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Telehealth and Diabetes Care Telehealth and Diabetes Care Management Paul R. Conlin, M.D. Paul R. Conlin, M.D. VA Boston Healthcare System Harvard Medical School Harvard Medical School 1
63

Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Jul 26, 2018

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Page 1: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Telehealth and Diabetes CareTelehealth and Diabetes Care Managementg

Paul R. Conlin, M.D.Paul R. Conlin, M.D.VA Boston Healthcare System

Harvard Medical SchoolHarvard Medical School

1

Page 2: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Poll QuestionPoll Question

What is your primary professional role?

• Clinician• Non-clinician InvestigatorNon clinician Investigator• Healthcare administration

Information technology support• Information technology support• Other

2

Page 3: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Poll QuestionPoll Question

What is your interest in telehealth?

• I’m using telehealth technologies in the care of patients.

• I’m not familiar with the topic and would like to learn more.learn more.

• I had nothing better to do today, so I decided to sign-up for this conferencesign-up for this conference.

3

Page 4: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

TelehealthTelehealth

• (Telemedicine)The use of information and communication technology to provide clinical care, patient education, provider education, and hospital , p , padministration in circumstances where distance separates those receiving services and those p gproviding services.

4

Page 5: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Care managementCare management

• (Care coordination or case management)Facilitating delivery of the right care, in the right g y g , gplace at the right time. In most cases the home is the preferred place ofIn most cases, the home is the preferred place of care

5

Page 6: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Interactive behavior change technologyInteractive behavior change technology

• The use of hardware and software to promote and sustain behavior change (e.g. PDAs, websites, automated telephone calls)

• Assists patients and clinicians in monitoring gpatient’s health status, supports patients’ efforts to make changes, and enhances communication gbetween patients and clinicians

6

Page 7: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Is Telehealth technology important?Is Telehealth technology important?

• Generally accepted based on validation studies or anecdotal reports

• Few studies to assess cost-effectiveness• FDA ranked home telehealth in top 5 of 36 new• FDA ranked home telehealth in top 5 of 36 new

medical technologies in terms of impact on healthcare over the next 10 yearshealthcare over the next 10 years

7

Page 8: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Telehealth applicationsTelehealth applications

• Patient-to-provider – basic information– Ask basic questions, offer prompts, limited data

• Patient-to-provider – complex information– Internet-based portalsp

• Clinical peer-to-peer – basic information– Tele-radiology dermatology ophthalmology– Tele-radiology, dermatology, ophthalmology

• Clinical Peer-to-peer – complex informationR t lt ti– Remote consultation

8

Page 9: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Patient to Provider TelehealthPatient-to-Provider Telehealth

Viterion 100

Home PC

Health Buddy

9

Page 10: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Can education andCan education and care management be delivered remotely?

10

Page 11: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Computer Use and Internet AccessComputer Use and Internet Access

• Survey of Ambulatory Care patients -VABHS 894 respondents, age 62 – 53% with computer access– 63% interested in receiving health information63% interested in receiving health information

via the InternetS f ti t i i ti• Survey of patients in a primary care practice– 54% use the Internet for health information– 60% felt information was the same or better than

that received from their doctorDiaz JA et al. J Gen Int Med 2002; 17: 180 11

Page 12: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Internet based applicationsInternet-based applications

• Weight management using e-counseling– Greater weight loss with website access and e-g

counseling• Interactive asthma education website• Interactive asthma education website

– Access to a website was associated with: • Increased asthma knowledge, reduced symptom

days, fewer ER visits, lower steroid doses

Tate DF et al JAMA 2003; 289: 1833 1836Krishna S et al. Pediatrics 2003; 111: 503-510. Tate DF et al. JAMA 2003; 289: 1833-1836

12

Page 13: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Telephone based managementTelephone-based management

• Telephone calls with RN follow-up– Biweekly automated telephone calls; most y p ;

benefit when A1c >8% (net effect- 0.5 -1.1%)• Mobile phone and SMS messaging• Mobile phone and SMS messaging

– Patients send glucose results via phone, i freceive message from nurse

– Decrease in A1c by 1.1% over 12 weeks

Piette JD et al Diabetes Care 2001;24:202 208Piette JD et al. Diabetes Care. 2001;24:202-208Kim HS. Int J Nurs Stud. 2007; 44:687-692 13

Page 14: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Care management cautionCare management - caution

• Nurse care management– 246 patients, A1c 9.3%p , %– Nurse care management using algorithms;

follow-up over 18 monthsfollow up over 18 months– No difference in A1c, BP, lipids

I t ti lt d i t ti f ti– Intervention resulted in greater satisfaction with diabetes care

Krein SL et al. Am J Med. 2004;116:732-739 14

Page 15: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Web based diabetes educationWeb-based diabetes education and care managementg

