June 2008




Screening diabetic patients across the miles

by Maxine Lipner Senior EyeWorld Contributing Editor


The Peruvian telemedical program’s nurse, Lic. Nelida Hilario Huapaya, photographing a patient in the endocrinology clinic of Universidad Peruana Cayetano Heredia, Lima, Peru Source: Lawrence M. Merin

New telemedical program provides a safety net for patients in Peru

A new cross cultural telemedical program is helping to bridge an important gap for at-risk diabetic patients in Peru. The new program spans a distance from the rooms of a clinic in Lima to a Vanderbilt University workstation in Nashville, Tennessee. While this is a pioneering effort in Peru, it is actually an offshoot of an American program already underway in Tennessee, according to Lawrence M. Merin, assistant professor of ophthalmology, Vanderbilt Eye Institute, Vanderbilt University, Nashville, Tenn.

Tennessee model

“We have been working in a program that’s been running in Tennessee for about seven years now and has met with considerable success here,” Mr. Merin said. “We thought that to be good neighbors, we should see if we could expand this to populations that really don’t have any hope of keeping eye health in the future.”

The program initiated in Tennessee services diabetic patients in low income clinics. “These are folks who simply don’t have the money or the education or the access to prevent blindness from diabetes—it’s all they can do to keep their diabetic medical condition intact,” Mr. Merin said. “The idea of seeking out specialty care when they don’t even have bus fare was really only a dream. We figured out that if we couldn’t get the patient to a physician, we could still get the medical care to the patient.”

In this pilot program practitioners created a network in which retinal cameras were initially placed in six locations in low income clinics. This has since been broadened out into a mobile network to include community health centers throughout the statethose in the rural eastern part of the state, according to Mr. Merin. “There are some counties that have no eye specialists health care providers at all,” he said. “We’ve really noticed a huge increase in the ability of finding patients with sight-threatening disease before they start suffering.”

Peruvian program

The same basic telemedical model has now been replicated in Peru. “We started this program by putting a fixed camera into a public hospital that’s associated with a medical school there,” Mr. Merin said. “That’s now been running for six or eight months nine months, and they’ve screened several hundred patients.” Peruvian patients are seen at a diabetes clinic there. This seemed to be a natural spot. “That’s where the patients obtain all of their medical needs associated with the disease,” Mr. Merin said. “The clinician understands whether a patient has had an eye exam by his chart, and if he hasn’t then the clinician simply brings the patient over to the camera and gets it done.”

The resulting images are then piped both to a “reading center” in Lima staffed by ophthalmologists as well as to practitioners at Vanderbilt University in Nashville. “The reading center in Lima is a workstation which is manned by ophthalmologists who on a daily basis review these images and apply evidence-based recommendations for follow up,” Mr. Merin said. “What I do in my office is provide sort of a second reading to make sure that the ophthalmologists there are operating according to well known international standards.” He sees the Nashville office as serving essentially as a safety net. “So far they’ve done a superb job,” Mr. Merin said. “There has been very little disagreement between what they think is there and what I’ve confirmed is there.”

Patient outcomes have been on par with what practitioners have seen in the Tennessee program. “Here in Tennessee we have been averaging about a 10% rate of people who after screening require urgent ophthalmic care, and it’s about the same in the particular population that we’re studying in Lima right now,” Mr. Merin said.

In cases where a problem is found, treatment is also given to the patient. “One of the requirements that we put in place when we began collaborating with the folks the diabetologists in Peru was the understanding that should a patient have treatable retinal disease, they will do their best to actually get the treatment done,” Mr. Merin said. “As a solution the clinicians there have put together a small group of volunteer ophthalmologists who will take the patients and treat them no matter what their economic status.”

Mr. Merin hopes that the Peruvian program can now be expanded out from the Lima hub into the countryside. “We have another camera that has been provided to us that we intend to locate we’re looking at placing far away from Lima,” he said. “Way up in the northern part of the country there’s an especially large burden of diabetes and again no availability of eye specialists for the poor.” Funding has been a bit of an issue. Two years of seed funding have been provided by Vanderbilt University’s Center for the Americas, and Canon Medical Systems (Lake Success, N.Y.) has been a strong supporter of the program, supplying some of the needed technology. However, as the program grows so will its funding needs. “Our thought is if we can take these little baby steps and prove the concept, eventually the government and other funders will come on board,” Mr. Merin said. “We’re optimistic that we can start making a difference.”

Editors’ note: Mr. Merin has no financial interests related to his comments.

Contact Information

Merin: lawrence.merin@vanderbilt.edu

Screening diabetic patients across the miles Screening diabetic patients across the miles
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