High-tech access to eye care in rural areas reduces cost and stress

Making eye care accessible and affordable to the greater population scattered throughout rural areas is the focus of tele-ophthalmology initiatives working in India.

For rural villagers, traveling to the nearest urban center for eye care may be more than they can afford. According to the Office of the Registrar General & Census Commissioner, about 70% of the population lives in rural areas; according to World Health Organization statistics, about 70% of public hospitals are situated in cities.

Telemedicine Society of India

The Telemedicine Society of India (TSI) convened recently in Chandigarh for its fourth national conference to discuss current issues in telehealth and to deliberate on practical problems faced in rural India. The TSI members promote the integration of telehealth into the health care delivery system of the country.

Meenu Singh, MD, organizing secretary of the conference, said “reaching the unreached” is the catch phrase, and the govern- ment has become involved and has a vision to introduce these services on a larger scale.

In the initiative, facilitated by the government-launched HealthSat satellite, 110,000 multipurpose kiosks are being established in remote villages to provide Internet access for health care purposes.

“Telemedicine at the moment in India is in for a big scale-up,” Dr. Singh said, which would include servicing the underserved in the urban areas as well.

“[Telemedicine] is basically now going to be used for solving the grassroots problems which are facing this country, relating to health. And that’s going to be established more through the e-health, that is, the use of information and technology in solving problems at the grassroots level because basically the problem in India is an availability of expert care to people who are living in the villages or residing in the [hard-to-reach] places,” Dr. Singh said.

A. P. Irungovel, department head of tele-ophthalmology of Sankara Nethra- laya, Chennai, said a number of centers are doing better service in rural areas, and through the National Program for Control of Blindness, a project aided by the Ministry of Health and Family Welfare, more ophthalmologists are practicing in rural areas.

Tele-ophthalmology

The objectives of tele-ophthalmology, according to the Aravind Tele-Ophthalmology Network (ATN), are to make eye care service accessible and affordable by reducing travel cost and time for patients, to enable people in remote areas to have access to specialized eye care facilities and to act as an interface between doctors to share their experience.

The technology is available now to reach all areas of India, R. Kim, MD, of Aravind, said. With the availability of commercial broadband service, very small aperture terminal satellite reception, which is used in conjunction with government health initiatives through the India Space Research Organization and ATN’s own towers, antennas and transmitters, connectivity is not a problem, he said.

ATN is advancing eye care to rural areas through vision centers in populations of about 50,000, where an interconnected kiosk is established and manned by a trained technician.

R. D. Thulasiraj, executive director of Aravind Eye Care System, said ATN looks to install its kiosk centers in areas where rural Indians come for trade or commerce and where there is access and enough human resources to assign “decent talent” to man the vision centers. ATN operates 26 centers and intends to open 10 more within a year.

“That is the lower end of the care,” Mr. Thulasiraj said. “In the primary care centers, what we’re trying to do is to address 80% of the problem, which is refractive errors, cataracts and some minor issues, where the patient doesn’t need to go to the hospital, where we can deal with it with consultation.”

For those who need to go to the hospital, the numbers can be reduced to some extent with high-end telemedicine capabilities, he said. Because these numbers would be small, it does not make sense to invest hardware, especially the ophthalmic diagnostic hardware, to screen or examine a few people.

“So this is where the mobile unit concept comes in,” Mr. Thulasiraj said.

Vision care vans

“[To] be mobile, you need to have broadband connectivity, which is also mobile,” Mr. Thulasiraj said.

Very small aperture terminal is the primary mode for exchanging data in mobile ophthalmology vans, although that is changing as the government licenses mobile companies for third-generation, or 3G, technology, a faster data transfer than second-generation, or 2G, technology, he said.

Vans are equipped with slit lamps, fundus cameras and software for gathering patient demographics and complaints, as well as encryption standards for transmission. A highly trained technician sends the data to a receiving hospital, where a clinician interprets the data, makes a diagnosis and sends back a report, which is printed in the mobile van, all within about 1 hour.

“The patient gets the full diagnostics before [he] leaves,” Mr. Thulasiraj said, thus reducing the number of people who would have to go to the hospital just for diagnostics.

Sankara Nethralaya in Chennai does similar work with mobile vans, adding the ability to make and deliver spectacles “on the spot,” according to its Web site. The van is preceded by a camp team to optimize the van’s visit. Started in 2002, the Sankara Nethralaya tele-ophthalmology project aims to link all Sankara Nethralaya satellite centers and allied institutions and promote the tele-ophthalmology concept to other institutions.

Diabetic retinopathy screening

Tele-ophthalmology makes it possible to go where the patients need eye care the most, which is not always in rural areas. The ATN is taking the tele-ophthalmology idea into endocrinologists’ offices to screen for diabetic retinopathy.

