What Is Its Role in Retina Medicine?
Anyone scanning the meeting program from the major retina conferences these days is bound to find a paper or 2 on the potential for using remote screening to identify patients in need of further follow up. Although difficult to quantify, research into teleophthalmology has certainly increased over the past decade—especially as imaging technology improves the ability to capture reliable fundus photographs, often through undilated pupils and despite media opacities. Coupled with advancing data capabilities that transmit images and other large files over the Internet, it seems the digital age is dawning in retina medicine.
Teleophthalmology can take many forms, but at its most basic level, it is understood as a way to extend eye care to remote and underserved areas; to expand ophthalmic disease screening, diagnosing, and monitoring; and to extend training capabilities.
But what, exactly, is the role of telemedicine in retina medicine today? Has technology advanced to the stage that remote screening can, in the right settings, replace or augment physical examinations, or are there technological impediments that prevent the widescale adoption of telemedicine? Is teleophthalmology a threat to the practice of retina medicine, or will it aid in identifying patients in need of further care, and thus help expand patient rosters?
IS TELEOPHTHALMOLOGY A THREAT?
Retina specialists are likely very familiar with Physicians Quality Reporting System, or PQRS, requirements. This set of initiatives developed by the Centers for Medicare and Medicaid Services (CMS) is aimed at improving health care delivery by linking the performance of certain core medical functions with bonus payments. Starting in 2015, CMS will start a system of penalties, realized as lower reimbursement, for providers or medical systems that fail to meet PQRS requirements.
One of the established benchmarks under the PQRS system is for a sufficient number of patients with diabetes to receive an annual documented screening for the presence of diabetic retinopathy. Thinking backwards from a health care system’s perspective, it would behoove providers of services to a wide swatch of patients to establish screening programs that may or may not involve eye care professionals. In other words, it would seem that teleophthalmology, with the potential to capture fundus photographs in a primary care provider’s office and send them to a reading center for evaluation, is the perfect instrument for health care systems to cheaply and effectively ensure compliance with PQRS mandates.
A majority of health plans in the United States now use a standardized performance measurement called Healthcare Effectiveness Data and Information Set, or HEDIS, to provide consumers with a metric to judge their delivery of care services. One major component of a health plan’s HEDIS score is the percentage of covered patients who receive screening for diabetic retinopathy. Here again it would seem that adoption of teleophthalmology would be a boon to the delivery of care.
But if health care systems might be incentivized to develop screening programs whereby primary health care providers capture fundus photographs, and the role of fellowship-trained retina specialists is reduced to involvement in reading centers, are retina specialists who will not be performing the imaging themselves be doomed to reduced revenues? Does it mean fewer patients will attend retina clinics for their screening, whether that is through imaging or a clinical examination?
“Retina surgeons may worry that their patient volume will be decreased” with teleophthalmology programs, said James C. Folk, MD, of the University of Iowa, which has been running a statewide teleophthalmology program since 2005. However, he added, that may be a shortsighted view, because telescreening programs may help screen the 40% of people with diabetes who are not screened yearly. It will also weed out patients who do not need immediate follow-up or care, thus leaving retina specialists to focus on providing care to those that do.
“I actually don’t think telescreening will negatively impact volume. I think that volume will stay the same or increase, and a more of those patients will need treatment,” Dr. Folk said.
On the surface, the idea of non-eye care professionals capturing fundus images and being involved in deciding which patients to refer would seem a detriment to retina practice. According to Dr. Folk, however, teleophthalmology could potentially have the opposite effect—and it could even facilitate involvement by retina specialists in combatting a serious public health crisis here and abroad. People who need an appointment and possible treatment could be referred from remote areas into a retina practice. Teleophthalmology could help streamline practice and improve access on the local, clinical level as well as on a grander, public health level.
There are approximately 4500 retina specialists in the United States serving a population of about 300 million individuals. The number of training slots for new subspecialty trained retina doctors is fixed, and as newly graduated fellows join the practice, older physicians are retiring at an equal or greater rate. By a simple back-of-the envelope calculation, it is easy to understand that the ability to supply proper retina care to the entire potential patient pool is limited; and, thus, efficiency in care delivery is both a desirable option and a mandate.
At the same time, metrics point to a potential upswing in new diabetes cases, each of which has the potential to be complicated by ocular manifestations. With swelling numbers of new patients and a fixed or diminishing pool of providers, a mechanism to narrow the focus of retina specialists to treat only those patients in need of their expertise seems all the more viable.
Teleophthalmology can extend care into rural and remote areas, while also identifying patients earlier in their disease course when treatment has greater potential to be beneficial.
“I think most retina specialists have seen patients come in with chronic macular edema or neglected proliferative retinopathy requiring surgery who would have done better had they been identified and treated earlier,” Dr. Folk said.
PUBLIC HEALTH IMPACT
About 12 years ago, the American Academy of Ophthalmology established an initiative to increase the number of patients being screened for diabetic retinopathy. According to Dr. Folk, although the program is well intentioned, it has fallen short of its objective, and for each of the last 10 years, only about 60% of people with diabetes were screened and it was not always the same 60% who are seen yearly. “The screening rate is lower and retinopathy is more severe in minorities and poorer populations,” Dr. Folk said.
In an ideal scenario, patients with type 1 diabetes would be screened for ocular manifestations starting at about 5 years after their diagnosis. Patients with type 2 diabetes should perhaps be screened immediately, because the disease’s onset is less certain. How exactly to achieve higher levels of screening, though, remains unclear.
