The benefits, challenges and future of telehealth in ophthalmic care

Interview by Jitesh Patel.

Rosa Tang is a former ATA Board Member and was one of the Founders of the ATA’s Ocular Telehealth SIG, formally known as the International Consortium for Ocular Telehealth Chapter. Currently, she is the Director of Neuro-Ophthalmology of Texas and of MS Eye CARE at the University of Houston, as well as Research Professor of University of Houston and Clinical Professor of the Department of Physical Medicine and Rehabilitation and Neurosurgery at UT Houston.

Giselle Ricur is a former International Consultant in Telemedicine for PAHO/WHO and founder of ATA’s Latin American and Caribbean Chapter, she is currently the Telemedicine Senior Medical Advisor and Head of the Education, R&D Department of Instituto Zaldivar in Mendoza, Argentina. She is also Chair of the Argentinean Council of Ophthalmology’s ICT and Education SIG, as well as Faculty for ‘Telehealth’ at the Healthcare Administration of the Aconcagua University in Mendoza, Argentina.

□ You are members of the American Telehealth Association (ATA). Please describe & explain what telehealth means to you.

Today, telehealth can be considered a multidimensional concept that may differ depending on the context, region, country or time where it is applied. It mainly implies ‘the use of telecommunication and information technologies to facilitate or enhance healthcare services remotely, as well as access to medical information for different purposes, whether it be training and educating healthcare professionals and consumers, increasing awareness and educating the public about health-related issues, as well as facilitating medical research across distances’ [101].

For many, telehealth is a term associated, related or synonymous to the concept of telemedicine, and thus used interchangeably. If we take a closer look to the definitions of telemedicine we can see why there is true lack of clarity:

• • The WHO has defined it as “The delivery of healthcare services, where distance is a critical factor, by all healthcare professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities” [1];

• • ATA formally defines it as “the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status. At present, Telemedicine includes a growing variety of applications and services using two-way video, email, smart phones, wireless tools and other forms of telecommunications technology” [102];

• • As can be seen, telehealth is really a broader definition that encompasses various components or domains that are related, but not exclusive to public health such as disease epidemiology, health behavior and health education, health services management and policy and environmental and industrial health;

• • Personally, we prefer to consider it a paradigmatic and disruptive concept where both telemedicine and telehealth are ‘modalities of care that challenge the traditional sine qua non dependence on physical presence and contact between providers and patients for medical/healthcare delivery’ as stated so beautifully by Rashid Bashshur in his recent work titled The Taxonomy of Telemedicine [2];

• • It is also a term that has evolved over the years. As described by Bashshur et al., the past decades have witnessed the evolution of ICTs and its relationship with healthcare provision, beginning with basic telecommunication technologies (telegraphs, radios) used to provide remote healthcare assistance, (origins of telemedicine), followed by expanding the scope of telemedicine described above (telehealth), the advent of Internet and its networking capability (e-health) and most recently, the ‘personalization’ of ICT networks (m-health and u-health) where the new paradigm of healthcare is now patient-centered and therefore ubiquitous.

□ What are the benefits & challenges of telehealth in ophthalmology?

The use of telehealth applications in ophthalmology allows for improved patient care by expanding the physician’s expertise and outreach as well as the patient’s access to eye care services regardless of time or distance.

At present, ocular telehealth solutions, whether they be in real-time or by means of store and forward tools, are impacting the related-healthcare services’ productivity and efficiency. This is accomplished by enabling the provision of remote and cost-effective clinical or surgical eye care, enhancing diagnostic capabilities, improving continuing medical education as well as healthcare management and research; all of which can occur, thanks to the use of ICTs in a collaborative environment or network. For the community in general, it represents the opportunity for universal access to quality services in underserved areas, the possibility of increasing public health awareness as well as education in wellness and disease management, thus impacting significantly the majority of the public health indicators.

