Care Matthew R. Tukel MD1, Dariah Lauer BS2, Alexander Ortiz BS3, Jae Kim, MD2, Anju Goyal MD2, Lisa Kelly MD MEd3,4
1. Department of Ophthalmology, University of Colorado, Aurora, CO
2. Department of Ophthalmology, Visual, and Anatomical Sciences, Kresge Eye Institute, Wayne State University School of Medicine, Detroit, Michigan, USA 3. University of Cincinnati College of Medicine, Cincinnati, OH 4. UC Health, Cincinnati, OH Overview Telehealth Definitions Population Health Barriers Current State of Teleophthalmology Future Key Takeaways Teleophthalmology Definitions Population Health Barriers Future Today
Definitions • Telehealth describes the delivery of care over time or distance using electronic communication technologies.1 • Asynchronous telemedicine is the transmission of healthcare data to a provider for evaluation without using real time interaction (e.g., medical images sent to specialist). This is the most common modality used in ophthalmology.2,3 Teleophthalmology Definitions Population Health Barriers Future Today
Why use Telehealth in Ophthalmology?
• To provide preventative measures for vision loss in the primary care setting.1 • To provide access to eye care in remote areas.1 Teleophthalmology Definitions Population Health Barriers Future Today
Why use Telehealth in Ophthalmology?
- Reasons to consider use of Telehealth for eye care: - Many underserved patients develop vision loss which could be prevented or delayed.4 For example, among ethnic groups in the United States, American Indians/Alaska Natives have the highest prevalence of diabetes.5 - Poor prevention leading to advanced disease causes significant economic burden to society.4 - Preventative measures are less likely to occur in populations with lower socioeconomic status and education levels.6 Teleophthalmology Definitions Population Health Barriers Future Today
Social Determinants of Health
Patient Barriers Physician Barriers
• Varying levels of patient • Prohibitive startup costs.9 education.7 • Lack of reimbursement.1 • Lack of access to technology • Inferior diagnostic platforms.8 capabilities.9
Physical Environment Economic Stability
• Lengthy travel times for rural • Even if patients are aware of patients discourages the use of the benefits of eye screening, specialty eye care for non- cost beyond their usual copay is emergent purposes.7 often prohibitive.10 Teleophthalmology Definitions Population Health Barriers Future Today
Major Barriers to Eye Care
Transportation11 Trust11
Health Literacy12 Insurance12 Teleophthalmology Definitions Population Health Barriers Future Today
Telehealth in the Primary Care Setting
High risk patient identified
Fundus photographs obtained by primary care provider (PCP)
- fundus photo captures disease state for diabetic disease, macular degeneration, and glaucoma1,7,9,13,14
Images transmitted to offsite specialist1,7,9,13,14
Diagnoses and management recommendations sent back to
PCP1,7,9,13,14 Teleophthalmology Definitions Population Health Barriers Future Today
Current Uses of Teleophthalmology
• For Diabetic Retinopathy (DR)15 • Telemedicine improves evaluation for DR through PCP retinal imaging with 16
remote interpretation by an expert. 13
• Retinal imaging by a PCP could reduce barriers and improve early detection of DR. 13 • Nonmydriatic fundus photography is a useful tool for screening in rural settings during annual eye exams and has been shown to increase the rate of evaluation for DR.13,14 Teleophthalmology Definitions Population Health Barriers Future Today
Current Uses of Teleophthalmology
• The asynchronous telemedicine model has been used by the following programs to provide DR screening for remote populations: • Indian Health Service and Joslin Vision Network: serving American Indians and Alaska Natives.17 • Kewa Pueblo Health Corporation and Seva: providing care for American Indian communities18 • Department of Veterans’ Affairs: expanding access for veterans. 19 Teleophthalmology Definitions Population Health Barriers Future Today
Current Uses of Teleophthalmology
• For Glaucoma • Telemedicine can be used for glaucoma screening, diagnostic consultation, treatment monitoring.20 • Data from a PCP analyzed electronically by eye care specialists.20 • Teleglaucoma may require more diagnostic tests. 20 • Optic nerve photographs • Optical Coherence Tomography (OCT) • Intraocular Pressure (IOP) measurements • Central corneal thickness (CCT) measurements • Visual field tests Teleophthalmology Definitions Population Health Barriers Future Today
Glaucoma : Current Uses of Teleophthalmology
• NYU Teleglaucoma during COVID-19.21 • Patients sent iCare HOME tonometer to acquire IOP data. • Patients used a mobile app to check visual acuity at 14 inches and central visual field with an Amsler grid. • Virtual visit where ophthalmologist reviewed visual fields, prior OCT, medications, and iCare HOME tonometer measurements. • The program allowed for safe, collaborative, virtual glaucoma visits. Teleophthalmology Definitions Population Health Barriers Future Today
Glaucoma Telehealth Screening Tools
23
22
To check the intraocular pressure (IOP) To check the progression visual field at home or office. using a Virtual Reality machine Teleophthalmology Definitions Population Health Barriers Future Today
Current Uses of Teleophthalmology
• Retinopathy of Prematurity (ROP) Screening
• Infants can be evaluated via remote retinal photography by an ROP specialist.24 • Stanford’s “SUNDROP” tele-ROP screening program, which found tele-ROP to have a sensitivity and specificity approaching 100% in over 1000 eyes.24 Teleophthalmology Definitions Population Health Barriers Future Today
Future of Telehealth in Ophthalmology
• Innovative “deep learning” artificial intelligence systems have taught themselves to identify signs of diabetic retinopathy and macular edema in fundus photos as well as age-related macular degeneration (AMD) and retinopathy of prematurity (ROP).25,26,27 29 28 Smartphone-based Fundus Imaging 30 Take home points • Telehealth uses electronic communications technologies to deliver care, provide diagnoses, educate and manage patients over time or distance.
