Primary Care Optometry News: How does each of you use telemedicine in your practice?
David J. Conway, OD: My primary experience with telemedicine relates to a transmission of corneal topography information between our laser centers and the comanaging optometrists with whom we work.
David Mills, OD: My experience with telemedicine is also limited to comanagement of refractive surgery patients. Im sure its going to expand in the future.
Irwin M. Shwom, OD, RDO: Im a novice at this, and Im just starting our program.
Stephen P. Byrnes, OD, FAAO: At the College of Optometry, we have a telemedicine system, but it has pretty much been a failure. The software company that developed the program is out of business, and we found that the image acquisition for the posterior segment was good but image acquisition for the anterior segment was not.
At my private practice, I do a lot of video. I videotape the anterior and posterior segments for lecturing purposes, but I havent used that in telemedicine.
At the VA hospital where I work, we dont use telemedicine. We have the technology to acquire images, but we dont have the ability to put those images on the computer.
Primary Care Optometry News: Are the shortcomings in the technology holding you back from using it more?
Dr. Byrnes: This is a lot like corneal topographers back in the early 1980s. There are issues regarding which companies will survive and with whom to network. You must have more than one person on the telemedicine net.
Dr. Shwom: Right now, we find it difficult making a smooth transition from image acquisition to computerization. We have been computerized in our office since 1986. At that point, we developed our own database and then opted to jump into some more commercial products that were available. Weve had a hard time linking this technology with what we already have. Its slowed down the development and the use of what we have.
Dr. Conway: One problem is that there are different formats for image transmission. I would like to see this issue resolved.
Dr. Mills: There is also an expense factor involved. Larger institutions can afford the latest technology, but private practices must wait until the resources become available to make large purchases. It is also important for the technology to be user-friendly so that novices can use it.
Benefits of telemedicine
Primary Care Optometry News: What are the benefits of the technology? How does the technology benefit you and your practice in a comanagement situation?
Dr. Conway: When it comes to transmission of corneal topography information, its going to be a big time saver for everyone involved the patient, the surgeon and the optometrist. If the corneal topography information represents a problem, such as a corneal irregularity, the patient is not a candidate for treatment at that time. That patient will be saved a trip to the surgeon. He or she will have to wait for new technology or for his or her cornea to stabilize further before being treated.
Dr. Byrnes: As far as making a diagnosis, I dont think it is really significant for the majority of patients. So I dont really see it as being a huge benefit for me to have in my practice. It is nice to be able to get an instant referral or an instant opinion, but you actually have to wait for someone at the other end to respond. In my early years of practice, it would have been very valuable. Now that I have enough experience, it wouldnt be that practical for me.
Dr. Mills: It becomes useful in rural locations when you need a consult or an opinion. Where I practice, there are so many
specialists that if I felt unsure about something, its a stones throw to that specialist. The specialist would probably rather see the problem in person, anyway.
Dr. Shwom: The technology is wonderful for getting our patients involved in grasping their own condition(s). Patients have the ability to download images of good quality directly onto their own computers. We can show them exactly how they are improving or failing. We can attach images to e-mails and send them to patients.
Dr. Byrnes: I like the concept of being able to educate your patients using the imagery that youre able to capture, download, save and send. Its a great patient educator.
Primary Care Optometry News: Have you ever had a situation where a patient didnt come back for follow-up care and you e-mailed an image to the patient just to remind him or her of the problem?
Dr. Shwom: Weve yet to do that. We want to, but it may be a medicolegal issue in terms of whether we are sending it in a secured way. We have yet to fully research these issues, but its proprietary information.
Primary Care Optometry News: Does the technology offer you any kind of safety net as far as giving you the opportunity to get a consultation?
Dr. Shwom: I wonder if maybe were taking too many pictures. Maybe we need to be careful about getting the proper interpretation. Do we need to go through and create an optometric radiology center to give us interpretations of these images before we end up just passing them out? Thats an issue we need to look at.
Dr. Byrnes: Ocular photography is for documenting a diagnosis. To use ocular photography to find a condition is improper use of the technology.
Primary Care Optometry News: Will telemedicine enable you to foster better comanagement relationships with ophthalmologists, or even other optometrists?
Dr. Conway: Dr. Byrnes has a lot of experience with rigid gas-permeable lenses in many different applications. So it would be beneficial for one of us, or a new graduate, to be able to send him an image to get some guidance regarding contact lens fit. Optical labs and contact lens laboratories may have an interest in this as well.
Dr. Byrnes: Maybe telemedicine is the wrong name for what were trying to do; maybe its teleconsultation.
