To describe the United States Army Ocular Teleconsultation program and all consultations received from its inception in July 2004 through December 2009.
Retrospective, noncomparative, consecutive case series.
All 301 consecutive ocular teleconsultations received were reviewed. The main outcome measures were differential diagnosis, evacuation recommendations, and origination of consultation. Secondary measures included patient demographics, reason for consultation, and inclusion of clinical images.
The average response time was 5 hours and 41 minutes. Most consultations originated from Iraq (58.8%) and Afghanistan (18.6%). Patient care-related requests accounted for 94.7% of consultations; nonphysicians submitted 26.3% of consultations. Most patients (220/285; 77.2%) were United States military personnel; the remainder included local nationals and coalition forces. Children accounted for 23 consultations (8.1%). Anterior segment disease represented the largest grouping of cases (129/285; 45.3%); oculoplastic problems represented nearly one quarter (68/285; 23.9%). Evacuation was recommended in 123 (43.2%) of 285 cases and in 21 (58.3%) of 36 cases associated with trauma. Photographs were included in 38.2%, and use was highest for pediatric and strabismus (83.3%) and oculoplastic (67.6%) consultations. Consultants facilitated evacuation in 87 (70.7%) of 123 consultations where evacuation was recommended and avoided unnecessary evacuations in 28 (17.3%) of 162 consultations.
This teleconsultation program has brought valuable tertiary level support to deployed providers, thereby helping to facilitate appropriate and timely referrals, and in some cases avoiding unnecessary evacuation. Advances in remote diagnostic and imaging technology could further enhance consultant support to distant providers and their patients.
Telemedicine uses telecommunication and information technologies to provide and support healthcare when distance separates participants. The United States military medical system, caring for globally distributed patients often located in austere and dangerous environments, is in a unique position to make use of telemedicine. As a specialty heavily reliant on visual information, ophthalmology is amenable to telemedicine applications. Teleconsultation, a method within telemedicine, focuses on assisting a remote provider by offering expert opinions and diagnostic support regarding the treatment of a patient. Because medical providers accompanying deployed military personnel may have limited experience in specialty areas like ophthalmology, teleconsultation is of particular interest.
Realizing both the need and potential benefit of such a teleconsultation system, the United States Army implemented a formal electronic mail (e-mail) teleconsultation program to give deployed military providers rapid access to specialty opinions. The ocular teleconsultation program, a component of this multispecialty system, began in July 2004. Since then, teleophthalmology consultations have constituted the third largest specialty group of the Army system, making up 5% of all consultations. In this article, we review the ocular teleconsultation program from its inception through December 2009.
The ocular teleconsultation program is a component of a larger e-mail consultation system described elsewhere (see Supplemental Figure 1 , available at AJO.com ). The program utilizes a pre-existing e-mail communication system known as Army Knowledge Online. Incoming messages are routed automatically from Army Knowledge Online to a global e-mail system (Microsoft Outlook; Microsoft Corporation, Redmond, Washington, USA) used by all United States-based specialty providers. Because of the nonsecure nature of this system, identifying patient information is excluded from the consultation by the sender (name, date of birth, etc.). The advantage of the system is that United States military providers worldwide can consult an ophthalmologist or optometrist by e-mailing a single address. The system is monitored by both a clinical and technical manager. Specific volunteer military ophthalmologists and optometrists are identified to respond to consultation requests. Because of the worldwide nature of the United States military mission, deployed providers may not be in the same time zone as consultants. These differing time zones were considered in the design of the system. Consultants stationed in various locations around the world ensure that whenever a consultation is initiated, a consultant is available. The local provider obtains history and other pertinent data from the patient. If desired, digital images focusing on the area of interest can be submitted with the consultation request. Because consultation information is deidentified by the local provider to ensure patient confidentiality, a unique patient code is generated and maintained by the submitting provider. The information and images are sent via e-mail to a central e-mail address where automated message routing forwards the message to consultants. The date and time of the consultation and responses are recorded by the technical manager, and reminders sent if the consultation request is not responded to within 24 hours.
All consultations and related e-mail responses from July 2004 through December 2009 were reviewed by 1 author (M.J.M.) for the specific criteria listed below. Results were entered into an Access 2007 database (Microsoft Corporation) for analysis. Consultations initially were analyzed to determine response time, geographic origin of consultation request, and type of consultation (administrative vs patient care). Requests not pertaining to a specific patient (e.g., medical resources available in a location, policy issues, etc.) were categorized as administrative. Those consultations related to patient care were analyzed further to determine (1) patient demographics (age, gender, military status); (2) professional training of the requesting provider; (3) whether other specialty consultants (e.g., dermatology) also participated in the answering the consultation request; (4) diagnostic category or differential diagnosis of the problem in question; (5) whether the consultation request was trauma related; (6) reason for the consultation request (diagnostic support vs management recommendation vs knowledge transfer vs arrange evacuation); (7) whether photographs were included; (8) whether evacuation was recommended; and (9) whether the consultant’s response either facilitated or avoided an evacuation.
