At Children’s Hospital Los Angeles, Scaling Telemedicine to Fill Gaps in Specialized Care

Nov. 29, 2017
At Children’s Hospital Los Angeles, a particular group of subspecialists, pediatric ophthalmologists, are using the technology to fill gaps in specialist care in developing countries, with the goal of eliminating preventable infant blindness.

Many hospitals and health care systems are leveraging telemedicine to bridge the distance between patients in underserved areas with medical specialists. At Children’s Hospital Los Angeles, a particular group of subspecialists, pediatric ophthalmologists, are using the technology to fill gaps in specialist care in developing countries, with the goal of eliminating preventable infant blindness.

Within Children's Hospital Los Angeles, a large multispecialty medical group, the Vision Center operates as a referral center for children with complex eye diseases and offers expertise in various pediatric ophthalmologic subspecialties. Thomas C. Lee, M.D., a pediatric retina surgeon and director of The Vision Center, is leading an innovative telemedicine project that delivers remote training for eye surgeons in Armenia in partnership with the Armenian EyeCare Project (AECP). The goal is to help reduce rates of a preventable infant blindness, called retinopathy of prematurity (ROP), which occurs three times as often in Armenia as in the United States and other Western countries, according to Lee.

Lee has been working with the AECP organization for eight years, and explains some of the core challenges around the gap in specialists for complex eye diseases in developing countries. While developing countries around the world have improved their neo-natal care services for premature infants, through the establishment of neo-natal intensive care units, an ongoing issue is that many physicians in developing countries have not always been prepared to handle the complications that can happen when babies are born premature and then going on to survive, he explains.

One of those issues is ROP, which is a very preventable but potentially devastating form of childhood blindness that affects both eyes in children. And, many of the sight-saving surgeries for premature infants with certain retinal conditions must take place within 48 hours of birth. In developing countries, such as Armenia, resources are often scarce and there are not enough surgeons available with the specialized knowledge required to provide complicated eye surgeries within the needed timeframe of a premature infant’s birth.

“So, the challenge was, how to school up their educational program and get it launched as quickly as possible so it doesn’t take them the standard learning curve to figure this out,” Lee says. He notes that the first case of ROP in the U.S. occurred in 1942, the first treatment program was established in 1987 and it wasn’t until 1990 that the program was validated. “So, from 1940 to 1990, years went by with children going blind from a preventable form of blindness and it took us 50 years to figure that out. We want to avoid the developing world go through a 50-year protracted learning experience like we did. And that’s where an online training program becomes so meaningful,” he says.

Thomas C. Lee, M.D.

Lee says he was approached in 2009 by the Armenia EyeCare Project to help the doctors in Armenia to diagnosis and treat this form of childhood blindness through a cost-effective, online remote training program, and the program as evolved as advances in health IT have accelerated. “We initially did it online, using store and forward photographs and using something called a RETCAM. That allowed us to review images remotely and then email them back with what we thought the diagnosis was, and then we compared whether their [the Armenian ophthalmologists’] diagnosis and our diagnosis correlated,” he says.

Year to date, through this telemedicine program, 4,437 infants have been screened for ROP, with 309 procedures completed to treat the ROP, and 40 operations performed the address the most severe form of ROP, Lee reports.

While the program was successful, there were still many premature infants with retinal conditions who had to be flown to Russia for surgery as the surgeons in Armenia were not trained to perform the more complex surgeries. Armenian health officials approached Lee and the Vison Center at CHLA with the idea of using video-enabled telemedicine to mentor and monitor the surgeons in Armenia.

“That started a longer conversation about how we could use real-time synchronous telemedicine to do that, where we would actually supervise their doctors remotely. My first initial response was, I can’t do that. But then we identified different platforms that would allow us to stream the signal out of their operating room,” Lee says. After conducting in-person training at CHLA with two Armenian retina surgeons, Lee says the Vision Center began “an evolution of a training platform that would allow us to continue to monitor, mentor and teach these surgeons in their operating rooms, on their patients, in real time.”

Lee says there were initially some limitations to the technology, primarily problems with either latency, because the system had to buffer the signal, or there was compression artifacts (a noticeable distortion of media) from the software compression that was occurring in the operating room.

In 2016, Lee and his team at CHLA began working with L.A.-based IT consulting firm SADA Systems to deploy Microsoft's cloud collaboration and communication platform, Skype for Business Online, to help bridge the 7,000-mile gap between Los Angeles and Armenia. Using Skype and Polycom videoconferencing endpoints, Lee and other pediatric retina surgeons can view the actual surgery in real time and communicate face-to-face with the surgical team. With the Armenian EyeCare Project and through this technology platform, Lee has remotely trained two surgeons and observed four surgeries in Armenia live from his office in California. The retina scan images and related diagnoses hosted by the technology platform make it possible for doctors to collaborate and reference past surgeries as needed.

According to Tony Safoian, president and CEO of SADA Systems, the technology platform is providing a foundation in which healthcare organization can actually crowdsource surgical training, making experts such as Dr. Lee, and others, accessible to healthcare providers around the world.

Lee says his sees the ability to scale this technology from its current capacity in Los Angeles to remote cities in the U.S., as well as other third-world countries such as Armenia and neighboring rural regions.

“I think with this kind of technology, we can crowdsource training for doctors and surgeons in the developing world in a way that is really efficient. And by crowdsourcing it, we’re not relying on a single individual to carry the weight, as we can have multiple people chime in and address the surgery for that day. So, the concept of a medical mission is becoming outdated, and given the technology, there should be better and more effective ways to do it.”

What’s more, he sees the potential for real-time, synchronous telemedicine platforms to be used for mentoring and proctoring in other surgery specialties. “This technology can be used for medically-oriented engagement, such as an evaluation of a skin rash or even a heartbeat, as we can now stream Bluetooth stethoscope audio signals onto the web,” he says.

Lee, who also is an associate professor of ophthalmology at the USC Roski Eye Institute at the Keck School of Medicine of the University of Southern California, has been practicing medicine for 18 years and he contends that health IT innovation, such as telemedicine, will play a transformative role in healthcare delivery moving forward.

“I think there’s some things about healthcare that have stayed the same, the doctor-patient relationship continues to survive despite all the changes to healthcare. I think what’s changed dramatically is that healthcare continues to be more expensive and continues to require more resources, and, in a fashion, that, in the end, is probably not sustainable,” he says, adding, “We need to find ways to become more efficient in how we deliver healthcare, and make it more productive for the doctors who are delivering the care to deliver care to as many patients as possible, whether they are here or whether they are halfway around the world. I think telemedicine will really allow us to leverage the time and effort that physicians spend; it’s really targeted to point of care.”

Lee also provides ophthalmology services, via telemedicine, to 12 hospitals throughout California, and in Phoenix, to help diagnosis and treat ROP. “I can now screen many more children just as effectively, and not have to go out to each NICU all the time. That has made the ability to deliver that level of care much more feasible, which is the direction that I think we need to go.”