Dr. Folk is currently involved in a research project testing computer algorithms developed at the University of Iowa that are able to automatically detect signs of diabetic retinopathy within seconds (see About the Authors). Such algorithms have several benefits. They allow an immediate result, obviating the need for a reader to be present at the time of image capture and file transfer, a problem that often leads to delay in the diagnosis, which in turn may mean losing the patient to follow up. They also allow a more objective and standardized way of determining the presence of retinopathy. If validated, such algorithms can extend the capability and reach of screening for diabetic retinopathy (and potentially many other posterior segment pathologies) to remote and rural areas—and even globally. “The ideal is to have imaging and get an immediate answer, either to just come back in 1 year or see an ophthalmologist as soon as possible,” Dr. Folk said. “I believe the easier it is for the patient to be screened, the higher the screening rate, the more timelier the diagnosis and treatment, and the lower the rate of vision loss.
“[Diabetic retinopathy] is a public health problem here, but it is an even worse public health problem in developing countries, where people often have to travel far distances to access the health network,” Dr. Folk said.
RETINOPATHY OF PREMATURITY (ROP)
A demonstration of the potential for teleophthalmology to have an impact on the global public health picture can be seen in the evolution of screening and management of ROP under a collaboration between the Vision Center at Children’s Hospital Los Angeles, and the Armenian Eye Care Project.
Founded in 1992, the Armenian Eye Care Project seeks to help grow the eye care infrastructure in the formerly war-torn nation of Armenia. Since its inception, the project has funded several mobile eye hospitals and mission trips to both care for patients and train local physicians.
Armenia, which became an independent state in the early 1990s, was largely unaware of ROP during its period of political reconstruction. As a conflict with neighboring Azerbaijan ended, and as its economy began to emerge to developing nation status, Armenia started financing a public health infrastructure. In 1995, the country began to build neonatal intensive care units (NICUs) to serve local needs—however, according to Thomas C. Lee, the division head of the Vision Center at Children’s Hospital Los Angeles, these NICUs were founded by individuals who may not have had expertise in the intricacies of ROP.
“Since 1995, essentially no premature infants in the country of Armenia had been screened for ROP,” Dr. Lee said.
Ironically, as NICUs were saving more premature children, the rates of children going blind from ROP also rose because of the lack of screening. As a result, Roger Ohanesian, MD, president of the Armenian Eye Care Project, asked Dr. Lee to start a training program.
At first, Dr. Lee did a 3-day workshop for pediatricians and local ophthalmologists who had never before seen the disease. Still, he felt that 3 days’ training was insufficient. “We felt it would be really impossible for them to have just a 3-day workshop and expect them to be a service for the kids,” Dr. Lee said.
In response, Dr. Lee established a passive remote training program: Armenian physicians would examine patients and populate an online spreadsheet of patient information and send the spreadsheet with images back to Dr. Lee and other training physicians to compare notes. In essence, it was the first step in remote training: a rudimentary teleophthalmology program of sorts.
In the first year of the program, Dr. Lee, along with R. V. Paul Chan, MD, of the Weill Eye Institute at Cornell, and Michael F. Chiang, MD, of Oregon Health and Sciences University, reviewed 1500 images from over 300 babies.
“By the end of that first year, we had gotten them to the point where, when you compare the failure rate they had with the failure rate for zone 1 disease in the National Institutes of Health-funded EDROP trial, their failure rate was comparable. This means the success rates was comparable to our own,” Dr. Lee said.
The concept evolved further when Armenian ophthalmologists started using Facebook to upload images for foreign specialists to comment on and share information—a novel example of social media intersecting with a unique brand of teleophthalmology.
“What this all shows is that you can teach a very complex condition remotely and you can improve health that way. You can engage the ministry of health that way, and then local physicians can run with it and take it in directions you hadn’t even thought of,” Dr. Lee said.
THE IMPACT OF IMPROVING TECHNOLOGY
Despite the success, 1 problem remained with remotely training local physicians: About 20% of children treated for advanced ROP were still going blind. And so, the local minister of health asked Dr. Lee to train physicians over the Internet in how to perform surgery to save vision. At first skeptical about the proposal, Dr. Lee soon realized that he is not the one operating when training fellows, and so, really, what would be the difference in being 12 time zones away while a new surgeon is being trained?
One day, during a visit to his local Best Buy, Dr. Lee passed by a display of Sling Boxes, which can stream a video signal from a television cable box, and had an inspiration: to send live video streams from a surgical microscope in Armenia back to Los Angeles, where Dr. Lee could observe the surgery and train the operating surgeon in much the same way he would while looking through the observation microscope in his own OR.
Two Armenian retina specialists came to the United States to spend a month with Dr. Lee to learn the mechanics of ROP surgery using endoscopy. They returned home with the Sling Boxes and furthered their training during live cases under the observation of 1 of Dr. Lee’s former fellows: Sui Chen Wong, MD, a full-time surgeon at the Moorfield’s Eye Hospital in London. During ROP surgeries, Dr. Wong would help Armenian surgeons understand the mechanics of performing surgery while conversing with Dr. Lee over the Internet, who was watching from his office in Los Angeles with the aid of the Sling Box and focusing on directing the overall surgical strategy.
“When we look historically in how we train surgeons, it has not changed in about 100 years,” Dr. Lee said. “It’s a laborintensive and expensive prospect. It’s very rare that you would have 2 or 3 retina surgeons supervising the same case because it’s just too expensive. This experience was interesting, because it let multiple levels of experience chime in on the exact same case at the same time. You can layer the levels of supervision.”
Teleophthalmology programs should be easy for operators to run and simple for patients to access, and they should demonstrate a positive benefit on the quality and extent of care delivered to patients before being widely adopted. Although more research is needed to advance the field, the potential for teleophthalmology to extend the reach and focus of the practice of retina medicine appears too great to be ignored.
“I think teleophthalmology is going to come to retina medicine, and I think for the retina surgeon, they can either embrace it at this point, or they will kind of be behind the curve a little bit,” Dr. Folk said.