WestNet Tele-Ophthalmology

Health and the Information Highway Division, Health Canada
March 16, 2004

Table of Contents

• 1.0 Executive Summary
• 2.0 Project Description
• 3.0 Achievements
  • 3.1 Goals Reached
  • 3.2 Unreached Goals
  • 3.3 Documents and Products Generated
• 4.0 Main Impact
  • 4.1 Human Resources Impact
  • 4.2 Privacy and Protection of Information
  • 4.3 Policy and Research Implications
• 5.0 The Future
• 6.0 Communications

1.0 Executive Summary

Diabetes, a serious disease with serious complications, is the seventh leading cause of death in Canada. Members of the Aboriginal population are three to five times more likely to fall victim to this disease.¹

Diabetes among the Aboriginal population was rare in the 1940s but has risen markedly since. Currently, more than 10 % of the members over 15 years of age are affected in Aboriginal communities in Canada. This compares negatively with the 3.1% found in the general Canadian population.²

A recent study has indicated that a quarter of First Nations people over 45 years have diabetes and individual native communities have rates two-to-eight times greater than the general population.³ Furthermore, a number of national studies have shown conversion rates of 25-60% to diabetes in the past decade. Projections indicate that the incidence of diabetes among all Aboriginal groups will continue to rise and 27% of First Nation adults are expected to succumb to it by 2020.⁴

Diabetes has a number of concomitant complications, including hypertension, neuropathy, and renal problems. One of the most serious complications is diabetic retinopathy, a micro-vascular disease affecting the tiny blood vessels or capillaries at the back of the eye. These vessels malfunction causing leakage, bleeding and eventual blindness. The risk of diabetic retinopathy increases the longer one has the disease. For example, according to American statistics, if one has diabetes for over 20 years, there is more than 60% risk of having retinopathy.⁵ In Canada, of people who have had diabetes for more than 15 years, 97% of insulin-dependent and 80% of non-insulin dependent diabetics will have retinopathy.⁶ If a person develops proliferate diabetic retinopathy, which is a progression of the disease, or develops other high-risk characteristics, there is a 25% risk of going blind within two years.

Because of the serious consequences of diabetic retinopathy, the Canadian Diabetes Association (CDA) has established a standard of annual, dilated, eye examinations for persons living with diabetes. Some of the retina problems associated with diabetic retinopathy can be allayed with laser surgery techniques, but this option is conditional on early diagnosis and treatment.

Currently in the Northwest Territories, Stanton Territorial Health Authority Certified Ophthalmic Medical Technicians and Technologists travel to all 33 Northwest Territories communities and 13 Nunavut communities at least twice a year to provide full Ophthalmology examinations (larger centers have 8-10 visits per year). The one Ophthalmologist in the Northwest Territories, who is located in Yellowknife, does client consultations in three of the larger regional centers on a referral basis only (Ft. Smith, Hay River, and Inuvik).

The only accessible Retinal Specialists are in Edmonton. All of these visits necessitate medical travel.

In order to increase the rate of compliance to the CDA standard of annual dilated eye examinations for persons living with diabetes, the WestNet Tele-Ophthalmology Project, a joint venture between the Stanton Territorial Health Authority and the Government of the Northwest Territories Department of Health and Social Services, in partnership with Alberta's Capital Health Authority, and the University of Alberta's Department of Ophthalmology, made possible through a contribution from Health Canada's CHIPP program, implemented a pilot project in which people living with diabetes in remote communities of the Northwest Territories were assessed for diabetic retinopathy through portable stereoscopic digital imaging technology.

This project was to be built on Telehealth technology currently in place (the Northwest Territories' Telehealth network - WestNet) and recent advances in portable digitalized ophthalmology technology. The project was also to be built on present programming; for example, the project expanded the role and services provided by the Stanton Territorial Health Authority Certified Ophthalmic Medical Technicians and Technologists.

