Eyeworld

EW GLAUCOMA 46 December 2016 by Ellen Stodola EyeWorld Senior Staff Writer burden. The best way to talk about reimbursement, she said, is to show how it eventually pays for itself even if there's an initial cost because there will be fewer blind people later. Limitations of teleglaucoma There are some concerns and lim- itations to consider. First, Dr. Lynch pointed out that the system needs to be set up on a secure network, and all patient privacy requirements need to be met. Additionally, some legal issues may need to be worked out, and patients have to under- stand that teleophthalmology, as currently practiced, is a screening tool and not a substitute for a dilat- ed fundus exam. Teleophthalmology has al- ready improved compliance and adherence in the VA. "The general no-show rate for an eye clinic visit nationally is about 15%," Dr. Lynch said. "However, for our patients who undergo teleophthalmology screen- ing in their primary care clinics and who are asked to come in for a clinic-based exam, the no-show rate is less than 1%." A telemedicine program is not meant to replace people but rather to be an extra tool in the toolbox. The remote sites have space and cost constraints, and there will be some patients who are not appropriate candidates. Most patients under- stand that, Dr. Maa said. There's also a difference be- tween screening and monitoring, she said. "Monitoring is relatively safe to do remotely, but screening has slightly higher stakes because you're trying to make sure you don't miss anyone," she said. Dr. Maa has been working with telemedicine since 2011 and specifically with teleophthalmology for the past 4 to 5 years. "It requires a change in thought process, so it takes some getting used to," she said. Dr. Maa thinks ophthalmology is embracing telemedicine because there is an understanding of limited resources, and this helps enhance the number of patients reached. EW Editors' note: The physicians have no financial interests related to this article. Contact information Lynch: reaymary@comcast.net Maa: amaa@emory.edu care clinics, Dr. Lynch said. An oph- thalmology technician is stationed in the primary care clinic with sev- eral diagnostic pieces of equipment. "All the clinical information and images are uploaded to an electron- ic health record shared with the eye clinic, and an ophthalmologist reviews the information on the same day." Patients with suspicious find- ings are called and scheduled in the eye clinic for a face-to-face exam. Through teleophthalmology, there has been increased access to care for patients who live far from the main eye clinic, Dr. Lynch said. By moving basic eyecare services to the rural primary care clinics, patients are more likely to keep their appointments and physicians are more likely to pick up serious conditions, Dr. Lynch said. "Of those patients we have screened and who have come in for a face-to-face exam, 57% have been diagnosed with a significant ocular condition of which they were unaware." Dr. Lynch said that approx- imately half of the patients with glaucoma in the U.S. are unaware of their condition. "Economics, dis- tance, and personal issues prevent many patients from seeking care in a traditional eye clinic setting," she said. "Having the teleophthalmology exam right next to the primary care exam has been a winning strategy." She added that about 65% of the patients screened have no visu- ally significant findings, but about 35% are asked to come into the eye clinic for further testing. Reimbursement options Decisions about the reimbursement for teleophthalmology are made at the state level, Dr. Lynch said. "Currently 48 states provide some coverage for telehealth services but only for those services delivered via live video," she said. "Live video is appropriate for telemental health but not for eyecare." Reimbursement can be tricky in this type of system, Dr. Maa said, adding that part of the issue is reim- bursement for teleophthalmology right now is poor. This is a major barrier to widespread implementa- tion. Most of the time when looking at teleglaucoma, it's a cost avoidance model, Dr. Maa said. Blindness has quality of life costs for patients and families, as well as a direct economic "I think teleglaucoma is useful as a tool to allow patients to get care closer so that compliance is hope- fully better," Dr. Maa said. It also helps address the growing number of people who have glaucoma. "In the next 30 to 40 years, the National Eye Institute has predicted that the number of people in the U.S. with glaucoma will more than double," Dr. Lynch said. "More than half of the people with glaucoma do not know they have it." This indicates two problems: increasing numbers of people with a poten- tially blinding, incurable disease and a large proportion of those people unaware of their condition. The conventional model of eyecare delivery—where patients self-seek an examination by an eyecare provid- er—hasn't been effective at detecting glaucoma and is not equipped to handle a doubling of the patient care needs, she said. "In the VA, we have started thinking about eyecare delivery in a new way, as a spectrum of needs: basic, intermediate, and advanced. We are targeting specific resources to support each level of care," Dr. Lynch said. With glaucoma, basic eyecare would be screening patients for the condition. Intermediate care would include the testing it takes to determine whether or not glaucoma exists, monitoring patients at risk for the development of optic nerve damage, and the management of early, stable glaucoma. Advanced care includes the management of patients with unstable and/or advanced glaucoma and surgical interventions, Dr. Lynch said. How a teleglaucoma clinic could improve access A teleglaucoma system is set up depending on what you're trying to do, Dr. Maa said. Sometimes it's about screening for glaucoma. Other times it's about monitoring patients. Once treatment starts and patients are stable after seeing their physi- cian, they might be sent to a remote site for follow-up where they can get information and the physician can follow them remotely, she said. The teleglaucoma clinic is usually a satel- lite that's much closer to the patient than the physician's main office. Currently the VA is using tele- medicine to extend basic eyecare services to patients in rural primary S ince glaucoma is a com- mon problem in the ophthalmic community, it's important to be able to catch and treat it early. April Maa, MD, assistant professor, Emory University School of Medicine, and director of the Technology-based Eye Care Services (TECS) program and comprehensive services, Atlanta Veterans Affairs Medical Center; and Mary Lynch, MD, professor, Emory University School of Medicine, and Atlanta Veterans Affairs Medical Center, discussed options for telemedicine as a tool for diagnosing and moni- toring patients who have glaucoma but who may not be able to make regular trips to the ophthalmolo- gist's office. In a conventional glaucoma treatment model, the expectation is that patients repeatedly go to an eye clinic and take their eye drops, but this is difficult for many to sustain long term, particularly with the as- ymptomatic nature of glaucoma. The burden of the number of visits to make sure patients stay healthy and don't lose vision is very high and tasking for physicians and patients, Dr. Maa said. Options for telemedicine in glaucoma Glaucoma editor's corner of the world T echnology will increasingly change our delivery of eyecare in general and glaucoma in particular. This is a trend that is just beginning. The VA is the biggest health care system in the U.S. and has been a leader in incorporating telemedicine advances into their primary care clinics. Some of these same strategies are now being utilized for glaucoma care. The VA has needed the decentralized approach of telemedicine to enable its patients to re- ceive care locally as much as possible and avoid the long trip to the closest facility. The results of the VA projects with telemedicine have been impressive. We are fortunate to have April Maa, MD, and Mary Lynch, MD, share their experiences. Teleglaucoma has led to improved access to care, high rates of discovery of undiagnosed glaucoma pathology, and lower no-show rates when patients are sent to the VA center. Reay Brown, MD, Glaucoma editor

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