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Optometry Facilitated Teleophthalmology: an Audit of the First Year in Western Australia

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Optometry Facilitated Teleophthalmology: an Audit of the First Year in Western Australia CLINICAL AND EXPERIMENTAL RESEARCH Optometry-facilitated teleophthalmology: an audit of the first year in Western Australia Clin Exp Optom 2018 DOI:10.1111/cxo.12658 Stephen E Bartnik* BSc MBBS MMed Background: Lions Outback Vision has run a state-wide teleophthalmology service since Stephen P Copeland* BAppSc (Optom) 2011. In September 2015 the Australian federal government introduced a Medicare reim- Angela J Aicken* DipBus bursement for optometry-facilitated teleophthalmology consultations under specific circum- † Angus W Turner* MBBS MSc FRANZCO stances. This audit demonstrates the first 12 months experience with this scheme. We aim *Lions Outback Vision, Lions Eye Institute, Perth, to provide practical insights for others looking to embed a telemedicine program as part of Western Australia, Australia delivering outreach clinical services. † The Centre for Vision and Ophthalmic Science, Methods: A 12-month retrospective audit was performed between September 2015 and The University of Western Australia, Perth, Western August 2016, inclusive. A research officer used a specifically designed data extraction tool to Australia, Australia record information from all teleophthalmology consultations performed in the time period. E-mail: [email protected] The primary outcome was the diagnosis at the end of the teleophthalmology consultation. Secondary outcome measures included the number of teleconsultations, cataract surgery rate, remoteness area of patients referred and imaging accompanying the referral. Results: In the 12-month period, 709 patients were referred resulting in 683 teleophthalmol- ogy teleconsultations. Cataract was the most frequent diagnosis (n = 287, 42.7 per cent), fol- lowed by glaucoma (n = 77, 11 per cent), age-related macular degeneration (n = 30, 4.4 per cent) and diabetic retinopathy (n = 26, 3.8 per cent). Of those who had teleconsultations, 98.6 per cent were from Outer Regional, Remote or Very Remote Australia. One or more accompanying images or investigations were part of 349 (49 per cent) teleconsultations, most commonly optical coherence tomography (215, 30 per cent) and fundus photography (148, 21 per cent). Face-to-face consultations were undertaken at an outreach clinic in 23 (3.4 per cent) cases, to determine the diagnosis. There were no statistically significant factors associated with attendance at teleophthalmology consultation, or for successfully undergoing cataract surgery. Submitted: 22 December 2016 Conclusion: Teleophthalmology is a valuable adjunct to regional outreach ophthalmology Revised: 17 December 2017 services, providing patients with increased access to specialist care for a wide range of oph- Accepted for publication: 18 December 2017 thalmic conditions, and more efficient access to surgical care. Key words: ophthalmology, optometry, telehealth, telemedicine, teleophthalmology Over the last decade the field of telemedi- Ophthalmology has been at the forefront teleophthalmology service as an adjunct to cine has developed from an interesting of telemedicine research, in part due to the its co-ordinated ophthalmology and optom- research modality1 to an established and already established use of imaging and the etry outreach services since 2011.11 The evidence-based mode of service delivery.2 lack of access to specialist ophthalmology ser- program combines store-and-forward and Telemedicine has been defined as the use vices in regional areas.4 Teleophthalmology is real-time teleophthalmology modalities. of a range of technologies to provide medi- a widely accepted term for the use of tele- A typical teleconsultation involves an initial cal care over a geographical distance.3 Tele- medicine to provide ophthalmology telecon- examination by the optometrist who takes a medicine can be broadly grouped into two sultations.5 Research to date has explored history and organises relevant scans and categories: store-and-forward and real-time. the use of teleophthalmology in screening for images. This information is forwarded to the Store-and-forward telemedicine refers to diabetic retinopathy6 and glaucoma,7 shared ophthalmologist who then participates in a the process of collecting information to be care models of care for glaucoma,8 in the real-time teleconsultation with the patient reviewed at another time by a specialist. emergency department,9 in rural outreach and local optometrist via video conference, However, real-time telemedicine requires clinics,1,10,11 and for the assessment of reti- either immediately if available, or otherwise face-to-face interaction between the pro- nopathy of prematurity.12 at a later scheduled time. vider and patient via a videoconferencing