September 6, 2019 Conference
AM - The Future of Ophthalmology
PROFESSION PRACTICE GAPS: Feedback from NEOS members and Program Committee review identified the need to expand awareness of future innovations in the field of ophthalmology; a desire to learn more about technological advances that may change the practice of ophthalmology
PROGRAM OBJECTIVES: The content and format of this education activity has been specifically designed to fill the practice gaps in the audientce's current potential scope of profession activities by:
1. Describing future directions in the field of ophthalmology.
2. Describing current state and identify future possible uses of artificial intelligence in ophthalmology.
3. List innovations int he pipeline that will impact the future practice of ophthalmology.
Niels Bohr famously said that "Prediction is very difficult, especially if it's about the future." However, given recent technological advancements in hardware and software, there are some hints as to where the eye exam may be headed. Advancements in swept source OCT will soon allow a fully automated 10-minute eye exam that produces extremely accurate measurments of visual acuity, refraction, color vision, pupillary responses, ocular alignment, confrontation visual fields, as well as high definition anterior segment, lens, vitreous, optic nerve and retinal imaging. Smartphone cameras with appropirate adapters are able to obtain high resolution fundus images. These devices provide an overwhelming amount of data that will require machine learning techniques to fully dissect and comprehend. It is hoped that these advances in the eye exam of the future will reduce the time required to examine the eye and improve reliability, reproducibility and accuracy of acertaining a diagnosis, and most importantly, will provide much more profound insights into general health status and disease states of our patients.
It has been almost 2 decades since an understanding of the role of Vascular Endothelial Growth Factor (VEGF) in retinal vascular disease and development of strong anti-VEGF agents has dramatically altered our abiility to mange common diseases like wet AMD, diabetic retinopathy, and retinal venous occlusive disease. However, the remarkable success of these agents created a high bar for further advances. Recent advances in drug development and drug delivery have led to an uprecedented explosion of exciting clinical trials in a myriad of retinal diseases. New mechanisms of actions beyong anti-VEGF therapy are being explored; gene therapy techniques are being used to attack wet and dry AMD, inherited retinal diseases, and soon, retinal vascular diseases; cell-based therapies are are being developed with renewed interest. Many of these approaches had been hinderd by appropriate means of drug delivery, but advances to include suprachoroidal delivery, reservoir implants, and subretinal delivery are under evaluation. We will touch upon many of these advances to appreciate the breadth and scope of current research.
The 2017 FDA approval of a gene augmentation therapy for RPE65-associated retinal dystrophy contributed to growing optimism regarding gene-specific treatments for inherited eye diseases. Ongoing efforts to develop these types of therapies has made identifying the genetic cause of disease for individual patients with inherited retinal degenerations (IRDs) increasingly important. Using IRDs to illustrate the potential power of precision medicine in ophthalmology, this presentation will review advances in genetic testing for Mendelian diseases and then focus on the types of gene-specific therapeutic strategies currently being evaluated in clinical trials.
In this talk we will describe how Artificial Intelligence (AI) can be helpful in various Ophthalmological conditions. AI-based grading algorithm may be used to identify which patients should be referred to an ophthalmologist for evaluation and treatment. AI can improve work efficiency in settings of limited healthcare resources and can generate novel disease-specific patterns and novel features to gain innovative scientific insights. We will describe various AI learning algorithms, including unsupervised learning, supervised learning (including deep learning convolutional neural networks) and semi-supervised learning. These are helpful to interpret ophthalmological images. Convolutional neural networks start off any fine tuning and progressively learn the combinations and permutations of important features. AI applications will be described for the following conditions: refractive error prediction, corneal topography, dry eye diagnosis, diabetic retinopathy, and AMD.
