technology-independent, healthcare delivery-based framework is accessible to policy makers and other stakeholders involved in health policy.
\n\t\t\t
\n\t\t\t\t
5.1. Triage model
\n\t\t\t\t
In the triage model, all dermatology referrals are first seen through teledermatology. A specialist reviews the cases rapidly with the goal of prioritizing which patients are suitable for in-person evaluation. The triage model prioritizes patients based on the severity and urgency of their skin condition. This modality has been primarily practiced in Europe in prioritization patients with cutaneous malignancies (Ferrandiz et al., 2007; Moreno-Ramirez et al., 2007).
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5.2. Consultative model
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In the consultative model, the referring providers decide which dermatology referrals are appropriate for teledermatology evaluation. From the dermatologist’s perspective, the primary goal of the consultative model is to provide detailed and useful recommendations to the primary care provider. In this healthcare delivery model, the dermatologist reviews the cases via either S&F or LI technology and provides detailed recommendations to the primary care provider. The primary care provider assumes responsibility for communicating with the patient and carrying out the recommendation plans. The consultative model is currently the most common model in the United States (Goldyne & Armstrong, 2010).
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5.3. Direct-care model
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In the direct-care model, the dermatologist assumes the responsibility of communicating and treating the patient. This model differs significantly from the triage or consultative model in that the dermatologist is responsible for caring for the patient. The provision of direct care includes evaluation, communicating the treatment plan to the patient, writing prescriptions, carrying out laboratory evaluations, and monitoring disease progression.
As healthcare delivery becomes more patient-centered and distance-independent (Hibbard, 2004; Hogarth et al., 2010; Robinson et al., 2011), proper application of teledermatology offers a versatile means of providing high quality care to patients in their own communities. Teledermatology can be used in various healthcare delivery modalities, including triage, consultation, and direct care.
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In addition to gathering the support of healthcare workers and patients for these newer models of healthcare delivery, those who work at the forefront of telemedicine need to also advocate for policy changes and technological innovations to continually improve the quality and experience of telemedicine. It is likely that the cost of technology will decline as the reliability and user-interface of technology continually improve. In this healthcare environment, innovations in teledermatology serve as examples for emerging paradigms in healthcare delivery.
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\n\t\n',keywords:null,chapterPDFUrl:"https://cdn.intechopen.com/pdfs/16890.pdf",chapterXML:"https://mts.intechopen.com/source/xml/16890.xml",downloadPdfUrl:"/chapter/pdf-download/16890",previewPdfUrl:"/chapter/pdf-preview/16890",totalDownloads:2626,totalViews:230,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,dateSubmitted:"October 29th 2010",dateReviewed:"March 22nd 2011",datePrePublished:null,datePublished:"June 20th 2011",dateFinished:null,readingETA:"0",abstract:null,reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/16890",risUrl:"/chapter/ris/16890",book:{slug:"telemedicine-techniques-and-applications"},signatures:"Akhilesh Pathipati and April Armstrong",authors:[{id:"32510",title:"Dr.",name:"April",middleName:"Wang",surname:"Armstrong",fullName:"April Armstrong",slug:"april-armstrong",email:"aprilarmstrong@post.harvard.edu",position:null,institution:{name:"University of California, Davis",institutionURL:null,country:{name:"United States of America"}}},{id:"37945",title:"Mr",name:"Akhilesh",middleName:"Srinivas",surname:"Pathipati",fullName:"Akhilesh Pathipati",slug:"akhilesh-pathipati",email:"apathipati@college.harvard.edu",position:null,institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Store-and-forward teledermatology",level:"1"},{id:"sec_2_2",title:"2.1. Outcomes measures of store-and-forward teledermatology",level:"2"},{id:"sec_2_3",title:"2.1.1. Diagnostic accuracy of store-and-forward teledermatology",level:"3"},{id:"sec_3_3",title:"Table 1.",level:"3"},{id:"sec_4_3",title:"Table 3.",level:"3"},{id:"sec_5_3",title:"2.1.4. Satisfaction with store-and-forward teledermatology",level:"3"},{id:"sec_7_2",title:"2.2. Economic