Article Date: 3/1/2006

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Telemedicine: Will it Ease the Burden on the Retina Community?
With the incidence of 3 common retinal diseases increasing, telemedicine is set to play a greater role.
BY ELIZABETH LIPP

In the United States, 3 separate factors are converging so that retinopathy of prematurity (ROP), diabetic retinopathy (DR), and age-related macular degeneration (AMD), may strike many more Americans in the next several years. Specifically, a greater number of premature babies being born earlier in their terms are surviving, the type II diabetes rate is continuing to climb, and an increasingly older American population are all factors for increased risks of ROP, DR, and AMD respectively.

As such, the retinal community has a great challenge and a major opportunity to care for millions of people. One tool that may be able to assist retinal specialists is the evolving telemedicine model. The American Telemedicine Association defines telemedicine as the use of medical information exchanged from 1 site to another via electronic communications to improve patients' health status.

With this in mind, this article will delve into how telemedicine works, how it is being used, and the benefits and limitations of this contemporary healthcare model.

A screener works with a retinal specialist and patient for a screening using a Canon CR-DGi 45 degrees with an 8 mega pixel camera.

INTEGRATION

Many view telemedicine as a natural progression in delivering healthcare. "House calls would be impractical now, yet 50 years ago, that was the [standard of] care," says Jerry Cavallerano, OD, PhD, assistant to the director, chief, Center for Ocular Telehealth, Beetham Eye Institute, Joslin Diabetes Center, Harvard Medical School. "Having patients come to centers is not always practical ideal, either. The idea of telemedicine is just another step in the evolution, and it will bring healthcare into the 21st century."

"In more remote areas, it makes sense to form a network," says Roger Novack, MD, PhD, partner, Retina Vitreous Associates Medical Group, Beverly Hills, Calif, and assistant clinical professor at the Jules Stein Eye Institute of UCLA, David Geffen School of Medicine. "You can hire a nurse practitioner to do the actual screenings and send the images to the retinal physicians to review. Not only is it safe, but as the technology improves, it's accurate, and it gets people screened who otherwise wouldn't travel to see a doctor."

APPLICATIONS AND IMPLICATIONS

The Vanderbilt Ophthalmic Imaging Center (VOIC) in Nashville, Tenn, has a telemedicine network comprised of 5 screening sites. Four sites provide screening as a component of direct patient care, while the fifth acquires data for a research grant funded outside the agency. Two sites are at community healthcare centers, and the other 2 are at Veterans Adminstration (VA) hospitals.

A full-time camera and camera operators (which include nurse practitioners, medical, and research assistants) facilitate on-site screening. CR6-45NM cameras (Canon, Lake Success, NY) are used to capture a moderately wide-angle view of the dilated pupil. Retinal images are then captured on digital cameras, which are attached to the fundus cameras. The community healthcare centers have 3-megapixel cameras, and the VAs have 6-megapixel cameras.

Images are then temporarily held in a laptop computer (in this case a Dell Latitude C-600, used throughout their network). The software used for image acquisition is designed exclusively for a retinal screening program called the EyeQ Superlite Program, (available though Canon Medical Products) and interfaces with its counterpart "review" software at the VOIC Reading Center.

The images are then reviewed by 3 graders who use a customized grading form that employs checkboxes to denote the presence of a wide variety of lesions customarily associated with diabetic retinopathy. The form also includes boxes for optic nerve cupping, and hypertensive changes and text boxes for additional comments. It also provides 3 referral options; re-screen in 1 year, non-urgent referral, and urgent referral, all based on the severity of diabetic and other retinal lesions detected upon review. (Please see the sidebar entitled, Telescreening vs Conventional Medicine: What works best? on this page for full reference information).

The core grading team at the VOIC site include: a first-level grader who is a physician trained as a dermato-venereologist, and whose background gives him the ability to identify significant lesions based on morphologic factors such as color size and shape; an intermediate grader who has photographed patients with retinopathy for 30 years — including participation as a study photographer in several multicenter research trials; and a senior grader who is a fellowship-trained vitreoretinal specialist with experience interpreting high-resolution digital images.

ENCOURAGING SCREENING FOR THE MASSES

One of the key tenets of modern medicine is early detection. The ability to catch pathology in the earliest stages of a disease can help slow or halt its progression. However, access to healthcare has become a national hot-button issue. Increasing healthcare costs, lack of insurance, or living in remote geographic locations are examples of the complexity of the access issue.

"Diabetic retinopathy is the leading cause for preventable blindness," says Lawrence Merin, RBP, FIMI, FOPS, FBCA, assistant professor of ophthalmology, and the director of the VOIC. "Here in the United States, there are millions of people at risk for disability, and many of them don't have access to eye care."

