The office of retina specialist Ingrid E. Zimmer-Galler, MD, at Johns Hopkins' Wilmer Eye Institute in
Since the early 2000s, the
Telemedicine is a rather broad term that describes a variety of methods for collecting and exchanging diagnostic data electronically. Even a simple telephone consult can be considered telemedicine. There are 19 bills in Congress that would widen use of telemedicine—ranging from telehealth for brain-injured patients in the Veterans Affairs system to Medicare pilot projects for home-based health monitors. The American Telemedicine Association has identified two policy priorities: Expand Medicare coverage for telemedicine and encourage wider use of home monitoring and remote disease management.
What 'Disruptive Innovation' Means
The term "disruptive innovation" was coined by
Health care, and specifically eye care, is in the path of this disruptive force. Drs. Hwang and Christensen chronicled these disruptions in their book The Innovator's Prescription: A Disruptive Solution for Health Care with the late Jerome Grossman.
This article looks at how such disruptive innovations are changing how doctors deliver and patients receive care.
Patients Like It
If you think your patients won't warm to these evolving models of medical care, think again. Consider these results from a PriceWaterhouseCoopers consumer survey in 2009: 50 percent said they would get health care through the Internet or other computer technology rather than face-to-face visits; 36 percent said they would use a retail clinic; and 73 percent said they would use biometric electronic remote monitoring to track their condition and vital signs.
Dr. Hwang, executive director of health care at the Innosight Institute, a nonprofit think tank dedicated to Dr. Christensen's theories of disruptive innovation, has studied how ever-more sophisticated technology such as telemedicine and evolving consumer attitudes are upsetting the traditional patient-doctor encounter.
Most threatening to the conventional physician's practice business model is the trend of disruptive innovations to simplify routine care so lower-cost providers can adopt it.
"Over time, as specialization became possible and disruption became possible through newer medical technologies, our physicians' practices really failed to focus on certain lines of business and continued to try to be all things to all people," he says.
'Well-Suited' to Telemedicine
The ATA estimates that today 2,000 medical institutions participate in some 200 telemedicine networks in the
Dr. Zimmer-Galler, an associate professor at Johns Hopkins, says ophthalmology is "well-suited" to telemedicine. "All the instruments we use we can attach to a camera and capture and share images," she says.
Hopkins
The
However, these are not the same fundus cameras that ophthalmologists use. They do not require an ophthalmic photographer to operate. EyeTel Imaging of Columbia, Md., developed a fundus camera that is cheaper than the typical ophthalmic-grade camera, is simpler to operate, and has been validated against the gold standard, seven-field stereo fundus photography for detecting diabetic retinopathy.
The images are sent back to the reading center, where Dr. Zimmer-Galler and her colleagues assess them, focusing on early stage disease. "We do use fairly strict criteria," she says. "We prefer to refer patients with early disease for a comprehensive eye examination because we still think it is better for them to be under the care of an ophthalmologist."
The Reimbursement Glitch
One glitch in the system involves reimbursement. "We don't really have specific codes that fall under teleophthalmology or ocular telehealth, so it's hard to get insurance companies and even Medicare to cover this," Dr. Zimmer-Galler says. Professional organizations are working to develop new codes. The next step will be getting payers to cover a service that is already highly utilized but can benefit thousands of patients who are otherwise not getting evaluated for diabetic retinopathy.
Telemedicine for DR has advanced to the point that the ATA has issued practice guidelines.1 No such standards exist for glaucoma, but telemedicine is moving forward in evaluating optic nerve head and neuroretinal rim changes.
As Good as Film
The Ocular Hypertension Treatment Study involved evaluating film images. Albert Khouri, MD, lead author of a study comparing film and digital images of the optic nerve head,2 says OHTS involved a high degree of manual labor—mailing film, labeling slides and archiving files. Digital images obviate this.
But the question looms: Are digital images suitable for evaluating subtle changes in the optic nerve fiber layer? "We compared the film to digital images and they were very close, so with this we established that with digital imaging, you're not compromising on any standards by moving from film to digital," he says.
Dr. Khouri's study at the
At both the VA and UMDNJ, Dr. Khouri has seen telemedicine help rule out patients who would have otherwise been glaucoma suspects triaged for unnecessary appointments. He sees great promise for telemedicine in glaucoma care. "And it's not just with the optic nerve imaging," he says. "We have complemented that with non-contact tonometry. That, with a brief history, and the optic nerve head image—putting all that data together is a pretty powerful indicator whether the patient is suspicious for glaucoma or not."