considerations of store-and-forward teledermatology",level:"2"},{id:"sec_9",title:"3. Live, Interactive Teledermatology",level:"1"},{id:"sec_9_2",title:"3.1. Outcomes measures of Live, Interactive Teledermatology",level:"2"},{id:"sec_9_3",title:"3.1.1. Diagnostic accuracy of LI Teledermatology",level:"3"},{id:"sec_10_3",title:"Table 5.",level:"3"},{id:"sec_11_3",title:"3.1.3. Clinical outcomes for LI Teledermatology",level:"3"},{id:"sec_12_3",title:"3.1.4. Satisfaction with Live, Interactive Teledermatology",level:"3"},{id:"sec_14_2",title:"3.2. Economic considerations of Live, Interactive Teledermatology",level:"2"},{id:"sec_16",title:"4. Comparison of store-and-forward and Live, Interactive Teledermatology",level:"1"},{id:"sec_17",title:"5. Novel classification teledermatology based on healthcare delivery models ",level:"1"},{id:"sec_17_2",title:"5.1. Triage model",level:"2"},{id:"sec_18_2",title:"5.2. Consultative model",level:"2"},{id:"sec_19_2",title:"5.3. Direct-care model",level:"2"},{id:"sec_21",title:"6. Conclusion",level:"1"}],chapterReferences:[{id:"B1",body:'\n\t\t\t\t\n\t\t\t\t\tArmstrong AW, Dorer DJ, Lugn NE, and Kvedar JC.\n\t\t\t\t\t2007 Economic evaluation of interactive teledermatology compared with conventional care. Telemed J E Health 13\n\t\t\t\t\t2\n\t\t\t\t\t91\n\t\t\t\t\t99 .\n\t\t\t'},{id:"B2",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tArtiles\n\t\t\t\t\t\t\tSanchez. 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K.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tFortier\n\t\t\t\t\t\t\tL. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBohjanen\n\t\t\t\t\t\t\tK. A.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tChen\n\t\t\t\t\t\t\tK.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLee\n\t\t\t\t\t\t\tP. K.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tRabinovitz\n\t\t\t\t\t\t\tH. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\tet al.\n\t\t\t\t\t\n\t\t\t\t\t2009b Accuracy of teledermatology for pigmented neoplasms. J Am Acad Dermatol 61\n\t\t\t\t\t5\n\t\t\t\t\t753\n\t\t\t\t\t765 .\n\t\t\t'},{id:"B77",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWatson\n\t\t\t\t\t\t\tA.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPena\n\t\t\t\t\t\t\tV.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKvedar\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2009 Teledermatology. eMedicine.\n\t\t\t'},{id:"B78",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWatson\n\t\t\t\t\t\t\tA. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBergman\n\t\t\t\t\t\t\tH.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWilliams\n\t\t\t\t\t\t\tC. M.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tKvedar\n\t\t\t\t\t\t\tJ. C.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2010 A randomized trial to evaluate the efficacy of online follow-up visits in the management of acne. Arch Dermatol 146\n\t\t\t\t\t4\n\t\t\t\t\t406\n\t\t\t\t\t411 .\n\t\t\t'},{id:"B79",body:'\n\t\t\t\t\n\t\t\t\t\tWeinstock MA, Nguyen FQ, and Risica PM.\n\t\t\t\t\t2002 Patient and referring provider satisfaction with teledermatology. J Am Acad Dermatol 47\n\t\t\t\t\t1\n\t\t\t\t\t68\n\t\t\t\t\t72 .\n\t\t\t'},{id:"B80",body:'\n\t\t\t\t\n\t\t\t\t\tWhited JD.\n\t\t\t\t\t2010 Summary of the Status of Teledermatology Research. Teledermatology Special Interest Group- American Telemedicine Association.\n\t\t\t'},{id:"B81",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJD\n\t\t\t\t\t\t\tWhited\n\t\t\t\t\t\t\tDatta. S.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHall\n\t\t\t\t\t\t\tR. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tME\n\t\t\t\t\t\t\tFoy\n\t\t\t\t\t\t\tMarbrey. L. E.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGrambow\n\t\t\t\t\t\t\tS. C.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDudley\n\t\t\t\t\t\t\tT. K.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSimel\n\t\t\t\t\t\t\tD. L.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tOddone\n\t\t\t\t\t\t\tE. Z.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2003 An economic analysis of a store and forward teledermatology consult system. Telemed J E Health 9\n\t\t\t\t\t4\n\t\t\t\t\t351\n\t\t\t\t\t360 .\n\t\t\t'},{id:"B82",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tJD\n\t\t\t\t\t\t\tWhited\n\t\t\t\t\t\t\tHall. R. P.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tME\n\t\t\t\t\t\t\tFoy\n\t\t\t\t\t\t\tMarbrey. L. E.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tGrambow\n\t\t\t\t\t\t\tS. C.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDudley\n\t\t\t\t\t\t\tT. K.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tDatta\n\t\t\t\t\t\t\tS.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSimel\n\t\t\t\t\t\t\tD. L.