Optometry

As technology continues to drive the evolution of optometry and other medical professions, telemedicine would seem to be a logical part of that progression. Currently, however, telemedicine is not as prevalent in optometry as it is in other areas of medicine, such as radiology.

“Its use is still minimal in optometric practices, probably due to the fact that offices are not set up for transmission of exam information,” said David P. Sendrowski, OD, FAAO, a professor at Southern California College of Optometry, in an interview with Primary Care Optometry News. “But I believe that telemedicine will continue to evolve to the point where it will become common to turn on your telemedicine unit, just as you do your computer, when opening your practice.”

Models of telemedicine

Boston-based practitioner Anthony Cavallerano, OD, FAAO, a PCON Editorial Board member, said he defines telemedicine as “the transmission of medical information, including visual images, from one site to another.” He said there are currently three typical ophthalmic telemedicine models:

Screening. “In this model, large numbers of patients undergo digital retinal imaging in an environment where you are only seeking to identify disease,” Dr. Cavallerano said. “This model relies on all or none: there is disease or no disease present.”

If disease is present, he said, the patient is automatically referred for an eye or other medical examination. “This model is used prevalently by the service organizations or lends itself very well to a site outside of the eye care environment,” he said.

Evaluative or diagnostic. In this model, more information is gleaned from reviewing the study, providing a more specific diagnosis of the patient. “In this model, patients then can be prioritized into an eye care program based on the severity of the disease,” Dr. Cavallerano said. “This model is prevalent within the Department of Veterans’ Affairs.”

Consultative or “second opinion” model. This model allows a clinician to capture images and send them to a consultant, Dr. Cavallerano said. Such scenarios might include sending images of a retinal problem to a retinologist, sending an image of a lid condition to a dermatologist or sending a visual field to a glaucoma specialist, he said.

Dr. Cavallerano said most optometric telemedicine emphasis is placed on diabetes and diabetic retinopathy, but he added that the monitoring of age-related macular degeneration (AMD) patients or glaucoma suspects are also conducive to a telemedicine approach.

Obstacles to telemedicine

According to Kim Alan Castleberry, OD, of Plano Eye Associates in Plano, Texas, telemedicine has yet to play a prominent role in optometry. “I don’t see much happening, outside of a few images being tossed around in a non-HIPAA-compliant way,” he said. “I have looked at some image consulting software and found it too cumbersome to use, so I just continue to send images via e-mail to friends, colleagues and suppliers.”

Dr. Cavallerano said some of the challenges and limiting factors for telemedicine include the initial cost of the equipment: a fundus camera ranges from $20,000 to $30,000.

“One important limiting factor is bandwidth, which dictates how rapidly images are transmitted and downloaded,” he said. “This problem can be overcome to a certain degree by image compression.” However, Dr. Cavallerano said, when an image is compressed, a practitioner must maintain quality so that the reader of the image can adequately examine it for findings.

“Finally, reimbursement and legal issues are at stake,” he said. “Currently, teleretinal image review is not a billable procedure, and it is not yet feasible to send images across state lines due to licensure issues.”

Dr. Sendrowski said another issue for optometry and telemedicine is the fact that although image information does not need to be a high-resolution transmission, the images do need to be acquired with good clarity using optometric diagnostic instruments.

“Training technicians to acquire accurate and clear ocular images is very important in the consultation of patients who require an immediate ocular diagnosis,” he said. “In many settings (i.e., battlefield, remote care clinics, physicians’ offices) there are no eye care specialists available to acquire these images for transmission, which would be vital for consultation purposes.”

Reading centers

Image reading centers for telemedicine have recently become more prevalent, Dr. Sendrowski said. “We use the Optomap system (Optos North America, Marlborough, Mass.) here at the college, and there are reading centers that evaluate the retinal image for the doctor if requested,” he said. “A report is then sent to the doctor. There is no reason to believe that hospitals, large group offices and teaching centers will not offer these services to the private practice doctor for a nominal fee.”

Dr. Sendrowski said such a reading center will benefit the patient, doctor and the center and will reduce the burden and cost of over-referrals.

Dr. Cavallerano said some of the more mature reading center models include the Emory Eye Center, Wilmer Eye Institute at Johns Hopkins, the Vanderbilt Ophthalmic Imaging Center in Nashville, the Joslin Diabetes Center, the University of Maryland and the Wisconsin Reading Center in Madison.

