Teleophthalmology, the remote diagnosis and treatment of eye conditions using internet protocols, can extend eye care access to patients in faraway locations. Studies have shown that telemedicine can also be a cheaper and environmentally friendly alternative to in-person consultation with a doctor for patients without a serious eye condition. The idea of internet-based medical consultation via a smartphone that can reduce our carbon footprint while saving money sounds reasonable. But is it really the case, especially in the eye care field?
To answer that question, Dr. Padmaja Kumari Rani, Network Head of Teleophthalmology at LVPEI, discusses her latest research paper where she evaluated the environmental (carbon emissions) and economic (cost-savings) impact of teleophthalmology for LVPEI’s patients. The study was recently highlighted in the daily newspaper, The Hindu.
What makes teleophthalmology such an effective approach in the eye care toolkit? What got you interested in the advancement of teleophthalmology?
Teleophthalmology can bridge geographical gaps. Even today, most Indians live in rural areas, while most healthcare professionals like ophthalmologists operate from urban locations. This leads to a gap in health care access. Teleconsultations are an effective way of bridging this gap. All that is required is a stable internet connection. Moreover, teleophthalmology saves time and money by eliminating the need for patients to travel long distances.
My journey in teleophthalmology began in 2003. Back then, I was a retina specialist working at Sankara Nethralaya on a diabetic retinopathy project in collaboration with the Indian Space Research Organization (ISRO). We would organize screening programs in remote areas of Tamil Nadu, where patients with diabetes would come to get their eyes screened. Their retinal fundus images would be taken at the site and then transmitted to the base hospital in Chennai using ISRO’s satellite technology, where the images were diagnosed for diabetic retinopathy. That was my first exposure to teleophthalmology. Eventually, I moved to LVPEI, where I became involved in LVPEI’s teleophthalmology and research initiatives, assessing its impact, and developing new strategies for its advancement.
How is teleophthalmology rolled out at LVPEI?
LVPEI uses two approaches to teleophthalmology. The primary teleconsultation system involves 285 primary eye care centers, or ‘vision’ centers. These centers have vision technicians, trained in eye care for two years, who perform a preliminary eye examination on the patients and prepare a report. The report is transmitted over the internet into LVPEI’s electronic medical records (EMR) system. A team of doctors at a tertiary hospital will review the patient data and follow-up with a video call—this process has been integrated into the EMR system. After the teleconsultation, the doctor uploads an e-prescription to the EMR which can be downloaded by the vision technician and given to the patient. The patient is also assigned to one of three color-coded flags based on their need to be referred to a hospital for an in-person consultation. Red means urgent referral within one-week, yellow means regular referral (within one month), and green indicates that the patient can be managed via teleconsultation alone.
The other system is deployed at LVPEI’s tertiary hospitals. A smartphone app called LVPEI Connect (previously known as ConnectCare) can be downloaded by patients who visit these centers. They can use the app to upload their reports and connect with an ophthalmologist at LVPEI, over video call. This system is primarily designed for follow-up patients, so they do not have to travel to an LVPEI tertiary hospital for subsequent visits after treatment. Many patients come from distant locations like Delhi or Assam. Teleconsultation saves a lot of time, money, and effort for such patients. While 75% of the tertiary teleophthalmology system are follow-up patients, the rest are new patients. A lot of new patients use teleconsultations for a second opinion before committing to a treatment plan at a hospital. During the COVID-19 pandemic, we received around 3000-4500 teleconsultations per month via this system. Even now, we have 1000-1200 monthly teleconsultations.
What are the similarities and differences between these two approaches?
Rural areas lack tech-savvy people, so the technicians act as a bridge between the patient and the doctor. The patient does not need to interact with any telecommunications technology, the vision technician is there to help throughout.
We also use vision centers as nodal points for preventive healthcare. Dr. Rao, LVPEI’s founder, believes that healthcare should be close to one’s home and have a permanent presence. A person who knows that a vision center is near their village—sometimes the only eye care option available—can walk in to get their eyes checked by an expert, despite the expert being located several kilometers away.
Meanwhile, the urban populace is usually more tech savvy. So, for them the app-based approach makes more sense.
Ideally, which patients should be opting for teleconsultations instead of an in-person appointment? When is teleconsultation not viable?
Patients with minor eye problems like mild refractive errors or regular preventive eye-checkups are the target demographic for teleconsultations, be it vision center or the app. Patients who have already received treatment at LVPEI and are scheduled for follow-up visits can also benefit from teleophthalmology. However, teleconsultation is not suitable for patients with an emergency such as a foreign body in their eye, ocular trauma, or those with a serious eye condition.
Can teleophthalmology be adopted by other eye hospitals which lack LVPEI’s robust network?
With the rise in internet connectivity across India, I think any hospital can develop their teleophthalmology service. It can be a primary-care or tertiary-care based model depending on the size of the hospital and their resources. Government programs like eSanjeevani can also help scale up a small hospital’s telemedicine set-up to the national level.
But before doing that, it is crucial to invest in an EMR system. Without that you cannot use the cloud to store or transfer patient files and e-transcriptions. Even at LVPEI, the EMR serves as the cornerstone of our teleophthalmology service.
What is the importance and impact of this study?
The climate crisis is no longer a conference topic; we are living in it. Every healthcare system should work towards carbon neutrality. Teleophthalmology is an efficient and effective tool that can help the eye care sector achieve that goal. Around 70-80% of patients do not require any referral. Deferring their travel not only saves money but a significant amount of carbon dioxide emissions. There is a saying, ‘drops of water can make an ocean.’ Adding up the thousands of patients who can avoid unnecessary travel, thanks to teleophthalmology, could over time save an ocean’s worth of fuel.
What are the future directions for teleophthalmology services at LVPEI?
We are working with Infosys to create a smartphone app called SightConnect. The app has AI-assisted protocols that turn the phone’s camera into an ocular screening tool, which the patient can use to screen their own eyes. The app then uses an algorithm to determine if the patient requires a referral (urgent or non-urgent) to an LVPEI hospital.
We have also developed a smartphone hardware attachment called Grabi™, which will allow anyone to take high-quality pictures of their eyes. These pictures can then be uploaded to LVPEI’s teleophthalmology app for assessment of corneal disorders.
We are also working on an AI-enabled referral pathway for patients with diabetic retinopathy called Smart DROP (Diabetic retinopathy outcomes and pathways). All patients with diabetes require a retina examination because they are at risk of diabetic retinopathy. The best way to tap into such patients is to connect with local general physicians who are the go-to doctors for most people. We are working with four Idea Clinics, which will be supplied with AI-assisted fundus cameras from LVPEI. These smart cameras use AI to make a diagnosis, the results of which are transmitted to LVPEI. Any person with diabetic retinopathy gets a referral to visit their nearest LVPEI tertiary center.
Finally, we are using teleophthalmology for education. Dr. Kavya Chandran has helped shape a remote training program for ophthalmology fellows in secondary centers, using teleophthalmology protocols.
Dr. Padmaja Kumari Rani spoke to Sayantan Mitra, Science Writer, LVPEI. Read more about her research here. Read the news article in The Hindu.
Citation
Rani, P. K., Khanna, R. C., Ravindrane, R., Yeleswarapu, S. C., Panaganti, A. K., Thakur, V. S., Sharadi, V., Iype, V., Rathi, V. M., & Vaddavalli, P. K. (2024). Teleophthalmology at a primary and tertiary eye care network from India: environmental and economic impact. Eye (London, England), 10.1038/s41433-024-02934-4. Advance online publication. https://doi.org/10.1038/s41433-024-02934-4