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tOddone\n\t\t\t\t\t\t\tE. Z.\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2002 Teledermatology’s impact on time to intervention among referrals to a dermatology consult service. Telemed J E Health 8\n\t\t\t\t\t3\n\t\t\t\t\t313\n\t\t\t\t\t321 .\n\t\t\t'},{id:"B83",body:'\n\t\t\t\t\n\t\t\t\t\tWhited JD, Hall RP, Foy ME, Marbrey LE, Grambow SC, Dudley TK, Datta SK, Simel DL, and Oddone EZ.\n\t\t\t\t\t2004 Patient and clinician satisfaction with a store-and-forward teledermatology consult system. Telemed J E Health 10\n\t\t\t\t\t4\n\t\t\t\t\t422\n\t\t\t\t\t431 .\n\t\t\t'},{id:"B84",body:'\n\t\t\t\t\n\t\t\t\t\tWhited JD, Hall RP, Simel DL, Foy ME, Stechuchak KM, Drugge RJ, Grichnik JM, Myers SA, and Horner RD.\n\t\t\t\t\t1999 Reliability and accuracy of dermatologists’ clinic-based and digital image consultations. J Am Acad Dermatol 41(5 Pt 1):693-702.\n\t\t\t'},{id:"B85",body:'\n\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tWootton\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tBloomer\n\t\t\t\t\t\t\tS. E.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tCorbett\n\t\t\t\t\t\t\tR.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tEedy\n\t\t\t\t\t\t\tD. J.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tHicks\n\t\t\t\t\t\t\tN.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tLotery\n\t\t\t\t\t\t\tH. E.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMathews\n\t\t\t\t\t\t\tC.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tPaisley\n\t\t\t\t\t\t\tJ.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tSteele\n\t\t\t\t\t\t\tK.\n\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\t\tMA\n\t\t\t\t\t\t\tLoane\n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\n\t\t\t\t\t\n\t\t\t\t\t2000 Multicentre randomised control trial comparing real time teledermatology with conventional outpatient dermatological care: societal cost-benefit analysis. BMJ 320\n\t\t\t\t\t7244\n\t\t\t\t\t1252\n\t\t\t\t\t1256 .\n\t\t\t'},{id:"B86",body:'\n\t\t\t\t\n\t\t\t\t\tZelickson BD, and Homan\n\t\t\t\t\t1997 1997. Teledermatology in the nursing home. Arch Dermatol 133\n\t\t\t\t\t2\n\t\t\t\t\t171\n\t\t\t\t\t174 .\n\t\t\t'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Akhilesh S. Pathipati",address:"",affiliation:'
Department of Dermatology, University of California, Davis, United States of America
'},{corresp:null,contributorFullName:"April W. Armstrong",address:null,affiliation:'
Department of Dermatology, University of California, Davis, United States of America
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1. Introduction
The mankind has relied on different sources of energy during its economic development throughout the centuries. Whereas coal has been the main energy source in the nineteenth century, oil was in twentieth one. The possible scenarios for remediation of greenhouse effect due to carbon dioxide released by energy production and industry are rendered to minimization of emissions and its recycling. The latter is accomplished by the production of energy sources and chemicals of practical importance from carbon dioxide.
The emission minimization consists in two approaches: replacement of the fossil fuels by renewable ones (solar, wind energies, biomass, etc.) or improvement of energy efficiency in all human activities in different ways. The distribution of energy sources for the European Union for the year 2016 is shown in Figure 1. One can see that the share of renewables is bigger than the powerful nuclear energy with a leading role in energy production. The biggest part (more than 60%) of the renewable energy sources is assigned to the biomass and waste utilization.
Figure 1.
Production of primary energy, EU-28, 2016 (% of total, based on tons of oil equivalent). Source: Eurostat (nrg_100a) and (nrg_107a) [1].
One of the ways to cope with the problem of carbon dioxide emissions is to close the carbon cycle using renewable fuels from presently grown biomass, by recycling the released carbon dioxide by the present vegetation by photosynthesis. This is the philosophy of biomass utilization as energy source. The most spread biofuels in the present period are biogas, produced by anaerobic digestion of organic waste, bioethanol, produced from cereals and/or lignocellulosic residues and biodiesel, produced by trans-esterification of lipids with methanol or ethanol.
In this review, we shall concentrate ourselves to the application of biogas as renewable energy source and also as a feedstock for the production of chemicals and other fuels.
2. Biogas production
Biogas is produced by anaerobic digestion of organic matter of natural origin [2, 3, 4]. The main advantage of this process consists in the combined environmental and energy effect.
