Telehealth and artificial intelligence hold the key to breaking down some of the biggest eye health inequities in Australian ophthalmology. But the sector needs to find ways for real-world implementation, says DR ANGUS TURNER.
The tyranny of distance in Australia – and the subsequent eye health disparities for rural and remote communities – was the focus of Dr Angus Turner’s presentation at SCC 2022 that offered new solutions by way of technology. Could optical dispensers play a role in eye disease telehealth consultations, and what impact could artificial intelligence (AI) have in addressing diabetic eye disease detection rates in outback communities?
These questions were posed in his discussion entitled ‘Integrating telemedicine and artificial intelligence into eyecare services’, where he outlined the real-world efficiencies brought about by telehealth consultations in eyecare. This technology is applied in regional and rural Western Australia where he founded the Lions Outback Vision outreach program.
Before going into his points, it’s important to define telehealth in eyecare. The current MBS reimbursement, introduced in 2015, for a telehealth consultation requires the optometrist and patient to be present together while an ophthalmologist participates via online video technology.
These MBS items are restricted to patients who are in ‘telehealth eligible’ areas which is non-metropolitan and outside a 15km radius from the treating ophthalmologist. This restricts use to those outside metropolitan areas, unless they are providing care in an aged care facility or for Aboriginal patients.
Turner started by outlining the slow traditional pathway to the ophthalmology clinic where a GP or optometrist writes a referral letter with the patient often waiting a long time to be seen in the tertiary eye clinic. This is exacerbated in regional and remote areas where the number of fulltime ophthalmologists per 100,000 people is much lower than in metro areas.
However, he said telehealth helps to expediate this pathway. Optometry practices are much more accessible for regional communities, with the optometrist able to perform the necessary tests and image acquisition. With these results in hand and the patient present, they can then schedule a video call with the specialist who then guides the diagnosis and treatment plan.
Highlighting the benefits brought about by telehealth, Turner said it provides patient-centric management; they’re able to view the images being discussed and reasons for diagnosis. It also formalises a medical record and makes it easier to follow through with what was discussed. Importantly, it makes specialist care more accessible, while creating patient retention for local optometry practices.
In addition to convenience for the patient, telehealth has been shown in peer-review papers to drive better eye health outcomes, including a halving the wait time for cataract surgery, a 10 times increase in access for Aboriginal people when an on-call service was introduced and high patient satisfaction. A systematic review also showed outcomes were equal or better with telehealth compared to regular specialist care, it improves surgeon efficiency and eliminates duplication, and reduces and eliminates pre- and post-op visits.
“So what cases can we use telehealth for?” Turner asked.
“It turns out the bread and butter of surgeons’ work, which is cataract, pterygium and various laser treatments, can all be expediated through telehealth because with good OCT scans, fundus images (if possible, depending on the cataract grade), and exam of eye, there is no point waiting for that clinical appointment with a specialist,” he said.
“It’s also useful for any aspect of optometry that carriers a risk outside their comfort zone, and you can talk to the specialist about anything through telehealth, it’s a great upskilling tool (disease process, acute management, contraindications), and certain cases require collaborative care by law (glaucoma and progressive cases), so we need to chat about those anyway and this process makes it easy.”
He said telehealth can also be used for systemic associations, and for talking through the case history with the guidance of the specialist, as well as discussing straight-forward surgical and procedural plans and direct bookings such as cataract, intravitreal injection, curettage, YAG peripheral iridotomy and capsulotomy.
Barriers to uptake and future prospects
While telehealth works well when executed correctly, Turner acknowledged it’s not always straight forward getting the optometrist, specialist and patient on the same call at the same time, especially if one is running late.
“A certain amount of rhythm needs to be established between the two healthcare practitioners to understand how the process works so one isn’t left waiting with the patient, so logistics is the key; it takes some goodwill, a bit of practice and understanding of rhythm.”
In terms of the future prospects for telehealth in optometry, Turner said there was a need to discuss dispenser and optometric assistant driven opportunities, so optometrists can provide reports and imaging, but not have to be present for all tasks. It also offers opportunities for more co-management and efficiency, especially in regional areas.
In a trial that was granted ethics approval and coincidentally conducted as COVID forced border closers, Turner said they tested telephone-based and hospital-based telehealth, which both hinged on the importance of a good optometry assessment.
In telephone-based telehealth, the patient was assessed at the nearest optometrist. If they lived hours away, the ophthalmologist would then receive the clinical information via the Oculo referral system, and then phone the patient at home.
“And that way the patient doesn’t have to come all way back to sit in the specialist’s rooms again. They might also have visual impairment and find the landline is more useful, so it worked quite well for certain patients,” Turner said, also noting the difficulties the visually impaired have with videoconferencing and travel.
