telemedicine
TELEMEDICINE Connects
How telemedicine is impacting eye care, across continents and in your back yard.

The promise of telemedicine spans across continents. In South Africa, where rural healthcare services suffered under apartheid, smaller district

hospitals now scan X-rays and electrocardiographs, and e-mail them together with digital photographs to the telemedicine unit at Tygerberg Children's Hospital, which can provide diagnoses from well-trained specialists. In the United States, telemedicine not only aids rural communities, but also metropolitan areas where access to comprehensive healthcare does not always equate to early detection and timely treatment.

This is especially true of vision-threatening diseases (VTDs). As a solution, telescreening can be set up in the general practitioner's office or in community-based facilities, such as churches or shopping malls. At these locations, technicians use a retinal camera or other imaging equipment to capture images and transmit them to eye care professionals (ECPs), who then evaluate the images for any number of conditions including glaucoma, diabetic retinopathy or age-related macular degeneration (AMD).

Anastas Pass, O.D., M.S., J.D., F.A.A.O., Chief Advisor at the Texas Eye Research and Technology Center, explains, "In addition to pursuing telemedi-cine extensively in rural areas, the University of Vermont is teaming with Texas A & M in developing technology that will be put in ambulances. This is very useful for teletrauma."

Telemedicine isn't exactly a new turn of phrase. Says Jeff Weaver, O.D., director of the American Optometric Association Clinical Care Group, "It can be said that anything requiring the use of a telephone, or really any kind of distance technology, is a form of telemedicine." The American Telemedicine Association (ATA), defines telemedicine as the use of medical information exchanged from one site to another via electronic communications to improve patients' health status.

Here's how to familiarize yourself with this increasingly common method of delivering medical care.

An eye care practitioner educates a patient about her condition with the help of telemedicine.

The future has arrived

Approximately 60 to 70 subspecialties are represented in the ATA, according to Jonathan Linkous, the organization's executive director. "Radiology probably makes the most frequent use of telemedicine, but other specialties taking advantage of the technology include dermatology, ophthalmology and cardiology."

But telemedicine is making inroads in optometry as well. The evolution of high-speed Internet access combined with the ability to produce high-quality digital images makes consulting work as easy as clicking the send button on an e-mail. Telemedicine is particularly useful in the areas of diabetic retinopathy, age-related macular degeneration, neuro-ophthalmic disorders and glaucoma.

"There are plenty of applications for telemedicine," notes Morris Berman, O.D., M.S., Vice President and Dean of Academic Affairs at Southern California College of Optometry. "Not only has it proven to be an effective tool in distance learning, but it's an effective way of getting experts to consult in particularly complicated cases. Many optometry-related procedures are now available for telescreening. These include many diagnostic procedures that can be captured in a digital format and transmitted electronically for consultation purposes." Examples include:

►Corneal topography and aberrometry

►Anterior and posterior segment imaging (digital cameras and videos, and binocular indirect ophthalmoscopy)

►Visual fields (perimetry), with various instruments

►Automated refractive technologies, such as keratometry, refractors, etc.

► Electrodiagnostic testing.

Educational institutions are already well on their way to applying telemedicine to the real world. The Pennsylvania College of Optometry's (PCO) Office for the Advancement of Telehealth (OAT) received a continuation grant from the Health Resources and Services Administration (HRSA) of nearly $115,000. The OAT project, Urban Ophthalmic Telemedicine Project, attempts to provide specialized eye care to underserved rural and urban areas. It uses telemedicine to link outlying PCO clinics in north central Pennsylvania to more specialized, central resources at PCO's The Eye Institute. PCO has the only federally-funded ophthalmic telemedicine program in the United States.

For optometrists who are interested in getting involved in telemedicine, the best place to get started is the American Telemedicine Exchange, at www.atmeda.org. Also, the Telemedicine Information Exchange, at http://tie.telemed.org, has state-specific information about practicing telemedicine.

How telemedicine works

The use of telemedicine technology to communicate between primary and specialty providers enables more definitive care in a more timely fashion. It also eliminates the necessity for the patient to travel to another site for a consultation visit.

