Risk Management

Teleophthalmology Across the Miles

By Rosa A. Tang, MD, MPH, and Joan Hearst, ARM

Dr. Tang is a neuro-ophthalmologist in Houston, TX. She has been practicing teleophthalmology since the mid-1990s.

Ms. Hearst is a risk management consultant in Pasadena, CA.

 This is the second of a two-part article on risk exposures and risk management strategies related to teleophthalmology. Part I focused on the Internet and email and can be found on OMIC’s Web site, www.omic.com. Part II reviews teleophthalmology applications and emerging risk management issues.

Digest, Fall, 1991

Separated by 210 miles of Pacific Ocean, an orbital specialist on the island of Oahu successfully guides a general ophthalmologist on the island of Hawaii in the removal of a lateral orbital tumor from the eye of a 15-year-old patient. It is the first time telemedicine technology is used to support real-time surgical telementoring to remove an orbital tumor, and it opens the door to further use and development of telementoring technology to disseminate surgical skills to distant sites (Camara et al, Ophthalmology, 2000, v. 107, 1468-1471).

Increasingly, ophthalmologists are using electronic communications to direct patient care and share patient information with health care providers at different locations. A 1998 annual program survey by Telemedicine Today indicated that 9.6% of interactive video and store and forward teleconsultations (images that are stored on disk or film for later review) were being performed by ophthalmologists. Ophthalmologists who incorporate telemedicine into their practice are joining medical disciplines such as teleradiology, which have been practicing telemedicine for years.

Telemedicine has many applications in ophthalmology: imaging technology for diabetic retinopathy examinations, interpretation of fluorescein angiograms, fundus photographs, visual fields, and CT scans; slit-lamp exams performed via videoconferencing; and real-time telemonitoring of complex ophthalmic procedures such as the above example. Telemedicine has a place in all stages of patient care (diagnosis, therapy, follow-up, and/or education) and may involve the transfer between distant sites of patient medical records, medical images, output data from medical devices, and sound and video files.

The most promising benefit of telemedicine is improved access to medical care, particularly for patients in remote locations. A patient can remain in his or her local physician’s office while the physician obtains test results and consults from healthcare practitioners in major hospitals and research centers hundreds or thousands of miles away. Other benefits include more efficient medical evaluation and management of patient care. As with any system, however, mismanagement can occur when roles and responsibilities for follow-up care and communication with other providers are not clearly delineated. The following case study illustrates this point.

 Case Study: Patient Management

A 72-year-old man underwent an uncomplicated cataract extraction of his right eye at a rural community outpatient clinic by a visiting surgeon from a city eye hospital 100 miles away. Postoperative care was provided via telemedicine with the help of an ophthalmic nurse at the clinic who had been personally trained by the ophthalmologist. Using a Zeiss video slit lamp, the nurse captured images of the patient’s eye and transmitted these images to the surgeon who viewed them during a live teleconsultation with the patient. The rural clinic was electronically linked to the city hospital by three integrated service digital lines with a transmission of 30 frames per second video.

On the first post-op day, the patient’s vision was 20/50 with pinhole. The video slit image sent to the surgeon by the nurse was interpreted by the surgeon as “expected mild inflammation.” During the live videoconference, the patient complained of mild foggy vision and some pain in the operated eye. Steroids and antibiotic drops were prescribed and the patient was given a one-week follow up telemedicine visit. Over the next two days, the patient called the clinic because of increasing pain and spoke to the nurse on duty (not the ophthalmic nurse), who told him to increase the drops he had been prescribed. On the fourth post-op day, because of no pain relief, the patient traveled to the city to be seen by the surgeon at the hospital. The surgeon found severe iritis and secondary glaucoma. Fortunately, the iritis was treated successfully and the glaucoma resolved. The patient’s final vision was 20/20. The patient sued the clinic and the surgeon for pain and suffering and misdiagnosis of his condition. He claimed his problem existed at the first post-op visit and would have been diagnosed had the ophthalmologist seen him face-to-face. The case was settled prior to trial with a payment to the patient.

This case points to a potentially fertile area of teleophthalmic liability; namely, follow-up care and continuity of patient management. Geographic distance between a patient and surgeon can complicate aspects of care coordination, particularly when multiple providers (nurse, surgeon, optometrist, etc.) are involved. Before this case, there had been 80 successful postoperative teleconsultations between the rural community clinic and the city eye hospital; however, there was a weak link in the arrangement.

