With Danson Muttuvelu, MD FEBO, DENMARK Consultant Ophthalmic Surgeon and Innovator. Chair for the Danish Society for Cataract and Refractive Surgery, founder of the telemedical screening company “Mit Øje” (My Eye).
Interviewer: Marie Louise Roed Rasmussen, Occuloplastic and Orbital consultant, Rigshospitalet, Copenhagen, Denmark. Past- Chair SOE-YO.
The company has employed 12 ophthalmologists, who are licensed to practice independently in Denmark. They are all sub-specialized or in the path of sub-specialization, currently screening 15,000 new cases annually. It is e-health-cloud based. Patients are referred by Optometrists.
We recently published an article, describing the system and about how screening can improve and streamline the health care systems in BMJ Open Ophthalmology (https://bmjophth.bmj.com/content/6/1/e000671).
MLR: How did you decide to create a tele-ophthalmic company?
DM: The idea and concept basically came from being in India for some time in 2016. Our Indian colleagues need to work efficiently including with e-health tools to maximise their resources. Coming back to the Nordics, I realised that the continuing aging population would put constraints on healthcare resources and the most cost-effective solution would be to stratify the referrals to ophthalmologists.
MLR: What happened before?
DM: In the same period opticians in Denmark had started to offer eye-related check-ups that included fundal images, IOP and visual field assessments.
This was highly controversial, and ophthalmologists found a higher number of unnecessary referrals and false positives, prolonging the already long waiting times. All “abnormal” cases were being referred to an ophthalmologist, as optometrists are not qualified to give diagnoses.
I proposed a systematic cloud-base e-Health system that would assess the risk of patients and only those with disease or those deemed to be high risk would be referred to the national healthcare system.
MLR: What are you screening for?
DM: When optometrists suspect posterior segment pathology that they believe should be referred to the national healthcare system, they would instead refer the patients to our service. This includes cases of papilledema, AMD, choroidal naevus and glaucoma suspects. Due to the high volume of cases, many rare cases are found as well, but naturally there is a high representation of the ‘big four’ eye diseases (AMD, diabetes, cataract and glaucoma)
MLR: What is the positive rate in the referred cases?
DM: Of those referred, around 20% have an active eye disease who need to be seen by an ophthalmologist. Few are truly urgent. We decreased the number of referred posterior-segment related cases from the optometrists by 80%.
MLR: What do you do with patients who need referral?
DM: We risk-strategize patients. Those who need follow-up at an optometrist level or by our service are evaluated telemedically. When we refer, we refer patients to the national health care system, using the patient’s unique ID no. In this way, patients can visit the eye-doctor they wish and any ophthalmologist in the primary healthcare sector can evaluate the patients based on our e-referral letter. If patients need admission (e.g. papilledema, retinal detachments, etc), patients are contacted directly by our consultant ophthalmologist, who will make sure the patient is admitted to the right department in their region. The company also has an optometrist hotline service for urgent cases.
Patients are always contacted the day after by the optometrist and informed of the triage. If urgent, they are contacted by our ophthalmologist. We also provide ID-linked answers to patients, when needed.
MLR: What is in your opinion the biggest difference between normal screening and your company?
DM: I believe our vision, our service and what we are developing is quite different.
We believe that eye-care of tomorrow must be industrialized. We believe this is done through utilising the digital era and the fourth industrial revolution coming along the way. We believe our difference is made in rigorous systematic guidelines that are created internally, quality check-up, big data management and the learning from this to improve diagnostic precision, educational opportunities, patient follow-up patterns etc. We focus on cloud-based solutions to get our systems to better connect and naturally utilize how AI can help us in this transition.
MLR: Some may say this is a costly set up – why don’t you hire more ophthalmologists who are cheaper?
DM: In the end it is not about the current situation of the planet. It’s about providing a plan that works for the local society as well as at a nationally, at the level of the optometrist as well as the ophthalmologist. This data is critical in providing information on how we risk-stratify our e-health patients. Furthermore, it is about communicating with the healthcare system as well as the patients on what is needed. For all these purposes, the local ophthalmologists have proved much more relevant for this service.
MLR: Describe the healthcare system you are working in – how does this private company fit in?
DM: Most eye care in Denmark is based on the national healthcare service. Half the ophthalmologists have contracts with the service, while the rest work in secondary or tertiary eye departments. Optometrists are not officially part of the national healthcare system. As a private company, we bridge the gap between the optometrist and ophthalmologist, and reducing referrals increases efficiency and cost-effectiveness of the national healthcare system.
MLR: Are the rest of the ophthalmologists in your country happy about this?
DM: The service has been supported by the ophthalmology association, and most ophthalmologists felt it was great that something was done about the many false positive referrals.
MLR: How do you see the future? How can screening combine with AI in your business?
DM: I believe in further automatization, big-data management, CLOUD-based management, AI and ID-security based on blockchain technology. This development is inevitable, but when these will be shared between different stakeholders is unknown and will be different from country to country.
We are looking into how the combination of big data and AI can further help us in industrializing the screening process and assist optometrist and ophthalmologists alike in the risk stratification process. Additionally, we have been engaged with AI-companies, as they have realized that the largest uniformed e-health-based eye doctor service can provide gold standard validation for new AI-algorithms, both in the development process and as well as in real time.
MLR: How do you see screening and AI in the future of ophthalmology and how do you think it will affect the job situation of younger ophthalmologists? DM: Change is inevitable and we should embrace technological change. Patients will head towards prevention and early detection, and as doctors we want to use as much of our valuable time on the truly ill patients. In this scenario AI can help us in coming closer to our goal.