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Lions Eye Institute, University of Western Australia, Nedlands, WA 6009, Australia
Correspondence to:
Sajeesh Kumar
Lions Eye Institute, University of Western Australia, 2 Verdun Street, Nedlands, WA 6009, Australia; sajeesh@cyllene.uwa.edu.au
Accepted for publication 12 April 2005
Keywords: telemedicine; remote; eye care; screening
In 2003, the Department of Health, Western Australia, commenced a teleophthalmology service between Carnarvon Regional Hospital (CRH) and Lions Eye Institute (LEI) at City of Perth (at 940 km), pioneering the use of remote, interactive consultations in ophthalmology. This assessment (a) reports the impact of teleophthalmology service on patient diagnosis, management, outcomes, and satisfaction; and (b) estimates the costs of teleophthalmology service.
Case report
An internet based system (www.e-icare.com) developed and evaluated at LEI, was used to store and transmit multimedia data to a secure, central database.1 Practitioners at CRH collected these data, which included patients’ demographic details, medical history, and ocular images. A portable slit lamp developed at LEI,2 tonometer (Keeler Pulsair 3000, Japan), and digital retinal camera (Canon CR4-45NM, Japan) were also used. A questionnaire and interview approach assessed the satisfaction of the patients and practitioners. Estimation of costs analysed additional activity data and associated costs.
During the 12 month study period, there were 118 teleophthalmology consultations (42% men, 58% women, mean age 42 years, range 4–73 years). Most patients (53%) became aware of the service through local media, while health professionals in Carnarvon referred 36% for teleophthalmology consultation. Of the 118 cases, 3% of the patients used teleophthalmology for emergency consultation, 94% for testing for glaucoma and diabetic retinopathy; 3% of the cases were for expert second opinion and postoperative follow up.
Teleophthalmology proved to have impact on all the patients, by improving the eye care facility at CRH itself, instead of the need to travel 940 km to the city. Following teleconsultation, only 3% of patients were referred to a city hospital. While 55% of patients had no abnormalities detected, 3% of patients received treatment at CRH itself. The ophthalmologist recommended regular follow up for 36% of patients seen by telemedicine.
The teleophthalmology consultation cost per patient, at current efficiency level, is $279.96 including fixed cost. A cost neutral analysis estimated, at optimal efficiency of 352 patients per annum, cost per patient would decrease to $107.72. In the remote area, without teleophthalmology, the cost to the service provider for a face to face consultation with an ophthalmologist is as high as $665.44 per patient. The minimum number of patients needed to make a cost effective teleophthalmology consultation is 126 per annum.
The majority of patients (98%) expressed satisfaction with the internet based consultation and observed it as convenient. Lack of physical contact with ophthalmologist was not a major concern to many patients (74%). CRH practitioners spoke favourably of using teleophthalmology, in that they were able to get advice from colleagues and discuss alternative management strategies. Practitioners at LEI found the experience informative and challenging.
Comment
While acknowledging that face to face consultations with ophthalmologists are unique, its costs are enormous in remote health centres.3–5 The project is a technical and clinical success and one that led to direct potential benefits for patients in terms of improved outcomes, as well as considerable educational experience for the participating medical practitioners. However, current assessment brought to light the importance of redefining utilisation criteria in order to achieve efficiency. For example, 126 patients per annum are required for a cost effective teleophthalmology service while the current efficiency rate is 118 per annum (2.2 patients per week). Better coordination between the local healthcare workforce and CRH may increase the number of teleophthalmology consultations, which in turn will help to achieve breakeven or even establish net savings. Overall, this assessment indicates that the success of teleophthalmology will be based upon identifying the requirements of the service and using appropriate technology.
ACKNOWLEDGEMENTS
Supported by an IPRS Scholarship and UPA(IS) Award from University of Western Australia. The authors thank the Department of Health, Western Australia, Mr Francisco Chaves (health economist), and Ms Beth Hudson for her support and assistance especially in data collection. The authors also thank the patients, clinical staff, and administrative officers in CRH, Carnarvon and at LEI, City of Perth for their assistance.
References
Yogesan K, Constable IJ, et al. International transmission of tele-ophthalmology images. J Telemed Telecare 2000;5:41–4.
Yogesan K, Cuypers M, et al. Tele-ophthalmology screening for retinal and anterior segment diseases. J Telemed Telecare 2000;5:96–8.
Keeffe JE, Weih LM, et al. Utilisation of eye care services by urban and rural Australians. Br J Ophthalmol 2002;86:24–7.
Whitten PS, Mair FS, et al. Systematic review of cost effectiveness studies of telemedicine interventions. BMJ 2002;324:1434–7.
Sajeesh KR, Mei-Ling TK, Chaves F, et al. Remote ophthalmology services: cost comparison of telemedicine and alternate scenarios. J Telemed Telecare. (in press).