Center uses web images to aid diabetes treatment

Digital photos of patients’ eyes evaluated

Vanderbilt University Medical Center in Nashville, TN, is using the Internet and high-speed telephone lines to transmit digital photographs of diabetes patients’ eyes to centralized evaluation centers, where technicians then look for evidence of disease.

The university has signed a contract with the Department of Veterans Affairs (VA) to provide services to at least 5,800 diabetes patients at the VA hospitals in Nashville and suburban Murfreesboro, according to Vanderbilt Ophthalmic Imaging Center.

Vanderbilt, which already has a camera at two public health clinics in Nashville and recently received a grant from the Frist Foundation for expansion to another clinic, will place specialized cameras at both VA hospitals. Photographs from those five locations will travel via Internet to Vanderbilt’s evaluation center, which operates in donated space in the BellSouth Tower in downtown Nashville.

"We’re in a strategic partnership with BellSouth Corp.," explains Lawrence Merin, RBP, FIMI, assistant professor of ophthalmology at Vanderbilt.

"They provide us with DSL lines for some of the closer clinics; the transmission speed is increased to 768 kilobits per second," he explains. Since the transmissions are quite extensive — 35 megabytes per patient visit — it’s not practical to send them in real time,’ while the patient is actually being examined. Rather, the in-house clinic staff uploads the information, and the next morning Merin and his colleagues examine and analyze the photos and transmit the results to the primary care physician.

It was a kind of meeting of the minds that brought Merin and Vanderbilt together. "I used to have a faculty position at the University of Arkansas, where I became interested in the whole issue of having patients with diabetes show up at the doorstep of an eye clinic way too late," he says.

It was there that he had a life-changing experience. "I had a 23-year-old lady come in who had had a vitreous hemorrhage, and we put in lots of intense work to try to save her," says Merin. "When last I saw her, she had a red-tipped cane. When she showed up at our clinic that first time, it was the first time she had ever had an eye exam. This didn’t have to happen, and that made me angry."

Merin knew the technology was available to make eye exams easier and more effective; it just took someone with the will to make the investment. "Not long after that, Vanderbilt gave me a call and said they wanted to look at using technology to improve eye exams," he says. "Their new department chairman, who came there about 2½ years ago, had a high interest in preventative ophthalmology."

The Vanderbilt system was designed to be operated not by a professional photographer, but by in-house staff trained right at the clinic — medical assists, secretaries, and so on. "This becomes an internal decision," notes Merin. "I train them, and after a few hours of practice, they are on their way."

The equipment basically is "off-the-shelf stuff," Merin says. The cameras are made by Canon, and the software, Digital Health Care, comes from Cambridge, England. "The turnkey camera setup is in the area of $25,000, including software at the camera, then you need routers and servers, which in our case are provided by BellSouth."

In-house staff not only acquire the images, but also talk with patients about risk factors for diabetes and what patients can do to be proactive.

Once the images are transmitted and read, Merin and his team offer suggestions to the primary care physician. Basically, they will either inform the physician that:

1. The findings are within normal limits, or there is very mild disease present, so the physician probably can wait another year before performing another eye exam on the patient.

2. The situation is a little more severe. Either it is urgent to get a referral, because the situation is deemed to be sight-threatening, or it is non-urgent; i.e., the patient has glaucoma, which is considered to be a comorbid condition with diabetes, Merin explains. "We apply some very rigorous grading parameters," he notes.

Ideally, every physical exam of every diabetes patient in the area would include an eye exam. Currently, however, it is up to the physicians and the participating institutions to make the decision to take advantage of this new technology. "The physicians know it’s there, and they don’t really have a problem with using it, but it requires them to think differently about how to manage patients with chronic problems," Merin says.

The benefits of the technology are clear to Merin. "For one thing, when the diabetes patient goes to routine health care venues, this becomes a truly one-stop shop for specialist care without needing a specialist," he says. "They won’t be at an eye clinic, but they’ll get the same high-level monitoring of their condition. It makes the whole throughput more efficient for both the doctor and the patient. The patient doesn’t have to worry about how to get there, or even how to pay, because our relationship is with the clinic — not the patient. What’s more, the secret to good eye health for diabetics is regular monitoring of the retina; the earlier you find problems, the more treatable they are. With this technology, we can close the gap."

Can any institution do what Vanderbilt is doing? Yes and no, says Merin. "Basically, anybody can buy this equipment and learn how to shoot the pictures," he admits. "But we may be one of only a few institutions with the potential to do this, because we are part of an academic institution and we have a high-powered retinal staff providing quality assurance to the program. Using the camera is easy; the question is, what do you do once you’ve shot the pictures? We have a long history here of looking at diabetic images of the retina." Still, he says, "Any place in the country or the world could do it as long as they had some validated method of analyzing the results."

Need More Information?

For more information, contact:

• Lawrence Merin, RBP, FIMI, Assistant Professor of Ophthalmology, Vanderbilt Ophthalmic Imaging Center, 333 Commerce St., Nashville, TN 37201. Telephone: (615) 936-3247.