Of course, access is not the only issue. Often, peoples' ignorance about their diseases or their unwillingness to visit a specialist makes it much more difficult to stay on top of potential ocular conditions. Ben Szirth, PhD, the director of the Applied Vision Research Laboratory at the Institute of Ophthalmology and Visual Science at the University of Medicine and Dentistry in New Jersey, sees this as a major issue, especially with diabetic retinopathy patients.

"We know, just speaking of DR, for example, that 45% to 50% of all persons with diabetes will never visit an eyecare specialist until it is often too late to stratify the ocular condition and prevent vision loss," Dr. Szirth says. "Telemedicine can target and specifically help those 50% of diabetic persons who will not visit an eye doctor and can help save vision and offer a better/productive quality of life to those persons and their families."

Nigel Timothy, MD, a retinal specialist at Harvard Medical School and associate medical director, Joslin Vision Network at the Joslin Eye Institute, concurs. "There have been several important validation studies in the last 5 years that show DR can be carefully followed — which allows improvement managed by way of telemedicine. Studies have shown that between 40% and 60% of diabetic patients do not receive routine eye care, mostly because there's a lack of access or compliance with this standard of care."

BRINGING RETINAL SPECIALISTS INTO THE PRIMARY CARE LOOP

Merin believes retinal specialists might be hesitant to incorporate telemedicine into their practices because it may take away from their traditional practice. "I think a lot of eye doctors shy away from telemedicine because they think telemedicine will somehow erode their scope of practice," says Merin. "While remote screening could reduce the number of screenings in the eye clinic, it by no means replaces a comprehensive eye examination."

One of the biggest boons to patients exploring telemedicine is that they may be participating in preventive medicine. Many patients only go a physician when there is a real problem, notes Merin. "The earliest stages of DR have no symptoms," he asserts. "For many patients, the first time they seek eye care is when they notice a change in vision. It would be much better if we could provide the standard of care — annual dilated retinal examinations — when patients still have 20/20 vision. Thus, if treatment is needed, good vision could be preserved. The problem with society is that people are used to episodic care — that is, they go to the doctor only when there's an emergency. Chronic illnesses like diabetes require a different healthcare delivery model. Routine screening in a generalist venue permits this to occur."

Dr. Novack agrees. "It's a lot more common than people think. There have been plenty of occasions in which the retinal screening is the first indication that a person is diabetic."

Merin notes that a starting point for telescreening should be at the local or large primary care clinic. "My dream is that every retinal specialist will create their own network of fundus cameras in local clinics where diabetic patients receive general healthcare. Although these cameras cost about $25,000, the number of previously unscreened patients who require laser photocoagulation could help to rapidly amortize the cost."

Merin adds that setting up clinics to do the screening would be a relatively easy task. "The cameras are easy enough to operate that anyone can be trained to use them," he says. Then, doctors coming through the clinic would be able to read them, or they could be forwarded electronically to retinal specialists or reading centers. "All you need are a screening camera, a laptop, and an Internet connection," he says.

All persons over the age of 40 can benefit from telemedicine, according to Dr. Szirth. "In the groups we serve, we know the following: black Americans and southeast Asians (Indians, Pakistani, and Bengali) over the age of 40 are at higher risk for glaucoma and diabetic retinopathy — especially when there is already a family history present. Hispanics are at higher risk than whites for DR. This is true especially when subjects are largely overweight (waistline of over 40 inches), live a sedentary life, and have poor eating habits. In the white population, AMD is highly prevalent (especially over the age of 75) but caucasians still have risk factors for diabetic retinopathy, glaucoma, and cataracts in addition to AMD."

RETINOPATHY OF PREMATURITY

Telescreening vs Conventional Medicine: What works best?

Telemedicine is gaining traction in ophthalmology, especially with its screening applications for the posterior segment. The following references are some telemedicine studies on the subject of diabetic retinopathy:

• Schneider S, Aldington SJ, Kohner EM, et al. Quality assurance for diabetic retinopathy telescreening. Diabet Med. 2005;22:794-802.

• Luzio S, Hatcher S, Zahlmann G, et al. Feasibility of using the TOSCA telescreening procedures for diabetic retinopathy. Diabet Med. 2004;21:1121-1128.

• Stefansson E, Bek T, Porta M, Larsen N, Kristinsson JK, Agardh E. Screening and prevention of diabetic blindness. Acta Ophthalmol Scand. 2000;78:374-385. Review.

• Liesenfeld B, Kohner E, Piehlmeier W, et al. A telemedical approach to the screening of diabetic retinopathy: digital
fundus photography. Diabetes Care. 2000;23:345-348.