The clinic did not have a full-time ophthalmic nurse on staff so when post-op patients called with questions or concerns, they spoke to the nurse on duty, who did not always consult with the local ophthalmic nurse or the surgeon at the hospital. After this incident, the clinic established protocols for documenting and referring patient calls to the ophthalmic nurse or surgeon.

Teleophthalmology protocols should address patient confidentiality issues, including judicious handling of medical information. Breaches in confidentiality may occur when patient information can be easily viewed or accessed on a computer screen by anyone walking by. Computer medical records should be protected by encryption and precautions taken to ensure that patient data is not forwarded to an inappropriate party. Since patients may not be in visual contact with providers and others at distant teleconsultation locations, privacy issues can arise unexpectedly. The following case study demonstrates the importance of maintaining patient confidentiality.

Case Study: Patient Confidentiality

A 45-year-old woman with a recurrent brain tumor following surgery and radiation therapy was scheduled to be flown overseas for gamma knife treatment. Before undertaking the trip, a third opinion was requested and a teleophthalmology consult was set up with a neuro-ophthalmologist. A neuroradiologist and neurosurgeon also were present at the consultant site, along with technical personnel and two medical students. The patient was not able to see who was in the consultant room as the cameras were directed only on the person speaking and on the materials being reviewed (medical records, visual fields, Xrays). Present at the patient’s site were the treating physicians and technical personnel as well as the patient and her family.

From a technical and medical standpoint, the consultation was successful. It was determined that the patient had brain radionecrosis from the radiation therapy, not a tumor recurrence, and did not need to travel abroad for gamma knife therapy. This opinion was later corroborated by the gamma knife surgeon when he reviewed the patient’s neuro-imaging.  During the teleconsultation, a medical student asked the patient a question. The patient and her family were surprised to learn other people were present in the room at the consultant’s site. They felt their privacy had not been respected since they had not been informed of nor consented to having medical students present.

Following this incident, the hospital ethics committee agreed that patients should know who would be attending the teleconference at the consultant end and who potentially might have access to the patient’s medical information and records. Henceforth, everyone present in the consultant room would be introduced to the patient to ensure patient consent.

 Informed Consent

In addition to patient management issues, informed consent was a contributing factor in the decision to settle the first case involving the cataract patient at the rural clinic. Although the patient did sign a consent form prior to surgery agreeing to have post-op care provided by telemedicine, a nurse had noted in the medical record that the patient was “anxious” about being involved in a teleconsultation.

Some states have enacted legislation requiring the attending physician to obtain verbal and written consent prior to delivery of healthcare via telemedicine. Not only is it legally required in some states, but having patients sign a specific Informed Consent for Telemedicine Services presents an opportunity to discuss protocols and allay concerns about the telemedicine process. If you provide a teleophthalmologic consult, obtain a copy of the patient’s signed informed consent for telemedicine from the referring physician before the consult and place it in the patient’s medical record. A sample consent form for telemedicine services can be found here.

New technology always has the potential to increase liability exposures, and telemedicine may prove to be a fertile ground for plaintiffs’ attorneys by offering more “targets” (referring physician, teleconsultant, or both) and the opportunity to “venue shop” for the trial location with the patient-friendly juries, higher limits on damages, or less effective tort reform, depending on where the referring physician, teleconsultant, or patient is based. There is little legal precedent to adequately assess telemedical liability exposures related to medical licensure, patient/physician relationships, national versus local standards of care, or venue for lawsuits; therefore, it is prudent to contact your malpractice insurance carrier or OMIC before providing telemedical services to ensure coverage in the jurisdiction(s) in which you will provide this service.

A list of source references used in preparing this article can be found here.

For further information on telemedicine, contact the American Telemedicine Association (ATA) or the International Consortium for Ocular Telehealth (ICOT) at http://www.americantelemed.org/i4a/pages/index.cfm?pageid=1   

Protocols for Teleophthalmology

 A comprehensive policy will define the scope of teleophthalmology in your practice and ensure that patients receive the maximum benefit. Update your policy annually and distribute it to staff and patients.

Clarify the physician-patient relationship, and define the limits of a teleconsultation.

Identify and outline the responsibilities of everyone in your practice who is involved in teleophthalmologic interactions to ensure seamless patient management. Include protocols for supervision of staff and equipment.