Multiple studies have shown that our patients are best served when physician diversity mirrors the diversity of the populations we serve. However, the proportion of under-represented minorities (URMs) among practicing ophthalmologists falls well below population levels (6% vs. 31%). The proportion of URMs among those currently in residency training in Ophthalmology (8%) is similar to that of practicing ophthalmologists, suggesting a stable but still problematic diversity gap between physicians in Ophthalmology and the general population. Three years ago, the American Academy of Ophthalmology (AAO) and Association of University Professors of Ophthalmology (AUPO) teamed up to form the Minority Ophthalmology Mentoring (MOM) Program, which is focused on increasing diversity among practicing ophthalmologists. The approach at present is on increasing the pool of URM applicants to Ophthalmology residency training through a focus on students in their first and second years of medical school, and then mentoring those students through the process of preparing, applying, training, and succeeding as practicing ophthalmologists. The main activity of MOM takes place on the weekend of the annual AAO meeting during which URM medical students from around the country, who have applied and been accepted to MOM, attend a specially designed program of events during which students hear from practicing ophthalmologists about their experiences as URMs in Ophthalmology and why these ophthalmologists love what they do. Students also meet with individual mentors assigned to them. The goal is to capture and enhance the interest of URM medical students who may be competitive for the Ophthalmology residency match and then to help them navigate the process successfully. Early feedback from MOM participants has been very positive.
Population Health and Value Based Care: The Role of Ophthalmology
Christopher M. Andreoli, MD, MBA
This talk will explore how an integrated ophthalmology practice supports population health and value based care. Atrius Health is a large multi-specialty medical group with a primary care foundation and integrated specialty care that covers a wide geography in eastern Massachusetts. Atrius Health is a leader in a population health approach to care with a significant portion of its contracts tied to value based care and quality outcomes. We will explore the role of Ophthalmology in such an organization and how we are delivering on the needs of our patients and increasing national trends around value based care.
In this talk we will discuss several surgical procedures for the correction of Presbyopia. These include corneal surgical presbyopia procedure (excimer laser corneal correction, CK, corneal inlays). Scleral surgical procedures include incisions, bands, and segments. Intraocular lens surgical procedures include multifocal IOLs (refractive, diffractive, and hybrid), accommodative IOLs, and smart IOLs. Quasi-surgical solutions will be addressed, including monovision. Comparison of the outcomes will be discussed.
With the number of hours in medical school curriculum dedicated to ophthalmology decreasing and faculty responsibilities and time pressures increasing, ophthalmic medical educators are challenged to develop innovative approaches to insure that we are teaching all medical students and other healthcare providers the fundamentals of ophthalmology that every health care provider should know. We also need to provide adequate exposure to ophthalmology in order to continue to attract promising medical students to our specialty. Flipped classrooms, buzz sessions , near peer teaching, outreach programs, as well as online teaching and learning will be discussed.
PM - Ethics and Risk Management
Professional Practice Gaps: Feedback from NEOS members and Program committee review identified Review of feedback from the prior two sessions revealed that attendees enjoyed speaker anecdotes about their own experiences. Sharing of personal experience may be lacking in clinical practice and so physician attendees could benefit from the infusion of anecdote to illustrate difficult physician situations in the Ethics/Risk Management Session.
PROGRAM OBJECTIVES: The content and format of this educational activity has been specifically designed to fill the practice gaps in the audience’s current potential scope of professional activities by:
1. Describe current practices and challenges in Tele-Ophthalmology
2. Describe legal aspects and risk management in Tele-Ophthalmology
3.Describe ethical considerations in Tele-Ophthalmology
- Learn how technologies such as mobile apps and wearables are changing healthcare delivery
- Learn the impact that augmented intelligence is having, particularly with reference to ophthalmology
- Learn the ethics/risk implications of integrating these technologies into care delivery
Telehealth and AI: Retooling Healthcare Delivery
The stark reality is, soon we won’t have enough healthcare providers to sufficiently care for our citizens. We must adopt the use of technology to create one-to-many care delivery models, rather than the more traditional one-to-one model that is already overburdened. In particular, artificial intelligence (AI) and other emerging technologies allow providers to outsource routine tasks to machines and, instead, focus on human interaction between a healthcare provider and patient. With the increasing application of these technologies, we must also manage the associated risks – from privacy and security to the ethical use of a growing pool of personal health data. As AI and other telehealth tools intersect with care delivery, how can we minimize the risks while improving care delivery, patient and provider satisfaction, and clinical outcomes?