For analysis, consultations were grouped into diagnostic categories that roughly parallel the major ophthalmologic subspecialties: anterior segment (includes cataract, glaucoma, cornea, and external diseases), oculoplastic (includes eyelid, adnexa, and orbit), retina and vitreous, neuro-ophthalmology, uveitis, pediatrics and strabismus, vision, and optometric. The differential diagnosis was determined as accurately as possible based on all the information contained within each consultation record. This included the presentation in the initial consultation request, photographs or imaging studies if applicable, the opinions of the consultant(s), and feedback from the referring providers when available. Business practice dictated that consultations were deidentified for consultants; therefore, final diagnoses generally were not available. Consultations consequently were subdivided based on the most likely diagnosis at the time of consultation. Because in certain instances overlap was unavoidable (e.g., floaters could fall under retina or vision), in cases potentially spanning 2 groups or more, the most likely diagnosis determined the specific category assigned. A consultation was considered trauma related if the requester or the consultant considered trauma a likely factor in their differential diagnosis.
Evacuation was defined as the movement of patients to the nearest ophthalmologist or optometrist for additional care or diagnostics. Depending on the geographic location of the patient, that care might have been within the same country, a country in the region, or in the United States. Consultations where evacuation was recommended were analyzed further to determine if the consultant’s recommendation facilitated the evacuation. An evacuation was considered facilitated if: (1) the requester was reluctant to evacuate the patient (because of the physical risk of doing so or the disruption the patient’s loss would create); (2) the requester’s stated plan did not include evacuation; (3) the requester did not state a plan; or (4) the requester asked whether the patient’s condition warranted evacuation. Consultations where the requester’s plan included evacuation were excluded. Consultations where evacuation was not recommended likewise were analyzed to determine whether the consultant’s recommendation avoided evacuation. In these consultations, an evacuation was considered avoided only if the requester specifically asked whether the patient’s condition warranted evacuation.
Patient-related consultations also were analyzed to determine the underlying reason or type of information sought by the requester. Diagnostic support consisted of consultations requesting assistance with both a differential diagnosis and management recommendations. Consultations in which the requester had developed a differential diagnosis and was seeking assistance with treatment options were categorized as management recommendations. Knowledge transfer consultations referred to questions relating to a specific patient (spectacle fabrication resources for a patient in need, whether a patient with a particular stable diagnosis could be deployed), but not an active illness or injury. Arrange evacuation consultations were those in which the requester already had determined the need to move the patient to a higher level of care and used the teleconsultation system to facilitate the process.
From July 2004 through December 2009, a total of 301 ocular consultation requests were received. All consultation requests were answered with an average response time of 5 hours and 41 minutes (range, 5 minutes to 80 hours). The number of different volunteer consultants answering requests gradually increased from 5 in 2004 to 28 in 2009. In 2009, the average number of consultants responding to each request was 1.5, up from 1.0 per consultation in the initial year of the program (see Supplemental Table 1 , available at AJO.com ). The large majority of consultations originated from Iraq (58.8%; 177/301) and Afghanistan (18.6%; 56/301), with the remainder representing a broad geographic distribution (see Supplemental Table 2 , available at AJO.com ). Consultation requests from Afghanistan gradually rose and in 2009 exceeded consultations originating in Iraq. Consultations from Navy afloat likewise rose in recent years (see Supplemental Figure 2 , available at AJO.com ). Sixteen consultation requests (5.3%) sought general or administrative information. The remaining 285 consultation requests (94.7%) were patient-related consultations and are described more fully below.
Physicians accounted for most consultations (73.7%; 210/285) and represented a diverse range of specialties and subspecialties. Nonphysician providers included physician assistants, optometrists, medical corpsmen, and 1 dentist (see Supplemental Table 3 , available at AJO.com ). Requests concerning United States military patients constituted 220 (77.2%) of 285 consultations; 36.8% (105/285) of patients were United States Army soldiers, and an equal percentage (36.8%; 105/285) represented the other 3 Department of Defense uniformed services and Coast Guard combined (see Supplemental Table 4 , available at AJO.com ). Of the non-United States military patients, local nationals were the largest group and accounted for 37 (13.0%) of all 285 consultations. Patient age was provided in 205 (71.9%) of 285 consultation requests. Of these, the mean age was 28 years (range, 2 to 67 years). Children—patients younger than 18 years or identified as children—accounted for 23 consultation requests (8.1%). There were 250 (87.7%) male patients and 34 (11.9%) female patients, and for 4 patients (1.4%), the gender was unspecified. These percentages total more than 100% because several consultation requests asked about more than 1 patient.