'Connected Care'
Telemedicine, however, is more than physicians exchanging digital pictures and data electronically. The newest wrinkle is "connected care." If patients won't or can't go to a doctor, have them gather their own clinical information, send it to the doctor, and have consults over the phone or Internet. Joseph Kvedar, MD, director of the Center for Connected Health, has written about the "connected medical home" outfitted with monitoring and messaging technologies connected to a team of providers.
Paul H. Keckley, PhD, executive director of the Deloitte Center for Health Solutions, says the effective application of in-home technologies could im-prove self care of chronic disease and lead to an annual savings of about 20 percent in overall health-care expenditures, or about $400 billion.
"Technology alone is not the key," he writes in the Deloitte report Connected Care: Technology-enabled Care at Home. "It must be incorporated into a care-management program personalized to an individual's needs and under the oversight of a care team. In-home technologies enable frequent, effective and personalized patient interactions to equip them to care for themselves."
While physicians could receive information such as blood pressure and glu-cose levels, charting retinal changes from an in-home fundus camera may be a stretch. Dr. Keckley, in the Delo- itte monograph The Medical Home: Disruptive Innovation for the Primary Care Model, estimates that setting up a so-called medical home program would cost individual physicians $100,000 up front with ongoing expenses of $150,000 or more. For physicians, he calculates the level of risk for in-home medicine is high.
Medical Home in Practice ... Almost
Meanwhile, the Hawaii Medical Ser-vice Association, a Blue Cross and Blue Shield licensee, moved toward the connected home when it became the first health plan in the country last year to launch Online Care, a service that connects patients and physicians via Internet or telephone.
"HMSA's Online Care is making
More than 140 local physicians from a variety of specialties, including ophthalmology, signed on initially, although an HMSA spokesperson says no ophthalmologists have actually accessed the system yet. Physicians can log on at anytime to interact with patients. HMSA won't say Online Care supplants face-to-face visits, but acknowledges it provides an alternative when a patient can't get to a physician's office.
Like Going to the Store
Broadening access to care is fueling the retail boom in primary-care medicine. In eye care, retail outlets are nothing new. Optometrists have provided examinations and other primary eye-care services in retail chains such as Pearl Vision and Lenscrafters for decades. Many LASIK centers have pursued a retail model with varying success.
In primary care, retail clinics are picking up steam. The California HealthCare Foundation reports that retail clinics in the
Ophthalmologists may be better poised than their primary-care colleagues to weather this trend. Besides, the nature of eye care may have its limits when it comes to a retail clinic model. Even operating the simplified fundus cameras at the primary-care practices in the
Dr. Hwang contends that all physicians should pay attention to why retail clinics are gaining traction. "Quality is not a significant portion of the purchasing at a retail clinic," he says. "If quality was a concern, they probably would have gone to a traditional provider."
Lessons from the LASIK Market
Physicians have a habit of misreading consumer trends, Dr. Hwang says. His own analysis of the LASIK market earlier this decade illustrated specifically how ophthalmologists reacted.
"If you view these retail optical shops or LASIK clinics as a potential threat where they're just stealing business away, then you're going to find yourself in the situation we often see, which is trying to firm up regulations and barriers to block these disruptions," he says. "Others see this as an opportunity to perhaps expand their practices to focus on the real complicated high-value care and shift the low-value care like the optical care to optometrists. Then you dramatically expand your capability to earn revenue."
He acknowledges, however, that physician practices don't behave like conventional businesses, even as payers cut reimbursements. "The retail clinics optical shops of the world, by virtue of having a lower-cost business model, can still make money if you pay them less," he says. "In any other industry, if you have a disruption coming that would allow you to focus on more profitable lines of business, then you would willingly give up the low end of the market to the disruptor," he says.
Skewered Pricing Structure
The pricing structure in health care, however, does not truly reflect market forces, and payers slashing reimbursements for specialized care is not the answer, Dr. Hwang says.
"You can squeeze a few more efficiencies out of system certainly, but high-cost care is going to remain high-cost care, and if you start paying doctors less you're simply going to get fewer providers and that ends up hurting the system. What you should pay less for is basically the routine type of care."
Of course, ophthalmologists who struggle to hold onto that routine type of care will also struggle against the force of disruptive innovations. In his research, Dr. Hwang has found that to be a losing proposition.
1. American Telemedicine Association, Ocular Telehealth Special Interest Group, National Institute of Standards and Technology Working Group. Telehealth practice recommendations for diabetic retinopathy. Telemedicine J e-Health. 2004;10:469-482.
2. Khouri AS, Szirth BC, Salti HI, Fechtner RD. DICOM transmission of simultaneous stereoscopic images of the optic nerve in patients with glaucoma. J Telemed Telecare. 2007;13:337-340.