15

Page 16: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Web based care managementHbA1 BP

Web-based care managementHbA1c, BP,

Quality of Life Questionnaires

U l CUsual CareRecruitment

and ScreeningWeb-based Care½ day

Education

and Screening

0 3 6 9 120 3 6 9 12Months 16

Page 17: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

MethodsMethods• Web-based care managementWeb based care management

– Provided with notebook computer, glucose and BP monitors and dial up access toand BP monitors and dial-up access to MyCareTeam™ websiteU l d l d BP d– Upload glucose and BP data

– Interact with care manager via internal messaging system on website

– Care manager uses algorithms to improve g g pglucose and BP control

• Usual care- on going care by their PCP• Usual care- on-going care by their PCP17

Page 18: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Clinical CharacteristicsClinical Characteristics

Baseline Characteristics (n = 104)• HbA1c 10%• HbA1c 10%• Age (years) 64• BMI (kg/m2) 33• Sex (% male) 99• Sex (% male) 99• Duration of diabetes (yrs) 12• Prior Internet access (%) 29

18

Page 19: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

HbA1c over 12 monthsWeb-based care

t

HbA1c over 12 months

0.0

(%) management

Usual care

-0.5

HbA

1c

P<0.05 vs. Usual care

-1.0

e in

H

-1.5

hang

e

-2.00 3 6 9 12

C

0 3 6 9 12

Months 19

Page 20: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Persistence with web site loginsPersistence with web-site logins

• Persistent users (n = 30)– At least one website login every 3 monthsg y

I t itt t ( 22)• Intermittent users (n = 22)– >3 months during the study with no registered

logins

20

Page 21: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

HbA1c based on persistenceUsual Care

HbA1c based on persistence

0 5

0.0

(%)

Usual CareIntermittentPersistent

-1 0

-0.5

bA1c

-1.5

1.0

e in

Hb

-2.0

hang

e

-2.50 3 6 9 12

Ch

0 3 6 9 12

Months 21

Page 22: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

IDEATel MethodsIDEATel – MethodsInformatics for Diabetes Education and Telemedicine• Telemedicine intervention

– Telemedicine in-home unit with nurse case– Telemedicine in-home unit with nurse case management

• Randomized trialRandomized trial– Intervention vs. usual care

Medicare beneficiaries (n = 1665)• Medicare beneficiaries (n = 1665)– Diabetes, >55 years, medically under-served areas in

NY (upstate and NYC)NY (upstate and NYC)

22

Page 23: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

IDEATel – Change in A1cg

Shea S et al. JAMIA 2009;16:446-456 23

Page 24: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

IDEATel CaveatsIDEATel – Caveats• Modest clinical effectsModest clinical effects

– Small but significant changes – A1c (0.29%), SBP (4.3 mm Hg), lipids (3.8 mg/dl)( g), p ( g )

• No mortality benefit– Likely under-powered– Likely under-powered

• Increased costs$8 000 f i t ti– $8,000 per person per year for intervention

– Total Medicare costs 71% higher in intervention group

Moreno L et al. Diabetes Care 2009; 32: 1202-4 24

Page 25: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Care management vs InternetCare management vs. Internet access?

25

Page 26: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Care management vs Internet accessCare management vs. Internet access

Questionnaires

Usual Care and Internet access

Recruitmentand Screening

Telephone Care Managementand Screening

Web-based Care Management

0 3 6 9 12Months

26

Page 27: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

MethodsMethods• Web-based care managementWeb based care management

– Notebook computer, glucose and BP monitors access to website care managermonitors, access to website, care manager

• Telephone-based care management– Glucose and BP monitors, routine access to

care manager via phone and office visitsg p• Internet access

N t b k t d I t t– Notebook computer and Internet access; home-page set to web-based diabetes care resources

27

Page 28: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Clinical CharacteristicsClinical Characteristics

Baseline Characteristics (n = 104)• HbA1c 9 9%• HbA1c 9.9%• Age (years) 60• Sex (% male) 95• Duration of diabetes > 5 y 78%• Duration of diabetes > 5 y 78%• Some college education 60%

28

Page 29: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

HbA1c over 12 monthsInternet access

HbA1c over 12 months

0 5

0.0

(%)

Internet accessTelephone Web-based

-1 0

-0.5

HbA

1c Web based

-1.5

-1.0

ge in

H

-2.0

Cha

ng

-2.50 3 6 9 12

C

0 3 6 9 12

Months 29

Page 30: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Clock drawing testClock-drawing test

• In the paper provided draw a clock face, with numbers, in the blue box ,

• Show the hands of the clock pointing to 10 minutes after 11 o’clockminutes after 11 o clock

30

Page 31: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

31

Page 32: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

32

Page 33: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

33

Page 34: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

34

Page 35: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Interactive Behavior Change TechnologyInteractive Behavior Change TechnologyCommunication links that could be targeted by IBCT

