Research

Original Investigation

Supply and Perceived Demand for Teleophthalmology

in Triage and Consultations in California
Emergency Departments
Lauren Wedekind; Kristin Sainani, PhD; Suzann Pershing, MD, MS

Invited Commentary page 543

IMPORTANCE Determining the perceived supply and potential demand for teleophthal- Journal Club Slides and
mology in emergency departments could help mitigate coverage gaps in emergency Supplemental content at
ophthalmic care. jamaophthalmology.com

OBJECTIVE To evaluate the perceived current need for and availability of ophthalmologist
coverage in California emergency departments and the potential effect of telemedicine for
ophthalmology triage and consultation.

DESIGN, SETTING, AND PARTICIPANTS Surveys were remotely administered to 187 of the 254
emergency departments throughout California via the telephone and Internet from June 30
to September 23, 2014. Emergency department nurse managers and physicians from all
emergency departments listed in the California Office of Statewide Health Planning and
Development database were individually surveyed to assess facility characteristics and
resources as well as the perceived usefulness of teleophthalmology consultation. Data
analysis was conducted from June 30, 2014, to March 11, 2015.

MAIN OUTCOMES AND MEASURES Perceived availability of ophthalmology consultation

coverage and perceived effect of telemedicine ophthalmology consultation at each facility.

RESULTS Of the 187 emergency departments surveyed, 18 of 37 rural facilities (48.6%)

reported availability of emergency ophthalmology coverage, compared with 112 of 150
nonrural facilities (74.7%). Rural facilities reported a mean (SD) of 23.72 (14.15) miles between
the facility and referral location, while nonrural facilities reported a mean of 4.41 (10.23) miles
(19.3% difference). On a scale of 1 to 5 (where 1 signifies very low value and 5 signifies very
high value), 124 of 187 nurse managers (66.3%) and 80 of 121 physicians (66.1%) rated
teleophthalmology as having high or very high value for triage purposes. The most frequently
cited potential advantage of emergency teleophthalmology was assistance in patient triage
and immediate real-time electronic communication, and the most frequently cited potential
disadvantages were unknown cost of contracting and maintenance and concern that eye
trauma might make photographs or videos less conclusive.

CONCLUSIONS AND RELEVANCE Availability of ophthalmology coverage for emergency eye

care is limited, particularly among rural emergency departments in California. Surveyed
emergency department nurse managers and physicians indicated moderately high interest
Author Affiliations: Department of
and perceived value for a teleophthalmology solution for remote triage and consultation. Ophthalmology, Veterans Affairs
Overall, the study suggests that teleophthalmology could play a role in mitigating coverage Palo Alto Health Care System,
gaps in emergency ophthalmic care and could be further investigated through similar studies Palo Alto, California (Wedekind,
Pershing); Department of Human
in other regions. Biology, Stanford University,
Stanford, California (Wedekind);
Department of Health Research and
Policy, Stanford University, Stanford,
California (Sainani); Byers Eye
Institute at Stanford University,
Palo Alto, California (Pershing).
Corresponding Author: Suzann
Pershing, MD, MS, Byers Eye Institute
at Stanford University, 2452 Watson
JAMA Ophthalmol. 2016;134(5):537-543. doi:10.1001/jamaophthalmol.2016.0316 Ct, Palo Alto, CA 94303 (pershing
Published online March 24, 2016. @stanford.edu).

(Reprinted) 537

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 Research Original Investigation Supply and Demand for Teleophthalmology in Emergency Departments

