Evolving telehealth services are significantly improving eye health in remote Western Australia. Optometrists and ophthalmologists are working collaboratively to screen, diagnose and book patients in for outback surgery using realtime video technology. But there’s still more to be done.
Lions Outback Vision has provided teleophthalmology consultations to rural Western Australia since 2011. Our telehealth clinics augment regular ophthalmology and optometry outreach clinics, and support resident local optometrists.
The evolution of telehealth in Australia has enabled the service we provide to move from pilot studies and novelty projects to an integrated daily service that has impact by reducing waiting times, providing continuity of care, and improving efficiency of outreach ophthalmology trips. All this leads to better outcomes for the patients and improved satisfaction with the services.
REALTIME VIDEO CONFERENCING
We started our service in 2011 to take advantage of an Australian government initiative. The government had decided to try something different for telehealth, and launched ‘realtime’ videoconferencing. There were high hopes that it would bridge the rural-city access problems for healthcare. The idea was that you could sit with your GP, call a specialist and conduct the consultation in real-time on video.
94 per cent of optometrists in the regions visited by Lions Outback Vision participated in telehealth in the first year of the new item numbers being introduced
This could happen on any platform, such as skype or facetime, and didn’t need fancy software.
When it came to eyes, sadly the initiative didn’t work. Although there was the odd GP who has a passionate interest in eyes, they are few and far between… and even though I like to think the eye is the most important organ, it turns out GPs have a lot more to manage on their plate.
In our first year it was actually rural optometrists who embraced the telehealth service. So with this in mind, an Ophthalmic Research Institute of Australia (ORIA) research project modelled the same realtime ‘government telehealth initiative’ but included optometrists to facilitate the consultation. It made sense – after all, they have the cameras and technology for excellent eye imaging as well as clinical skills to provide the ocular assessment.
Associate Professor Angus Turner conducting telehealth outside Nickol Bay Hospital in the Pilbara
Jigalong patient and carer being supported by Stephen Copeland, optometrist.
Stephen Copeland, visiting optometrist, working with telehealth patient.
Stephen Copeland, visiting optometrist summarising a patient condition.
The trial was successful and the nature of the referrals evolved. Initially optometrists only used the realtime videoconferencing for acute presentations such as a red eye and diagnostic dilemmas. Now, with more routine use of optical coherence tomography, there are many more cases booked with an obvious diagnosis that need to be fixed with surgery. Buoyed by these positive findings and advocacy, which included education modules and support from the Royal Australia and New Zealand College of Ophthalmology (RANZCO) and Optometry Australia, Medicare moved swiftly to provide funding, introducing the Medicare item numbers 10945 and 10946 for optometry-facilitated telehealth with a specialist.
Analysis of three audits of all optometry referred teleophthalmology consultations undertaken over the same five-month period in 2012, 2014 and 2016 clearly showed that realtime videoconferencing was having a positive impact. The average monthly frequency of consultations increase significantly (Figure 1) and the trajectory continues with well over 100 consultations performed per month in 2017. Interestingly, there has been a shift towards chronic eye disease and a greater number of referrals are now accompanied by relevant imaging or investigations. Surgical management as an outcome, has increased since 2012 – while there were no patients booked directly in that first year, now over 50 per cent of patients are being directly listed for surgery as a result of teleophthalmology consultations. This significant finding highlights the need to embed a telehealth program within an outreach or visiting ophthalmology service to provide surgical management.
Figure 1. Average frequency of teleophthalmology consultations in each audit year. P-values indicate significant change from the previous audit period.
POSITIVE OUTCOMES
The direct booking to surgery for half the patients has achieved three main outcomes:
1. It has eliminated the ‘wait for the waiting list’ which is the well-documented wait of up to one year for public service outpatients prior to being placed on the waiting list for surgery.1
2. The outreach trips ratio of surgery: clinic has reversed, with more surgical management now taking place, which means the visiting team is able to have greater impact on visual outcomes.
3. Distillation of patient pathology means a great proportion of primary eye care is now being appropriately managed by optometry with less duplication of patient assessment.
| The Northwest Hub – a Proposal |
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| Significant progress has been made in reducing blindness and vision loss, but more needs to be done.
