THE HOT-button issue of remote technology is likely to bring a visceral response from many optometrists. It is one debate in the larger discussion of how remote technology will play a greater role in the provision of health care to millions of consumers worldwide. Here, we discuss the realities and challenges of remote technology in the delivery of health care and, in particular, eye care, both now and in the future (See “Wearables for Vision and Ocular Health?” p.28.)
TRENDS IN TELEMEDICINE
As we go to press, an IOP-self-monitoring device has received FDA clearance (ICare HOME, ICare USA). The patient uses the self-tonometry device at home. The results, not displayed to the patient, are retrieved electronically by the health care provider.
Diabetic retinopathy (DR) screening represents another example of telemedicine. Here, trained clinical staff acquire retina photographs and send them electronically to retina specialists for interpretation. Several years ago, a telemedicine network in North Carolina, increased DR evaluation rates from 32% to 71% within a year after the program launched.
Late last year, the JAMA Network reported that an algorithm, based on deep machine learning, had high sensitivity and specificity for detecting referable DR in fundus photographs. The report points toward a trend in automated detection.
More recently, an American Diabetes Association (ADA) position paper stated no consensus exists on whether telemedicine “represents an improvement” over screening by eye care professionals for DR. The paper reports that telemedicine works best when patients have limited access to providers, due to distance to the provider or low provider/patient ratios, or when “the alternative is no patient screening.”
Yet consumers are reading headlines, such as “How Telemedicine Is Transforming Health Care,” which contains the statement “ . . . telemedicine is finally living up to its potential,” from a Wall Street Journal article (June 26), making it clear: Many consumers are becoming comfortable with remote approaches to managing their health care. (See “Top Telemedine Apps,” p.27)
Telemedicine has been given a boost through smart device use. (Are you reading this article on your mobile device?) Using apps, these devices can transmit certain personal health information in real time in the patient’s own environment, instead of the “artificial” environment of a professional office.
By the Numbers
Telemedicine is on the rise, shows these statistics:
- 64%. Patients who said they would undergo a video telehealth doctor visit, reports American Well’s 2015 telehealth survey.
- 350,000 to 7 million. The projected growth of telemedicine patients from 2013 to 2018, reports The IHS report, “World Market for Telehealth” - 2014 Edition
- 34. States that have active laws governing private payer telehealth reimbursement policies, reports the “Center for Connected Health Policy’s State Health Telehealth Laws and Reimbursement Policies Report,” April.
- 35%. The number of employee on-site health facilities that offer telemedicine services, reports the “Towers Watson 2015 Employer-Sponsored Health Care Centers Survey.”
- 15. Number of states that enacted anti-remote vision testing laws as of March 2017, according to the AOA.
As the sophistication of smart devices continues in eye care, we likely will see testing via virtual reality in various scenarios, at different distances, in different light conditions and with different visual targets. These likely will be a significant improvement over the black letters on a white screen at a fixed distance.
Something else to consider: Remote technology might lead consumers to purchase multiple pairs of eye wear that are specific to their visual needs, instead of the one pair of universal glasses that they think “solves” all their problems. Remote technology also might change the economics of eye care by providing optometry with processes that are faster and more efficient. For example, some remote tests might free up the doctor and staff, as these may require little or no office time to administer.
EYE CARE CHALLENGES
Remote eye care is not without challenges. Some consumers don’t own a mobile smart device. Others will prefer talking to people, rather than a device.
In a 2016 study of 500 tech-savvy consumers, the consumer health engagement company HealthMine found that 45% of those who have telemedicine access have not used it. Of these non-users, 42% said they preferred a traditional provider, and 28% said they didn’t know when it was appropriate to use telemedicine. Of course, views may change as consumers become more familiar with, and trusting of, the technology, for better or worse.
Top Telemedicine Apps
Healthline, a consumer health information site, chose the following telemedicine apps as the best of 2016, based the apps’ user ratings and quality interfaces.
In terms of technology available for remote refraction tests, many questions need to be answered regarding accuracy, repeatability and sensitivity. “Currently available technology” may only be able to measure lower-order refractive error, such as myopia, hyperopia and astigmatism, and not the higher-order aberrations, such as coma, trefoil and defocus that cause many “unexplained visual issues.” The latter can be determined with advanced office-based technology.
In addition, although current remote refractive technology has limitations, it may still lead to subjective user errors of +/- 0.25 to 0.50 or more, users of future remote technology may test their vision in fluctuating light conditions, vs. a real-world lighting environment, that also could lead to errors.
Further, remote technology may not pick up the early forms of many ocular diseases, such as dry eye disease, allergy and lid margin disease, that affect the 20% to 50% of our populations who are currently being observed and treated by providers in the foreseeable myopic future. Chemical markers, such as immunoglobulins, endocrine markers, tissue-modulating markers or osmolarity currently can be tested only through in-office technology.
Would these exams require a trained professional to administer? That depends on several factors, including test design and the technological proficiency of the consumer. But what if the technology becomes no more challenging to use than a consumer-centric technology, such as the iPhone or iPad?
Also, there is the issue of consumer education. Aside from the limitations of the remote refractive technologies, as described above, optometrists must disclose and educate consumers that vision is only part of the eye exam and that health monitoring is still crucial.
Obviously, all of the tests require scientific validation. That said, it is in the realm of near-term possibility that health monitoring through an interactive, interoperable retinal or overall ocular imaging system may soon be able to perform many wellness exams. If this information were simultaneously transferred to an ECP for interpretation, many of the ethical concerns and legal arguments might become irrelevant.
Consumer demand drives the success of any innovative technology. Here is both the saving grace and the ultimate challenge of the remote examination and the consumer: Many consumers will still want the hands-on experience of an in-person examination. That said, many younger consumers desire ease of access and are completely comfortable getting and giving their information through their mobile devices and an app, so long as they see value in it.
Remote testing, including eye exams, will not happen overnight, but it also will not wait decades. By being aware of the pluses and minuses of remote technology, you can prepare for how you will deal with, accept or adopt these technologies through the future of your career. OM
Wearables for Vision and Ocular Health?
Today’s wearables, such as the Fitbit, can monitor body temperature, blood pressure, heart rate and skin hydration. A “pregnancy wearable” that measures contractions was launched at this year’s Consumer Electronic Show in Las Vegas.
The utility of eye-related wearables may extend beyond vision to include ocular and systemic health. For example, contact lenses that can monitor aqueous humor glucose levels may someday extend to include extraocular or intraocular devices that constantly measure IOP and other potential biochemical markers. This real-world, real-time big data analysis may provide insights that will revolutionize the management of disease states.
For example, in the IOP patterns of tens of thousands of primary open-angle glaucoma patients, we might find some trends in night time perfusion pressure that could alter the therapy we decide to prescribe. Or, imagine measuring oxygen and metabolic by-product concentrations induced by poor contact lens fitting that would lead to better patient comfort, care and health.
Taking this one step further, continual monitoring that would be available for diseases, such as glaucoma or various other vascular diseases, such as diabetic retinopathy, could provide invaluable information that could be used to tailor management plans or even specific treatments for individual patients to a certain time of the day with a certain drug — and even real-time feedback if the “new” timed therapy is effective. Now, physicians could monitor on a daily, weekly and monthly basis and have a phone or electronic consultation to alter medication, if needed.