R
ural emergency departments often have limited re-
sources relative to nonrural emergency departments and Key Points
patients may face inequities in access to quality emer-
Question What is the perceived need for and current availability
gency care based on their proximity to health care facilities.1 of ophthalmologist coverage in emergency department settings
These geographic differences in resources result in coverage and what would be the perceived potential effect of
gaps, which are more severe for access to specialized care such teleophthalmology consultation in California emergency
as ophthalmology.2 Approximately 18 805 board-certified oph- departments?
thalmologists practice in the United States, with disproportion- Findings Eighteen of 37 rural facilities (48.6%) reported existing
ately more in nonrural vs rural regions.3 Prior studies have dem- emergency ophthalmology coverage vs 112 of 150 nonrural
onstrated that the likelihood of adults with diabetes receiving facilities (74.7%), and 123 of 187 nurse managers (65.8%) and 58
annual dilated eye examinations is reduced in areas with a lower of 121 physicians (47.9%) rated teleophthalmology as having high
geographic density of eye care professionals.4 Currently, there or very high value for triage.
is a lack of published literature on the unavailability of on-call Meaning Teleophthalmology may play a role in mitigating
ophthalmologists for emergency eye care. coverage gaps in emergency ophthalmic care and warrants further
Emergency eye care exhibits significant coverage gaps, es- study.
pecially in rural settings with greater distances between emer-
gency care facilities. Patients requiring emergency eye care may to receipt of care, projected increased efficiency, and cost-
be treated by local on-call ophthalmologists or may need to be effective delivery of care.5-7 When teleophthalmology was ap-
transferred to another facility with available ophthalmolo- plied in an ophthalmic emergency department, images of the
gists. Multiple studies since the latter part of the 20th cen- anterior segment and posterior pole were found to have high
tury have suggested that applying telemedicine to eye care in clinical utility (100% agreement between telemedicine and on-
emergency situations may assist with patient flow in remote site examination diagnoses), while images of the vitreous and
emergency departments and help fill coverage gaps in 2 main peripheral retina had less utility.8 Patient satisfaction was high,
ways: assistance with triage within and between remote emer- with 48 of 49 patients (98%) indicating a preference for teleoph-
gency departments, and performance of remote ophthalmic thalmology at their next emergency department visit, rather
consultations for patients presenting with emergency eye than traditional on-site examination Teleophthalmology evalu-
conditions.5-8 ation has the potential to expand access to eye care in areas
According to the American Telemedicine Association, tele- with little to no existing in-person coverage; however, it is not
medicine is “the use of medical information exchanged yet the standard of care for addressing emergency eye prob-
from one site to another via electronic communications to lems in underserved areas.
improve a patient’s clinical health status.”9 Teleophthalmol- In this study, we developed and prospectively adminis-
ogy, which involves telemedicine applied to clinical ophthal- tered a structured survey to a comprehensive list of Califor-
mology, is already in widespread use for nonemergency eye nia emergency departments to evaluate current availability of
care. It is well established to screen for diabetic retinopathy10-13 emergency eye care by ophthalmologists and the potential util-
and retinopathy of prematurity.14-16 The concept of Internet- ity of teleophthalmology for patient triage and/or consulta-
based counseling of ophthalmology patients located re- tions.
motely has existed for more than a decade,17 and its use for
urgent consultations has been described internationally, es-
pecially in Australia.18-22 It has also been cited as a teaching
tool to educate general practitioners.19,20 In the United States,
Methods
teleophthalmology has been used by large health care sys- Study Design, Population, and Data Collection
tem networks, such as Kaiser Permanente and the US military23 We developed a database of all 254 California emergency
and Veterans Affairs systems. For example, since 2005, Vet- departments that are included in the outpatient emergency
erans Affairs hospitals have implemented teleretinal imaging, department encounter data published by the California Of-
a store-and-forward mode of teleophthalmology that uses fice of Statewide Health Planning and Development (OSHPD).28
digital retina cameras and remote image interpretation18,24; this Facilities were identified as rural or nonrural in the OSHPD da-
program has been successful for accurate and sensitive diag- tabase based on acute care capacity, local population size, and
nosis and referral.25 Anticipated shortages of health care pro- distance from the most common referral facility. The OSHPD
fessionals and new technology may make teleophthalmol- defines a rural hospital as one that is “a general acute care hos-
ogy increasingly needed and increasingly feasible in broader pital of no more than 76 general acute care beds that is also
contexts in the US health care system. Teleophthalmology has located in an incorporated place or census tract of 15,000 or
been heralded as a potentially radical transformer of care less population according to the 1980 census,”29 while non-
delivery.26,27 rural facilities include all that do not meet these criteria.
Despite the logistical challenges for a feasible teleophthal- Self-reported outpatient emergency department encounter
mology program, previous studies have successfully imple- data, including patient demographic information, patient vol-
mented Internet-based emergency teleophthalmology pilot ume, number of surgical procedures performed, rural hospi-
programs in rural areas, achieving reductions in the need for tal status, and disproportionate share hospital status (hospi-
acute transfers to external tertiary care centers, shortened time tals serving above a certain proportion of low-income patients