There is a global need to provide appropriate diabetes eye care to the rapidly growing diabetes population which is projected reach over half a billion over the next 20 years. Current evidence based diabetes eye care is highly effective and has been shown to reduce the risk of severe and moderate vision loss by over 95%. However more than half of the diabetes population do not receive appropriate care. The current challenge lies in appropriately identifying patients at risk and enhancing the ability to deliver eye care to ultimately lead to preservation vision and prevention diabetes related blindness. Ocular telemedicine has the potential address these needs and expand the scope of eye care to virtually any location across different barriers to care. Maximizing telemedicine-based outcomes by utilizing technical enhancements to optimize image acquisition and automate image analysis as well as identification of predictive novel retinal lesions can potentially transform the way diabetes eye care is delivered and significantly expand its reach.
David G. Hunter
The diagnosis of strabismus requires assessment of ocular motility and eye alignment in 9 diagnostic positions of gaze. As we attempted to expand our telemedicine efforts in pediatric and adult strabismus, we asked patients to submit images of their eye alignment in different gaze directions. These images were cumbersome to manage, frequently out of focus, and improperly formatted; privacy was also a concern. We therefore collaborated with the Boston Children’s Hospital (BCH) Innovation and Digital Health Accelerator to develop a smartphone application we call “StrabisPIX” to guide patients through the process of obtaining a series of images to provide a complete picture of eye alignment in 9 gaze positions. The app formats the images, transfers them to a secure BCH server in a HIPAA-compliant manner, and then deletes the images from the patient’s phone to further enhance privacy. The provider is then notified that an image is available, accesses the StrabisPIX dashboard, and reviews and comments on the findings. In this presentation I will highlight some of the challenges we faced in developing the app and dashboard, describe the current functionality within the context of the BCH Virtual Visit Program, and propose next steps for offer this technology to other institutions and expand its functionality for the benefit of other specialties within and beyond ophthalmology.
Telemedicine as a means to deliver care is expanding beyond diabetic retinopathy. There is mismatch of patients and resources for eye care needs, especially outside of traditional “business hours”. Anterior eye diseases represent a large portion of reasons for visits to an eye provider and are especially common conditions in acute care settings. Patients have cellphone cameras and are not afraid to use them. Physicians need to know if they care trust the information they are receiving (via a cellphone) to make a diagnostic or management decision. We as physicians have trusted (and validated) ways to remotely evaluate anterior eye complaints. New technology shows promise to improve our accuracy when managing diseases, help screen for diseases in remote and underserved populations, and diagnose diseases that carry a high-risk of vision loss.
The healthcare system is undergoing a digital transformation, similar to the digital disruption that has impacted other key industries. A growing number of digital tools have been developed and implemented to support the delivery of healthcare as well as the clinical and business operational foundations of healthcare. Digital solutions are increasingly being used to create new models of care delivery that increase patient access, achieve cost avoidance, and create more personalized, integrated patient care.
While the in-person meeting of physicians and patients in a clinical practice or hospital will remain an enduring and central element of patient care, an increasing number of virtual and remote options will be available to patients. Big data, artificial intelligence, and decision support tools will be available to physicians, other health care providers, and health systems to aid in care delivery.
The future of healthcare will likely be a convergence of traditional patient care models coupled with digital solutions that meet the needs of the patient as the healthcare consumer, facilitate healthcare delivery, and advance decision-making and knowledge.
Laura C. Fine
Risk Management Issues of Telemedicine
Laura C. Fine, MD
Ophthalmologists are often asked to review photos of patients to screen for conditions such as glaucoma, diabetic retinopathy, and ROP. These reviews are considered telemedicine and are subject to licensure and informed consent regulations in many states. They also establish a limited physician-patient relationship whose duties may not always be understood. Inadequate documentation of the findings and recommendations may lead to delay in diagnosis and treatment. This talk will address these risk management and liability issues.
Clarify the duties created by telemedicine.
Understand informed consent requirements and challenges.
Determine how findings and recommendations should be documented.
Ophthalmic digital healthcare (telemedicine and artificial intelligence) is a rapidly changing space. Industry has entered the healthcare space and affects the delivery of patient care. Physicians will always have a role in the new landscape of medicine, but who is seen in traditional in-person settings likely will evolve. Physicians need to be able to evaluate the technology on the market to assess safety of devices and software. Physicians need to understand the effectiveness and limitations of current technology