Although AMD and older potential patients for this disease have been garnering a great deal of attention in recent years, ROP in infants is also on the rise and patients can also benefit from telemedicine. Jill Rogers, marketing manager for RetCam at Clarity Medical Systems (Pleasanton, Calif) notes that ROP is the leading cause of blindness in premature newborns.

The disease is characterized by incomplete vascularization of the retina during early-term development and can result in complete blindness. The incidence of ROP has been increasing due to the increased survival rate of extremely premature infants. According to the American Academy of Pediatrics 2006 revised guidelines, screening for ROP must occur at distinct intervals due to the critical time window that must be met for treatment to be successful. This creates a tremendous logistical problem for the few qualified physicians, who don't have timely access to all the premature babies that need to be screened. Telemedicine is a viable, effective solution. At-risk infants can be photographed with a retinal camera by the nursing staff in the neonatal intensive care unit, then the images are sent to the retinal specialist at another location for review.

This telemedicine approach is employed by a number of large institutions in the United States, including Stanford University Medical Center, UCLA Jules Stein Eye Institute, and St. Jude's Children's Hospital.

Remote screening allows timely treatment intervention for these tiny, delicate, babies, and may also mitigate legal risks assumed by the physician and the hospital.

"The main problem with ROP screening is that it's considered high-risk," says Dr. Novack. "Anything that concerns the health of a newborn can be extremely high risk from a legal standpoint. And I'm the person the hospital calls when there is any risk of ROP." Dr. Novack reports that the hospitals he works with have a RetCam onsite, and the neonatologists use it to scan babies weighing less than 1 500 grams at birth and/or less than 31 weeks gestational age — those at the greatest risk for ROP.

"Either the neonatologist or the nurse practitioner can take the images. He or she puts the images on a Zip disk and FedExes it," Dr. Novack says. "They call me and let me know it's coming, so I'll be prepared to review and make recommendations right away." A mail delivery service is used instead of sending the photos via e-mail because Internet bandwidth is not large enough to accommodate the size of the images.

Telemedicine can help mitigate blindness in babies by setting up a staging system that includes taking the images, examining the photos, and then treating infants who are at high risk for retinal detachment, according to Dr. Novack. "Once upon a time, when a baby started to develop scar tissue, he or she would become blind," explains Dr. Novack.

LIMITING FACTORS

Everyone agrees that getting started is not cheap. Retinal cameras range in cost from $20 000-$30 000.

"At the moment, the technology is not good at identifying peripheral retinal disease such as retinal tears," notes Matthew Tennant, MD, Teleophthalmology Services Assistant and clinical professor, Department of Ophthalmology, University of Alberta, Canada.

"Economics is another limiting factor in that we still haven't figured out how to bill for telemed consultations," says Dr. Novack. "If you're doing evaluations, it takes the same amount of work and time. Also, the networks need to get bigger. Yes, telemedicine is definitely gaining ground, but among retinal specialists, it has a ways to go."

"Although we have the software, hardware, and experience to bring and provide better health to Americans," says Dr. Szirth. "Reimbursement is where we have failed."

Screening includes the capture station, educators, and readers of images (interpreters). "If we look at other systems such as in the UK where telemedicine costs are covered by something like Medicare," Dr. Szirth notes, "we could do a much better job in saving thousands from losing their vision and could save millions of dollars, direct and indirect."

Dr. Szirth further notes that Congress, after years of debate, has still not passed a bill that would help reimburse the cost of telemedicine. In the United States, the only way a successful telemedicine program can exist is by seeking grants that pay for such services.

"Telemedicine is used successfully at VA Hospitals where their screening programs have not only saved loss of vision but millions of dollars to tax payers," Dr. Szirth asserts. "The most common question I have when lecturing on telemedicine is: 'Who will pay for this program and who will pay for me to review the images (graders)?' This is the main reason why telemedicine in ophthalmology has not flourished in the United States."

COST/BENEFIT RATIO

"The bottom line is that patients need the care," says Dr. Novack. "As the cameras get smaller, cheaper, and have better resolution, there's no technical reason why telemedicine shouldn't be more prevalent."

The experts agree that putting a telemedicine plan in place benefits patients, but reimbursement is still an issue that needs to be worked out. "The eye is a window to the vascular and systemic health of the patient. By accessing more patients at an earlier stage of disease, long-term morbidity and overall health care and socioeconomic costs are reduced," says Dr. Timothy.

Merin notes, "It would be a great thing if more clinics really wanted this. The technology is there, but the funding is not. The VA has a terrific integrated healthcare system and has made great use of telemedicine, and we would do well to follow that lead."

Elizabeth Lipp is a freelance medical writer and editor. She can be reached at lipponati@comcast.net.



Retinal Physician, Issue: March 2006