Doctors place focus on delivery of care
Has the time come for widespread adoption of telemedicine screening for retinopathy of prematurity (ROP)?
Dr William Good, suggests that many of the supposed advantages of ROP telemedicine are misleading, but that it could eventually have a useful role.
Communication is awkward, since parents, neonatologists and nurses have no idea what the doctor has seen. Following up on patients requires remembering retinal appearance and recognizing disease progression and if a second opinion is needed or disease is severe, a local expert must be found immediately or arrangements made to transfer the baby elsewhere. The expert who examines the baby must rely on the original sketches and perhaps a description given by phone before transferring the baby back to the ophthalmologist's care or performing laser treatment.
In the second strategy, the examiner takes a detailed look at wide-angle retinal images that can be manipulated to emphasize or highlight certain features. To make clinical decisions, the ophthalmologist measures and compares directly on the images to identify plus disease or zone 1 disease. Documentation is performed by placing the images in the medical record, and communication is easy because everyone can see these images. During follow-up, old and new images can be compared side-by-side. Second opinions can be obtained immediately through secure access to experts throughout the world who can view the series of images.
While acknowledging the important role of ophthalmoscopy in the first scenario, Dr Chiang commented that it was a legitimate question to ask who would choose this technique over the second strategy if both were developed at the same time.
"Indirect ophthalmoscopy is time-intensive and logistically difficult and huge amounts of travel time and coordination time are required," Dr Chiang said.
"It's often subjective and qualitative, and these hand-drawn sketches are a very imprecise way to document findings," he said. "There is enormous medico-legal liability, possibly the biggest in all of ophthalmology, and there are major problems involving ophthalmologist access."
Telemedicine programmes for ROP have been operational since the early 2000s at several major medical centres.
There have been no known cases of treatment-requiring ROP that were missed by telemedicine in these programmes, he continued and predicted that telemedicine images eventually will be integrated into electronic medical records systems and computer-based diagnostic algorithms for identifying plus disease. He cited research studies that demonstrated extremely high accuracy of telemedicine for ROP diagnosis, including cases where it may have been better than indirect ophthalmoscopy exam.
"All of us want to improve the delivery of care and this is a situation where technologies can be applied to … make things [continuously] better," he concluded.