The ultimate objective of the WestNet Tele-Ophthalmology project was to cost effectively reduce the risk of loss of vision for diabetic patients in remote communities through the early detection and treatment of diabetic retinopathy.
To achieve this objective, trained Certified Ophthalmic Medical Technicians and Technologists equipped with a Digital Retinal fundus camera, a laptop computer and specialized software, took diagnostic images of the retinas of persons living with diabetes in remote communities in the NWT. These images were then transmitted to the Retinal Specialists at the University of Alberta's Department of Ophthalmology in Edmonton where the images were assessed.

One hundred and eighteen persons living with diabetes from remote Northwest Territories communities were screened during the Tele-Ophthalmology project. These communities include:

• Hay River (75 patients screened)
• Fort Smith (21 patients screened)
• Inuvik (14 patients screened)
• Fort Simpson (8 patients screened)

The advantages to 118 patients were considerable: all received screening by a Retinal Specialist, their condition was followed more closely by the Retinal Specialist, and they did not have to travel to access screening. In addition, travel for pre- and post- operative instruction and treatment were reduced through the use of Tele-Ophthalmology.

The diagnoses made by the Retinal Specialist of the 118 patients were: 56% of diabetic patients had a normal eye exam, 19% had diabetic retinopathy, 19% had another retinal abnormality, and 6% had a non-retinal eye problem. Patients with normal exams were recommended to follow-up in one year for a dilated eye exam. Patients with abnormal eye exams were recommended to follow-up sooner, e.g. 3-9 months. Approximately 13% of patients with an abnormal exam were referred to see an ophthalmologist or retinal surgeon for follow-up, usually within six weeks. One patient with a potential retinal detachment was referred within the week. The most common reasons for the referral included the need for a more in-depth exam by the specialist to determine if the patient would benefit from surgery, e.g. laser, or to get diagnostic eye tests not available in the patients community, e.g. visual field testing, flourescein angiogram.

The legacy of the WestNet Tele-Ophthalmology project includes proven protocols that were developed and evaluated during the Tele-Ophthalmology project, and Certified Ophthalmic Medical Technicians and Technologists that are familiar with the protocols and equipment required to provide the optimal method of screening persons living with diabetes for diabetic retinopathy. This legacy can be used to in subsequent years to achieve the ultimate objective of cost effectively reducing the risk of loss of vision for in remote communities through the early detection and treatment of diabetic retinopathy.

The WestNet Tele-Ophthalmology project has national implications, including the potential to provide a partial solution to the chronic shortage of eye specialists in remote communities across Canada, and the issues involved in electronic data collection, storage and sharing, all steps towards implementation of the electronic health record.

In conclusion, the WestNet Tele-ophthalmology Project met its ultimate goal to cost effectively reduce the risk of loss of vision for diabetic patients in remote communities through the early detection and treatment of diabetic retinopathy.

2.0 Project Description

The Northwest Territories and Alberta are teaming up to develop a Tele-ophthalmology project, which will use advanced technologies to screen Aboriginal people with diabetes for early signs of the retinal deterioration that can lead to blindness.

A new component of the Northwest Territories government's WestNet Telehealth network, the Tele-ophthalmology project will train eye technicians from the Stanton Regional Health Board in Yellowknife to conduct annual retinal screening tests on an initial sample of 100 Aboriginal diabetics living in seven Northern communities.

The images created with the portable digital testing devices will be forwarded to Edmonton's Capital Health Authority. The authority, in turn, will transmit the images to retinal specialists at the University of Alberta's Intelligent Screening of Imagery by Tele-Ophthalmology (I-SITE) program for analysis and treatment recommendations.

The remote retinal screening project represents an expansion of the WestNet Telehealth network, which uses telecommunications links between the Fort Smith Health Centre and the Inuvik and Stanton regional hospitals to provide remote services in internal medicine, orthopedics, psychiatry, ear, nose and throat medicine, kidney dialysis and diabetes education.

The tele-ophthalmology project will ensure more residents of remote communities are tested regularly for diabetic retinopathy, a condition that, if left untreated, leads to blindness. Every tenth Aboriginal adult suffers from diabetes, and is therefore at risk of eyesight loss. Considering the speed with which this disorder progresses, the Canadian Diabetes Association calls for annual dilated-eye examinations for diabetics.