Patients’ Care Team Informal Caregivers

g y

Patients

Other Patients

Piette JD. Diabetes Care 2007; 30:2425-2432 35

Page 36: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Interactive behavior change technologyInteractive behavior change technology

• Look before you leap• Look before you leap• One size does not fit all• Beware of “cool” applications• IBCT should support human contactpp• Diabetes self-management is rarely patients’

primary life concernprimary life concern• Not all patients need IBCT

I ti i ltidi i li• Innovations require multidisciplinary collaborations

Piette JD. Diabetes Care 2007; 30:2425-2432 36

Page 37: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Future DirectionsFuture Directions• What component(s) are responsible for• What component(s) are responsible for

improved glucose control?• Which patient characteristics identify

those who will benefit from e-healhthose who will benefit from e healh applications?Fitti t h l ith ti t• Fitting technology with patients

• Identifying cost-effective strategiesy g g• How to sustain persistence

37

Page 38: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

SummarySummaryTelehealth based diabetes managementTelehealth-based diabetes management• Clinical benefits demonstrated – but…

– Key components are unclear– One size does not fit all– One size does not fit all– Patient persistence is likely required

Q i bl ff i– Questionable cost-effectiveness

38

Page 39: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

When you come to a fork in theWhen you come to a fork in the road, take it.,

Lawrence “Yogi” Berra

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Page 40: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Tele-retinal Imaging

Who? What? Where? When? Why?Who? What? Where? When? Why?

40

Page 41: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

History of Teleretinal Imaging in VISN 1Imaging in VISN-1

FY1998 VA D t t f D f J li• FY1998 – VA – Department of Defense – Joslin Diabetes Center collaboration established

• FY1999 – Teleretinal imaging begun at VA Boston andFY1999 Teleretinal imaging begun at VA Boston and in VISN-20

• FY2000 – Image acquisition at Togus VAMCg q g• FY2001 – VHA convenes expert panel to review criteria• FY2006 – VHA establishes national teleretinal imaging

programNational Training Center at VA Boston

FY2007 I i iti t lti l it i• FY2007 – Image acquisition at multiple sites; image interpretation at VA Boston

• FY2008 >200 000 patients accessedFY2008 >200,000 patients accessed41

Page 42: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Tele retinal ImagingTele-retinal Imaging

• Who?– Patients with diabetes mellitus– No recent eye examination or scheduled for

eye exams with known low-risk characteristicseye exams with known low risk characteristics– Not for those with known, advanced DR

• What?– Technology-assisted evaluation for diabetic gy

retinopathy – NOT a substitute for a complete eye examNOT a substitute for a complete eye exam

42

Page 43: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Acquisition stationAcquisition station

• Retinal camera • Computer workstation• Computer workstation• No pupil dilation

Hi h l ti di it l• High-resolution digital stereo, color images

• Data transmission using standard network links

43

Page 44: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Normal RetinaNormal Retina

Retina Blood Vessels

Optic Nerve

Macula

44

Page 45: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Diabetic RetinopathyDiabetic Retinopathy

Pre-retinal h h

Abnormal Retinal Vesselshemorrhage

45

Page 46: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Non diabetes eye findingsNon-diabetes eye findings

Glaucoma

Age-related macularAge related macular degeneration

46

Page 47: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Tele retinal ImagingTele-retinal Imaging

• When?– “Capture” patients when they present for p p y p

primary care, subspecialty care, other visits • Where?• Where?

– NOT in the Ophthalmology or Optometry clinics

47

Page 48: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

A Clinical Pathway for Tele-retinal ImagingCandidate for tele-

retinal imagingReview medical

and eye care history

Patient Identified With Clinic

AppointmentAppointment

Transmit images to Acquire images

gReading Center

Review Report

Technician Triage/Appoint patients based

images in CPRSpatients based

on findings48

Page 49: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Tele retinal ImagingTele-retinal Imaging

• Why?– Frequency of annual eye exams are less than q y y

optimal– Eye clinic appointments require separate visitEye clinic appointments require separate visit– Most patients have no retinopathy

Abilit t t i ti t– Ability to triage patients

49

Page 50: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Tele-retinal imaging studies

50

Page 51: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Agreement with clinical examAgreement with clinical exam

• Exact agreement 72%268 patients examined by TRI and retina specialist

• Exact agreement 72%• Within one DR level 89%• Appropriate referral 92%

• Other referable eye findings 25%P ti t ith DR ild DR 67%• Patients with no DR or mild DR 67%

Cavallerano AA, et al. Retina 2003; 23: 215 – 223. 51

Page 52: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Other Ocular ConditionsOther Ocular Conditions1219 patients examined by TRI

