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Telemedicine: Will it Stay on the Periphery?
A mixture of successes and limitations leaves questions about greater integration.
BY JOHN PARKINSON, ASSOCIATE EDITOR

Upon first glance, telemedicine appears to be relegated to a limited role in ophthalmology. Many physicians might be aware of some of its applications, but they are not actively pursuing or practicing it.

The perception has been that telemedicine is good for those who practice in rural areas, teaching hospitals and universities, and in countries where socialized healthcare is practiced. However, in delving deeper, its scope and capabilities could create greater potential opportunities for the larger ophthalmic medical community.

Here are some ways telemedicine is being effectively utilized, along with a discussion about its challenges as some seek its broader integration into ophthalmology.

Physicians from the Joslin Vision Network examine a fundus photo of a patient that was taken remotely.

Preventative Screening

It has become a paramount belief in health care that the earlier a disease can be diagnosed, the better it can be treated or managed. However, some ocular diseases remain asymptomatic after the onset of the illness, and often it is not until these diseases have progressed to a stage of irreversible damage that people seek out medical care because their vision has become compromised.

In addition to patients' ignorance about their disease, other factors prevent people from getting screened. "Many people face barriers to assessment by an ophthalmologist right now, either due to economics or geography," explains Matthew Tennant, M.D., teleophthalmology services assistant clinical professor, Department of Ophthalmology, University of Alberta, partner of Alberta Retina Consultants and secretary for the American Telemedicine Association's Ocular Telehealth (ATA OT) special interest group.

With these concerns in mind, leading institutions and universities are trying their hand at preventative telemedicine programs utilizing screenings in physicians' practices and public places.

One such example is the Joslin Diabetes Center in Boston, which has created the Joslin Vision Network (JVN), designed to bring vision resources to primary-care physicians by utilizing diabetic retinopathy (DR) screenings.

According to the Centers for Disease Control and Prevention's latest numbers taken in 2002, there were 18.2 million people in the United States estimated to have diabetes, and 5.2 million of those people were undiagnosed. In addition to those numbers, DR causes 12,000 to 24,000 cases of blindness each year.

Gene Hopper, chief business officer, JVN, talks about the reason Joslin is targeting the general practitioner. "We bring the [DR] evaluation into the primary-care environment, and we identify those patients in need of eye care and get them into the eyecare cycle." Hopper notes that JVN is not excluding ophthalmologists, but rather trying to strengthen the relationship between primary-care doctors and ophthalmologists.

"The fact is, most patients with diabetes are not getting any eye care," says Hopper. "We work with primary-care physicians and ophthalmologists to ensure patients get the care they need."

Pediatric ailments such as strabismus can be easily diagnosed via telemedicine.

Hopper says a number of factors have hindered diabetes sufferers from getting appropriate eye evaluations and the JVN is one way to publicize the importance of eye care.

For physicians who are interested in the program, the diagnostic tools must be acquired and the practice's image technicians must take a short course at Joslin.

Upon completion, JVN is able to assist these practices by evaluating if patients have DR, assessing the level of disease, providing risk analysis of disease progression and offering treatment recommendations.

While Joslin has been working toward integrating general practitioners into its network, the diabetes center has an ophthalmology practice as its intial partner. Koch Eye Associates, of Warwick, R.I., has become the first official
network affiliate.

Harry Kachadoorian, director of clinical imaging at Koch Eye Associates, says the practice's decision to pursue a relationship with Joslin was twofold. Kachadoorian says the patient care element was critical, especially after the staff had witnessed the ravaging effects of the disease.

"We are getting to see these [diabetic] patients much too late because they are not getting eye care and vision screening," Kachadoorian explains.

In addition, Koch has several offices in Rhode Island with large patient populations, which makes it well-suited as a testing center.

Certainly a major advantage for having an ophthalmology practice as the first network member is its experience in understanding the nuances of eye care, so Koch is poised to help develop protocols for future members.

"Koch Eye Associates are innovators in eyecare programs," says Hopper. "They came to Joslin with the idea of putting the service in a large eyecare environment."

Kachadoorian also points out that telemedicine may have peripheral patient-care benefits. He mentions one case in which a Koch imager requested an immediate read from Joslin because the imager saw what appeared to be an abnormal pigment in a patient. Through the help of Joslin, suspicion of ocular cancer was noted. The patient was triaged and seen by an ophthalmologist within an hour of capturing the images.

Although there is great enthusiasm for such projects, challenges remain in setting up preventative screening centers. The University of Maryland established a pilot project back in 2003 that publicly screened people at a shopping mall in Baltimore for DR and glaucoma. One hundred and three people were screened, with 10 of them being diagnosed with serious eye problems.

Scott Steidl, M.D., associate professor of ophthalmology at the University School of Medicine and director of the Retina Service at University of Maryland Medical Center, worked on the project and says an understanding of the limitations of technology was reached. Dr. Steidl acknowledges a number of issues existed, including obtaining good image quality and providing adequate staffing to facilitate and assess the photos.

While there may be some issues associated with such projects, Dr. Steidl believes these types of screenings are beneficial.

"At this time, telemedicine does not offer the patients a complete examination, but it is excellent in informing patients that they might have a problem and may need an earlier appointment or further investigation," says Dr. Steidl.

Volunteerism

At some point, most physicians have thought about lending their efforts to helping others in need. However, after considering their obligations to their practices and families, it is understandable if volunteering is put off for another day.

Fortunately, telemedicine offers another opportunity to volunteer, without ever having to leave home.

ORBIS International has a program called Cyber-Sight which utilizes American ophthalmologists' guidance in helping diagnose ocular diseases of patients in third-world countries via telemedicine.

