Telemedicine continues to offer a tantalizing look at the future of ophthalmology. An industry long plagued by increasing patient populations coupled with a declining physician base, ophthalmology stands to benefit in a large way if the difficulties inherent in the implementation of telemedicine services can be addressed in an efficacious way. As the situation currently stands, telemedicine ophthalmology practice management leaves much to be desired.
What are the issues that face ophthalmology practices wishing to integrate telemedicine into their practice? And how best can ophthalmologists use the available technologies to help their patients while maintaining economic viability?
Problems With Using Telemedicine
The term “telemedicine” typically refers to methods whereby patient care can be coordinated between health-care facilities in two disparate places and/or methods whereby ocular pathologies can be monitored and interpreted remotely.
While the technologies that make telemedicine possible continue to evolve, so far the willingness of insurance carriers to reimburse physicians for its use have not kept pace with the science. Smaller practices struggle with decisions regarding the economic viability of investing in the technologies required, both monetarily and from the perspective of the time needed to train staff appropriately in its use. Added to the uncertainty of insurance reimbursement for exams performed is the reluctance of patients to spend money for what may be considered as preventive care. If telemedicine programs are to truly succeed, widespread coverage of assessment services, with remote retinal imaging and an appropriate reimbursement structure by insurers is necessary.
Ideally, telemedicine at its best could be used to expand patient monitoring in populations where ophthalmologists are not readily available. It is projected that rural areas would particularly benefit from the use of telemedicine. However, even in more affluent areas, statistics bear out the fact that a high percentage of the population does not routinely receive annual eye exams. This being the case, telemedicine offers the possibility of better monitoring across all social and economic levels.
A problem facing ophthalmologists, however, is the sheer scope of the work to be done. If screening was done routinely for all diabetic retinopathy, for instance, physicians would find their practice inundated with cases that do not currently need intervention. In this case, screening would accomplish just the opposite of what is actually needed.
Therefore, telemedicine technologies must be accurate, and the physicians who utilize them must be properly trained to undertake the appropriate amount of intervention with each patient. Only in this way will telemedicine actually enhance the ability of a physician to provide a high quality of care for patients.
Current Areas of Promise
Telemedicine in the field of ophthalmology has been used with variable success for the screening of diabetes, glaucoma, and macular disease. Google and Alcon recently announced a partnership to commercialize a contact lens-based insulin monitor for patients with diabetes. A similar system is also being developed to monitor intraocular pressure in glaucoma patients. Telemedicine currently shows particular promise in detection and treatment in two areas: pediatric retinal disease and diabetic retinopathy.
Retinopathy of Prematurity Screening
Telemedicine as it currently exists has been successful in detecting pediatric retinal disease for several reasons:
- remote screening is highly effective at identifying a treatment intervention time point
- the disease is self-limited, as it will either spontaneously resolve or result in retinal detachment and blindness within 15 weeks
- all NICUs are required to perform the screening to maintain accreditation, effectively eliminating the uncertainty of financial reimbursement.
The lessons learned from this are clear. For the purpose of telemedicine ophthalmology practice management, it is essential for the physician to identify specific diseases or conditions with well-defined intervention points that can be easily detected with the technology available. Defining these narrow ranges of targeted telemedicine will likely be the key to using the available technologies in a way that is both economically feasible and of lasting benefit to patients.
Diabetic Retinopathy
Telemedicine for DR eye care is used to accurately detect the condition and gauge the severity of the disease. An effective telemedicine program involves:
- adequate quality assurance
- cost containment
- efficient patient and health care provider workflow
- adequate reimbursement for sustainability
- compliance with all regulatory requirement
The American Telemedicine Association (ATA) has published position statements to provide standards and guidelines for telemedicine programs for DR. These practice recommendations for DR include four categories of clinical validation of a DR telemedicine program. Each category of validation identifies a certain segment of the patient population, and appropriate physician-directed intervention and treatment. While the ATA delineates clearly the categories and their appropriate actions, the essence of the multi-levels schematic is clear. To be viable as a tool, a telemedicine program must reduce the public health burden of retinal examination by providing evidence-based care recommendations to patients at low risk for vision loss and identifying patients who require further ophthalmic intervention without placing an undue burden on present eye care systems. If that sounds like a tall order, it is.
Down in Carolina
A two-year project funded by The Duke Endowment, the North Carolina Diabetic Retinopathy Telemedicine Network is currently bringing DR evaluation via telemedicine to primary clinics in rural North Carolina. In the first year, DR evaluation rates rose from 32 percent before implementation of the telemedicine program to 71 percent. More than 80 percent of diabetic patients could be followed with retinal photographs and remote interpretation in their own primary care settings. Efficiency and patient satisfaction rates both improved. The program demonstrably reduced unnecessary referrals to ophthalmologists and resulted in savings to patients. Additionally, those patients in true need of ophthalmology services were referred more quickly, so that treatment could begin immediately.
The Bottom Line
Programs like this illuminate the benefits that telemedicine will likely bring to the field of ophthalmology in the near future. Much work must still be done to realize the full potential of this technology. Ophthalmologists themselves will, of necessity, play a large role in shaping telemedicine to accommodate the specific needs of the industry and overcome the hurdles now inherent in telemedicine ophthalmology practice management.
If you would welcome more information about technologies that can work for your practice, please contact us. As healthcare consultants, we can help you build a better practice.