While eye clinic personnel now travel to many remote communities to conduct routine eye exams, the territory's sole ophthalmologist sees referred patients only at the three large regional centres. The closest retinal specialists are in Edmonton.

The Tele-ophthalmology project would therefore bring a vital service closer to home for many Aboriginal residents of the Northwest Territories, because the technicians would come to the communities on a rotating basis, conduct the tests, and send the information south to Alberta for diagnosis.

Project Management: Department of Health and Social Services, Government of Northwest Territories
Contact: Kees Hamming - Telephone: (867) 873-7429

3.0 Achievements

The ultimate goal of the WestNet Tele-Ophthalmology Project was to cost effectively reduce the risk of loss of vision for diabetic patients in remote communities through the early detection and treatment of diabetic retinopathy. The rationale for the project included the Canadian Diabetes Association's recommendation to provide annual eye exams for diabetic patients, combined with the increasing number of individuals with diabetes in the NWT, especially within the Aboriginal population. During the project, two different eye services were evaluated; still image exams and video indirect exams. Both of these were new services, not previously provided by the GNWT, and required an ophthalmic technician to travel to the remote communities to perform the exams.

3.1 Goals Reached

Still image exams
The NWT Tele-Ophthalmology Project demonstrated that still image retinal exams could be conducted satisfactorily. To conduct a still image exam, ophthalmic technicians traveled to remote communities and captured retinal images from diabetic patients using portable still image technology (Zeiss 450+ funduscope combined with a 6 MB Nikon / Kodak digital camera). The images were burned to CD-ROM and then couriered from Yellowknife to a retinal surgeon at the Department of Ophthalmology, University of Alberta to review. Ophthalmic technicians and the retinal surgeon, who reviewed the images, were satisfied with the quality of the images produced by the still image exam technology. The retinal surgeon felt confident using the images to make a diagnosis and treatment recommendations. A total of 118 still image exams were conducted and reviewed by the retinal surgeon. Patients were also satisfied with the still image exams. It had been anticipated that some still image exams would be transmitted electronically to the retinal surgeon, however the University of Alberta did not develop this capability during the project. Burning the images to CD-ROM and transporting them by courier to Edmonton to be read by a retinal specialist was found to be satisfactory.

The primary benefit of the still image exam was its ability to assist in triaging the patient. Basically, it made sure that patients who needed to see an ophthalmologist or retinal surgeon did so in a timely manner, and patients who did not need to see a specialist, were not referred. Other benefits included, improved efficiency of the retinal surgeon's time, e.g. it took less time for the retinal surgeon to review retinal images compared to seeing each patient in person. Ophthalmic technicians stated that having the digital retinal images would allow NWT eye care professionals to better follow patients over time e.g. compare new images to previous images. Benefits for the patients included: a significant percentage of diabetics in the NWT received screening, patients did not have to travel to access screening, some patients saved travel costs, and patients had improved access to an eye specialist e.g. images reviewed by a retinal surgeon within days versus waiting weeks to months to see a retinal surgeon in person. Patients also indicated that being able to see images of their retina was educational and would encourage them to take better care of their diabetes.

The diagnoses made by the retinal surgeon were: 56% of diabetic patients had a normal eye exam, 19% had diabetic retinopathy, 19% had another retinal abnormality, and 6% had a non-retinal eye problem. Patients with normal exams were recommended to follow-up in one year for a dilated eye exam. Patients with abnormal eye exams were recommended to follow-up sooner, e.g. 3-9 months. Approximately 13% of patients with an abnormal exam were referred to see an ophthalmologist or retinal surgeon for follow-up, usually within six weeks. One patient with a potential retinal detachment was referred within the week. The most common reasons for the referral included the need for a more in-depth exam by the specialist to determine if the patient would benefit from surgery, e.g. laser, or to get diagnostic eye tests not available in the patients community, e.g. visual field testing, flourescein angiogram.