• Urgent ocular conditions 1%1219 patients examined by TRI

• Retinal vein occlusion, vitreous hemorrhage

• Urgent medical conditions 4%Urgent medical conditions 4%• Retinal emboli, hypertensive retinopathy

• Additional ocular diagnoses 61%• Additional ocular diagnoses 61%• Cataract, glaucoma suspect, choroidal nevus,

macular degenerationmacular degeneration

Cavallerano AA, et al. Am J Ophthalmol 2005; 139:597-604 52

Page 53: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Tele retinal imaging and glaucomaTele-retinal imaging and glaucomaCase control study of patients examined by TRI

• 175 diagnosed as “glaucoma suspect”Case-control study of patients examined by TRI

• 175 without glaucomatous findings• Matched for age sex and race• Matched for age, sex and race

• Results from comprehensive eye exam– 103/175 (59%) “cases” met glaucoma criteria– 7/175 (4%)”controls” met glaucoma criteria– Intra-ocular pressure was identical between groups

Pasquale LR, et al. Optometry 2007; 78:657-63 53

Page 54: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Adherence with eye careAdherence with eye carePatients with diabetes randomly assigned to havePatients with diabetes randomly assigned to have tele-retinal imaging or not (n = 447)

• Tele-retinal imaging (n = 223)– Follow-up based on results of imagesFollow up based on results of images

• Control group (n = 224)F ll b d id li ( l )– Follow-up based on guidelines (e.g. annual eye exam)

• End points – Eye exam within 12 months, level of agreement

between imaging and follow-up exam

54

Page 55: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Eye care follow-upEye care follow up

Follow-up No follow-upVisit Visit

TRI group 194 (87%)* 29TRI group 194 (87%) 29(Documented eye care within 12 months)

Control group 172 (77%) 52(No eye care in 12 months)(No eye care in 12 months)

*P<0.01

Conlin PR et al. J Rehabil Res Dev 2006 55

Page 56: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Level of SatisfactionLevel of SatisfactionHow satisfied were you overall with

hi id i i ?this video examination?

60

cy 40

50

eque

nc

30

40

Fre

10

20

0 1 2 3 4 5 6 7 80

S f fVery Satisfied Very DissatisfiedConlin PR et al. J Rehabil Res Dev 2006

56

Page 57: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

A billi h d billi thA billion here and a billion there, and pretty soon you’re talkingand pretty soon you re talking

real money.yEverett Dirksen

57

Page 58: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Effectiveness of tele retinal imagingEffectiveness of tele-retinal imaging

6053

Digital retinal imaging Ophthalmoscopy with dilation

572559575634

5000

60006053

3000

4000

Cas

es

207 2121000

2000

C

0Proliferative DiabeticRetinopathy Detected

Panretinal LaserPhotocoagulation

Severe Vision Loss

Whited J et al. Telemedicine and E-Health 2005 58

Page 59: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Total Costs of tele retinal imagingTotal Costs of tele-retinal imaging

$29 34

Digital retinal imaging Ophthalmoscopy with dilation

$20.26

$27.07

$22.67

$29.34

$25.00

$30.00

)

$9 12

$20.26

$12.09$15.00

$20.00

mill

ions

$9.12

$5.00

$10.00

$ (in

$0.00Proliferative DiabeticRetinopathy Detected

Panretinal LaserPhotocoagulation

Severe Vision Loss

Whited J et al. Telemedicine and E-Health 2005 59

Page 60: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Future Research DirectionsFuture Research Directions• Does tele retinal imaging reliably• Does tele-retinal imaging reliably

identify ocular diseases other than DR?

• Can tele-retinal imaging substitute for• Can tele-retinal imaging substitute for an eye exam in low-risk patients?

60

Page 61: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

SummarySummaryTele-retinal ImagingTele retinal Imaging• effective and cost-effective care

di ti t l t icoordination tool to improve eye care • high level of agreement with follow-up g g p

eye exams• often reveals other findings that warrant• often reveals other findings that warrant

a referral for eye exam• results are more than “screening” and

less than “diagnostic” (i.e. evaluative)less than diagnostic (i.e. evaluative)61

Page 62: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

CollaboratorsCollaborators

Care management• Helen Gomes

Tele-retinal imaging• Barry Fisch

• George Alexis• Betty A. Levine

• Sven E. Bursell• Anthony Cavallerano

• Graham McMahon• Stephanie Fonda

• Gerald Selvin• Louis Pasquale• Baharak Asefzadeh• John Whited

Page 63: Telehealth and Diabetes Care Management · Poll QuestionPoll Question ... • Generally accepted based on validation studies or ... • Mobile phone and SMS messagingMobile phone

Contact InformationContact Information

Paul R. Conlin, M.D.Medical Service (111)Medical Service (111)VA Boston Healthcare System1400 VFW ParkwayWest Roxbury MA 02130West Roxbury, MA 02130857-203-5111 FAX [email protected]

63