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Telemedicine facilitates diagnosis, management of diabetes in remote locations
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The accuracy and effectiveness of diagnosing diabetic retinopathy from retinal images alone, as well as the ease and low cost of taking the images, has provided clinicians with a unique opportunity to deliver eye care to those with diabetes who would otherwise not receive it.
“If you look at diabetics in the U.S., of which there are around 26 million, only about 13 million of them get to see their eye care provider,” David S. Dyer, MD, chairman of the board, chief medical officer and co-founder of the Physician Referral Network (PRN), said in an interview with Primary Care Optometry News. “It’s a huge medical need, and the best way to meet it is to put cameras into primary care offices so that you can actively participate in providing eye care for significantly more diabetic patients and have an opportunity to educate them on the need to be seen by a local eye care provider.
“In the U.K., Germany, South Africa, Australia, they had the same issue 10 to 15 years ago,” Dyer continued. “They were only capturing about 50% of their patients, so they put cameras in their primary care offices, and now their capture rate of diabetics is about 90% to 95%. We’re trying to bring that same philosophy to the U.S. and believe we can make a difference in the lives of millions of diabetic Americans consistent with many innovations occuring in the health care industry, including the Patient-Centered Medical Home standards that are helping lead innovation within primary care.”
“Validated clinical pathways and systems were developed more than a decade ago to screen for diabetic retinopathy,” Anthony Cavallerano, OD, FAAO, the director of the Store and Forward National Training Center for the Veterans Health Administration (VHA) and a PCON Editorial Board member, told PCON. “While not yet validated for other eye diseases, such as age-related macular degeneration, glaucoma and interferon retinopathy, it is clear that the potential for teleoptometry is enormous.”
The use of telemedicine allows for rapid access to remote experts, reduced costs and greater collaboration among health care providers, Jorge Cuadros, OD, PhD, said.
Image: Cuadros J
Because it is possible to diagnose diabetic retinopathy from retinal imaging alone, only a nonmydriatic camera and a mode of storing and transmitting its images is needed to provide an effective means of screening. That means rapid access to remote specialty care, reduced costs for patients and clinicians alike and greater collaboration and two-way communication among health care providers, according to Jorge Cuadros, OD, PhD, assistant clinical professor and director of clinical informatics research at the University of California, Berkeley School of Optometry.
Christopher Stansbury, OD, who practices in West Virginia, agrees that while teleretinal imaging has its limitations, they are minimal, and its benefit to diabetic eye care is undeniable.
Christopher
Stansbury
“Some nuances and intervention opportunities can be missed when the patient is not physically present with the doctor, so telemedicine-based eye care visits don’t replace face-to-face full eye exams,” Cuadros said in an interview with PCON. “However, they have greatly helped in detecting and managing patients with sight-threatening disease.”
“We do have issues sometimes with the resolution and quality of the photographs,” he told PCON. “Some patients will have a cataract or some other vitreous opacity that makes it more difficult to get a good view of the fundus. If we see anything like that, though, we’ll have the patient come in for a dilated fundus exam right away, because we can’t make any conclusive findings otherwise.
“For the average patient, however, we’re able to review the photographs within a few minutes and tell the patient if they have any visible retinopathy or not, and if so, to what extent and how urgently they need to be seen,” he said. “It may take only 5 minutes.”
Store and forward
Of the three general modes of providing telemedicine, the mostly commonly practiced is “store and forward” telehealth.
According to Cavallerano, the store and forward method is entirely asynchronous. Data in the form of digital images, video or audio are captured, stored locally, then transmitted to a distal site to be reviewed by a specialist.
For the VHA, store and forward has provided an important means of delivering care to veterans living in remote or rural areas, Cavallerano said. Using this modality, the VHA has imaged more than a million unique patients since the program’s inception in 2006,.
Anthony
Cavallerano
Currently, more than 1,300 teleretinal imagers and more than 300 readers have been certified to participate in the VHA’s Teleretinal Imaging Diabetes Screening program, and 700 cameras are housed in all varieties of VHA clinics and health centers, Cavallerano said.
“Best practices call for the images to be reviewed by the reader within 3 days, so the imager can receive a report and act on the recommendation of the reader in a timely way,” he said. “Of course, immediate image review is always available for the less-than-routine situation.”
The Physician Referral Network
PRN is a HIPAA-compliant, cloud-based, remote image interpretation and referral network that utilizes a telemedicine platform to take fundus images of patients with diabetes in primary care offices and send them to a local optometrist or ophthalmologist for interpretation, according to Dyer.
“We started this about 8 months ago and we’ve had a good response from patients and the health care community,” he said. “We have 15 primary care optometrist and ophthalmologist practices in our network from West Virginia to Hawaii. Through our recent completion of a partnership with Alliance Healthcare Investment Fund and the hiring of one of their partners (Vince Rinaldi) as CEO of PRN, we’re now beginning to work with many of the largest hospital systems in the U.S. as well as international hospital systems.
“We also have cameras in prison systems,” he added, “which have a significant need for them.”
The primary care offices with the PRN system take images onsite with a nonmydriatic fundus camera, and those images are loaded into PRN’s cloud, which will then notify the reading doctor an image is ready for review either by text or email. The images are also prioritized as “routine,” “ASAP” or “STAT.” Photographs classified as routine are generally turned around within 24 hours, ASAP images are turned around within 2 hours, and STAT images are turned around right away, Dyer said.
“The doctor can log on anywhere there’s Internet access, pull the images down and read them,” he said. “It takes about a minute to read the images, and we have the ability to zoom in, adjust the brightness and contrast, etc., so if the image quality is not so good, you can adjust it.
“Also, we don’t necessarily use a reading center,” he added. “We try to connect local reading doctors with local primary care doctors so you’re establishing relationships between practices.”