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 Supply and Demand for Teleophthalmology in Emergency Departments Original Investigation Research

Table 1. Facility Characteristics of Surveyed Emergency Departmentsa a

Derived from data reported by
facilities to the California Office of
Facility
Statewide Health Planning and
Characteristic All (N = 187) Nonrural (n = 150) Rural (n = 37) Development for January 1 to March
Disproportionate share hospital status, 60 (32.1) 47 (31.3) 24 (64.9) 31, 2014.
No. (%)b b
Referring to hospitals serving above
Emergency ocular surgical procedures, 5.49 (5.46) 6.04 (5.66) 2.79 (3.36) a certain proportion of low-income
mean (SD), No.
patients and receiving a
Emergency department patient volume, 9370.42 (6107.36) 10496.31 (5792.26) 3471.23 (2949.82) corresponding adjustment in
mean (SD), No.
Medicare payments to offset
Emergency ocular surgical procedures 0.06 (0.06) 0.06 (0.05) 0.09 (0.09) undercompensated or
per patient, mean (SD), No.
uncompensated care.

and receiving a corresponding adjustment in Medicare pay-

ments to offset undercompensated or uncompensated Results
care),30 were available for each facility from submissions
through the Medical Information Reporting for California OSHPD Data and Facility Characteristics
system.31 We excluded 67 emergency departments from the Aggregate reported characteristics of surveyed emergency de-
study that did not report data for the January 1 through partments (from OSHPD data) are listed in Table 1. Of the 254
March 31, 2014, reporting period, and we contacted 187 emergency departments, 43 (16.9%) were classified as rural and
facilities through this study. 211 (83.1%) as nonrural.
We contacted nurse managers and physicians from each Data collected from nurse managers (Table 2) showed that
emergency department by telephone and email from June 30 almost all facilities encountered patients requiring emer-
to September 23, 2014, to participate in surveys evaluating the gency eye care, and approximately half had to transfer such
current availability of ophthalmology coverage and potential patients to another facility for evaluation and management,
demand for teleophthalmology at their facilities (eTable 1 in with higher transfer rates among rural facilities (nonrural, 68
the Supplement). In part 1 of this survey, nurse managers were of 150 [45.3%] in 2013 and 2014; rural, 28 of 37 [75.8%] in 2013
asked to evaluate the availability of on-call ophthalmologists and 32 [86.5%] in 2014). Most facilities had at least 1 ophthal-
and retrospectively estimate the volume of referrals of pa- mologist on staff, but fewer ophthalmologists available after
tients requiring emergency eye care to external facilities in 2013 hospital operating hours. Rural facilities in particular faced
and 2014. In part 2 of the survey, up to 1 nurse manager and 1 challenges in arranging timely evaluation by an ophthalmolo-
physician per facility were asked to rate the potential utility gist: 18 (48.6%) lacked readily available access to an ophthal-
of teleophthalmology for assistance in triage and full emer- mologist.
gency consultation. Each respondent reported his or her per-
ception of the value of teleophthalmology for triage and full Facility Staff Perceptions of Emergency Teleophthalmology
remote consultation by a teleophthalmologist and selected any Of the 187 emergency department nurse managers con-
potential advantages and disadvantages that contributed to tacted, all completed parts 1 and 2 of the survey. On a scale of
their decisions from a standardized list (or the option “not ap- 1 (very low value) to 5 (very high value), nurse managers rated
plicable”). We obtained exemption from the Stanford Univer- the potential value of emergency teleophthalmology as a mean
sity Institutional Review Board as no identifiable patient data of 3.78 for assistance in triage (3.63 for nonrural facilities and
were used in this study. 4.44 for rural facilities) and 3.51 for obtaining full consulta-
tions remotely (3.35 for nonrural facilities and 4.26 for rural
Statistical Analysis facilities). Although rural facilities had lower patient volume
Data analysis was conducted from June 30, 2014, to March 11, and emergency ocular surgical procedures compared with
2015. We used R, version 3.1.2 (R Foundation for Statistical nonrural facilities, in aggregate, the proportion of patients
Computing), to calculate basic descriptive statistics on hospi- undergoing ocular surgery was slightly higher among rural
tal characteristics, estimates of potential demand for emer- facilities.
gency teleophthalmology, and standardized advantages and By contrast, of the 187 emergency department physicians
disadvantages. Means and SDs of each facility characteristic contacted, 166 completed parts 1 and 2 of the survey (88.8%
were calculated individually for 3 groups: all facilities, nonru- completion rate). On a scale of 1 to 5, physicians rated the
ral facilities, and rural facilities. Multivariable linear regres- potential value of emergency teleophthalmology as a mean
sion analysis (with a threshold of P < .05 and 95% CI) was of 3.37 for assistance in triage (3.26 for nonrural facilities and
used to evaluate the association between reported advan- 3.96 for rural facilities) and 3.19 for obtaining full remote con-
tages and disadvantages and subjective ratings of potential sultations (3.09 for nonrural facilities and 3.67 for rural facili-
usefulness of emergency teleophthalmology. Since rural ties). On a scale of 1 to 5, a total of 124 nurse managers
facilities often face lower per capita availability of ophthal- (66.3%) and 80 of 121 physicians (66.1%) rated teleophthal-
mologists, nonrural facilities and rural facilities were ana- mology as having high or very high value (4 or 5) for triage
lyzed separately. purposes (Table 3).