Biogas consists mainly of methane, carbon dioxide, and traces of hydrogen sulfide and mercaptanes, as well as residual amounts of oxygen and nitrogen. Small amounts of ethane and hydrogen are possible too. Biogas is obtained by anaerobic digestion of organic waste of biologic origin. The most exploited ones are of agricultural origin (manure, poultry litter, hay, and straw) [5], from food industry, stillage from ethanol production [6], landfill gas, activated sludge from wastewater treatment plants, etc. One of the simplest and the mostly spread flow sheets for biogas production and utilization is shown in Figure 2 [7].
Figure 2.
Illustration of biogas cycle, formation, and applications. Scheme taken from [7].
The main fuel in the scheme, shown in Figure 2, is biogas, utilized for energy (thermal one and electricity) or fuel for transport. The carbon dioxide released after combustion is absorbed by the vegetation by photosynthesis, thus closing the carbon cycle. The residual sludge from the digester is rich of organic nitrogen, and therefore, it is suitable for fertilizing the soil.
In the past, biogas has been widely spread as an energy source in the households in the countries of Africa and Asia. Although quite primitive as design, the anaerobic digesters have solved the problems with autonomous energy supply for many households in India, Pakistan, Indo-China, etc.
Later, biogas became very important and essential share as energy source for the countries in Western Europe and Northern America. Besides heating, biogas is now more frequently used for the production of electricity and transport fuel in many municipalities. It is already added to the pipelines for natural gas distribution of household purposes.
A new trend in biogas production and utilization is the so-called biorefinery concept. This concept not only presumes the use of renewable biomass as energy source but also combines it with the production of chemicals, such as plastics, solvents, and synthetic fuels [8]. An example for this is the Danish Bioethanol Concept presented by Zafar [9]. It comprises the ethanol production from lignocellulosic biomass with biogas production of the stillage and cellulose waste. The residual cellulose waste is additionally recycled after wet-oxidation for additional conversion into biogas. A detailed review on biogas applications is published recently by Sawyerr et al. [10].
2.1 Some constructions of anaerobic digesters
The variety of anaerobic digesters for biogas production is very broad: from the very primitive pits to most sophisticated bioreactors, such as the floating drum reactor, the upflow anaerobic sludge blanket (UASB) reactor [11, 12, 13], and multistage bioreactor with separated compartments [14, 15]. The choice for anaerobic digester depends on the origin of substrate, and the intermediates are converted during the consecutive steps of hydrolysis, acidification, acetogenesis, and final methanation. In case an accumulation of fatty acids takes place, the reactor with separated compartments is preferable. The most exploited digester for biogas production from domestic waste, activated sludge, and manure is the UASB reactor.
2.2 Substrates for biogas
The mostly used substrates for biogas production are the manure from cattle, pigs, and poultry litter. This application competes with the traditional use of manure for soil fertilization. When the amounts of manure prevail the demand for fertilization, biogas production is welcome because double problem is solved: on the one hand, the waste is destroyed and removed, and on the other hand, renewable energy is produced saving money and contributing for carbon cycle closing. That is why attention is paid to the utilization of cattle dung, lignocellulose waste, waste from food and beverage processing, activated sludge from wastewater treatment plants, and household solid waste with landfill gas use. The waste treatment is associated with energy production and reduction of the energy demand of the main enterprise.
2.2.1 Biogas from glycerol
Crude glycerol is the main residue from biodiesel production. The amount of this waste product is about 10% from the produced fuel. The poor quality of this glycerol, containing water, potassium hydroxide, and some methanol makes it non-suitable for market purposes even after purification. One alternative utilization of this residual glycerol is in its direct conversion into biogas, thus supplying the biodiesel plant with energy simultaneously. However, as a very simple and digestible substrate, glycerol yields large amounts of organic acids as intermediates, leading to strong inhibition of methanogenic bacteria [16, 17, 18]. That is why glycerol must be used as substrate for biogas production very cautiously with the addition of small amounts, thus making this process with little practical use. It is reported, however, that small additions of glycerol to other basic substrates, i.e. manure, can boost biogas production, as reported by Robra et al. [19] and Astals et al. [20].
Food industry is also a good source for biogas production.