Telemedicine customarily uses two methods to transmit images, data and sound. The first method involves a "live," real-time transmission in which the consulting professional participates in the examination of a patient while diagnostic information is collected and transmitted. So in the case of two consulting doctors, one could actually be performing a procedure on a patient while being "coached" via satellite. The second method is a "store and forward" transmission. In this case, an ECP sends diagnostic information from one location to another, where a consulting specialist can review the data. Many telemedicine programs employ both transmission methods to maximize efficient use of resources appropriate to the medical services being provided. For example, an optometrist could forward an image electronically via e-mail or FTP site to a retinal or corneal specialist.

Based on studies conducted by several agencies within the federal government and other assessments by commercial vendors and ATA, it's estimated that there are about 200 telemedicine networks in the United States involving close to 3,500 medical and healthcare institutions throughout the country. Many combine clinical services with continuing education programs as well.

Experts view the advent of telemedicine as a natural progression in healthcare delivery. "House calls would be impractical now, yet 50 years ago, that was the [standard of] care," says Jerry Cavallerano, O.D., Ph.D., Assistant to the Director, Chief, Center for Ocular Telehealth at Beetham Eye Institute's Joslin Diabetes Center. "Having patients come to centers is not ideal, either. The idea of telemedicine is just another step in the evolution, and it will bring healthcare into the 21st century."

Funding the future

Over the last five years, financial support for the costs of equipment, telecommunications and clinical services that use telemedicine has significantly improved. The U.S. federal government's spending for telemedicine is composed of three segments: grants and contracts; direct services; and Medicaid reimbursement. The ATA estimates that the government spent about $270 million on federal grants and contracts for telemedicine in 2003 (the most recent estimates available at this time).

While the amount that federal agencies spend directly on telemedical services is not tracked, the Veterans Health Administration, the largest provider of remote medical services, was projected to deliver remote care to approximately 350,000 patients. Grants are available to all healthcare professionals who want to get started in telemedi-cine. For more information, contact the National Institutes of Health (NIH) at www.nih.gov.

Coverage considerations

Medicare, which provides medical coverage for approximately 10% of the U.S. population, accounts for more than 25% of all medical expenditures. Its spending for telemedicine is only partially tracked (the largest source of Medicare expenditures for telemedicine is for teleradiology) so the total amount is unknown.

However, a Medicare program supporting videoconference-based patient services in non-metropolitan areas is rapidly growing. This year, the program will reimburse practitioners less than $1 million this year (based on preliminary data from the Centers For Medicare and Medicaid Services with projections by ATA). In addition, Medicare reimburses for remote cardiac monitoring services and in some areas for telepathology and remote screening for diabetic retinopathy.

State-run Medicaid programs vary considerably in their coverage. All state Medicaid programs will reimburse for the remote interpretation of medical images, such as X-rays. About half of states currently reimburse for additional forms of telemedicine, including interactive liver consultations between patients and specialists. Several other states are following suit and actively looking into expanding coverage to include remote services.

Notably, private insurance coverage for remote medical services today exceeds coverage by either federal or state programs. A 2001 survey of private insurers revealed that most will reimburse for remote services at the same levels as face-to-face services, without the need for separate coding. Some states, such as California and Kentucky, have enacted legislation that requires private insurers reimburse equally for face-to-face consultations.

Benefits in screening

Telemedicine helps outreach program go into communities to screen the population for vision threatening diseases.

As for applying telemedicine to optometry, Dr. Berman says, there's no doubt that telemed-icine benefits those who are not ambulatory, do not live near a specialist, are impoverished and require a quick diagnosis.

Bernard Szirth, Ph.D., is 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. He participates in an outreach program that goes into nearby communities to screen the population (in community centers, worship places, work place, etc.) for VTDs. Every year the program attempts to recapture images in the same population, at the same angle in each eye. The information gathered tells doctors if patients are in danger of losing their vision and whether to refer them for immediate attention.