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 Research Original Investigation Supply and Demand for Teleophthalmology in Emergency Departments

Table 2. Emergency Department Survey Resultsa

Facility
Characteristic All (N = 187)b Nonrural (n = 150) Rural (n = 37)
Telemedicine use by hospital, No. (%) 88 (47.1) 70 (46.7) 18 (48.6)
Ophthalmologists at hospital, mean (SD), No. 4.07 (5.88) 4.69 (6.26) 1.16 (1.49)
Ophthalmologists available during hospital 4.06 (5.88) 4.67 (6.26) 1.19 (1.48)
operating hours, mean (SD), No.
Ophthalmologists available after hospital 0.94 (1.07) 1.06 (1.11) 0.40 (0.58)
operating hours, mean (SD), No.
Availability of ophthalmologist examination 131 (70.1) 112 (74.7) 18 (48.6)
immediately following emergency
consultation, No. (%)
Time before follow-up by referral site, mean 0.39 (1.56) 0.30 (1.69) 0.84 (0.51)
(SD), h
Distance between facility and referral 7.81 (13.28) 4.41 (10.23) 23.72 (14.15)
location, mean (SD), miles
Any emergency eye encounter(s) recalled in 181 (96.8) 148 (98.7) 33 (89.2)
2014, No. (%)
Any emergency eye encounter(s) recalled in 183 (97.9) 148 (98.7) 35 (94.6)
2013, No. (%)
Any patient(s) presenting with an emergency 93 (49.7) 68 (45.3) 28 (75.7)
eye problem who had to be transferred in
a
2014, No. (%) Data collected from nurse
Any patient(s) presenting with an emergency 97 (51.9) 68 (45.3) 32 (86.5) managers.
eye problem who had to be transferred in b
Results reported for the 187 total
2013, No. (%)
facilities surveyed.