Dr. Mills: Weve been speaking about a situation where one licensed professional is consulting with another licensed professional. This is nothing more than making a system work better than the way it works right now. This would be better than actually sending the patient a distance. If the images are good, we save the patient the aggravation of having to travel.
My fear with telemedicine is not the doctor-to-doctor communication but the patient-to-doctor communication. What if a patient takes an image and sends it to someone outside of the state to get a second opinion about the condition? This is a totally unregulated area. With the doctor-to-doctor consultation, the liability is known. The technology is going quicker than the regulation side.
Dr. Conway: It goes into the patient record, and patients are entitled to it.
Dr. Mills: Thats right, but if an out-of-state doctor offers an opinion, who is liable? The state boards of optometry, the state associations and national association must start to work on these issues to try to protect the public.
Primary Care Optometry News: Dr. Mills, are you involved with those types of issues at the American Optometric Association (AOA) level?
Dr. Mills: At AOA and the state board level.
Primary Care Optometry News: How is the AOA looking into it?
Dr. Mills: The state legislative center of the AOA has been looking at this for many years. The problem is that optometrists in different states are licensed to do different things. So its not so much an AOA problem as it is a state board issue.
Primary Care Optometry News: What about reimbursement for this? Is the AOA looking into that at all?
Dr. Mills: Im sure there are people out there who are trying to get reimbursed, but by and large youre just asking someones opinion. Clearly, the system is in place where you could get reimbursed for a consultation as long as it fits within certain coding guidelines. However, if a patient asks you for a second opinion, how will you bill?
Dr. Shwom: This may end up being free technology, much like the Internet. Regulation, almost by design, has been a few steps behind technology.
Primary Care Optometry News: Are any of you using the technology to comanage surgery?
Dr. Byrnes: Regarding contact lens wear and refractive surgery, when you stop contact lens wear, at what point is the cornea back to its original topography? There is a need for serial corneal topography in these cases. That is something that you would do over a period of time and could involve going back and forth.
Dr. Conway: Typically, the optometrist determines the point at which he or she thinks the cornea is stable. Perhaps the surgeon would then see the patient a few weeks beyond that. Comparing the final optometrist topography and the first surgeon topography would be confirmation that there is stabilization.
Many surgeons will repeat that testing, not because they have any lack of confidence in the referring optometrist, but just to have that medicolegal confirmation.
Dr. Byrnes: The resolution has to be there. However, there may be a weak link the camera, the transmission of light or the software that compresses the image.
Dr. Shwom: If we had big dollars, we could find good technology right now but it just doesnt price compete. Cost containment
Primary Care Optometry News: What effect, if any, has this technology had on cost containment, both for the practitioner and for the patient?
Dr. Shwom: I dont think it saves anything for the patient.
Dr. Byrnes: This technology is not very valuable in our neighborhood, because we have a specialist on the street corner to whom we can send patients. However, ex-students of mine who are now doctors on Indian reservations are 300 to 500 miles away from the closest consultant. Thats where the true advantage of this system is. Thats where it belongs.
In that environment, the cost of the technology compared with the savings for the patient is probably balanced in the right direction. In metropolitan areas, it probably isnt balanced until the cost comes down. But, the cost will come down. My first computer cost $2,000 or $3,000. Today, I can buy a much better computer for $500. When the cost ratio changes, then these systems will be useful for us.
Primary Care Optometry News: What is telemedicines place in the future?
Dr. Shwom: Ultimately, I envision someone sitting in front a computer screen being autorefracted, selecting a frame, having head measurements taken and having his or her eye wear delivered to his or her house the next morning.
Dr. Mills: The educational level of the patients with whom we deal is so much greater now. With refractive surgery, patients know exactly what will happen to them because they have done the research. This
has become an issue for practitioners. Its more important now than ever to stay abreast of the latest developments. Its almost to the point where patients know as much as we do about their condition, and not all the information the patient has is factual.
For Your Information:
- David J. Conway, OD, can be contacted at 2161 Massachusetts Ave., Cambridge, MA 02140; (617) 576-2020; fax: (617) 576-1958; e-mail: firstname.lastname@example.org.
- David Mills, OD, can be contacted at 1050 Centerville Rd., Warwick, RI 02886; (401) 828-3200; fax: (401) 828-3202.
- Irwin M. Shwom, OD, RDO, can be contacted at 421 Broadway, Everett, MA 02149-3435; (617) 387-1904; fax: (617) 387-2781; e-mail: email@example.com.
- Stephen P. Byrnes, OD, FAAO, can be contacted at 80 Nashua Rd., Londonderry, NH 03053; (603) 434-4449; fax: (603) 432-6059; e-mail: firstname.lastname@example.org.