“We are doing research in a few hospitals. All the diabetic patients who go to these diabetic centers get screened by a technician who takes their retinal pictures and sends the images to the reading center, which we have established here,” Dr. Kim said.

The intention is for the retinopathy screening to become a routine part of the diabetes screening laboratory work and for the patients to receive reports indicating whether or not they need follow-up.

“I think it makes a big difference, especially for the diabetic patients who do not have an eye examination at all until very late stage,” Dr. Kim said. “That is what is happening today in India. You don’t get referred otherwise, not as a routine.”

Regarding the use of telemedicine beyond eye care, such as in the endocrinologist’s office, Dr. Singh said, “As you can see, [telemedicine] is a holistic kind of approach. You can’t go for just the eye problems or just the fundus changes. It is a package. It’s a package of good health.”

Orbis initiatives and e-consults

Since 2002, through the use of Internet connections and expert mentors, Orbis International has been connecting ophthalmologists in countries where health care is lacking. Thirty-two Indian centers are involved in the Orbis Cyber-Sight initiative, outstripping the next most-involved country, China, by about three centers to one.

Cyber-Sight experts are volunteer specialists from around the world who provide electronic consultation to participating centers through a Web-based interchange of data called “e-consult.”

G. Madhavi, MD, medical director of Goutami Eye Institute, was the first physician in India to use Cyber-Sight and worked with its founder, Eugene Helveston, MD.

“I used to send e-consultations to Dr. Helveston on almost all the topics related to children’s eye problems,” Dr. Madhavi said. “At that time in India, Internet was not so fast, and I used to spend so much time sending those consults, but I used to enjoy it because it was helping a lot of children.

“With the proper equipment and knowledge to provide good quality eye care to children or adults, we can … manage in rural areas,” she said. “Our institute is able to do this because we learned a great deal from telemedicine.”

Getting involved: awareness and education

General ophthalmologists can become more involved in tele-ophthalmology in three ways, Mr. Thulasiraj said.

“I think the centers which are promoting or having the wherewithal for telemedicine, I think they have to reach out a little more and make it more … available. At the same time, education has to take place for the ophthalmologist on how to use this technology. And the third part … is to develop the business model around [telemedicine],” he said.

The biggest problem in getting the telemedicine to the outreach centers is the training of the manpower, Dr. Singh said.

Some local ophthalmologists might be reluctant to participate because they might fear losing their patients to bigger hospitals, Dr. Kim said.

“That’s a fear I think is there. But, in fact, it is the reverse,” he said. “When these things happen, they get to keep these patients and treat them locally.”

“Wherever I go to give any guest lecture, I mention about telemedicine and how I [was able] to become a good pediatric ophthalmologist and strabismologist with the help of telemedicine,” Dr. Madhavi said. “Young ophthalmologists should be exposed to this, and I explain [to] them the uses of telemedicine and how we can improve our practices.”

“The Indian ophthalmologist has to understand the basic telemedicine concept to extend [his or her] service to the rural population,” Mr. Irungovel said, adding that public health education and creating awareness about health issues among the rural population is important and is possible through telemedicine.

Connectivity

Ericsson, a provider of technology and services to telecom operators, works with the Apollo Telemedicine Networking Foundation to supply wireless connectivity to its mobile units.

“Mobility has proven to be a major catalyst for social and economic empowerment and a key ingredient in helping to bridge the digital divide,” Mats Granryd, president of Ericsson India, said in a press release.

“We are putting an ecosystem in place to support telemedicine applications once the 3G network is deployed,” he said.

Going from 2G to 3G connectivity will increase the speed of data transmission, making video conferencing in real-time more feasible and diminishing the role of very small aperture terminal. — by Pat Nale

• A.P. Irungovel can be reached at HOD-Eye Bank and Tele-ophthalmology, Sankara Nethralaya, 18 College Road, Chennai 600-006; 44-282-71616; e-mail: api@snmail.org.
• R. Kim, MD, can be reached at Retinal Vitreous Service, Aravind Eye Hospital, Madurai, 625 020; 91-452-4356102; fax: 91-452-253-0984; e-mail: kim@aravind.org.
• G. Madhavi, MD, can be reached at Goutami Eye Institute, 1 RV Nagar, Korukonda Road, Rajahmundry 533 105, Andhra Pradesh; 91-883-244341; fax: 91-883-2443449; e-mail: madhavi.ghanta@gmail.com.
• Meenu Singh, MD, can be reached at Telemedicine Center, Block A, Second Floor, Nehru Hospital, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012; 91-172-2745193; fax: 91-172-274401; e-mail: meenusingh4@rediffmail.com.
• R.D. Thulasiraj can be reached at the Lions Aravind Institute of Community Ophthalmology, Aravind Eye Care System, 72 Kuruvikaran Salai, Gandhi Nagar; 452-2537580; fax: 452-2530984; e-mail: thulsi@aravind.org; Web site: www.aravind.org.