The most commonly cited perceived advantages of

teleophthalmology (Table 4) were assistance in patient triage Discussion
and immediate real-time electronic communication; the most
commonly cited perceived disadvantages were unknown cost Our study found there is evidence of a coverage gap for emer-
of contracting and maintenance and concern that eye trauma gency department ophthalmology care, particularly among ru-
might make photographs or videos less conclusive. Physi- ral facilities in California. For daytime coverage, less than one-
cians and nurse managers provided similar responses for per- third as many ophthalmologists were available in rural facilities
ceived disadvantages, but nurse managers were more likely to as in nonrural facilities, and on evenings and weekends (after
identify patient triage as a potential advantage of teleophthal- hours) less than half as many ophthalmologists were avail-
mology (172 nurse managers [92.0%] vs 105 physicians able. Emergency departments in rural facilities were also much
[63.3%]). Physicians were more likely than nurse managers to more likely to transfer patients requiring emergency eye care
perceive teleophthalmology as a way to attract patients to their to another facility and tended to be much farther from their most
emergency department (70 [42.2%] vs 34 [18.2%]). Beyond lim- common referral sites (more than 5 times farther than similar
ited availability, both physicians and nurse managers indi- transfers from nonrural facilities, taking approximately 30 min-
cated that their reasons for not already using teleophthalmol- utes longer for patients to be seen at the referral site). In addi-
ogy included cost concerns and the possibility that it would tion to higher transfer rates and wait times from rural emer-
be less efficient than existing coverage by on-call ophthal- gency departments, only 48.6% of rural emergency departments
mologists. reportedly had ophthalmologists immediately available to ex-
In multivariable linear regression analysis, identified ad- amine patients following emergency consultations, compared
vantages were significantly predictive of perceived high value with 74.7% of nonrural emergency departments. These results
and disadvantages were predictive of perceived low value for imply a need for additional local ophthalmology coverage, pos-
teleophthalmology (eTable 2 in the Supplement). Increased tri- sibly with a role for teleophthalmology.
age efficiency and providing previously unavailable ophthal- Nearly half of surveyed emergency departments (regard-
mology coverage were most predictive of high perceived value less of rural status) reported using some form of telemedi-
for teleophthalmology among nurse managers (P < .001). Nega- cine, but none reported current use of teleophthalmology for
tive prior experiences with other telemedicine programs was photograph or video transmission to address coverage gaps in
most associated with perception of low value for teleophthal- emergency eye care. Most nurse managers and physicians be-
mology among nurse managers (P < .01). Among physicians, lieved that teleophthalmology would be a valuable addition
new or increased ophthalmology coverage was most associ- to patient care, and both groups rated teleophthalmology as
ated with perceived high value for teleophthalmology more valuable for triage than for full patient consultations.
(P < .001), and sufficient existing coverage or concerns regard- Nurse managers tended to rate teleophthalmology with slightly
ing quality of care with telemedicine were most predictive of more potential benefit than did physicians, and both groups
perceived low benefit (P < .001). Regression values specifi- rated teleophthalmology higher at rural facilities than at nonru-
cally for rural facilities were not statistically significant. ral facilities.

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 Supply and Demand for Teleophthalmology in Emergency Departments Original Investigation Research

Table 3. Perceived Value of Emergency Teleophthalmology Table 4. Advantages and Disadvantages of Teleophthalmology
for Triage and Consultation
Nurse Managers, Physicians,
Ratinga Nurse Managers, No. (%)b Physicians, No. (%)b Characteristic No. (%)a No. (%)a
Perceived utility for triage Advantages

1 8 (4.3) 8 (4.8) Could make triage more efficient 172 (92.0) 105 (63.3)

