Telemedicine, Teleophthalmology Programs in Action at Johns Hopkins

Telemedicine, teleophthalmology
programs in action at Johns

Hopkins
 Steve Lenier
April 17, 2019
Volume:
44
Issue:
7
Abstract / Synopsis:
Artificial intelligence can provide a knowledge base that can be

a foundation for the interpretation of data. The importance of
the humanistic elements of medicine remain vital.
Creative disruption of an existing model can be the path forward to a

new technology, such as telehealth, a market that has grown rapidly
since 2012, and is expected to continue to do so over the next several
years.
What is telemedicine?
The American Telemedicine Association defines telemedicine as the
transfer of medical information via telecommunication (both
synchronous and asynchronous) technology or specially designed
medical devices for the purpose of delivering healthcare services and
clinical information.
In Maryland, where Johns Hopkins University is located, telemedicine is

described as the use of interactive audio, video, or other
telecommunications or electronic technology by a physician in the
practice of medicine outside the physical presence of the patient.
Multiple layers make up a telemedicine system—tools and equipment,
modes or types of telemedicine, specialty areas of care, individual
patients and providers, and the locations where virtual care will be
delivered.
Equipment
Both the patient and the clinician need certain tools to perform
telemedicine. For the patient these can include a laptop, smartphone, or
other personal smart device, equipped with a camera, and the
appropriate app or software. In some cases remote monitoring
equipment at home can be useful as well. The physician will need similar
equipment, plus additional software and peripherals for use in
diagnosing disease or progression and reporting results.
Modes
There are three main types of telemedicine, each good for certain uses.
Only one of them (synchronous) requires the physician and patient to be
available at the same time. Telehealth makes individualized, patient-
centric care possible for patients across the continuum of care.
Locations Served
At Johns Hopkins, telemedicine connects the entire healthcare system
including community physician practices, all Johns Hopkins’ hospitals,
affiliated hospitals, the home-care group, skilled-nursing facilities, and
other collaborative facilities.
Challenges
Many challenges remain in using telemedicine, most significant of which
include policies and reimbursement.
While the telehealth market continues to grow, telemedicine volumes
expand at the speed of reimbursement. Commercial payors have largely
embraced telemedicine but government payors (Medicare and Medicaid)
have been more reluctant. There has been an uptick in reimbursement
for telemedicine services from government payors.
Without appropriate reimbursement, providers will not utilize new
technology tools for health care delivery. Direct-to-consumer online
virtual care has been more successful with self-pay options. Other
notable concerns include obtaining licensing to practice medicine across
state lines (a medical license is required in the state where the patient is
located), and credentialing and privileging at the originating site.
Telemedicine at Johns Hopkins

The Johns Hopkins Medicine (JHM) Office of Telemedicine, established
July 1, 2016, coordinates all telemedicine efforts across the Hopkins
healthcare enterprise.
The goals of the JHM system are to:
 Create and increase access for patients

 Expand the populations served
 Lower the total cost of care
 Simplify and streamline the process for physicians
 Ensure compliance
 Embed reporting within the electronic health record
 Maintain quality and safety
 Standardize documentation
 Minimize risk
Telemedicine reduces costs by avoiding unnecessary patient visits and

face-to-face consultations with physicians and by replacing clinic visits
with less-expensive virtual care. It increases revenue by giving patients
greater access to healthcare, expanding patient share capture, and by
increasing a facility’s capacity to accommodate referrals and transfers
for more appropriate higher-acuity patients.
Johns Hopkins Medicine has launched 44 telemedicine programs, in 31

specialties, for more than 16,700 patient encounters. Another 38
programs are being prepared to launch, with 30 more in the early
pipeline stages.
Diving deeper: Teleophthalmology
Ingrid Zimmer-Galler, MD, associate professor of ophthalmology at
the Johns Hopkins Wilmer Eye Institute, points out that
teleophthalmology has the potential to be a radical transformer of care
delivery.
Current teleophthalmology programs include diabetic retinopathy

screening; retinopathy of prematurity (ROP) screening; glaucoma
screening and disease management; age-related macular degeneration
screening and management; anterior segment and ocular adnexal
disease’ and remote consultation and remote emergency department
(ED) evaluations.
Diabetic retinopathy screening

Diabetic retinopathy screening is one of the first and most beneficial
uses of telemedicine in ophthalmology. In the United Kingdom, diabetic
retinopathy is no longer the leading cause of vision loss in working age
adults in part due to a robust national telemedicine diabetic retinopathy
screening (Liew, Michaelides, Bunce. BMJ Open. 2014;4:e004015).
Telemedicine programs allow patients with diabetes to receive

appropriate and timely screening for retinopathy so that necessary
intervention can be performed when it is most likely to be beneficial.
Telemedicine with photographic documentation for ROP screening offers

increased access for neonatal intensive care units where specialty
coverage is often limited.
Telemedicine ROP evaluations may become part of the gold standard for
diagnosis and monitoring of the disease given the benefits of retinal
imaging over traditional retinal drawings.
Need for improved methods

By 2030, nearly 440 million individuals worldwide will have diabetes. It is
projected that by 2020 there will be a significant undersupply of
ophthalmologists worldwide. The task of detecting and evaluating
diabetic retinopathy will create a resource and economic burden to
healthcare systems and telemedicine screening programs will be crucial
to meet the demand.
The FDA recently cleared the first artificial intelligence system for use in
the United States for diabetic retinopathy screening. This is expected to
enhance the efficiency of diabetic retinopathy screening as physician
review of every image will no longer be necessary.
Emergency department (ED)

Urgent eye problems account for a significant percentage of ED to ED
transfers from community hospitals to tertiary care hospitals due to the
lack of ophthalmology coverage.
Telemedicine provides an opportunity to use an external high-resolution

camera for a video visit and consultation to avoid transferring the
patients from one ED to another.
It is anticipated there will be significant opportunity for growth of

telemedicine in ophthalmology and those practices flexible enough to
embrace it and integrate new

Disclosures:
Ingrid Zimmer-Galler, MD
E: [email protected]
This article was adapted from Dr. Zimmer-Galler’s presentation at the
2018 meeting of the Johns Hopkins’ Wilmer Eye Institute Current
Concepts in Ophthalmology in Baltimore. Dr. Zimmer-Galler has no
financial interests to disclose.

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Telemedicine, teleophthalmology

programs in action at Johns

Artificial intelligence can provide a knowledge base that can be

Creative disruption of an existing model can be the path forward to a

In Maryland, where Johns Hopkins University is located, telemedicine is

Telemedicine at Johns Hopkins

 Create and increase access for patients

Telemedicine reduces costs by avoiding unnecessary patient visits and

Johns Hopkins Medicine has launched 44 telemedicine programs, in 31

Current teleophthalmology programs include diabetic retinopathy

Diabetic retinopathy screening

Telemedicine programs allow patients with diabetes to receive

Telemedicine with photographic documentation for ROP screening offers

Need for improved methods

Emergency department (ED)

Telemedicine provides an opportunity to use an external high-resolution

It is anticipated there will be significant opportunity for growth of

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