In addition, Dr. Cavallerano said the Department of Veterans Affairs has recently launched a nationwide program using a telemedicine platform in conjunction with its proprietary electronic medical record system, to access retinal images of veterans with diabetes.

Dr. Cavallerano said optometrists should look into possibilities for telemedicine within their communities. “However, the optometrist should discuss the notion of telemedicine with his or her local consultant to determine if sending images for consultative review is possible,” he said.

Dr. Castleberry has also used the image reading center from Optos. In addition, he has also used OfficeMate’s ExamWriter (Marchon Software Solutions, Irvine, Calif.).

“OfficeMate’s ExamWriter makes telemedicine practical, as all of the special testing and images, including interpretation and reports, are available to do remote exams,” he said. “You can even bill and submit electronic claims remotely.”

Future advantages of telemedicine

Dr. Sendrowski said telemedicine is likely to play an increasingly prominent role in optometry’s future. “As we enter an era of electronic medical records for patient care, this will only help allow access to telemedicine in the optometric practice,” he said. “During the next decade or so, optometric offices that offer the patient complete access to multiple subspecialties will become more prevalent.”

He said the transmission of information to specialists through telemedicine will make for a more efficient optometric practice. “Sending an internist or endocrinologist an image of diabetic retinopathy will allow better care of the patient without requiring the patient to travel long distances and without taking the time to write a detailed letter,” he said. “Altering systemic medication based on retinal evaluations for diabetes will become more commonplace in the eye care setting.”

Dr. Castleberry discussed a patient case that he handled through telemedicine. The patient came to his office at 4:30 p.m. on a Friday afternoon with flashes and floaters, and no doctors were in the office at that time. “I did not have time to get the patient to a colleague,” he said.

“I was the doctor on call, and my tech called me wanting to know what to do,” he continued. “I realized with my technology-integrated practice, I could examine the patient sitting on a balcony in Laguna Beach.”

Dr. Castleberry had the technician do an external exam, visual field and Optomap Plus retinal exam. He spoke with the patient over the telephone, reviewed her history and symptoms and evaluated her visual field and retinal exam results. “I was able to manage her sitting on a balcony at my hotel room, with my wireless tablet PC hooked up to my office in Plano, Texas,” he said.

“I always see patients with flashes and floaters back at 1 month, so I did have the opportunity to see her at that time,” he continued. “This is the first and only case that I have handled like this, but it will not be my last.”

Dr. Castleberry said he has also sought consultation with William Jones, OD, a Primary Care Optometry News Editorial Board member located in Albuquerque, N.M., for retinal cases.

“I can also get quick online consultations for glaucoma with Joe DeLoach, OD, a glaucoma specialist with the University of Houston College of Optometry,” Dr. Castleberry said. “So for me, the benefits are providing care to patients remotely and getting consultations online when I need them to help me provide higher quality care.”

Dr. Cavallerano said telemedicine has the capacity to not only save time, but to detect eye disease more quickly. “In most cases of eye disease, one of the key tenets of early treatment is early detection,” he said. “Technology such as telemedicine allows the optometrist to have convenient access to resources that might be less attainable or otherwise unavailable.”

For more information:

• David P. Sendrowski, OD, FAAO, is a professor at Southern California College of Optometry. He can be reached at 2575 Yorba Linda Blvd., Fullerton, CA 92831; (714) 449-7414; fax: (714) 992-4878; e-mail: dsendrowski@scco.edu.
• Anthony Cavallerano, OD, FAAO, is a Primary Care Optometry News Editorial Board member who practices at VA Boston Health Care System, Jamaica Plain Campus. He can be reached at 150 S. Huntington Ave., Boston, MA 02130; (857) 364-2281; fax: (857) 364-6538; e-mail: anthony.cavallerano@med.va.gov.
• Kim Alan Castleberry, OD, can be reached at 5509 Pleasant Valley Dr., Plano, TX 75023; e-mail: kim.castleberry@gte.net. Drs. Sendrowski, Cavallerano and Castleberry have no direct financial interest in the products mentioned in this article, nor are they paid consultants for any companies mentioned.