2 13 (7.0) 22 (13.3) Immediate electronic sending and 153 (81.8) 108 (65.1)
response
3 42 (22.5) 56 (33.7) Could increase facility’s existing 50 (26.7) 38 (22.9)
4 74 (39.6) 60 (36.1) on-call ophthalmology coverage
5 50 (26.7) 20 (12.0) Could provide new coverage since 47 (25.1) 45 (27.1)
facility does not have on-call
Perceived utility for remote consultation ophthalmologists
1 12 (6.4) 13 (7.8) Hospital has had positive 45 (24.1) 22 (13.3)
experiences with other
2 21 (11.2) 24 (14.5) telemedicine programs
3 47 (25.1) 57 (34.3) Could help increase patient interest 34 (18.2) 70 (42.2)
4 71 (38.0) 63 (38.0) and attract patients to the facility
Could provide helpful second 28 (15.0) 53 (31.9)
5 36 (19.3) 9 (5.4) opinions to existing emergency
a staff
Ratings given in whole number values from 1 (very low value) to 5 (very high
value) of a possible 5. Not applicable 4 (2.1) 3 (1.8)
b
Percentages may not total 100% owing to rounding. Disadvantages
Unknown cost of installation, 165 (88.2) 131 (78.9)
maintenance, and contracting
payments to
Key perceived advantages of teleophthalmology included teleophthalmologist(s)
improved triage and timeliness of evaluation. Nurse managers Emergency eye trauma could make 125 (66.8) 95 (57.2)
images less conclusive in remote
in particular believed that teleophthalmology could improve consultation
their emergency department’s efficiency by assisting with tri- Could negatively effect patients 99 (52.9) 90 (54.2)
age (92.0%). Barriers to future adoption included potential costs since they cannot directly see the
remote ophthalmologist
of installation, maintenance, and contracting payments for Could be less efficient than existing 84 (44.9) 65 (39.2)
teleophthalmologists (cited by 165 nurse managers [88.2%] and on-call ophthalmologists
131 physicians [78.9%]) and effect on workflow efficiency (cited Could be dependent on electricity 45 (24.1) 15 (9.0)
and Internet availability; not
by 84 nurse managers [44.9%] and 65 physicians [39.2%]). Six always available
nurse managers (3.2%) but no physicians indicated negative The emergency department’s 43 (23.0) 22 (13.3)
prior experiences with other telemedicine programs (not nec- existing referral system is already
efficient enough
essarily ophthalmology related). Nurse managers were also more
Hospital has had negative 6 (3.2) 0
likely to be concerned regarding quality and ability of teleoph- experiences with other
telemedicine programs
thalmology to interpret eye images in the setting of ocular
Not applicable 0 0
trauma (125 nurse managers [66.8%] vs 95 physicians [57.2%]).
Main reasons not currently using
Anticipated increased triage efficiency and need for new or in- teleophthalmology (other than
creased ophthalmology coverage were most predictive of high limited availability)b
perceived value for teleophthalmology. Costs of installation, maintenance, 103 (55.1) 116 (69.9)
and contracting
One limitation of our study is that 67 of the 254 emergency
Less efficient than existing on-call 52 (27.8) 32 (19.3)
departments indexed by the OSHPD were not included in the coverage
study owing to lack of available data at the time of assessment. a
Numbers sum to greater than 100% since respondents were able to select
Other limitations included that only 1 nurse manager and 1 phy- multiple responses.
sician were surveyed from each emergency department. Al- b
Other responses were each cited with frequency of 5% or less.
though contacting more individuals at each facility was not
feasible given study size, we did attempt to speak to nurses and
physicians in administrative or leadership roles and asked that aggregate characteristics for all facilities recorded in OSHPD
they consider the perspective of the staff at large. If the re- data, suggesting a representative sample. However, rural fa-
quested nurse manager or physician was unavailable or did not cilities exhibited lower numbers of statistically significant data
start the survey, the emergency department was contacted up points, suggesting that the lower number of rural facilities
to 3 subsequent times to administer the survey to any emer- (compared with nonrural facilities), the many variables evalu-
gency department nurse manager or physician, respectively. ated, and/or confounding factors may have affected results.
We achieved a 100% survey completion rate for nurse man-
agers, but only approximately 88.8% of contacted physicians
completed the survey. Although this response rate limits our
results, it is above average for survey response rates in
Conclusions
general.32 Emergency departments with responses from both Teleophthalmology theoretically involves provision of medi-
nurse managers and physicians had characteristics similar to cal eye care to patients who are at a distant location from

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 Research Original Investigation Supply and Demand for Teleophthalmology in Emergency Departments

ophthalmologists via advice to local health care profession- settings such as screening for diabetic retinopathy), it may have
als or communication directly to patients.33 It has been suc- value for acute patient triage and consultation, particularly in
cessfully used in specific settings, such as the Veterans rural settings. Recognizing the inevitable challenges in inte-
Affairs health care system, for retinal screening25 and has grating teleophthalmology into the clinical workflow,35 fur-
been found to be cost-effective for care delivery: in an Aus- ther development and investigation into teleophthalmology
tralian study, teleophthalmology was less expensive than technology, delivery, and reimbursement systems is war-
traditional options for a rural clinic, at a threshold of 128 ranted, particularly in the current policy landscape with con-
patients.34 tinued interest in reducing access disparities, caring for a grow-
Although teleophthalmology is not currently wide- ing patient population, and providing high-value, efficient
spread or considered the standard of care (except in specific health care.