• Telehealth has the potential to expand access to specialty care in underserved and rural communities.
• Common current uses include screening for diabetic retinopathy, retinopathy of
prematurity, and glaucoma.
• Patient barriers to telehealth include limited access to technology platforms,
varying educational levels, variations in insurance coverage, and perceived increased costs.
• The future of teleophthalmology is bright and many new technologies and uses are currently being investigated. Bibliography 1. “Telemedicine for Ophthalmology Information Statement - 2018.” American Academy of Ophthalmology, 18 May 2018, www.aao.org/clinical-statement/telemedicine-ophthalmology-information-statement. 2. Mechanic, Oren J. and Alexa B. Kimball. “Telehealth Systems.” StatPearls, StatPearls Publishing, 2020. 3. “PAR-14-028: Mobile Health: Technology and Outcomes in Low and Middle Income Countries (R21).” National Institutes of Health, U.S. Department of Health and Human Services, 11 Dec. 2013, grants.nih.gov/grants/guide/pa-files/PAR-14-028.html. 4. C. Sommer A, Tielsch JM, Katz J, et al. Racial differences in the cause-specific prevalence of blindness in east Baltimore. N Engl J Med. 1991;325:1412—7 5. Centers for Disease Control and Prevention, 2020. National Diabetes Statistics Report, 2020. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, p.4. 6. Baker RS, Bazargan M, Bazargan-Hejazi S, et al. Access to vision care in an urban low-income multiethnic population. Ophthalmol Epidem. 2005;12:1--12 7. Liu Y, Zupan NJ, Swearingen R, et al. Identification of barriers, facilitators and system-based implementation strategies to increase teleophthalmology use for diabetic eye screening in a rural US primary care clinic: a qualitative study. BMJ Open 2019;9:e022594. 8. Scott Kruse C, Karem P, Shifflett K, Vegi L, Ravi K, Brooks M. Evaluating barriers to adopting telemedicine worldwide: A systematic review. J Telemed Telecare. 2018;24(1):4-12. 9. Rathi, Siddarth, et al. “The Current State of Teleophthalmology in the United States.” Ophthalmology, vol. 124, no. 12, 2017, pp. 1729– 1734. 10. Ramchandran RS, Yilmaz S, Greaux E, Dozier A (2020) Patient perceived value of teleophthalmology in an urban, low income US population with diabetes. PLoS ONE 15(1): e0225300. 11. Owsley C, McGwin G, Scilley K, Girkin CA, Phillips JM, Searcey K. Perceived barriers to care and attitudes about vision and eye care: focus groups with older African Americans and eye care providers. Invest Ophthalmol Vis Sci. 2006;47(7):2797-2802. doi:10.1167/iovs.06-0107 12. Friedman, D. S., Cassard, S. D., Williams, S. K., Baldonado, K., O’Brien, R. W., & Gower, E. W. (2013). Outcomes of a vision screening program for underserved populations in the United States. Ophthalmic Epidemiology, 20(4), 201–211. 13. Jani PD, Forbes L, Choudhury A, Preisser JS, Viera AJ, Garg S. Evaluation of Diabetic Retinal Screening and Factors for Ophthalmology Referral in a Telemedicine Network. JAMA Ophthalmol. 2017;135(7):706–714. doi:10.1001/jamaophthalmol.2017.1150 14. Chin EK, Ventura BV, See KY, Seibles J, Park SS. Nonmydriatic fundus photography for teleophthalmology diabetic retinopathy screening in rural and urban clinics. Telemed J E Health. 2014 Feb;20(2):102-8. doi: 10.1089/tmj.2013.0042. Epub 2013 Nov 12. PMID: 24219153; PMCID: PMC3910561. 