Lions Outback Vision, based in Perth, In 2014 Lions Outback Vision demon- platform. Western Australia, has been running a strated that providing a teleconsultation © 2018 Optometry Australia Clinical and Experimental Optometry 2018 1 Optometry-facilitated teleophthalmology Bartnik, Copeland, Aicken et al. reimbursement to optometrists for provid- Service during the 12-month period from Lions Outback Vision ophthalmologists ing a teleophthalmology consultation led to September 2015 to August 2016 inclusive. conduct consultations using their internet- significantly more teleophthalmology con- Appointments were made by community connected laptop or smart phone. While sultations being performed.13 This research optometrists via a secure booking form on some consultations are conducted from the evidence was used to successfully lobby the the Lions Outback Vision website. The main clinic site in Perth, Western Australia, Australian government to provide funding patient was then assigned into the next many are done from regional areas at the for a reimbursement through the public available appointment slot, or if the matter end of an outreach clinic or surgery day. health system, Medicare. In September was urgent a teleconsultation was con- A part-time administrative assistant is 2015 a Medicare Benefit Schedule reim- ducted as soon as the ophthalmologist was employed by Lions Outback Vision to coordi- bursement for optometrists was introduced available. Once the teleconsultation was nate the booking of teleconsultations, and to facilitate teleophthalmology consulta- completed, a research officer reviewed the to follow up on outcomes such as surgery tions. The reimbursement was made avail- teleconsultation note and recorded a stan- bookings following a teleconsultation. able to optometrists to provide real-time dard set of information using a custom- teleophthalmology consultations with oph- designed data collection tool. If there was Outcome measures thalmologists for patients that are at least uncertainty about the information, it was The primary outcome measure was the 15 km by road from the ophthalmologist resolved by discussion with the ophthalmol- diagnosis at the conclusion of the teleophthal- providing the service, are based at an ogist who performed the teleconsultation. If mology consultation. Secondary outcome mea- Aboriginal Medical Service, or are in care at a teleconsultation was booked, but not com- sures included number of teleconsultations, an aged care facility. pleted (for example as the patient cancelled cataract surgery rate, remoteness area of The aim of this audit is to assess the first the appointment) this was recorded as a patient, and imaging accompanying referral. year of Medicare-funded teleophthalmology ‘did not attend’ for the purposes of data Standard demographic details were col- consultations performed by Lions Outback analysis. lected about each patient including age, Vision, and to provide insight into our pro- gender, Aboriginal and Torres Strait Islander gram for other groups looking to embed a Infrastructure (ATSI) status and postcode of normal resi- telemedicine service as part of a regional The Lions Outback Vision Teleophthalmol- dential address. outreach model of care. ogy Service does not have a minimum infra- structure requirement for referring Data collection and analysis optometrists. Referrals are received from Data collection was performed using a practices with only a slitlamp as well as custom-designed data collection template in Methods practices capable of performing optical Microsoft Excel. coherence tomography, visual fields, and Patient postcodes were classified accord- Ethics wide angle retinal photography. Referrals ing to the Australian Bureau of Statistics This study was granted exemption from for- are sent via a secure messaging system on Australian Standard Geographical Classifica- mal ethics approval by The University of the Lions Outback Vision website, known as tion, Remoteness Area.14 Western Australia Human Research Ethics ‘Oculo’ (Centre for Eye Research, Melbourne, Data analysis was performed in Stata Committee on the basis that it was a review Australia), or via fax or email. (StataCorp, College Station, Texas, USA). of routinely collected clinical data. Video conferencing is performed using Descriptive analysis was performed on the freely available software such as Skype collected outcome measures. The chi- Study design (Microsoft), and FaceTime (Apple). Practi- squared test and univariate logistic regres- This study is a retrospective audit of all tele- tioners are prompted to ensure that these sion was used to test for association ophthalmology consultations performed by platforms satisfy privacy requirements in between categorical outcome variables and Lions Outback Vision Teleophthalmology their area of practice prior to using them. explanatory variables.
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