How Telemedicine Could Improve Glaucoma Screening and Treatment
When ophthalmologists identify glaucoma in the early stage, it is much more possible to preserve eyesight. Unfortunately, the condition has few symptoms until patients begin to experience some degree of vision loss, at which point it is impossible to reverse the process, though it can be halted.
Researchers have focused on methods for detecting the condition as early as possible, so people can receive vision-preserving treatments. One option being considered to accomplish this is telemedicine: using electronic communication for the remote delivery of healthcare by providers in different locations. Telemedicine also has potential for increasing patient adherence to medical advice.
Traditionally, patients with glaucoma are expected to visit a physician regularly for check-ups and to adhere to a medication regime exactly as prescribed. For many people, this task is difficult since they may not understand the importance of treatment and follow-up, especially given the considerable time and money needed to get to appointments and purchase medications. In addition, many people do not live within a reasonable distance of an ophthalmologist. This may become more complicated when people don’t have a diagnosis, but must undergo screening because they have some risk factors. Telemedicine is a way to reduce the travel and waiting time involved with care and screening.
Telemedicine Used by Veterans Affairs to Facilitate Glaucoma Screening
Telemedicine benefits many aspects of glaucoma care, from screening for the disease to monitoring after diagnosis. The telemedicine model for management of glaucoma has already been explored by the Department of Veterans Affairs (VA), as described in a December 2016 EyeWorld article.
Currently, VA hospitals offer patients in rural areas telemedicine eye care services through primary care satellite clinics. A specially trained technician is located at the clinic to run the diagnostic equipment and all clinical information and images are uploaded into the patient’s electronic health record to be shared with the ophthalmologist for review the same day. When a patient has an abnormal screening, only then do they need to go to the main eye clinic.
Moving many aspects of ocular care to satellite clinics helped the VA identify more cases of serious eye conditions, largely because patients are more likely to keep their appointments when they don’t have to travel long distances. Moreover, nearly 60 percent of patients who are called in for an in-person exam ultimately are diagnosed with a significant condition, such as glaucoma. Part of the burden of glaucoma is the fact that half the people with the disease do not know it, so the ability of telemedicine to increase screening compliance could ultimately help save many people’s vision.
The Limits of Using Telemedicine to Screen for Glaucoma
In the December 2016 EyeWorld article, Mary Lynch, MD, affiliated with the Atlanta Veterans Affairs Medical Center, notes the rate of missed appointments at VA eye clinics nationally is about 15 percent. However, VA patients participating in teleophthalmology screenings have a no-show rate of less than one percent. While this is encouraging, it is also important to note that a third of these patients still had to go to a main clinic for further evaluation, since the screening tools at satellite clinics aren’t a substitute for diagnostic clinical exams. Patients should understand this condition before they agree to a telemedicine approach.
Also in the EyeWorld article, April Maa, MD, clinical director of the Technology-based Eye Care Services at the Atlanta Veterans Affairs Medical Center, commented on the distinction between monitoring and screening. She noted monitoring diseases remotely is generally safer than screening remotely, because the stakes are lower. Furthermore, there are certain space and cost constraints at satellite locations, so not all will be able to utilize telemedicine.
Telemedicine also raises cost concerns. Currently, decisions about insurance reimbursements for teleophthalmology are made at the state level. While the majority of states provide some degree of coverage for telehealth services, they typically only cover services delivered via live video, which isn’t appropriate for eye care. Overall, reimbursement rates for teleophthalmology are quite poor, making this a major barrier to widespread implementation of this model. However, some physicians point to the direct and indirect economic cost of blindness to argue that reimbursing this type of screening may eventually pay for itself.
Using Telemedicine to Monitor the Progress of Glaucoma
While the VA program focuses largely on screening, the Kaiser Permanente Eye Monitoring Center launched a pilot project in 2013 to monitor patients who had been diagnosed as low-risk glaucoma suspects. During the program, patients went to a local office to get measurements and tests done, and the data was forwarded to a centralized telemedicine center for comparison with previous visits. A follow-up appointment with an ophthalmologist was required only when disease progress was noted. The program maintained an impressively high adherence rate, with more than 97 percent of patients coming to the first-year appointment and more than 92 percent to the second-year appointment. Four out of five patients said the program was especially helpful and convenient. The program suggests that telemedicine can be beneficial for glaucoma monitoring, especially in the early years after a diagnosis when only small changes are likely to be noted.