Although this project was funded to identify diabetic retinopathy, a number of other retinal and non-retinal eye problems were also identified. In fact, over half of the abnormalities found were not related to diabetes, e.g. glaucoma, macular degeneration. These patients were triaged and referred to the appropriate specialist. This means that the still image exam has the potential to benefit not only diabetic patients, but patients with a wide variety of vision-threatening diseases.

The cost analysis found that the still image exam service increased the amount of time ophthalmic technicians needed to spend in the communities and increased ophthalmic technician travel, resulting in increased costs to the GNWT. All eye care professionals felt that the extra time and cost to obtain the images was worth it. Continuing the still image exam service, specifically having an ophthalmic technician capture still images during a traveling clinic and then sending the images to Edmonton to be read, was calculated to cost approximately $300,000.00 annually ($250.00 per patient). The alternative, specifically having all patients travel to Yellowknife to obtain a still image exam was estimated to cost $788,240.00 annually ($656.87 per patient). Since the GNWT does not reimburse all patient travel (in this project only 45% of patients had their travel reimbursed by the GNWT) the actual cost of the alternative, e.g. patients travel to obtain exam, was $354,708 annually ($295.59 per patient). Consequently, the cost analysis concluded that the continuing the still image exam service was the most cost efficient for the GNWT.

After all data collection was complete, a comparative study was conducted. The comparative study compared the diagnoses made by a retinal surgeon after reviewing the original, high-resolution TIFF images on the I-SITE technology, to the diagnoses made by a different retinal surgeon reviewing the same images in compressed JPEG format on a regular computer monitor. The study found that the less expensive option to be acceptable for triage purposes, but less accurate in regards to the diagnosis, e.g. the retinal surgeon was less confident in rating the severity of the diabetic retinopathy. There was a trend to refer patients more often because of this decreased level of confidence. The benefit of the lower cost option was that the smaller size images could be transmitted much faster over an electronic connection and the images could be reviewed on computer technology that most health professionals would have in their office.

Difficulties encountered with the still image exams included delayed procurement of the technology, additional costs involved in transporting the still image exam technology due to the large size of the transport containers, and a power surge that damaged some still image technology.

The Evaluation team recommended that the still image exam service continue, ideally in combination with the traditional Eye Clinic traveling clinics.

3.2 Unreached Goals

Still image exams
Although the project had initially intended to integrate the still image exam technology with the WestNet videoconferencing systems, this was not possible, due to the I-SITE still image software being proprietary. Specifically, the I-SITE software was not T.120 or DIACOM compliant (T.120 and DICOM are international standards that videoconferencing systems use for data transmission). In addition, the Department of Ophthalmology at the University of Alberta did not have easy access to a videoconferencing system. Because of these two reasons, it was not possible to utilize the WestNet Telehealth Network to transmit the still images to the I-SITE Reading Centre. (See appendix F)

Video indirect exams
The technology chosen for the video indirect exam included the Aethra STAT 100 videoconferencing system (same system used by other WestNet Telehealth Network communities) and a head mount peripheral device, i.e. Heine Video Omega 2C Indirect Ophthalmoscope with Panasonic GP-KS162 Camera. When conducting a traditional indirect exam, the ophthalmic technician, looks through a hand-held lens to view the retina, i.e. Heine AR20 20 Diopter Lens. During a video indirect exam, in addition to the traditional head-mount light, a small video camera and microphone are located on the ophthalmic technician's headband.

When the ophthalmic technicians and ophthalmologist used the video indirect technology, it was found not to be clinically satisfactory. Although the ophthalmic technician was able to get an excellent view of the patient's fundus, he was unable to use the video indirect ophthalmoscope to get an acceptable image on the WestNet Telehealth workstations. Dr. Len MacBeath, Ophthalmologist for the Stanton Regional Health Board, stated that the detail of the captured video was not of a sufficient diagnostic quality to make proper diagnoses. The problem was due to the video camera having difficulty focusing through the hand-held glass lens to the retina at the back of the patient's eye and due to the light reflections off the lens. After extensive trouble-shooting and discussion, it was determined that the problem was a result of the video camera being unable to adjust quickly enough to the small head and hand movements of the ophthalmic technician (who had the video camera mounted on his head and held the glass lens in his hand) and the small movements by the patient. This resulted in the video camera having to make a number of very quick, tiny adjustments, which it was unable to perform satisfactorily. When this video was digitized and compressed, it resulted in video at the receiving end that was of even poorer quality. During three separate video indirect exams, the ophthalmologist at the receiving end was not satisfied with the quality of the video. Another factor that may have influenced the ophthalmic technicians' and ophthalmologist's level of satisfaction with the quality of the video was that the television monitor screen had significantly less resolution than a computer monitor. The television monitors used for videoconferencing had about 450 lines of resolution (this is approximately 640 x 480 pixels) compared to a typical computer monitor that has a resolution of 1024 x 780 pixels.