While the majority of eye care practitioners involved with PRN are ophthalmologists, there are about 70 optometrists, and PRN is in discussions with a strategic partner to roll out to optometry practices nationwide, Dyer said.
“We can put our system into optometry offices, and then if they have questions on an OCT image, they can send it to us, a local retinal specialist, a local glaucoma specialist … to anyone they want,” he said, “because PRN is an open platform.”
The system creates efficiencies because, for example, if an optometrist takes an optical coherence tomography scan and sees a peripheral retinal detachment, he or she can send it to a specialist in PRN’s network, and the specialist can confirm the diagnosis remotely to save time for the patient, he said.
“So instead of having a patient come to our office, wait 2 or 3 hours to be seen, go to the hospital and wait a few more hours to get into surgery, we can now have the patient go straight from the optometrist’s office to the surgery center or the operating room to get them into surgery 5 or 6 hours sooner than without the network,” Dyer said. “Post-surgery, the patient can be managed at the optometrist’s office through collaboration with the specialist via the PRN network.”
EyePACS
The Picture Archive and Communication System for Eye Care (EyePACS) is a license-free Internet-based program/website, developed by Cuadros, where ocular images and relevant health care information can be transmitted and archived securely in a standards-compliant way, according to Cuadros.
EyePACS was launched in January 2001 by the University of California, Berkeley School of Optometry. The pilot program utilized clinician-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, Cuadros wrote in an Optometry and Vision Science editorial piece in 2006.
During the pilot period, clinicians used the system to obtain informal curbside consults, to replace telephone and fax referrals, to conduct ocular teleconsultations and remote diabetic retinopathy screening, to teach and evaluate students through digital ground rounds and competency tests, and to conduct research. The resulting database serves as a searchable reference for clinicians, he wrote.
“Our network of 170 organizations and 40 or so consultants strictly uses store and forward telemedicine,” Cuadros said in the interview. “Images are captured at a general medical facility, community center or health fair and uploaded to EyePACS. Consultants then view the images from the EyePACS website and use a validated protocol to grade the images and offer any recommendations for care. The turnaround is, at most, 48 hours from the time images are captured by the photographers to the time consultants provide the reports.
“The consultants can be in their office, at home or anywhere there is a reliable Internet connection and an adequate viewing monitor,” he said. “I review cases whenever I have some time — before and after work or between patients.”
According to Cuadros, the EyePACS program is currently active in 10 states and four countries and records about 300 encounters per day.
EyePACS has also spurred the enactment of two telemedicine bills, AB1224 and AB175, in California, he said.
“These bills put optometrists on par with medical doctors with regard to telemedicine and specifically mandate reimbursement through Medicaid for telemedicine services provided by optometrists, whether through real-time or store-and-forward modalities,” Cuadros said.
Rural applications
Primary care clinics that serve people in some of the more remote areas of West Virginia have reported that about one in three of their patients has diabetes, according to Stansbury.
“It’s a huge issue for those clinics, and a lot of those patients don’t have access to eye care because they may not have an eye care provider located anywhere near them,” he said.
To account for this medical need, the Charleston Area Medical Center Health System (CAMC) launched a telemedicine program with primary care offices and optometric and ophthalmic offices in the area, one of which is Stansbury’s practice, that combines teleretinal imaging with videoconferencing, Stansbury said.
“They set us up with a camera system so we can communicate with the primary care clinics and view the retinal photographs online, live, and talk to the patient about the retinal photographs while they’re sitting in front of the screen,” he said. “It’s a really nice way for us to be able to screen the patients, talk to them and tell them about diabetes and why it’s so damaging to the eyes. And then if the patient has any questions that are eye related, they can certainly ask them then.
“And if we have any diabetic eye findings,” Stansbury added, “we certainly encourage them to get an eye exam from their regular eye care provider if they have one; if not, we offer to see them at our clinic.”
One drawback to the system CAMC has in place, according to Stansbury, is that the reading doctor is unable to manipulate the photograph.
“We have to tell the technician to zoom in, pan out, scroll over here, so it’s a little cumbersome in that sense, but once we’ve worked with a certain technician a few times, they are able to do pretty much anything we ask,” he said.
“I would encourage any optometrists who are interested in pathology and have a hospital system in the community to partner with to look into doing a program like this,” Stansbury said. “It’s an opportunity to get your name out there, build a name for your practice and provide patient care to underserved areas.”
Reimbursement
Reimbursement varies by state and payer, Dyer said. With payers that reimburse with the 92250 code, which pays about $70, about $45 goes to whoever owns the camera, which is reimbursement for the technical component. The professional component, up to about $25, goes to the reading doctor.
“Every state’s or every Medicare carrier’s policies are a little different, but many policies will pay to take a diabetic photograph,” Dyer said. “They won’t pay for a screening photograph, though, so you have to separate the diabetic patients who meet medical necessity requirements from routine patients. If you have type 1 diabetics who have been diabetic for more than 5 years or type 2 diabetics, we know clinically that there is underlying retinopathy, even on normal fundus photography. We know that, microscopically, there’s been damage at that point, so we’re not screening those patients; you’re actually performing a medically necessary service on an active retinal disease.
“In California, Hawaii and Nevada, for example, they reimburse on the 92228 code for remote monitoring and management of active retinal disease, so reimbursement is lower,” he continued. “Florida is one of the most difficult states for reimbursement and, thus, for improving diabetic care.”
However, it is possible to get reimbursed for this in many states, he said.
“As a physician, it’s my goal and mission to improve diabetic eye care and to be a patient advocate for enhancing reimbursement rules by leveraging technology to meet this growing and approaching-epidemic need,” Dyer said. – by Daniel R. Morgan