This is where telemedicine comes into the picture, making the screening even more effective. Dr. Szirth says that optometrists grade the captured images at the screening site. If they find AMD, cataracts, diabetic retinopathy or glaucoma, they suggest appropriate referrals, which are made electronically, and include the images they've taken. The doctors are better able to intervene to prevent blindness, as the people they screen ordinarily would not seek treatment until they experienced serious visual problems or lost their sight altogether.

Dr. Szirth has found over the last few years that 13% of the people screened will have ocular findings consistent with VTD. For Dr. Szirth and his team, telemedicine has become part of delivering health care to people that otherwise would never seek help. Because it brings the care directly to the patient with minimal hassle and waiting, it also makes them happy.

And by delivering healthcare to a low-income segment of the population, telemedicine saves society the higher cost of care for treating preventable blindness.

What's more, people may be more likely to comply with doctors' schedules for examinations. A study at the University of South Carolina showed that patients with diabetes were six times more likely to participate in remote eye examinations via telemedicine than they were to obtain examinations through their eye care providers.

Participants were randomized two receive either a referral for an eye exam from their primary eye care provider, or the opportunity to participate in a tele-medicine retinal screening program (TRSP). For the TRSP group, an ophthalmologist evaluated the retinal photographs and consulted with the patient using real-time video conferencing. Of those in the TRSP group, 77% received an exam, compared with 14% in the referral group.

Facing today's limitations

However, like everything else, telemedicine has its drawbacks. For example, encryption and privacy issues can be problematic, Dr. Pass reports.

Professionals agree that consulting is a good application for telemedicine in optometry. However, in this area too, there are complications. Dr. Pass warns that liability is an important issue. For instance, if you participate in a telemedicine consult, is there a doctor-patient relationship? "It depends on how you interact," says Dr. Pass, "but if you get involved in directing a case, then you are creating a doctor-patient relationship." Doing that, he warns, is the first of four steps necessary for making a case for negligence if things go wrong.

Yet another factor to consider is licensing. As Dr. Weaver points out, "Optometry licensing differs from state to state, so if you are doing a consult for a patient located in New Jersey, are you practicing in New Jersey? Or what if you are licensed in Missouri and are operating from your laptop in Florida; do you need to be licensed in Florida? You can go on and on with this kind of thing."

Finally, there are concerns in the financial department. "From an insurance standpoint, there is not a great amount of reimbursement," Dr. Pass says.

Get started

Becoming involved in telemedicine is not difficult, but start-up costs for equipment costs can be significant, says Dr. Berman.

Equipment required for "tele-optometry" includes fundus and non-mydriatic retinal cameras to review, analyze, print and digitally communicate images.

"We're seeing an extremely high demand for equipment, I think primarily because diabetes is such a big issue," Ron Kaiser, National Sales Manager at Canon, said. "We provide the camera and software, and it's just amazing. Back in the day, doctors would take Polaroids, and the Polaroids would eventually degrade. Digital technology allows for a much more durable recording of images. You can zoom in with very high resolution, and there is no question as to what you are seeing."

Help is available for optometrists who wish to become involved in telemedicine. The Ocular Telehealth Special Interest Group (formally the International Consortium for Ocular Telehealth (ICOT) Chapter) of the ATA promotes the development and advancement of the use of telemedicine in fields related to ophthalmology, optometry and optical engineering. Participants include individuals from academia, industry, government and healthcare. Membership fees range from $100 to $225 annually.

What lies ahead?

Telemedicine gives eye care practitioners the power to overcome what have been significant hurdles for healthy sight — access to patients and financial resources. As the technologies for telemedicine improve, these obstacles will become smaller still.

The U.S. government has played an important role in assuring this. "It's passed a lot of IT legislation to get high-speed lines to rural areas," Dr. Pass notes. "Distance learning started with telemedicine and getting funding for those T1 (high-speed telecom) lines, which have a lot of applications."

For many, the future of telemedicine is clear. Technology costs will drop, new applications will be developed, the demand for healthcare services will increase and society will recognize the benefits and savings realized by preventive medicine offered at the local level. In light of these trends, telemedicine will only become more prevalent. OM

Ms. Lipp is a medical and technical writer who lives in Oreland, Pa. Contact her at Lipponati@comcast.net.