The videoconferencing connection was made using the equivalent of three ISDN lines (384kbps). Prior to the video indirect exam being performed, the quality of the video and audio was assessed and was considered to be very good (for videoconferencing purposes) at both ends.

Many attempts were made to try and improve the quality of the video including turning off the video camera's auto focus. Although this did result in an improvement in the quality of the video, it required the ophthalmic technician and patient to be totally still and the glass lens to be positioned perfectly between the video camera and the patient's eye. Any movement however, caused the video of the retinal image to look blurred. Additionally, only one section of the retina could be visualized at a time using this technique. Since the video indirect exam was divided up into a number of different sections of the retina, it required the ophthalmic technician and patient to re-position, and then the ophthalmic technician had to re-focus the video camera. Manually focusing the video camera was difficult as the focusing ring on the camera was small and the camera was mounted on the ophthalmic technician's head. The entire process was cumbersome, tedious and took an excessive amount of time. In the end, the ophthalmologist at the receiving end was still not satisfied with the quality of the video.

In addition to poor video quality, the ophthalmologist felt that observing the video indirect exams was an inefficient use of his time. In the past, the ophthalmologist relied on the ophthalmic technicians to do a screening exam, and only saw patients that the ophthalmic technicians felt had a problem. Now the ophthalmologist was being asked to sit through every video indirect exam, and each of these exams took longer, than if he had seen the patient in-person. Because the ophthalmologist was confident in the ability of the ophthalmic technicians to perform screening exams, he felt observing every video indirect exam was not the most efficient use of his time, and not necessary. However, he did indicate that if he had not been confident in the ophthalmic technician's ability, he could see how the video indirect exam may be useful.

Because the video indirect exam technology was unable to produce clinically satisfactory video, only three video indirect exams were conducted (all were conducted on June 13, 2002 between Deline and Yellowknife). After the ophthalmic technician returned to Yellowknife, further trouble-shooting was done with similar unsatisfactory results. A discussion involving the ophthalmic technicians, ophthalmologist and Evaluation Team came to the conclusion that continuing to do video indirect exams in other communities would be a waste of time and money. Consequently, no other video indirect exams were conducted during the duration of the project.

3.3 Documents or Products Generated

Document /Product Name	Available in Paper and/or Electronic Form	License Fee Required for use (Yes/No)	Previously Provided to Health Canada (Yes/No)	Appendix Name /Number
Template(s) for vendor RFP	Both	No	Yes	Appendix H
Template(s) for vendor contract(s)	Both	No	Yes	Appendix G
Policy, Procedure and Training Manual(s)	Both	No	Yes	Appendix A, B, C, D
Job Descriptions and/or recruitment material	Both	No	Yes	Appendix I,J
Video Conference Protocols and Etiquette Guide	Both	No	Yes	Appendix D
Consent Forms	Both	No	Yes	Appendix E

4.0 Main Impact

Prior to starting the project the quality of service provided to patients was acceptable. Patients with diabetes were routinely examined in their community by an ophthalmic technician. If there was any pathology found that required further investigation the patient was sent to Yellowknife to see the ophthalmologist. If the patient needed any treatment for the problem they were then sent to Edmonton to see the retinal specialist. With the new technology that the project offered the ophthalmologist in Yellowknife and Edmonton were able to assess the patient without them having to leave their home community. If any treatment was needed the patient was flown directly to Edmonton. Decreasing the amount of travel the patient had to do aloud them to avoid the stress of travel to the big city therefore increasing patient compliance and interest in continuing proper eye and health care. Ideally having the patient screened by a doctor sooner and causing less disruption to their lives the incidence of retinal problems would go down. Having the doctor review all the photos taken not only benefited the patients but also made for a closer working relationship between doctor and technician.