15. Tang, Rosa A, and Giselle Ricur. “The Benefits, Challenges and Future of Telehealth in Ophthalmic Care.” Expert Review of Ophthalmology, vol. 8, no. 4, 2013, pp. 331–335. Bibliography 16. American Academy of Ophthalmology, 2018. Color Fundus Photo. [image] Available at: <https://eyewiki.aao.org/File:Fundus_Photo_Collage.PNG> [Accessed 16 July 2021]. 17. Hays H, Carroll M, Ferguson S, Fore C, Horton M. The Success of Telehealth Care in the Indian Health Service. Virtual Mentor. 2014;16(12):986-996. Published 2014 Dec 1. 18. Seva.org. 2021. The Promise of Telemedicine - Seva Foundation. [online] Available at: <https://www.seva.org/site/SPageServer/?pagename=Telemedicine> [Accessed 3 August 2021]. 19. Kirkizlar, Eser et al. “Evaluation of telemedicine for screening of diabetic retinopathy in the Veterans Health Administration.” Ophthalmology vol. 120,12 (2013): 2604-2610. doi:10.1016/j.ophtha.2013.06.029 20. Thomas SM, Jeyaraman MM, Hodge WG, Hutnik C, Costella J, Malvankar-Mehta MS. The effectiveness of teleglaucoma versus in-patient examination for glaucoma screening: a systematic review and meta-analysis [published correction appears in PLoS One. 2015;10(3):e0118688. Jeyaraman, Maya [corrected to Jeyaraman, Maya M]]. PLoS One. 2014;9(12):e113779. Published 2014 Dec 5. doi:10.1371/journal.pone.0113779. 21. Do A, Al-Aswad LA. Current Status and Needs in Teleglaucoma. Glaucoma Physician. 2020 June 1;24:14-16. 22. American Academy of Ophthalmology, 2018. iCARE HOME tonometer. [image] Available at: <https://eyewiki.aao.org/File:Icare_HOME_image_Cara.png> [Accessed 15 July 2021]. 23. American Academy of Ophthalmology, 2020. 3D Printed Prototype of a C3FA Virtual Reality Visual Field Analyzer. [image] Available at: <https://eyewiki.aao.org/File:Prototype-C3FA.jpg> [Accessed 15 July 2021]. 24. Wang, Sean K et al. “SUNDROP: six years of screening for retinopathy of prematurity with telemedicine.” Canadian journal of ophthalmology. Journal canadien d'ophtalmologie vol. 50,2 (2015) 25. Gulshan V, Peng L, Coram M, et al. Development and Validation of a Deep Learning Algorithm for Detection of Diabetic Retinopathy in Retinal Fundus Photographs. JAMA. 2016;316(22):2402-2410. doi:10.1001/jama.2016.17216 26. Campbell JP, Kim SJ, Brown JM, et al. Evaluation of a Deep Learning-Derived Quantitative Retinopathy of Prematurity Severity Scale. Ophthalmology. 2021;128(7):1070-1076. doi:10.1016/j.ophtha.2020.10.025 27. Ting DSW, Cheung CY, Lim G, et al. Development and Validation of a Deep Learning System for Diabetic Retinopathy and Related Eye Diseases Using Retinal Images From Multiethnic Populations With Diabetes. JAMA. 2017;318(22):2211-2223. doi:10.1001/jama.2017.18152 28. American Academy of Ophthalmology, 2018. Artificial Intelligence. [image] Available at: <https://www.aao.org/eye-health/news/artificial- intelligence-trends-in-eye-care> [Accessed 15 July 2021]. 29. American Academy of Ophthalmology, 2017. Automated segmentation algorithm for the posterior vitreous boundary. [image] Available at: <https://www.aao.org/eyenet/article/artificial-intelligence> [Accessed 15 July 2021]. 30. American Academy of Ophthalmology, 2018. Smartphone Funduscopy. [image] Available at: <https://eyewiki.aao.org/File:Figure_1_Base_position_setup.jpeg> [Accessed 15 July 2021].
