ORBIS AND TELEMEDICINE

While its DC-10 airplane may be the most recognised icon of ORBIS, the Flying Eye Hospital represents just a fraction of how the humanitarian organisation is acting on its mission to preserve and restore sight by strengthening the capacity of local partners to prevent and treat blindness, said Daniel E Neely MD. Speaking at the 2nd World Congress of Paediatric Ophthalmology and Strabismus, Dr Neely discussed Cyber-Sight, the ORBIS telemedicine and tele-education programme. He provided a review of its basic mechanics, current capabilities, and information on programme updates.

“There is a lot that goes on beneath the surface of the programme weeks that take place when the Flying Eye Hospital is onsite, and Cyber-Sight is a prime example of that,†said Dr Neely, professor of ophthalmology, Indiana University School of Medicine, Indianapolis, and ORBIS senior medical advisor to Cyber-Sight.

“Cyber-Sight is an extremely effective and inexpensive way to educate physicians in developing countries, and it establishes an extended presence that allows for continuing education and patient care. Now, new Cyber-Sight capabilities designed to enhance patient selection, case documentation, and outcomes monitoring represent an exciting expansion of the telemedicine programme.†Cyber-Sight E-Consultation was initially developed to provide remote strabismusoriented consultation, but “partners†in developing countries can submit questions about patients with any condition. Since inception of the programme, consultations have covered a broad spectrum of issues in general and subspecialty ophthalmology, including: cataract, cornea/external disease, glaucoma, neuro-ophthalmology, oculoplastics, ophthalmic genetics, paediatric cataract and retina, vitreoretinal disease, retinoblastoma and uveitis.

Cyber-Sight E-Consultation users comprise both physicians who have taken advantage of the system to continue information exchange following a Flying Eye Hospital visit and those who have initiated a consultation after finding the site online. In requesting a consultation, users are asked initially to provide some basic information and to prioritise the need for a reply as normal, high, or urgent (within 24 hours). The system has a full strabismus template as well as blank templates for other ophthalmic subspecialties and allows for uploading of photos along with additional supporting information, including diagnostic images, pathology slides, scanned notes and even short videos. “It usually doesn’t take a lot of information for a mentor to give an opinion about the case. Photographs and other supplemental images are nice, but not critical. Rather, in my opinion, the two most important elements that partners should complete when filling out the consultation request are their presumed diagnosis and tentative plan,†said Dr Neely.

“With that information, the mentor can develop an understanding of the partner’s background and skill set and tailor the response appropriately. It’s of no benefit to make suggestions that the partner is unable to accomplish or carry out.†A submitted consultation is immediately processed by the ORBIS server and triaged out to a subspecialist teaching mentor who is immediately notified of the consultation request via email. The email will contain the basic information and priority, but details are accessible only by secure log-in. Sometimes the mentor may feel confident answering a question right away, but depending on the clarity and depth of the information provided, further communication may be needed. “There have been about 8,000 E-consultations submitted over the last eight years since Cyber-Sight began. However, those cases represent 35,000 exchanges back and forth between partners and mentors, and it is this discussion of the findings, diagnostic and therapeutic options that is important in the teaching process,†noted Dr Neely.

Entering the EMR era

While Cyber- Sight has traditionally functioned as an educational exchange process, its expanded capabilities relate specifically to care of patients seen during a Flying Eye Hospital visit. New additions include a pre-screening form, which has already been implemented, along with a programme record that includes forms for a screening exam, operative report, medical/laser treatment, discharge report and surgical case review. Beta-testing of the programme record elements began at the end of August, 2012. Dr Neely explained that access to prescreening patient information allows ORBIS physicians to select appropriate cases for the programme week. Not only does that enhance the educational value for the local physicians by ensuring their experience will involve good cases, but it limits the need to turn away people who come from rural areas hoping to receive care.

“The pre-screening has been very valuable for helping to make the most productive use of limited time during a Flying Eye Hospital visit, and it minimises our disappointed patients who are not selected, especially if they have travelled some distance to the programme site,†Dr Neely said. With the new features in the programme record, Cyber-Sight will function like a primitive electronic medical record. Its advantages include eliminating the need for transporting hard-copy charts for use on the screening day, providing immediate access to operative reports, and facilitating distribution of discharge reports to the family and local physicians.

Information collected in the surgical case review is expected to provide value for partners, their patients and ORBIS itself. The surgical case review form was developed to be completed by the ORBIS staff ophthalmologist who returns about six to eight weeks after a Flying Eye Hospital visit to examine as many patient participants as possible. Online access to the data through the Cyber-Sight system will enable subsequent patient monitoring through mentor consultation, should it be needed, and also enhances the ability to perform internal analysis, which is vital for quality assurance of patient medical and surgical care provided either on the Flying Eye Hospital or in the local hospital of the partner physicians in developing countries.