Current challenges are mostly related to human factors issues, in contrast with the past’s barriers dealing with costs and acquisition of the proper technology. In many countries, the low rate of adoption is due to the lack of appropriate capacity building and the resistance to change the traditional paradigm of the physician-patient relationship and its in-person environment. When one takes a deeper look, the presence of boundary-related legislation restrictions, liability and reimbursement issues seem to dominate the scenario of barriers over the traditional hurdles of implementing and maintaining an adequate telecommunication infrastructure, accessing proper equipment and computer-assisted software, as well as dealing with the costs of avant-garde technology. Nonetheless, data security and the lack of universal adherence to healthcare-related information and communication standards has made impossible the assurance of guaranteed-interoperability between systems and in consequence has hindered the true possibility of universal health information exchange.

□ Is there a particular subset of patients that a telehealth approach will benefit? How can ophthalmologists best identify those who will benefit?

There are several subsets of patients that benefit greatly in teleophthalmology. The most studied and reported group concerns the diabetic retinopathy (DR) population. In the USA alone, it affects more than 5.3 million Americans over the age of 18 (2.5% of the US population). As reported in the second edition of ATA’s Telehealth Practice Recommendations for Diabetic Retinopathy, “because DR is often asymptomatic in its early stages, many people do not seek annual retinal examination as recommended by the American Diabetes Association, the American Academy of Ophthalmology, the American Optometric Association, and other professional societies. Others may lack care due to socio-economic factors, geographic or travel restrictions, or ignorance of the need for regular retinal examination for DR. It is estimated that 40–50% of adults with DM in the US do not receive recommended eye care to diagnose and treat DR. Studies also show no major improvement in examination rates over the previous five years.” Thus, elimination of preventable vision loss from diabetic retinopathy remains a major unresolved clinical challenge in ophthalmology [3].

Other groups that benefit also from ocular telescreening solutions includes patients requiring detection of cataracts, glaucoma, age-related macular degeneration, retinopathy of prematurity, retinoblastoma or other microvascular retinopathies associated to potential heart disease or stroke. Acute neuropathies can also be assessed remotely by ocular telehealth initiatives.

□ What are the current limitations of telehealth in ophthalmic conditions? Can these be overcome in the foreseeable future?

In our opinion two of the most important limitations concern guaranteeing the accuracy of the remote ophthalmic diagnostic capability and the quality of the ocular telehealth disease management programs offered.

In time, issues regarding limited digital imaging resolution, automated-diagnostic algorithms, evidence-based ophthalmic decision support systems, will enhance the quality of the services rendered. Nonetheless, there still remains some concern among eye care providers that telemedicine systems will compete unfairly with conventional eye examinations. It must be emphasized that these ocular telehealth programs or procedures must follow validated guidelines against globally-accepted gold standards in eye care and thus provide a complement to the conventional eye examinations; not their replacement. This is particularly true in conditions that impede adequate visualization or image capturing of the eye structures or lesions, such as in patients with poorly dilated pupils and cataracts or other causes of media opacities such as leukokoria. Other causes for unreadable images or faulty patient extender presentations are when image acquisition staff (photographers) or the trained readers are insufficiently trained, unqualified or unaccredited to perform the tasks described in difficult or poorly complaint patients. For example, assessing pupillary reflexes or ocular movements under real-time videoconferencing scenarios require a steep learning curve, as does the capturing of the structures of the anterior or posterior segment of the eye with a slit-lamp linked to the videoconferencing equipment equipment.

On the other hand, independently of the ophthalmic condition, remote disease management programs require the need to oversee and ensure patient compliance with the established referral process or system. Some programs have benefited greatly by incorporating alerts and reminders for follow up care and motivational reminders for both patients and staff. Others have integrated their workflow with broader public healthcare systems and benefit from legislative policies favoring reimbursements. Otherwise, the risk of patients loosing the appointments or having the specialist being able to close the loop with final treatment and disease monitoring may come down to a compliance rate of 43 and 28%, respectively, out of the original 100% of patient referrals made by teleophthalmology programs [103].

□ The 2013 ATA meeting was held in Austin (TX, USA). Are there any innovations that have particularly interested you? What/how could these innovations impact the way you manage your clinic &/or patients?