Robert Deitch, M.D., says he has always wanted to practice medicine in its "purest form," away from the reimbursement and legal issues, yet he has many responsibilities that discourage him from traveling overseas.

"Cyber-Sight allows me to do some of that type of work and still be at home," he says. Dr. Deitch is on the Cyber-Sight Advisory Board and practices in Indiana.

Cyber-Sight is set up through the organization's Web site. ORBIS typically encourages American ophthalmologists who have "sufficient clinical experience" to volunteer for this program. Volunteers are called mentors. They work with developing country doctors called partners.

The mentor doctor participates by first receiving an
e-mail called an e-consultation from the partner doctor. The e-consultation includes digital images and a text presentation.

Dr. Deitch specializes in corneal and external eye disease, and says in his telemedicine experience, he has seen a variety of ailments including infections, immune-mediated processes, tumors and questions regarding suitable corneal donors. Typically, he says the partner doctors need the most assistance with arriving at a diagnosis. Dr. Deitch tries to teach the other doctor a method of approaching every patient, starting with looking at the larger context and eventually narrowing it down to a diagnosis.

"I try to help the consulting doctor think about the problem in the broader sense before trying to decide on the exact diagnosis. Is it autoimmune. Is it infectious?"

The partner physician in the developing country is responsible for obtaining a consent form from the patient and for the care of the patient.

Gene Helveston, M.D., the founder and ophthalmologist-in-chief for the program, says Cyber-Sight volunteer physicians have helped to diagnose 2,265 patients, and within all those diagnoses, had over 10,000 communications between the telescreeners and developing-country doctors.

Dr. Helveston sees this type of healthcare model easily adaptable for taking on many more patients.

"We can go from 2,000 [patients screened] to 100,000 without changing qualitatively what we do."

With diagnostic equipment limitations in these developing countries, Dr. Helveston says a simple digital camera can easily serve oculoplastics and pediatric care patients. Strabismus is a good example of an ailment that can easily be screened and diagnosed via telemedicine.

Dr. Helveston says that along with the altruistic aspects of the program, this gives physicians an opportunity to stay current with contemporary technology that may someday have greater integration into the ophthalmology healthcare model.

"I could see this type of medical leveraging, [Cyber-Sight] so to speak, has enormous potential for the future," says Dr. Helveston.

Roz Stevens, M.D., a volunteer retinal surgeon for ORBIS International, helps establish a telemedicine program at Muhimbili Hospital in Tanzania.

Quality of Care, Reimbursement and Inertia

It is understandable that some may be skeptical of telemedicine's capabilities vs. a comprehensive eye exam given by an ophthalmologist. The clinical eye exam has served physicians and patients very well. Dr. Deitch says that while telemedicine can be practiced with certain types of diseases such as DR or pediatric ophthalmology, there are nuances to a clinical exam, especially in the anterior segment, that do not translate with images taken at other sites.

"We look at the eye with a slit lamp and there often are subtle findings that we're able to come up with, but they don't photograph well or can't be transmitted," explains Dr. Deitch.

Certainly, reimbursement is a major issue. "Lack of an ocular telemedicine fee for service is the main hindrance to expansion of ocular telehealth [in the United States]. In the province of Alberta where I practice, we have a fee code for teleophthalmology," says Dr. Tennant.

Dr. Tennant has spent portions of his medical career in Canada and the United States, and has witnessed firsthand the two countries' different healthcare models. The other large telemedicine issue he sees is physicians' reluctance to adopt new technology.

Dr. Steidl agrees, but believes eventual adoption will happen.

"There are many barriers to the application of telemedicine and many of them involve healthcare community acceptance as well as legislative acceptance, but history will tell us that along with the telephone, fax and Internet, all technologies will eventually be incorporated into the medical modality," says Dr. Steidl.

Dr. Tennant believes much of the criticism about telemedicine's limitations is unfounded. He points to his experience with DR patients as an example.

"I need only look at my own practice where I am able to see patients at a distance more efficiently and with a greater degree of sensitivity and specificity for identifying diabetic retinopathy than a clinical examination," says Dr. Tennant.

Government Involvement

The federal government's involvement is one way telemedicine could be pushed towards greater utilization. Dr. Tennant points to the Veterans Administration (VA) hospital system as an example. The VA purchased several cameras to streamline DR screening in veterans.

If savings can be realized from creating such efficiencies, the government may begin to think about larger investments into telemedicine. However, as veterans' healthcare costs are covered, there will have to be other incentives in order to create a tipping point for the private sector.

Helen Li, M.D., associate professor of the Department of Ophthalmology and Visual Sciences at the University of Texas Medical Branch and vice-chair of ATA OT, does think a Medicare reimbursement fee would be ideal for telemedicine's proliferation. "The federal government can play a progressive role," she says.

Overall, Dr. Li thinks American telemedicine is moving in the right direction, but acknowledges the integration in other countries has been much smoother where there is single-payer coverage. "I think progress has been made in this country, but with diverse payers [insurance companies] it is difficult."

While movement towards a greater integration of a for-profit telemedicine healthcare model appears to be moving slowly, organizations like Drs. Tennant and Li's ATA OT will continue to petition the federal government, as well as assist others in setting up telemedicine operations.

For now, telemedicine is being used in a number of pilot projects all over the country. The outcomes of these projects may also help to make or break the argument for greater utilization.

Telemedicine advocates believe this healthcare model can be an effective adjunctive diagnostic model, but it remains to be seen whether the government or the private sector will push telemedicine toward greater integration in the larger ophthalmic community.