The notion of using telecommunications in health care dates back to the beginning of telecommunications. Over a century ago, doctors experimented transmitting stethoscope sounds and radiology images as soon as the communication technology was available. Since then, telemedicine has evolved into a formal concept. The American Telemedicine Association defines telemedicine and telehealth as “the use of medical and health related information exchanged from one site to another via electronic communications to improve patients' health status.”
Teleconferencing, transmission of medical images, e-health web sites, remote monitoring of vital signs, online continuing medical education, and triage call centers are all considered part of telemedicine and telehealth. Although telemedicine has become a familiar concept to many eye care clinicians, it is not yet a routine activity in a typical eye care practice.
The first generation of formal telemedicine began in the late 1950s with Dr. Cecil Wittson's microwave-mediated rural telepsychiatry program in Omaha, Nebraska, and with Dr. Albert Jutras' cable-mediated teleradiology program in Montreal.
Telemedicine's second generation used digital compression and transmission technologies in the late 1980s that allowed point-to-point interactive videoconferencing to and from anywhere that had access to adequate telephone lines. Since the mid-1990s, telemedicine programs have grown exponentially throughout the world in nearly every specialty and area of health care: radiology, pathology, continuing education, home care, emergency care, mental health, rehabilitation, cardiac monitoring, and every medical and surgical specialty. Technologies have ranged from high-bandwidth interactive video to low-bandwidth wireless programs.
Telemedicine in eye care is also advancing rapidly as inexpensive high-quality digital imaging devices and faster more efficient telecommunications systems appear. Optometric researchers have used telemedicine for many applications, including contact lens evaluations, binocular vision testing, examination of prison inmates, and diabetic retinopathy screening.
The University of California, Berkeley School of Optometry (UCBSO) has been involved in telemedicine since 1995 with demonstration projects linking private practice optometrists in San Jose, California, to ophthalmic specialists at the UCBSO. Several other projects have been completed since then, including telemedicine exchanges between UCBSO and Beijing Medical University in China in 1999 and 2000.
In January 2001, UCBSO launched and tested EyePACS, an Internet-based system for communicating and archiving eye-related patient information, images, and diagnostic data. Clinicians uploaded clinical cases from six pilot sites: a university teaching clinic, a university glaucoma clinic, an urban private optometric practice, a rural elderly care facility, a diabetic management program, and an eye hospital in India. During the pilot period, clinicians used the system for various purposes: 1) to get informal “curbside” consults, 2) to replace telephone and fax referrals, 3) to conduct ocular teleconsultations and remote diabetic retinopathy screening, 4) to teach and evaluate students through digital grand rounds and competency tests, and 5) to conduct research. The resulting database of digital cases serves as a searchable reference for clinicians.
Since then, ocular telemedicine has grown considerably, most notably in diabetic retinopathy detection. The Joslin Vision Network, Vanderbilt Ophthalmic Imaging Center, and Inoveon are a few of the hundreds of programs that have been developed for remote diabetic retinopathy screening. In these programs, retinal images are transmitted to remote reading sites and the images are read by eye clinicians or by trained nonclinicians who then provide reports indicating the level of retinopathy and whether or not to refer for further follow up.
In December 2003, the Meredith Morgan Optometric Eye Center at UCBSO began diabetic retinopathy screening programs in county medical centers and community clinics in urban and rural areas of California. Two UCBSO projects have been funded to provide screening services to over a dozen diabetes and primary care clinics. In 2003, The Alameda County Medical Center contracted with UCBSO to convert the EyePACS software for diabetic retinopathy within three of their urban indigent clinics. In 2005, the California Endowment provided $630,000 through the California Telemedicine and eHealth Center to UCBSO to develop diabetic retinopathy screening in rural counties of California. The purpose of the grant is to develop sustainable retinopathy screening programs in a dozen indigent clinics and provide free access to clinical communication software for all community clinics in California. Under this grant, UCBSO equipped rural clinics with retinal cameras that are connected to UCBSO through the Internet where UCBSO clinicians interpret the images and send back reports about the retinal status of patients at the rural sites. Nearly 12% of the diabetic patients examined so far have been identified as having sight-threatening retinopathy yet were not receiving timely eye examinations. Although traditional eye care services were available to many of these patients, all of them had not had an eye examination in over a year and all were at significant risk of developing blinding complications.
