• Implementing Telemedicine in a Developing Country

    MEXICO CITY – Five years ago, after finishing my international retina fellowship at UCLA, I returned to Mexico City and started working in a diabetes clinic. 

    Initially, I was not aware of the potential benefits of telemedicine screening programs. I now believe that telemedicine technologies will be essential for detection and treatment of diabetic retinopathy.  

    Teleophthalmology is a branch of telemedicine that can be used for detecting eye diseases, including glaucoma, age-related macular degeneration and cataracts. In Mexico, the main application is for diabetic retinopathy, and we have a great need for improved diabetic retinopathy screening programs. Mexico has a population with high prevalence of diabetes, with current estimates suggesting that 9.2% of the adult population is affected. 

    Our program illustrates the value of telemedicine in Mexico and is located in a clinic in the state of Oaxaca, about 461 kilometers (286 miles) from Mexico City, where my reading center is. Oaxaca is one of the poorest states in Mexico, and a local hematologist offered to do the examinations with a nonmydriatic camera for about $10 per working day (for the price, this could be considered a voluntary activity). 

    The doctor sends the images electronically to our practice in Mexico City, we interpret the image and send the results to Oaxaca. We refer patients who need detailed examinations or treatment to an ophthalmologist who goes to Oaxaca every two weeks. Using this team approach along with technology, we have detected several patients with diabetic retinopathy who have received timely treatment.

    Since 2014, I have worked to implement diabetic retinopathy telemedicine screening programs such as this within Mexico City and across Mexico. We have encountered a few challenges, some of which may be unique to Mexico, but are likely seen in other countries around the world. I believe discussing these challenges will be of interest to anyone implementing telemedicine.

    First, even well-educated health professionals from all specialties know very little about telemedicine and often underestimate its usefulness. Many health care professionals have never been educated about telemedicine. 

    It is important to include telemedicine in medical and health care personnel education curriculums. If students encounter telemedicine during their educational years, they will understand its advantages and be more willing to work towards its implementation.

    Advocacy is a second important challenge. Full implementation of a nationwide screening program will require support from politicians and public health professionals. We need to focus on advocacy so that we can inform policymakers of the improved outcomes and cost-effectiveness of screening programs.  

    Early detection can prevent 95% of diabetes-related blindness and can prevent patients from needing complex surgery, allowing the use of less-costly lasers or intravitreal injections. For example, vitreoretinal surgery costs seven times more than a laser procedure, and 10 vitreoretinal surgeries are equivalent to the price of a fundus camera. These cameras can screen up to 25 patients per day without an ophthalmologist present.. 

    Some of the most relevant issues I have faced on the ground are the cost of the equipment and its maintenance (cameras, computers, PACS, servers). Training certified photographers and readers has been a surprising challenge. There are no established courses for certifying readers and photographers given in Spanish, and many of the health care providers do not have a sufficient level of English for online training. 

    Furthermore, without a national system in place and reimbursements set up, there is no incentive for health care workers to become certified in ophthalmic photography or a certified reader. Hopefully, artificial intelligence (AI) will eventually address most (but not all) of these challenges.

    Diabetic retinopathy is highly prevalent throughout Mexico. Initial experiences with telemedicine will always have difficulties whether administrative, political, technological or adequately trained personnel, but eventually as time passes all these issues will get solved.

    In the last five years, I have witnessed increases of the number of fundus cameras and the number of institutions interested in teleophthalmology. Health professionals in the public and private sector are pushing to have more teleophthalmology programs. A lot of work is still needed, but every day we are closer to having a service that meets the needs of our diabetic population.

    The work is necessary if we hope to save vision in our diabetic patients. I was referred a 17-year-old girl who had uncontrolled Type 1 diabetes for 10 years. She had very few economic resources and had never received an eye examination. 

    The girl’s vision was fine, but using my first nonmydriatic camera in a diabetic retinopathy campaign, we detected diabetic macular edema. Fortunately, she was treated with laser, and her retina responded well, decreasing her risk of visual impairment. I look forward to implementing technology, building teams and using telemedicine to detect many more patients whose vision can be saved.

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    David Rivera de la ParraAbout the author: David Rivera De La Parra, MD, PhD, completed his retina/vitreous fellowship at UCLA and his doctorate at the Universidad Nacional Autónoma de México. He practices in Mexico City, Mexico.