Telemedicine delivers advanced vision screening for diabetic eye disease in remote regions

Pippa Wysong
in Toronto, Canada

Review of stereoscopic digital images by Dr Greve (left) and Dr Tennant at the University of Alberta Tele-ophthalmology, Reading Centre.

A LONG-DISTANCE telemedicine system has penetrated the most remote northern regions of the province of Alberta, Canada to provide the natives with advanced vision screening and treatment.

The idea began over a casual dinner conversation between ophthalmologist Matt Tennant MD, FRCS(C) and an old school friend who worked for a company specialising in satellite communications and digital imaging technology. Dr Tennant was then a resident in ophthalmology at the University of Alberta, Canada in 1998.
The two friends determined that there might be a way to combine their areas of expertise and come up with a way to screen for diabetic eye disease in those living in remote areas.

The First Nations population in Canada has a high rate of diabetes and an associated high rate of retinopathy. The Canadian Diabetes Association reports that the country's aboriginal populations are three to five times more likely than non-natives to develop diabetes.
One of the first obstacles to setting up a tele-ophthalmology programme was getting images from patients' eyes in stereo form. At the time, this couldn't be done with digital photography, Dr Tennant said.

Fortunately, his friend’s satellite company, which did a lot of aerial mapping projects, had expertise in creating stereo images and could adapt the techniques to meet the ophthalmologist’s needs. In 1998, a pilot program was set-up in Fort Vermilion, a small community 600km north of Edmonton, Alberta.

“I was a resident in ophthalmology at that time. I went up there with the camera and a photographer. We tested vision, took intraocular pressures and examined the patients,” he recalled.

An ophthalmologist in Edmonton, Mark Greve MD, FRCS(C) assessed the images. He looked mostly for diabetic retinopathy, but also for other eye diseases. Patients who needed surgery or other treatments not available in the far north would then be invited to go to a hospital in Edmonton. The rest were followed at a distance.

The pilot project revealed that 35% of the Fort Vermillion population had some degree of diabetic retinopathy and 10% of them needed laser treatment. It also demonstrated there were significant cost savings in doing screening through tele-technology.
Prior to the project, patients with retinopathy ended up travelling to Edmonton every year or two for in-person assessments. Many were not seen at all. With the new programme, only the 10% who needed treatment were sent.

Alberta: The basics Alberta is the most western of Canada's three prairie provinces, bordering Saskatchewan on the east and British Columbia on the west. It lies north of the conterminous US and south of the North West Territories between the 49th and 60th parallels. It is the fourth largest province in Canada, with an area of 661,185sqkm. Alberta is 1,217 km from north to south and between 293km and 650km in width from west to east. It covers an area roughly equal in size to the state of Texas in the US. The majority of the population of European extraction live in the urban areas to the south, while the aboriginal people inhabit the vast wilderness territory in the north.

Treating just 10% was much cheaper for the federal government which footed the bills. It saved on air travel, hotel bills, the hiring of Cree-speaking interpreters and avoided patients having to take a couple of days out of their routine to travel, Dr Tennant said.
The programme then linked up with the First Nations and Inuit Medical Board and the programme expanded to include all 44 communities in Alberta's far north. It was also expanded so patients got general assessments of their diabetes, not just for eye conditions.

Some of the communities participating in the project are more than 1,000km north of Edmonton. To date the eyes of about 600 patients have been assessed this way.
Patients are assessed in specially equipped vans driven to the communities. Two vans covered all the northern Alberta. They were each equipped with a fundus camera, a locally trained photographer and nurses.

For many areas, the vans can only be driven in the winter months when bodies of water are frozen over to form ice roads. During warmer months when the ice roads have thawed, the equipment and personnel are flown up in small airplanes.
“Patients have a comprehensive physical examination for diabetic changes, all at once. The eye images are saved on compact discs, which are flown down to Edmonton. At this point, transmission by satellite hasn't proven reliable,” Dr Tennant said.
Shortly, there will be a web server along with a high-speed electronic transmission line between a hospital in Yellowknife and Edmonton. It will be a virtual private network (VPN), not accessible through the public internet, and should be operational within the next few months.

Once the network is set up, images can be sent from Yellowknife to the web server, which can be accessed by distant retinal specialists on the same day. A report would be generated directly online, which doctors could print.
Alberta isn’t the only place operating a tele-health programme. Indeed, each of Canada's provinces and territories has established tele-health programme of some sort, said Penny Jennett PhD, who is President of the Canadian Society of Telehealth.
“One of the real drivers for tele-health programmes is the geography of Canada. We have to cover large distances. Our providers are generally located in centres, not in every little community.

“Another key driver is found in the principles of the Canadian Health Act. We have five principles, some related to access and equality. If we’re going to deliver on those principles, we need mechanisms for delivering care that will help us provide more appropriate and timely access,” Dr Jennett said.
Getting appropriate and timely care to people who live in the far north has always been a challenge. Many small towns or villages are hundreds of kilometres apart, many accessible only by airplane, boat or ice road. Few physicians opt to practice in remote areas for long.

Telehealth provides an alternative way of delivering services. Technologically, Canada is already one of the world's most ‘wired’ countries and is in a good position to attempt such programmes. And now is the time to do it, since telecommunications technologies are evolving rapidly and the costs are dropping.
Telehealth ranges from the transmission of images to specialists in the south, to live video conferencing for consultations. The technologies are not a replacement for usual care, but is used in conjunction with it, she said.
“You need to know when it's appropriate to use it, when the best benefits for the patient come into play.”

Matt Tennant MD, FRCS(C)
Wills Eye Hospital, Philadelphia, US
Email: mtennant@alberta-retina.com

Penny Jennett PhD
Health Telematics Unit, University of Calgary, Canada
Email: jennett@ucalgary.ca

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