3. Biogas applications
3.1 Biogas for heating
Traditional biogas contains approximately 60% (vol.) methane, almost 40% carbon dioxide, small amounts of ethane and hydrogen (less than 0.5% together), hydrogen sulfide and mercaptanes (some ppm), humidity, and traces of oxygen. Its net energy capacity is ca. 24 MJ/nm3 at methane content of 60% (vol.). The first and most direct use of biogas is for heating purposes for maintenance of the equipment and the farm, where the animal dung is treated. The same applies for its use for domestic purposes, besides heating, e.g., cooking and lighting, as firstly used in Asian and African countries.
Another more sophisticated use of the biogas heating capacity is its utilization as heat energy in beverage and ethanol production. There the stillage remaining after distillation is recycled for biogas production. The resulting biogas is combusted for boiler heating and for energy for operation of distillation columns. Thus, the problems with the treatment of the residual stillage are solved by conversion into biogas, thus mitigating the problems with energy supply and spending. Calculations show that in some cases, stillage utilization as biogas can cover almost the whole energy demand for heating the distillation process. Besides these straightforward applications, biogas is also injected into the grid for natural gas supply for domestic use [21, 22]. For this purpose, a preliminary scrubbing of the carbon dioxide and sulfur compounds is necessary.
3.2 Biogas for electricity
Biogas is suitable for generation of electric power in combination with heat recovery. Usually the gas is combusted in engines with internal combustion coupled to turbine. The released heat (being around 60% of the utilized energy) is used for heating purposes for maintenance of the anaerobic digester or for household needs. This method is widely applied for the treatment of activated sludge, a residue from municipal wastewater treatment plants [23, 24].
Electricity production by gas turbines can be applied by biogas as a fuel, thus replacing the natural gas for small-scale applications (or power within 25–100 kW).
3.3 Biogas for transport
The use of biogas as a fuel for civil transport and road vehicles instead of natural gas is already spread in Western Europe and the United States [25]. There are many vehicles in Sweden operating on biogas in the urban public transport [26].
3.4 Biogas in fuel cells
Another very attractive application of biogas for electricity production is its use in fuel cells. The specialized cells for these purposes are described briefly by O’Hayre et al. [27]. Prior to biogas feed, carbon dioxide and sulfur compounds must be removed by scrubbing to avoid corrosion and catalyst poisoning and to rise the gas energy capacity. A sketch of such a fuel cell is shown in Figure 3, cf. [28].
Figure 3.
Principal sketch of methane-driven fuel cell, from [28].
The classic process for methane-driven fuel cells is to convert catalytically by steam reforming methane into a mixture of carbon monoxide and hydrogen and to use the latter in a traditional hydrogen/oxygen fuel cell to generate electricity. The advantages of fuel cell applications with methane as a fuel compared to the traditional heat power stations consist in their higher efficiency, clean waste gases (containing almost only carbon dioxide), and higher efficiency at low loads than the gas turbine equipment [29]. Moreover, the released heat can be utilized for different purposes; the main one is to maintain the temperature regime in the fuel cell. There are many practical applications of these methods. It is already widely commercialized. A disadvantage of this method is the necessity of consequent reactions of steam reforming and carbon monoxide removal as well as the operation at high temperatures (about 750°C), being harmful for the metal parts of the equipment [30, 31]. Higher temperatures are preferred to avoid coke deposition on the catalyst [31].
There are new efforts to lower the operation temperature to 500°C in order to keep the equipment durability [32, 33]. Another improvement of the technology is to use the mixture of carbon monoxide and hydrogen as a fuel simultaneously, thus simplifying the whole process, but applying new catalytic process.
The most attractive option is to convert methane (biogas, respectively) into electricity in one step, thus avoiding the steam reforming and carbon dioxide removal. There are some new studies showing direct catalytic oxidation of methane in the anodic space of solid oxide fuel cells (SOFCs), with direct activation of the C-H bonds in the methane molecule [28, 34, 35, 36]. A platinum catalyst was used for this purpose at low temperatures, e.g., 80°C. However, the catalyst deactivates, and the process is limited by methane diffusion in the anodic space. As a result, the power density is still low for practical use.
3.5 Biogas for chemicals
Besides as a fuel, biogas could be used as a feedstock for synthetic organic fuel production. There are studies claiming for biogas recovery as fuels applying catalytic auto-reforming. Another approach is the dry reforming consisting in converting the equimolar mixture of methane and carbon dioxide into synthesis gas (an equimolar mixture of carbon monoxide and hydrogen).