The hospital-based telehealth concept put to work ophthalmic equipment such as OCTs, visual fields, and biometry machines that are located in public hospitals, but used infrequently by visiting specialists. In this case, an optometrist was able to run a clinic in the hospital and conduct work-ups for surgery.
“In the end, the outcomes showed that a third (28%) of patients were able to be discharged completely by telehealth, another third (35%) were sent for specialist review (laser or injection/face-to-face clinic), a quarter (25%) needed surgery booked directly, and 12% could be followed up and plan developed via telehealth,” Turner said.
“As you can see, telehealth halves the amount of work a specialist has to do in person or face-to-face – and that’s got to be worth something when there is a low workforce.”
AI in eye health
Another major technological puzzle piece to overcome distance barriers to care is AI. Turner’s presentation focused on applying the technology to diabetic eye disease, which his team’s recent study found affected Aboriginal people more than non-Aboriginal.
“We thought diabetic retinopathy affected Aboriginal people as much as non-Aboriginal, but a recent systematic review showed that’s actually not the case; we knew there was a higher prevalence, but we didn’t know retinopathy was more worse or severe,” he said.
Turner said many patients were not getting recommended screening checks, with data showing 28% haven’t been checked in the Kimberley region. This added impetus for new ways to make it easier for patients to receive a screening grade on the spot.
Lions Outback Vision is conducting projects to address this in Australia collaborating with Google, the Centre for Eye Research Australia (CERA) and Eyetelligence, and Topcon and Thirona, applying their deep learning systems (DLSs) in this space.
With the Google technology, Turner said they wanted to validate this in a large group of Aboriginal people in an urban setting (Perth), using 1,682 retinal images from 864 diabetic patients. It was compared against findings from retinal specialists, including a three-person adjudication panel as a reference standard, and was shown to be significantly more sensitive (98%) compared to human graders (96%) for more than mild DR and vision-threatening DR, with a slight drop in specificity (95%) vs human graders (96%).
The system was also applied to diabetic macular oedema, which brought in OCT scans alongside fundus images, combining of multiple datasets from around the world. It was shown to have non-inferior sensitivity and higher specificity than human graders.
Turner then provided an update on a second DLS: the CERA-Eyetelligence system developed by Professor Mingguang He. Using a different algorithm, it showed overall referrable retinopathy was found in 96.9% of patients and 87.7% specificity. However, a subgroup analysis saw the specificity reduced to 70% in Aboriginal patients for various possible reasons.
The final DLS (Topcon-Thirona) has been installed in five clinics in various clinical settings, including the Lions Outback Vision Van, optometry and an Aboriginal medical service.
“These machines are a fantastic tool taking a colour photo and OCT at same time. With the first 100 eyes compared to retinal specialists, two eyes had incorrect diagnosis and 80% had the correct diagnosis if the probably score of that disease was more than 50%,” Turner said.
“At the moment, this is all research, however Thirona and Eyetelligence are TGA-approved and can be used in Australia. But how to incorporate them into our flow to ensure patients get a point-of-care test is a current area of focus for real world implementation.
“The future is bright if Aboriginal health workers can have a traffic light system to grade their diabetes, and tell the patient they are fine at the moment and see you in one year, or you need a referral let’s talk to a specialist right now about what that means, that will be very beneficial.”
Northwest Hub Update
Turner also provided an update on the Northwest Hub, the first permanent eye clinic in the sparse Kimberley region based in Broome.
Lions Outback Vision (LOV) has transformed a former backpacker accommodation into a new eyecare facility, featuring at least two resident ophthalmologists available for 24-hour emergency support including retinal surgery.
The second phase of the facility opened in October, with the service to feature a hub-and-spoke model servicing six towns through outreach services, while providing access to ophthalmology and telehealth clinics, seminar rooms and open space for community diabetic health education. The new part will also house an area for optometry education, research facilities and a café.
The facility has been made possible through philanthropic donations from Wen Giving/Hawaiian, the Federal Government, Zeiss, Topcon, Alcon, Novartis, Fred Hollows and Australian Capital Equity. A $4.7 million Western Australian Government investment will help to employ the eye health workforce.
Turner also touched on the new University of WA optometry school that will soon begin turning out its first graduates with a cohort spending a term of regional practice at the new Kimberley Hub.
“WA rural still has lowest access to optometry in Australia, according to recent 2020 stats, so we need to do something about that maldistribution. This optometry school will be sending students to Broome and Geraldton so it will be giving them a taste of country practice and some will say they want to do this rest of my life, so we look forward to this in future.”
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