ARTICLE INFORMATION recently trained ophthalmologists: a study of male evaluation of retinopathy of prematurity. Pediatrics.
Submitted for Publication: September 18, 2016; and female physicians. J Am Med Womens Assoc. 2015;135(1):e238-e254.
final revision received January 26, 2016; accepted 2000;55(1):20-22, 26. 15. Quinn GE, Ying GS, Daniel E, et al; e-ROP
February 3, 2016. 3. Resnikoff S, Felch W, Gauthier T-M, Spivey B. The Cooperative Group. Validity of a telemedicine
Published Online: March 24, 2016. number of ophthalmologists in practice and training system for the evaluation of acute-phase
doi:10.1001/jamaophthalmol.2016.0316. worldwide: a growing gap despite more than retinopathy of prematurity. JAMA Ophthalmol.
200,000 practitioners. Br J Ophthalmol. 2012;96 2014;132(10):1178-1184.
Author Contributions: Dr Pershing and Ms (6):783-787.
Wedekind had full access to all the data in the study 16. Fijalkowski N, Zheng LL, Henderson MT, et al.
and take responsibility for the integrity of the data 4. Chou C-F, Zhang X, Crews JE, Barker LE, Lee PP, Stanford University Network for Diagnosis of
and the accuracy of the data analysis. Saaddine JB. Impact of geographic density of eye Retinopathy of Prematurity (SUNDROP): five years
Study concept and design: Wedekind, Pershing. care professionals on eye care among adults with of screening with telemedicine. Ophthalmic Surg
Acquisition, analysis, or interpretation of data: All diabetes. Ophthalmic Epidemiol. 2012;19(6):340-349. Lasers Imaging Retina. 2014;45(2):106-113.
authors. 5. Mueller KJ, Potter AJ, MacKinney AC, Ward MM. 17. Labiris G, Petounis A, Kitsos G, Aspiotis M,
Drafting of the manuscript: Wedekind, Pershing. Lessons from tele-emergency: improving care Psillas K. Internet-based counselling of remote
Critical revision of the manuscript for important quality and health outcomes by expanding support ophthalmological patients. Acta Ophthalmol Scand.
intellectual content: All authors. for rural care systems. Health Aff (Millwood). 2014; 2003;81(1):86-88.
Statistical analysis: Wedekind, Pershing. 33(2):228-234. 18. Kirkizlar E, Serban N, Sisson JA, Swann JL,
Study supervision: Sainani, Pershing. 6. Kennedy C, Bowman R, Fariza N, Ackuaku E, Barnes CS, Williams MD. Evaluation of telemedicine
Conflict of Interest Disclosures: All authors have Ntim-Amponsah C, Murdoch I. Audit of Web-based for screening of diabetic retinopathy in the
completed and submitted the ICMJE Form for telemedicine in ophthalmology. J Telemed Telecare. Veterans Health Administration. Ophthalmology.
Disclosure of Potential Conflicts of Interest. Dr 2006;12(2):88-91. 2013;120(12):2604-2610.
Pershing reported serving as a consultant/advisory 7. Kumar S, Tay-Kearney M-L, Constable IJ, 19. Blomdahl S, Calissendorff B, Jacobsson U.
board member for Digisight Technologies. No other Yogesan K. Internet based ophthalmology service: Patient-focused urban tele-ophthalmology
disclosures were reported. impact assessment. Br J Ophthalmol. 2005;89(10): services. J Telemed Telecare. 2002;8(suppl 2):43-44.
Funding/Support: The Human Biology Research 1382-1383. 20. Lamminen H, Salminen L, Uusitalo H.
Experience Grant Program of the Stanford 8. Bar-Sela SM, Glovinsky Y. A feasibility study of an Teleconsultations between general practitioners
University Department of Human Biology Internet-based telemedicine system for and ophthalmologists in Finland. J Telemed Telecare.
supported Ms Wedekind’s residence at Stanford consultation in an ophthalmic emergency room. 1999;5(2):118-121.
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Invited Commentary