The effectiveness of the telemedicine intervention goes beyond just early detection and is exemplified by a patient who was recently seen in Fresno, California, through telemedicine. The two images show the left retina of a 34-year-old Mexican woman with uncontrolled diabetes who did not want to begin using insulin as a result of fear of blindness from the medication. Not only were the preproliferative retinal lesions detected in time, but also her physician became aware of the urgency of initiating treatment, and the patient also realized the necessity of using insulin when she was shown her retina. Interestingly, this case was subsequently sent electronically to a retinal specialist who interpreted the atypical lesions and recommended further laboratory tests to the primary care physician to rule out type I diabetes. This example illustrates how several clinicians at remote sites can communicate about a case in a web of collaboration all within the primary care visit.
The future of this type of clinical intervention is bright as academic, business, and government groups increasingly invest in new programs and technology. The National Institutes of Health National Eye Institute has recently awarded multimillion-dollar grants for the development of low-cost digital imaging devices that can be used for remote diabetic retinopathy detection. This technology and the lessons learned in subsequent projects will be valuable assets in the development of broader remote eye care programs applied to other conditions such as glaucoma and macular degeneration. For example, a recent study of remote detection of glaucoma was conducted by the author in cooperation with glaucoma experts of the Optometric Glaucoma Society and ophthalmologic glaucoma experts nationwide. The results are to be published in subsequent papers and show that remote detection of glaucoma is comparable to face-to-face consults under the proper conditions. Some eye care providers are searching to innovate other aspects of patient care as new higher-quality, faster, and smaller devices are developed. The future will surely bring a synthesis of telemedicine with other informatics endeavors such as integration of remote care with electronic medical records.
The professionals, who have embraced these evolving technologies, surely fall into the category of early adopters. It is through their experiences, both good and bad, that the rest of the professional community will adopt these new concepts into practice. The validation, assimilation, complementary innovations, and evolution associated with these methods will turn telemedicine simply into the routine practice of health care in the future that may seem unrecognizable to most of us now. In this view, the practice of “telemedicine” and “telehealth” simply becomes the practice of “medicine” and “health care.” Telemedicine can be viewed as a new tool, much like the keratome or laser that has the potential to transform the daily practice of eye care. The difference, however, is in the interactive nature of this new tool. Without interaction among colleagues and patients, telemedicine is meaningless. It is because of the rapid increase in the demands for communication and interaction that it creates a rich and promising environment for new ways to communicate.
Our society's new technologic and communications infrastructure now allows us to realize decades of theoretical work in medical computing and informatics. The traditional healthcare encounter can now be divided into three components: data-gathering, decision-making, and patient communication (not to mention billing). Telemedicine allows healthcare workers to provide expertise in the component in which they are most effective. For example, highly trained experts may not need to gather data if someone else can provide it for them more efficiently, and they may not be the most effective communicator to impart their advice and knowledge to their patients. Data-gathering can be at multiple locations far from the practitioner contributing to diagnosing and treatment decisions, and communication with the patient can be provided by patient educators or clinicians whose expertise lies in face-to-face intervention and interaction with patients.
Communicators may be local primary care clinicians, including primary eye care clinicians, who are well acquainted with the patient's complete health picture; or they may even be community-based individuals with a deeper understanding of the social context in which they are interacting with the patient. Through telemedicine, there is a potential to increase the efficiency of each component of the healthcare encounter, because they are no longer bound by time and location. We may find that the doctor–patient relationship can evolve into a more communal activity involving groups of doctors and patients as well as their families, allied health workers, educators, public health workers, and numerous others tightly woven into a matrix of information gatherers, information processors, and communicators.
How will this new mode of eye care affect the training and practice of optometrists? Until now, with the exception of a handful of isolated programs, optometry has been absent in the development, accreditation, and legislation of telemedicine. For example, California's recent telemedicine law, AB 384, requires the state's Medicaid system to pay ophthalmologists for telemedicine, but not optometrists. Seven other states in the United States have also enacted “store-and-forward” legislation, and almost all 50 states have some type of telemedicine legislation with varying levels of participation by optometrists. International telemedicine is growing faster than telemedicine in the United States.
There are many issues that need to be resolved such as how to regulate interstate and international practice. For example, how do we regulate eye care clinicians who are consulting patients in Wisconsin from Florida or India? These types of consults are already occurring now as you read this. Ethics, quality control, and reimbursement are at the forefront of debates regarding telemedicine. Fortunately, it is still early in the game and there is time to ensure that optometry has a presence in this new arena of medical care. Optometrists are in an excellent position to be part of this evolution of medical care, but we must act now. We can be part of chronic disease management teams and interact with professionals outside of eye care as well as with our own patients in more convenient settings for them. However, we must be proactive, active, and well-prepared.
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