Interestingly, one of the things that we observed was the increased use of unified video communications within the healthcare settings, as a means for facilitating extended patient care, physician training, continuing medical education as well as healthcare awareness and promotion campaigns. For example, many presentations as well as exhibits on the trade show’s floor demonstrated the use of real-time web-based video solutions for enhancing communication with patients or physicians. With the aid of user-friendly software solutions, hub and spoke sites can be linked in real-time with high quality video and audio capability in a collaborative environment. Additionally, some of the solutions showcased offer integrated digital imaging management tools that are currently interoperable with different commercially available EMRs and compliant with the existing health information exchange regulations and standards.

Based on our previous experience with real-time teleconsults, the use of these new unified video solutions allows for ubiquitous extended patient care. The fact that theses solutions are web-based that enables physicians, healthcare personnel and patients to access the communication platform on multiple devices such as desktop computers, notebooks, tablets or handheld devices and smartphones. In the past, acquisition of costly and space-consuming videoconferencing equipment was mandatory in order to set up a virtual consult examining room.

Currently, the designs of portable kits and virtual suites have undergone a mayor change, both esthetically and functionally; and the market demands have driven down the costs of the commercially available solutions. These new solutions also provide user-friendly interfaces that allow for a point-and-click sharing of content on a collaborative network, which is clearly more effective compared to a stand-alone approach. Networks can now share a live video feed, enhancing not only the physician-patient encounter, but also the learning-by-seeing and doing experience, which in turn improves the knowledge management and skills uptake of the users.

The increased access to these tools will enable us to setup cost-effective outreach programs, where telescreening applications as well as clinical patient services and second opinions will undoubtedly enrich our portfolio. Our aim is to not only improve quality patient care, and strengthen our referral models, but also to provide continuing education not only for the attending physician community but also for the hired staff, nurses and allied healthcare personnel. We also see a window of opportunity for the in-training ophthalmologists and fellows on a national and international level, who can now access the expertise of their mentors or trainers regardless of their geographic locations.

□ What unique challenges does running a telehealth clinic provide? What advice would you give to ophthalmologists looking to invest in this technology?

Technology does not operate on its own. Therefore, we strongly believe that the unique challenge of this healthcare modality is defying the paradigm of traditional in-person encounters, and although avant-garde technology such as telepresence solutions can undoubtedly help overcome it, the human factor remains as our main goal for change management. In other words, we would recommend that our fellow colleagues take into consideration all the issues related to organizational change management when deciding upon implementing a virtual clinic. Top-level institutional commitment must be guaranteed before the startup phase is initiated. Capacity building as well as adequate team building represents crucial key-success issues, and they must be properly dealt with, while designing the strategic plan. Thus all the necessary resources should be allocated to provide for it. This does not only concern the aspects related to interdisciplinary staff hiring and training, but it also should include identifying local champions that will readily adopt this new modus operandi of attending patients or training and help create synergy among the rest of the newly appointed team. Additionally, troubleshooting and supporting the users during the entire process is as critical as identifying the proper technology for the applications to be used.

Once this organizational aspect has been managed, the team should decide upon the scope and modality of the programs that will be offered. This will necessarily affect the design of the telecommunication network, the selection and acquisition of the proper technology, the needs for training and the design of all the processes, procedures and monitoring that will support the pre-defined ocular telehealth programs in a validated and structured format.

Once again, the effort of building a telehealth clinic really implies an interdisciplinary and collaborative approach, with an integrated vision of being able to provide cost-effective and quality services, regardless of the technology applied.

□ The benefits of telehealth services in rural & remote areas of the world are clear. What do these services offer developed or industrialized nations where access to services might not be the main issue?

Access is always an issue, regardless of the degree of a country’s development or social and economic scenario; and this does not necessarily refer to ‘access to the services’ per se… In many urban or metropolitan cities, time and distance continue to hinder the possibility of timely access to pertinent clinical information or educational contents that will definitely impact on the outcomes of the diagnosis or knowledge acquisition. As Viviane Reding stated, “ICT systems that provide timely information can save lives, improve the quality and efficiency of the health delivery system, and contain the costs” [104]. In 2005, a cross-sectional survey study published in JAMA stated that primary care physicians of the Colorado State Network reported information missing in 13.6% of clinical visits. In 52% of these instances, information was available but outside their clinical system, in 44% of instances, the lack of information could adversely affect patients and in 59.5% it could potentially result in delayed care or additional services [4].