With a population of 100,000 people in north-west Australia, at least three full time specialists are needed to service this vast region. However, no specialists reside there, and outreach only manages to provide one tenth the access compared to urban areas. The ‘fly-in-fly-out’ (FIFO) model, which enables outreach teams to visit remote areas and transfer patients to the city, is not sustainable, particularly as the burden of disease and treatments increases. For example, modern treatment for diabetic eye disease needs monthly visits to keep people at work. To overcome this problem, Lions Outback Vision has developed the concept for a regional ‘hub and spoke’ eye health model, located in Broome, with outreach to ‘Nodes’. The Hub has been designed to directly address existing barriers to closing the vision gap in the NW. From here, weekly optometry and ophthalmology services will be delivered throughout the Pilbara and Kimberley with outreach to regional Nodes, including Karratha; Port Hedland; Fitzroy Crossing; Halls Creek etc. The services delivered will include: • Clinics (includes telehealth) • Surgical facilities • Education and training facilities • Junior doctor short-stay apartments • A diabetic nutrition hub and commercial kitchen • Parking for mobile clinics • Capacity to share facilities and foster collaboration with visiting specialists to co-manage diabetic complications Broome was chosen as the site for the hub because it reduces the barriers in attracting professionals to a remote location. It offers good infrastructure, work opportunities for spouses and a stable community over other regional destinations. Importantly, government and sector support is needed to bring the Vision to fruition for the people of northwest Australia. |
MASKED TRIAL COMPARES ACCURACY
It has been important to compare real-world equivalence of telehealth diagnostic accuracy to a gold standard. After conducting a systematic review on the useful outcome measures for this comparison,2 a trial was designed to assess, in a masked fashion, whether telehealth assessment was equivalent to routine ophthalmology assessment.
A pilot study of the first 50 patients demonstrated diagnosis and management outcomes of real-time teleophthalmology had high agreement with standard face- to-face consultation for the diagnosis of cataract, and surgical waitlisting (k=0.86).
A final significant highlight of the telehealth service has been the extraordinary attendance rates achieved – with only 3 per cent non-attendance. This is in stark contrast to the average of 50 per cent in the community visits. Patients also demonstrated very high satisfaction, which was evaluated in 2015 in a published study.3
Engagement and uptake with optometry has been remarkable – 94 per cent of optometrists in the regions visited by Lions Outback Vision participated in telehealth in the first year of the new item numbers being introduced.
EVOLVING TECHNOLOGY DRIVES SERVICE
The telehealth services will continue to evolve as the technology for the videoconference services becoming ubiquitous (in the form of smart phones/ tablets), the use of OCT becomes standard and more available, and we experience improved cellular reception. New trials with hospital-based optometrists and registrars in the regions are planned for 2018 to continue improving the access to eye care in remote areas, and we will continue to tackle the issue of long-term workforce maldistribution, which hampers adequate eye care services in regional and remote areas.
| The Reality: Change is Possible |
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| The majority of existing eye issues in North West (NW) Australia are both preventable and curable.
96,646 Total population of Northwest WA who are exposed to lower levels of eye-care1 27% Proportion of these who identify as Aboriginal and Torres Strait islands (A&TSI)1,2 14x Comparative rate of NW A&TSI blindness and vision impairment due to diabetes relative to the national average 35% NW A&TSI adult population who have never had an eye examination (~7,930)3 11% NW A&TSI population who are vision impaired or blind (~2,500)3 95% Preventable vision impairment and blindness in Indigenous population3 References: 1 ABS 2016 2 ABS 2011 figures. ABS 2016 includes 24%, with an additional 13% who did not state an indigenous status 3 National Indigenous Eye Health Survey 2009 |
References
1. Quang Do, Vet al. Are cataract surgery referrals to public hospital s in Australia poorly targeted. Clin Exp Ophthal 2017.
2. Tan I, et al. Real-time teleophthalmology versus face-to-face consultation: A systematic review. J Telemed Telecare 2016.
3. Host B, et al. Real-time teleophthalmology: an analysis of patient satisfaction in rural Western Australia. Clin Exp Optom Jan 2017 .