4.1 Human Resources Impact

From a human resource perspective, the project was relatively easy to implement. It did not require training new eye care professionals, but developed on the skills they previously had. Already knowledgeable in basic retinal photography, the ophthalmic technicians main learning curve was becoming familiar with computer software and how it operated with the camera. The ophthalmic technicians needed to be trained on how to use the new state of the art digital imaging system. After completing the project the technicians and in particular the project coordinator developed a broader understanding of the computer and software and its integration with the retinal camera. With the healthcare system moving more and more towards new high technology the skills ascertained with this project would most certainly be transferable to many other jobs or situations.

Although there was an increased demand on all the people involved there were no new positions developed. However if the project were to continue the ophthalmic technicians indicated that this would require an extra 0.75 FTE ophthalmic technician at the Eye Clinic and an expanded travel budget. The extra human resource time required for this project was estimated to be:

• Oversight committee - 1-2 hours per person per month
• Project Coordinator - 0.5 FTE for 12 months
• Ophthalmic Technicians - 2-3 days per month for 9 months
• Ophthalmologist - 1/2 day per month for 12 months
• Retinal surgeon - 1 day per month for 12 months
• Clerks (Interpreter) -2-3 days per month for 9 months

Ophthalmic technicians were initially a little reluctant to support the telehealth project (both still image and video indirect technology), as a new position was not created for the project, leaving them one technician down in the clinic. They also felt that the traditional Traveling Eye Clinic service they provided was acceptable. They indicated that the new protocols would take extra time and have additional costs and did not know if this would be worth the potential benefits. The overall number of patients seen by the ophthalmic technicians with the digital imaging system was less then what a traveling eye clinic would see on a regular trip. However, the number of patients seen by the doctor went up as he screened each patient's photos seen by the technician instead of only seeing the patients referred to him.

Still Image Exam
After using the new fundus camera, the ophthalmic technicians found that they preferred the newer technology because it was more user friendly and produced better images than the older fundus camera. The new digital technology allowed them to transfer and store retinal images on the laptop they took to each community. This allowed them to show the images to the patient and do some education. The ophthalmic technicians felt having the images stored on the laptop would be very helpful during future traveling clinics, e.g. they could compare new images to the older ones. Ophthalmic technicians also liked that if they had any questions, they could review the images with the ophthalmologist in Yellowknife. In addition, ophthalmic technicians felt the still image system improved patient access to the retinal surgeon, and the majority felt the project improved collaboration between health professionals. Ophthalmic technicians felt that all the above factors improved the quality of the service/care they were able to provide to patients.

Video Indirect Exam
Although the ophthalmic technicians were personally able to obtain an excellent view of the patient's retina, the video indirect exam technology could not provide clinically satisfactory video. A number of ophthalmic technicians attempted to perform a video indirect exam and found the technology unsatisfactory. This was because it was very difficult to get a consistently clear retinal image captured by the video camera and transmitted to the remote videoconferencing system. The problem was due to a combination of factors. The video camera (on the head-mount peripheral) had difficulty focusing through the glass lens, that the ophthalmic technician held in his hand during an indirect exam, onto the retina at the back of the patient's eye. Secondly, the light on the head-mount peripheral caused many reflections to come off the glass lens. Finally, any small movements by the ophthalmic technician, who had the video camera mounted on his head and held the glass lens in his hand, or small movements by the patient, resulted in the video camera having to make many very fine, tiny adjustments, which when digitized and compressed resulted in video at the receiving end that was of poor quality. For the above reasons, the ophthalmic technicians felt that the quality of the service/care they were able to provide to patients with the video indirect exam was not clinically acceptable.