The overwhelming majority (90.9%) of requests sought information concerning management recommendations (37.9%; 108/285) or diagnostic support (53.0%; 151/285). Direct requests to arrange evacuation accounted for only 2.1% (6/285) of requests (see Supplemental Figure 3 , available at AJO.com ).
Questions concerning anterior segment issues represented nearly one half of all cases (129/285; 45.3%), and oculoplastic diseases represented approximately one quarter of requests (68/285; 23.9%). However, all disease categories were represented, and the range of clinical problems was very broad ( Table 1 ). A number of consultations spanned other body systems and were sent to consultants of other specialties in addition to ophthalmology. Twenty-eight (9.8%) consultation requests also were responded to by consultants from dermatology, neurology, infectious disease, or orthopedics.
|Diagnostic Category of Consult||No. by Group||No. of Consultations (N = 285)||Consultation Requests with Photographs by Category||Evacuation Recommended by Category||Trauma Consultations by Category|
|Anterior segment||129 (45.3%)||49 (38.0%)||48 (37.2%)||13 (10.0%)|
|Corneal surface disease||30|
|Superficial conjunctival lesions||19|
|Refractive surgery related||14|
|Conjunctival or corneal foreign body||12|
|Anterior segment intraocular lesion||3|
|Red eye related||2|
|Pigmented conjunctival lesion||2|
|Oculoplastic, adnexa, and orbit||68 (23.9%)||46 (67.6%)||20 (29.4%)||8 (11.8%)|
|R/O orbital mass or fracture||12|
|Noninflammatory eyelid lesion||6|
|Noninfectious periocular skin changes||6|
|Herpes zoster dermatitis related||5|
|Eyelid myokymia and blepharospasm||5|
|Herpes simplex dermatitis related||4|
|Ptosis and/or dermatochalasis||2|
|Infectious periocular skin changes||1|
|Lymphangioma vs. neurofibromatosis||1|
|Canaliculitis vs dacryocystitis||1|
|Orbitopathy, thyroid related||1|
|Facial nerve palsy||1|
|Retina||27 (9.5%)||3 (11.1%)||18 (66.7%)||7 (25.9%)|
|Retinal detachment related||10|
|Trauma-related retinopathy (not RD)||7|
|Posterior intraocular lesion||3|
|Neuro-ophthalmology||24 (8.4%)||3 (12.5%)||10 (41.7%)||2 (8.3%)|
|Anisocoria or pupil defect||7|
|Visual field defect||3|
|Idiopathic intracranial hypertension||1|
|Uveitis||15 (5.3%)||3 (20.0%)||10 (66.7%)||4 (26.7%)|
|Vision||13 (4.6%)||0 (0.0%)||11 (84.6%)||2 (15.4%)|
|Pediatrics and strabismus||6 (2.1%)||5 (83.3%)||6 (100%)||0 (0.0%)|
|Optometric||3 (1.1%)||0 (0.0%)||0 (0.0%)||0 (0.0%)|
|Total||285||285||109 (38.2%)||123 (43.2%)||36 (12.6%)|
If desired, providers had the ability to include photographs with consultation requests; 109 (38.2%) of the 285 patient-related consultation requests included photographs. The likelihood of photographs being included varied depending on the diagnostic category ( Table 1 ).
We received 36 consultation requests related to trauma (12.6%). Of these, evacuation was recommended by the consultant in 58.3% (21/36; Table 2 ). In 249 non–trauma-related consultations, evacuation was recommended in 102 cases (41.0%). Considering all patient-related cases, evacuation was recommended in 123 (43.2%) of 285 consultations. Evacuation statistics are given in Table 1 . Consultants’ recommendations facilitated 87 patient evacuations. Although the consultation program did not require it, feedback from requesters provided confirmation of this in 28 of those 87 evacuations. For consultations in which evacuation was not recommended, the consultant’s recommendation helped to avoid evacuation in 28 cases.
|Trauma-Related Consultations||No.||Trauma Consultations by Location||No.||Evacuation Recommended||Consulted Within 24 h||Consulted Within 7 days|
|Total||36||36||21 (58.3%)||7 (19.4%)||19 (52.8%)|