Verify the credentials and insurance coverage of all licensed practitioners involved in teleophthalmologic applications. Failure to verify the credentials of a consulting specialist could lead to claims of negligent referral if there is an adverse outcome.

Identify the accepted “standard of care” for telemedicine in your field of expertise, if one exists. If you are providing teleophthalmologic services across state lines, check the licensing and credentialing requirements for each affected state. Request approval from licensing boards and professional associations for your teleophthalmology programs; this will demonstrate that you sought guidance from your peers.

Before a teleconsultation, verify that you are using the same medical record information as distant practitioners.

Outline the process for assuring confidentiality of patient information including: security and retention protections for electronic communication; protocols for identifying persons at distant locations; confidentiality agreements for third-party vendors; compliance with confidentiality requirements in each state to which information may be transmitted; and patient informed consent.

Determine payment requirements for Medicare, Medicaid, and/or private insurance carriers in teleophthalmologic interactions, and advise patients of these requirements.

Outline standards for image acquisition, resolution bandwidth, transmission, storage resolution, method and time, retrieval, and manipulation. Have backup procedures in place in case of equipment failure, weather interference, or other emergency.

Citations for Telemedicine Article Part II

Abke, Ann, RN, ARM and Mouse-Young, Donna, Telemedicine: New Technology = New Questions = New Exposures, Journal of Healthcare Risk Management, Fall, 1997, p 3-6.

Allen A, and Grigsby B (Oct 1998) 5th Annual Program Survey – Part 2: Consultation activity in 35 specialties. Telemedicine Today 6(5) : 18-9

Bekker, Mary Coupe, Exploring Telemedicine, Ophthalmology Management, Sept, 1998, P44-51.

Heneghan, Conor, PhD, Ophthalmology Rides Wave of Telemedicine, Tech Talk, Ophthalmology Times, May, 1997, p9-10.

C. Heneghan, Telemedicine Today: Legal and Financial Challenges, http://www.nyee.edu/teleinf/telemed.htm

Kvedar, Joseph C, MD, Menn, Eric R, Developing Standards of Care Specific to Telemedicine, Forum, Risk Management Foundation, Sept, 1998.v

Lattimore, Jr, Col Morris R., OD, PhD, A Store-Forward Ophthalmic Telemedicine Case Report from Deployed US Army Forces in Kuwait, Telemedicine Journal, 1999, 3:309-313.

Li, Helen K, MD, Telemedicine and Ophthalmology, Surv Ophthalmol 44 (1) Jul-Aug 1999, p 61-72.

Li, Helen K., MD, Tang, Rosa A., MD, MPH, Oschner, Katherine, MD, Koplos, Chris, OD, Grady, James, Dr.PH., and Crump, William J, MD, Telemedicine Screening of Glaucoma, Telemedicine Journal, 1999, 5:283- 290.

Maheu, Marlene M, PhD, Risk Management in the Re-tooling of Healthcare, Behavioral Information Tomorrow Conference, Mar 18-21, 1999, San Jose, CA

Murdoch I, Bainbridge J, Taylor P, Smith L, Burns J, and Rendall J (2000) Postoperative evaluation of patients following ophthalmic surgery. Journal of Telemedicine and Telecare 6(Suppl 1) : S1:84-S1:86.

Rosenblum, James, Telemedicine: Modern Miracle or Liability Landmine?, Reprinted from 18th Annual Conference of the American Society for Healthcare Risk Management, 1996.

Smith, Loren A, Esq, Legal Issues in Telemedicine, Dateline, The Newsletter of the Medical Liability Mutual Insurance Company, Sept, 1998.

Tange-duPré, Katherine, Telemedicine – Opportunities and Issues, Risk Management Monograph, American Society for Healthcare Risk Management, Jul/Aug, 1997.

Telemedicine: A Medical Liability White Paper, Physician Insurers Association of America (PIAA), 1998.

Tuulonen A, Ohinmaa T, Alanko HI, Hyytinen P, Juutinen A, Toppinen E, The application of teleophthalmology in examining patients with glaucoma: a pilot study. J Glaucoma 1999 Dec;8(6):367-73.

Yogesan K, Cuypers M, Barry CJ, Constable IJ, and Jitskaia L (2000) Tele-ophthalmology screening for retinal and anterior segment diseases. Journal of Telemedicine and Telecare 6(Suppl 1) : S1:96-S1:98.

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