Afterward, this synthesis gas is converted into a mixture of light hydrocarbons by the catalytic Fischer-Tropsch process. The resulting Fischer-Tropsch process yields liquid hydrocarbon fuels (methanol and dimethyl ether). The intrinsically high-energy density of these fuels and their transportability make them highly desirable. Such synthetic fuels do not contain any sulfur. In addition, methanol (arguably the “simplest” synthetic carbonaceous fuel) is a candidate both as a hydrogen source for a fuel cell vehicle and indeed as a transport fuel, and dimethyl ether is viewed as a “superclean” diesel fuel [36]. It is well known that methanol is a starting material in chemical industry. It is a liquid at room temperature and has much easier storage and transport capabilities than alternatives such as methane and hydrogen. Methanol is used as solvent, gasoline additive, and a chemical feedstock for production of biodiesel and other chemicals of high value. Therefore, the wide application of methanol motivates its large-scale production, which is ever increasing.
However, presently, the dominant technology of methanol is a two-step catalytic process, which is too expensive. A large number of industrial-scale chemical manufacturing processes are currently operated worldwide on the basis of strongly endothermic chemical reactions. The steam reforming of hydrocarbons to yield syngas and hydrogen is a classic example:
CH4+H2O→CO+3H2ΔH298K0=+206.3kJ/molE1
The above, highly endothermic reaction is used worldwide for the high-volume production of “merchant hydrogen” in the gas, food, and fertilizer industries, i.e., other portions of energy have to be spent with the consequent air pollution by carbon dioxide.
At present, a relevant technology for methanol production resides in the transformation of CO2 and CH4 to molecules having industrial added values. Among such technologies, a great attention is focused on the production of synthesis gas (gaseous mixture of CO and H2) that constitutes a versatile building block for subsequent production of methanol or chemical intermediates in petrochemical industries. Methanol is still produced on a world scale from synthesis gas, which is combination of varying amounts of H2, CO, and CO2 (at 200–300°C, 50–100 bar), which is itself product of steam reforming of methane (SRM; at ca. 800°C over Ni-based catalyst), followed by further conversion processes such as Fischer-Tropsch (FT) synthesis. This two-step process incurs high energy and capital demands. Additionally, this process gives many other light and heavy weight co-products along with the methanol product. Therefore, additional energy and cost in the conventional methanol plants are directed to the separation of these coproducts from methanol prior to the final deposition of product.
The direct synthesis of methanol from syngas requires a H2/CO ratio of about 2 [37, 38]. Since the syngas produced by dry reforming of methane (DRM) is too poor of H2 (H2/CO ≤ 1) to be fed to a FT synthesis unit, the bi-reforming of methane (BRM), combining DRM with steam reforming of methane (SRM) (H2/CO = 3) and the utilization of the most important two greenhouse gases CH4 and CO2 with water, may yield a syngas with ratio close to 2, the so-called “metgas”:
3CH4+CO2+H2O⇔4CO+8H2E2
To date, only one plant with the combination of steam and dry reforming has been recently demonstrated by the Japan Oil, Gas, and Metals National Cooperation. No other industrial technology for DRM has been developed because the selection and design of suitable reforming catalyst remain an important challenge. Ni-based catalysts are the most attractive candidates for large-scale industrial applications due to their high activity in DRM and SRM [39, 40, 41, 42, 43], low cost, and wide availability compared to noble metals. However, they are sensitive to deactivation caused by the metal particles sintering and carbon formation at high reaction temperature of reforming processes. Development of selective and coke-resistance modified Ni-based reforming catalysts is a key challenge for successful application of bi-reforming for methanol production. Modifying Ni catalysts with suitable promoters and supported on reducible metal oxide carriers will give the opportunity to develop active and stable catalysts for bi-reforming of methane.
A “super-dry” CH4 reforming reaction for enhanced CO production from CH4 and CO2 was developed [44]. Ni/MgAl2O4 was used as a CH4 reforming catalyst, Fe2O3/MgAl2O4 was used as a solid oxygen carrier, and CaO/Al2O3 was used as a CO2 sorbent. The isothermal coupling of these three different processes resulted in a higher CO production than conventional dry reforming by avoiding back reactions with water. Equation (3) shows the global reaction of this two-step process, in which CO and H2O are inherently separated because of the two-step process configuration:
It is important to note that despite the apparently higher endothermic effect of the super-dry reforming process than conventional DRM (Eq. 1), the required heat input per mole CO2 converted is much lower (110 kJ/mol CO2 compared to 247 kJ/mol CO2). Finally, given the availability of a renewable source of H2, applications are possible where CO and H2 can be combined in different ratios for the formation of chemicals or fuels [45, 46]. Indeed, an efficient and separate production of high purity CO and H2 would further establish the role of syngas as a versatile and flexible platform mixture.
All these methods and techniques are applicable when biogas is available. Some other applications are described briefly below.