The Use of Telemedicine to Extend Ophthalmology Care

Mary G. Lynch, MD; April Y. Maa, MD

In this issue of JAMA Ophthalmology, Wedekind et al1 de- photographs were taken by a trained nurse and routed to a
scribe the results of a survey conducted among emergency de- trained reader who would provide input for appropriate tri-
partment nurse managers and physicians in California regard- age of the patient. Of 350 patients presenting to the emer-
ing the perceived need for ophthalmology coverage in the gency department who were enrolled in the phase 1 portion
emergency department and of this study, 44 had relevant ocular findings (eg, disc edema,
the role that telemedicine disc pallor, and retinopathy), none of which were detected by
Related article page 537
might play in meeting those emergency department health care professionals via direct
needs. The authors found that emergency departments in ru- ophthalmoscopy. Eleven patients (25%) had ocular findings
ral communities were less likely to have ophthalmology cov- that were known prior to the emergency department visit.
erage than were emergency departments in nonrural areas. Pa- Six patients (14%) were evaluated and diagnosed by ophthal-
tients in rural communities also were more likely to be referred mology consultants. Twenty-seven patients (61%) had find-
to another facility and to travel a greater distance to obtain an ings detected only by fundus photography.
ophthalmology consultation. Nearly half of both nurse man- Teleophthalmology has also been shown to be a valuable
agers and physicians believed that teleophthalmology would tool for extending care to larger populations of high-risk pa-
be helpful for patient triage. tients. In the Veterans Affairs Healthcare System, the use of
Emergency departments may be vulnerable places for pa- teleretinal cameras in primary care clinics has improved the care
tients with eye care issues. Emergency department physi- of patients with diabetes mellitus. In fiscal year 2015, a total of
cians may not be comfortable examining the eye, especially 89% of veterans with diabetes underwent time-appropriate reti-
assessing the optic nerve and retina.2 They may lack the ap- nal examinations, with more than 310 000 patients screened
propriate tools to examine the eye (eg, tonometers). Most emer- through teleretinal imaging.3 In contrast, between 47% and 69%
gency departments do not have an ophthalmologist on call 24 of patients with diabetes cared for in the community under-
hours a day and emergency departments in rural communi- went time-appropriate retinal examinations.4
ties may not have an ophthalmologist available at all, espe- Other forms of teleophthalmology have been adopted in
cially since these locations are often in medically under- the United Kingdom, Canada, India,5 and the United States6
served areas. Inadequate ophthalmic assessment puts the to extend eye care access to at-risk populations (eg, patients
patient at increased risk for delayed care and visual impair- with diabetes, rural patients) and address disparities in health
ment. Teleophthalmology could be a valuable care extender care. The Atlanta Veterans Affairs Medical Center has devel-
in these situations. Both store-and-forward (ie, transferring im- oped an innovative program, Technology-based Eye Care Ser-
ages) and live contact (ie, videoconferencing) telemedicine vices (TECS), to provide basic eye care to veterans through ru-
methods could be used to help emergency departments pro- ral primary care facilities.7 An ophthalmology technician is
vide specialty care consultations without requiring the physi- stationed at the community-based clinic full time. The tech-
cal presence of a specialist. nician obtains an extensive ocular history from the patient and
The Fundus Photography vs Ophthalmoscopy Trial Out- performs basic diagnostic tests (vision, refraction, intraocu-
comes in the Emergency Department study2 has shown that lar pressure, pachymetry) and imaging (both of the retina and
nonmydriatic ocular fundus photography is a highly sensitive external ocular adnexa). The patient is measured for spec-
method to screen emergency department patients who pre- tacles and all information is uploaded into the electronic health
sent with headache, focal neurologic deficits, visual loss, or record. The reading ophthalmologist reviews all findings on
diastolic blood pressure more than 120 mm Hg. In this study, the same day and completes the clinical note. The examina-

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