Internet‐based counselling of remote ophthalmological patients

Sir, The explosive development of the Internet, supported by faster and more stable communications, has granted ophthalmology the technical means of providing reliable, Internet-based counselling services to remote patients. Remote counselling is a form of telemedicine which has developed out of the growing need to provide basic medical services to a wider range of patients, especially those who find it difficult, for a variety of reasons, to access conventional services. We conducted a prospective study over 8 years to assess the efficiency of Internet-based counselling to remote ophthalmological patients. The Intermedico Network, a non profit-making medical organization, was founded in 1993. It has an Internet portal through which users can request information and advice on ophthalmological matters via electronic mail (email). During the study period, these requests were processed by 23 physicians, including consultant ophthalmologists and general practitioners, who forwarded their responses to the corresponding patients. To be eligible for counselling, requests must quote information about age, sex, place of residence and family status and give a brief account of medical as well as ophthalmological history. As the responses were addressed to members of the general public, they were presented using simple language, void of complex medical terminology. A seven-member committee supervised the scientific and ethical standards of the service. It was made clear to users in all cases that the role of the service was advisory, and the importance of physical examination and appropriate personal patient− doctor contact was emphasized. Internet-based remote counselling is a form of store-and-forward tele-ophthalmology. Thus, by definition, it does not support acute events and emergencies. During the study period, 1040 ophthalmological patients visited the Internet portal and requested advice. The patient group consisted of 803 men (mean age 44 years, range 38–72 years) and 237 women (mean age 48 years, range 40–63 years). The majority of subjects (787) were citizens of western societies (i.e. the USA, the EU, Canada and Australia) and residents of urban areas (705 subjects) (Table 1). The subjects requested remote counselling for a variety of reasons. A total of 562 subjects wanted to evaluate Internet-based health services; 298 subjects had already contacted local ophthalmologists but were unsatisfied by their overall diagnostic and therapeutic approach, and 219 subjects stated that conventional medical services were inaccessible or unaffordable. Remote subjects inquired on almost every field in ophthalmological discipline. Counselling was granted to 993 patients (87.1%). The necessity of physical examination and insufficient provision of medical data were the main reasons for not responding to all requests. In descending order, the subjects requested information mainly on ocular manifestations of systemic diseases (266 requests), glaucoma (183 requests), refractive surgery (180 requests), conjunctival/corneal infections (92 requests), lacrimal apparatus disorders (67 requests) and paediatric ophthalmology (35 requests) (Table 2). As well as having their medical queries answered, a significant number of remote subjects participated in interactive educational sessions on common chronic ophthalmological diseases. During these sessions, groups of patients (e.g. patients with glaucoma, patients with diabetes, etc.) responded to questionnaires and actively participated in web forums where the principal details of the corresponding diseases were discussed. The importance of compliance with glaucoma treatment was emphasized among other issues, as well as the necessity of tight glucose monitoring and regular ophthalmological follow-up of diabetic patients in order to prevent retinal complications. The remote patients' perceptions of the service were ascertained by asking them specific questions concerning the responsiveness of the service and the quality of communication between themselves and the medical staff. In order of frequency, remote subjects complained of the predictable delays of the service, language barriers (the service was offered in English and German only), and availability of access to the Internet. However, the vast majority of the remote subjects (94%) favoured Internet-based counselling and said they planned to use the service again. The doctors who participated in the study were interviewed and asked to describe their experiences with the service. All of them proposed that Internet-based counselling should be upgraded to the status of a regular medical service and sponsored by local health authorities. They stressed the following prerequisites as necessary to prevent ethical and legal irregularities in the service and to ensure maintenance of scientific and medical standards: The application of specific legislation, preferably initiated by the EU, regarding Internet-based medical services; The adjuvant role of the service should not be changed (it cannot replace conventional, local counselling), and The importance of personal conduct between local doctors and patients should always be emphasized. Ophthalmology has always pioneered the adoption of modern technologies in diagnostic and therapeutic procedures. In this study, the Internet was the medium used to provide all necessary information to remote patients regarding their ophthalmological concerns. Most remote patients, even residents of western countries with advanced national health care systems, presented with misperceptions and lacked basic information on major ophthalmological diseases including glaucoma, age-related macular degeneration and diabetic retinopathy. All these diseases have significant impact on the patient's quality of life and dramatically increase the overall cost of care for national health systems. The high percentage of misinformed patients may partly be explained by the fact that many ophthalmological outpatient departments are overcrowded; thus the overall time many patients spend with their doctor is limited. On the other hand, it should be stressed that the term ‘remote patient’ does not necessarily refer to physical remoteness or imply that local medical resources are inadequate. Poverty, social isolation, ethnic discrimination, prejudice, cultural ethics and religion create remote patients even in city centres. The Internet overcomes both physical and non-physical remoteness and provides ophthalmological patients with an alternative way of making closer contact with physicians and having their problems heard and explained. The benefits of Internet-based counselling are apparent. Educated patients are likely to comply better with doctors' instructions, to adhere to preventive medicine programmes and to adopt lifestyles that oppose potential complications of ophthalmological diseases. The almost universal acceptance of the service by remote populations and the warm support from the doctors involved suggest that Internet-based counselling should be studied further and possibly upgraded to provide a regular service in conjunction with conventional medical practices.

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