It is clear that the lack of adequate information exchange has proven its negative effect on the quality and delivery of healthcare services. The Institute of Medicine reported in its ‘To err is human’ report, that as many as 98,000 Americans die each year due to medical errors, mostly medication errors [5]. A decade later, experts claim the problem persists [6]. As William Hersh of the Oregon Health and Science University (OR, USA) explains, in most cases the errors are the result of faulty systems; “the solution is not in making people smarter or punishing them, but building better ‘systems’ to identify and prevent errors [7]”. Therefore, the experts agree that the impact of ICT tools on patient’s safety can be measured in three ways: firstly, by preventing errors and adverse events; secondly, by facilitating rapid responses after an adverse event; and thirdly, by tracking and providing feedback about adverse events [8].

Another issue concerns the high concentration of specialists in the secondary, tertiary or academic levels that leave many primary urban sites underserved. Current estimates calculate that by the year 2020 there will be a significant undersupply of ophthalmologists in the USA [105], that will in turn hinder the availability of satisfying the growing demand for retinal evaluations due to the continuing increase in the prevalence of chronic diseases such as diabetes and hypertension. Thus, ocular telehealth programs can be designed ad hoc to address the need of telementoring and training general physicians, allied healthcare personnel as well as comprehensive ophthalmologists as needed. Other examples are the lack of on-site ophthalmologists in the emergency rooms of many of the hospitals worldwide. The provision of live video feeds can enhance onsite ophthalmic triage on behalf of the attending physicians.

□ What are your expectations for the field of telehealth-based ophthalmology in the next 5 years?

We expect to witness the growth of the currently successful ocular telehealth programs such as the Veterans Administration and Indian Health Service, as well as of the other existing private sector programs (EyePacs, EyeTel, Inoveon, Joslin Vision Network, Retasure). We also expect to see the deployment of new ones, hopefully integrated with cross-state and international efforts.

Technology-wise we hope to see the advent and widespread adoption of computer-assisted or automated diagnosis, which will noticeably improve the current quality of the diagnostic capability in ophthalmology. Newly designed computer software applications with the automated assessment of retinal images may aid in recognizing lesions associated with ocular diseases. As described in the recently published hardcover book “Digital Teleretinal Screening: Teleophthalmology in Practice” by Yogesan, Goldschmidt and Cuadros, and in several studies published by Tobin, Chaum et al. “the clinical process entails initially discriminating retinal lesions from non-factor artifacts, subsequently distinguishing lesions associated with the disease in question from other types of lesions and finally grading the disease according to guideline-endorsed severity scales set by medical authorities” [9,10]. Artificial intelligence, based on the development of neural networks and content-based sample comparisons, is usually deployed for automated image recognition technology.

□ How can telehealth help address the future issues & eye health targets in America?

One of the major contributions we feel Ocular Telehealth could make is by providing a logical alternative approach to current public health problems due to poor patient compliance with national and international recommendations for eye-related chronic disease assessment and management. As so well described by Ingrid Zimmer Galler in her recent keynote talk in Buenos Aires, Argentina, at the annual Argentinean Council of Ophthalmology’s Meeting, “Teleophthalmology could very well provide the means for eliminating the main causes of preventable vision loss by improving timely screening and disease management, which still remains a major unresolved clinical challenge in ophthalmology.” [11].

Another controversial issue in America undoubtedly will be unraveling the issues related to coding, insurance coverage, and reimbursement of ocular telehealth encounters and procedures. Recent legislative changes applied as of the year 2011 have negatively impacted on the provision of such services by limiting and decreasing the level of perceived payment. As an example, changes in coding regarding DR screening has decreased the ROI of the current business models and made it unsustainable for many institutions. Advocacy and endorsement of ocular telehealth initiatives on behalf of the scientific societies such as the AAO, ICO would definitely impact positively on the adoption and expansion of ocular telehealth.

Disclaimer

The opinions expressed in this interview are those of the interviewee and do not necessarily reflect the views of Expert Reviews Ltd.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.