3.5.1 Biogas as a feedstock for value-added chemicals
First of all, biogas must be purified for sulfur compounds prior to its use [47]. Afterward, methane and carbon dioxide have to be separated by membrane processes using gas-liquid systems [48] or swing pressure adsorption [49]. Once methane and carbon dioxide are separated, each of them has its own route for further application. Besides the already mentioned applications as a fuel for transport and energy purposes, dry reforming and steam reforming to obtain synthesis gas, the purified methane can be converted into light hydrocarbons, e.g., ethane and ethylene by advanced methods, like the so-called VYJ process [50, 51, 52, 53]. By this method, methane is converted in one step into ethylene by catalytic or electrocatalytic reaction [54, 55, 56].
High yields up to 88% in total are attained [50]. The rest of nonreacted methane is trapped in molecular sieves and recycled to the reactor [50, 53, 54]. In this way, the use of methane reaches 97% with an ethylene yield of 85% [50].
As ethylene is a basic feedstock for the mostly spread polymerizations and many value-added chemicals, it is clear that this way of biogas utilization is quite promising one.
4. Methodologies for energy demand evaluation in biogas production
The usual criteria for the feasibility of an anaerobic digestion technology are the type of digester, the operation temperature, the necessary retention time of the substrate in the reactor, the substrate acidity (the initial pH value), and the presence of certain chemicals in the inlet slurry.
However, the most important one is energy demand for the biogas formation and the energy potential of the produced biogas.
There are two typical temperature ranges for biogas production: mesophilic one (at 30–35°C) and thermophilic one (at 55–60°C). Different genera of methanogenic microorganisms are capable to accomplish the processes in those two cases. The advantages of the thermophilic regime are in the higher production rate and the lack of pathogens in the outlet slurry. However, the energy input for maintenance of this regime is higher than for the mesophilic one.
The question of the energy demand for any industrial process is of crucial importance for its economic reliability. The same applies to biogas production.
There are some methodologies for the estimation of the feasibility of biogas production [57, 58]. They all involve the demand of heat for temperature maintenance and electricity for mechanical operations (stirring, pumping, and transport) and comparison to the energy yield after anaerobic digestion.
Generally, the operations for a certain flowsheet are separated into production processes and support ones. The production processes in the considered case are the reception of the substrate and its storage, pre-treatment of feed (dilution, pH adjustment, acid hydrolysis, etc.), and anaerobic digestion with biogas production. The removal of the digestate and its storage and processing are also included. This set of processes is called as Level 1 [57].
Once biogas is produced, it could be used for direct heat and/or electricity production and supplied to customers or for own use (Level 2). More sophisticated operations, such as gas cleaning, upgrading (i.e., removal of carbon dioxide), and compressing the upgraded gas, are required if the gas will be distributed by the gas distribution grid or for some chemical applications.
The methodologies for energy demand evaluation consist in the inventory of all such processes and auxiliary ones with their energy demand per unit production (i.e., amount of produced biogas with certain energy potential). Then, the overall energy demand is compared to the biogas yield with its energy potential, and the percentage of the energy input to the overall yield is a measure for feasibility of the studied technology.
The structures of the energy demand for different flow sheets and the weight of different subprocesses depend on the substrate properties (particles size, chemical structure and content, moisture, and total solid content) and the amount to be treated, the digester construction and design.
Berglund and Borjesson [58] proposed a methodology based on the life-cycle perspective including the energy required for the production of the substrates (including crop growth, harvesting, transport, etc.). The energy efficiency is defined by the ratio of the energy input to the energy yield of the produced biogas. It was found that the energy input corresponds mainly to 15–40% of the energy content of the produced biogas. The subprocesses of extensive handling of raw materials may lead to considerably increase the energy input and thus to undermine the feasibility of the entire technology.
In case the gas will be used as a feedstock for other chemical applications (e.g., dry reforming and steam reforming), the operational costs of the processes at Levels 1 and 2 have to be compared to the operational costs for the chemical processes and the prices of the produced chemicals or other final products.
5. Residual carbon dioxide
The main disadvantage of biomass produced fuels is the inevitable release of CO2 in the atmosphere after combustion. Therefore, big efforts are made in the recent years for remediation of this adverse effect of greenhouse gas. The best way to cope with this problem is the natural assimilation by the vegetation by photosynthesis, but it is not sufficient due to the very large emissions from industrial sources, energy production, transport, and household. That is why many other methods are proposed and studied in the recent years.