4.2 Privacy and Protection of Information

The still image software utilized in this project contained a simple electronic health record. Patient demographics, some clinical information and retinal images were contained in the record. As health care professionals, the ophthalmic technicians policies and procedures for the handling of confidential information is an integral part of their job, working on this project was no different from that point of view. The patient examinations were done privately. The laptop computer used to capture the still images was protected with a user ID and password to secure access. However, there were some instances that were dealt with when they became apparent. For example the introduction of the Internet to the ophthalmic exam did bring up some concerns for the protection of private patient information. The sending of information over the Internet if not on a secure server is not protected therefore certain measures had to be taken to ensure patient confidentiality was not breached. On the odd occasion, when the information was required ASAP any information identifying the patient was removed from the emailed copy and a number was assigned to that file. Then a faxed letter was sent to the receiving doctor with the file number and necessary information for that patient.

Although the project has not changed any privacy and protection of information policies, It has most certainly made the technicians more aware of some of the privacy issues that can arise with increased integration if the Internet and the medical world. To further increase the protection of the information contained on the laptop computer patient information will be copied to CD and then permanently removed from the computer hard drive. This will alleviate any potential information leaks to unauthorized persons who may gain access to the computer. The hard copies will then be stored in a locked cabinet. Since the project a secure server and website accessible only with a password has been developed. The still images taken can now be sent via the internet and the retinal specialists comments are attached to the patients file that can be accessed by the ophthalmologist in Yellowknife as well as the ophthalmic technicians.

Privacy of health information did not seem to be much of an issue for the patients in this project. Most patients were not concerned if others knew they were diabetic, or if others saw their retinal images. The reasons for this attitude were not determined, however it may have been because people in smaller communities were used to their neighbors knowing a lot about what was going on in everyone else's lives, or it could have been that diabetes was a relatively common illness that did not have a negative stigma. Only a minority of patients were concerned about privacy and stated that their images might be used in the wrong way.

4.3 Policy and Research Implications

The set up in the north is very unique. Having only one ophthalmologist servicing the entire territory the technicians have more responsibilities compared to their counterparts down south. When this type of service is not available the set up represented by this project could be quite feasible. The camera worked as a good screening tool for diabetic retinopathy but having knowledgeable staff operating it helps with patient education and understanding. The Zeiss camera provides excellent optics and very clear pictures but is fairly big and cumbersome for traveling, a more compact camera might be worthwhile considering. The software used with the project did what was required but a more user-friendly version would facilitate the picture converting process.

5.0 The Future

At the moment there are no plans to continue the project. The main barrier for its continuation is financing. If the project were to continue the ophthalmic technicians would travel more often to each community in order to conduct still image retinal exams. This increase in travel would require another ophthalmic technician at the eye clinic. These changes mean there would need to be an increase in the travel budget and the salary budget. At present time the Stanton Territorial Health Board does not have such funding.

Another barrier would be access to some of the remote communities. The equipment that the technicians traveled with is quite large. Some of the communities are only accessible by small plane and they have restrictions on the size and weight of their cargo. A more feasible plan to get around this issue might be to travel to the larger communities with the digital imaging system and if need be fly the few patients from surrounding communities. Although there would be some travel for those patients living in smaller communities they would not have to travel as far or for as long yet they still get the benefits of the still imaging system.

Although the project as it were is not continuing the project has shown functionality not only for diabetic retinopathy but many other ophthalmic disorders such as glaucoma or retinal detachments.

6.0 Communications

Methods or Tools	Date	Targeted Audience	Documents or Presentations Produced	Appendix Name /Number
Media Events	January 23, 2003	General Public	Television Interview with CBC North Television, North Beat, local evening news
Media Events	January 30, 2003	General Public	Radio Interview with CBC North Radio, Trailbreaker, local radio morning program
Media Events	February 3, 2003	General Public	Newspaper interview and article, News North	News North Article Appendix O
Publications	Spring 2003	Medical, Information Technology and Telehealth Com-munities	Article in InfoRoute (IM/IT/KM) Newsletter	InfoRoute Article Appendix P
Conference	To take place in October 2003	Telehealth Community	Oral Presentation at the 6th Annual Meeting of the Canadian Society of Telehealth