Teleophthalmology aims to improve eye health among Latinos

Take-home message: A community-based teleophthalmology program providing diabetic retinopathy screening is helping to improve the eye health of the Latino population in Milwaukee.

By Nancy Groves; Reviewed by Judy E. Kim, MD

Milwaukee-A telemedicine eye-health-screening program run by an academic-community partnership has improved access to care among the Latino population of Milwaukee.

Teleophthalmology to Improve Eye Health among Latinos (TIEHL)-initially funded by a 2-year, $200,000 grant from the Healthy Wisconsin Partnership Program-provides diabetic retinopathy screening to at-risk individuals at a community center serving more than 15,000 Latinos and is unique in its aim of training lay people to take the images with a specialized digital camera.

“Latinos are at high risk for developing diabetes, and the Latino population is continually increasing in the United States,” said grant recipient Judy E. Kim, MD, professor of ophthalmology, Medical College of Wisconsin, Milwaukee. “It is important that we start to concentrate on these high-risk populations in hopes of keeping them healthy for the rest of their lives.”

As a part of the TIEHL program, children, adults, and seniors have undergone imaging.

Getting the program started

To launch the program, Dr. Kim worked with both the staff of the United Community Center of Milwaukee-a main community center for Latinos in Milwaukee-and experts in medical informatics, who developed a platform to transmit the images in a HIPAA-compliant manner and designed an online survey as part of the research project.

While telemedicine is an established concept, teleophthalmology is less common, Dr. Kim said. When utilized, it is usually performed at a primary-care setting to screen for diabetic retinopathy.

One of TIEHL’s objectives is to evaluate the effectiveness of combining telemedicine and community-based screening. This approach ideally improves access to care by overcoming such issues as language and cultural barriers and lack of transportation.

The TIEHL program also makes its screenings more approachable by teaching staff members and nursing students who rotate through the center to take the images.

“We wanted to see if we could train lay people who are part of the community,” Dr. Kim said. “The people who attend various functions at the UCC are already familiar with the staff.

“In addition, the staff members are bilingual, and they understand the cultural nuances,” she said. “We have found that these factors, as well as bringing the care to the community, result in favorable acceptance of teleophthalmology as a modality of health-care delivery for this population.”

Image capture

To date, about 500 individuals have been screened. If an abnormality is discovered when the images are reviewed, the staff works with the patient to help locate a physician; navigate paperwork for insurance, Medicare, or Medicaid; or provide a referral to a clinic that provides care to the indigent through a partnership with TIEHL.

The success of the community-screening program is also dependent on obtaining the right camera for the setting and clients. Research had shown that individuals in the target population disliked or feared having their eyes dilated.

Therefore, the camera needed to be able to consistently capture good images from undilated eyes, as well as eyes with small pupils or opacity from conditions, such as cataracts, while being user friendly.

After comparing various cameras, Dr. Kim chose a digital, non-mydriatic, ultra-widefield scanning laser ophthalmoscope (Daytona, Optos) that can capture a 200° view of the retina in one image. The manufacturer loaned a camera for the TIEHL project and sent representatives to the UCC to train the staff to take images.

“Upgradable images have been very few with this camera,” Dr. Kim said. “While some peripheral views are covered by lid artifacts, in most instances, there is a view of the posterior pole that can be graded for presence or absence of diabetic retinopathy.”

Also, Dr. Kim noted she appreciates the detailed view extending well out to the periphery, which allows her to see midperipheral hemorrhages that otherwise would have been missed.

However, she noted some disadvantages of the camera, such as the device not being as portable as she and the staff would like, and it being costly for a non-profit organization to purchase for screening purposes.

Educational initiative

While screenings and eye health are at its core, the TIEHL project also has an educational aim directed at children who attend a school affiliated with the UCC.

The hope is that “by exposing them early to this type of technology in medicine, they will develop an interest in healthcare, medicine, industry, and science,” Dr. Kim said.

The project has received additional funding to continue beyond the initial grant from the Healthy Wisconsin Partnership.

Another hope is that “this model can be used in other places as well, since we have demonstrated feasibility,” Dr. Kim said.

“Delivery of medical care will be changing,” she added. “It will be more mobile [with] more apps being used [and] more self-testing by patients that gets transmitted to a central area or to the physician.”

Patients will be more technologically savvy and will want convenience. With improvements in video conferencing, primary-care providers will be more easily connected with subspecialists, she noted.

“Other specialties have successfully used telemedicine, and there’s no reason why ophthalmology can’t be a part of this evolution in health-care models, as we are a very image-heavy specialty,” Dr. Kim said. “We need to focus on preventative care, early disease detection, and improved self-care. We can do all these with less cost through teleophthalmology.”

Judy E. Kim, MD

E: jekim@mcw.edu

Dr. Kim received research support from Optos in the form of an instrument.