One of them is the direct use of pure carbon dioxide as a solvent in supercritical extraction in the pharmaceutical industry. However, this application is limited and cannot be a substantial solution of the problem. There are many efforts to recycle carbon dioxide to produce different organic chemicals: formic acid, methanol, dimethyl-ether, poly-carbonates, acrylic acid, etc. [59, 60]. All of these methods are applicable for the residual carbon dioxide after separation from biogas. Therefore, not only methane but also carbon dioxide in biogas is valuable source of energy and value-added product.
6. Conclusions
The data presented here illustrate one of the very important biorefinery approaches to produce simultaneous energy and value-added chemicals from biomass, thus reducing the demand of fossil fuels and resulting in overloading of atmosphere by greenhouse gases. The same applies to the water and soil pollution, since those resulting from biomass processing are nature compatible and facilitate the formation of close energy and material cycle. One of the ways to do it is biogas production from such waste.
At the end, we can say that biogas extends its area of application leading simultaneously to protect the environment by waste treatment, natural gas, and fossil fuel saving, as well as to replace, at least partially, the oil as a feedstock for organic value-added products.
Acknowledgments
This work was supported by the Bulgarian Ministry of Education and Science under the National Research Program Eplus: Low Carbon Energy for the Transport and Households, grant agreement D01-214/2018.
Conflict of interest
The authors declare no conflict of interest.
\n',keywords:"biogas, renewable energy, fuels, fuel cells, chemicals",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/70804.pdf",chapterXML:"https://mts.intechopen.com/source/xml/70804.xml",downloadPdfUrl:"/chapter/pdf-download/70804",previewPdfUrl:"/chapter/pdf-preview/70804",totalDownloads:277,totalViews:0,totalCrossrefCites:2,dateSubmitted:"April 29th 2019",dateReviewed:"November 19th 2019",datePrePublished:"January 13th 2020",datePublished:null,dateFinished:null,readingETA:"0",abstract:"The global economic development in the twentieth century has led to extensive use of fossils, such as oil, natural gas, and coal as fuels and chemical feedstocks. This extensive use of fossil fuels has led to enormous emissions of carbon dioxide as final product of combustion. The high absorption rate of infra-red rays by carbon dioxide has led to the so-called “greenhouse” effect. Nowadays, the renewable energy sources based on biomass have become very important with a trend to replace oil consumption at least partially and hence to remediate the emissions of greenhouse gases in atmosphere. Biofuels could be used as alternative raw material for chemical production. One of these biofuels is biogas released at anaerobic digestion of different natural organic waste. Another feature of biogas applications is its utilization as feedstock for the production of synthetic fuels and chemicals being now produced from oil and coal. A new approach is to use biogas as a fuel in fuel cells as a very promising option for energy production from renewable sources. The present review summarizes the applications of biogas for chemicals, starting with dry reforming and Fischer-Tropsch syntheses and as a source of energy, as heat and electricity production by co-generation and fuel cells.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/70804",risUrl:"/chapter/ris/70804",signatures:"Sonia Damyanova and Venko Beschkov",book:{id:"9184",title:"Biorefinery Concepts, Energy and Products",subtitle:null,fullTitle:"Biorefinery Concepts, Energy and Products",slug:"biorefinery-concepts-energy-and-products",publishedDate:"October 7th 2020",bookSignature:"Venko Beschkov",coverURL:"https://cdn.intechopen.com/books/images_new/9184.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"191530",title:"Prof.",name:"Venko",middleName:null,surname:"Beschkov",slug:"venko-beschkov",fullName:"Venko Beschkov"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Biogas production",level:"1"},{id:"sec_2_2",title:"2.1 Some constructions of anaerobic digesters",level:"2"},{id:"sec_3_2",title:"2.2 Substrates for biogas",level:"2"},{id:"sec_3_3",title:"2.2.1 Biogas from glycerol",level:"3"},{id:"sec_6",title:"3. Biogas applications",level:"1"},{id:"sec_6_2",title:"3.1 Biogas for heating",level:"2"},{id:"sec_7_2",title:"3.2 Biogas for electricity",level:"2"},{id:"sec_8_2",title:"3.3 Biogas for transport",level:"2"},{id:"sec_9_2",title:"3.4 Biogas in fuel cells",level:"2"},{id:"sec_10_2",title:"3.5 Biogas for chemicals",level:"2"},{id:"sec_10_3",title:"3.5.1 Biogas as a feedstock for value-added chemicals",level:"3"},{id:"sec_13",title:"4. Methodologies for energy demand evaluation in biogas production",level:"1"},{id:"sec_14",title:"5. Residual carbon dioxide",level:"1"},{id:"sec_15",title:"6. 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