title: Teleophthalmology for first nations clients at risk of diabetic retinopathy: a mixed methods evaluation.
abstract: BACKGROUND
  Access to health services is a particular challenge for First Nations (aboriginal Canadians) communities living in remote or underserviced areas. Teleophthalmology can provide them with the same level of retinal screening services provided to those in urban centers. This screening can lead to the identification of high-risk individuals who can then be monitored and receive treatment related to their diabetes or other health issues.
  
  
  OBJECTIVE
  The intent was to develop, implement, and evaluate a service delivery model for teleophthalmology screening and follow-up for at-risk and diabetic First Nations clients on Vancouver Island, British Columbia, Canada.
  
  
  METHODS
  A highly consultative, culturally appropriate, and collaborative approach was used to develop and deploy a teleophthalmology service delivery model to First Nations communities. This project was evaluated with regard to utilization and operational costs. Also, clinicians and team members involved in the teleophthalmology project provided assessments of the teleopthalmology quality, productivity, and access. Health providers in First Nations communities provided their perceptions of areas of improvement for the remote retinal screening services, areas where expansion of services could be offered, and opportunities to increase client education and health promotion.
  
  
  RESULTS
  All 51 First Nations communities on Vancouver Island expressed interest in receiving teleopthalmology services. During the 1-year project, teleopthalmology clinics were held in 43 of 51 communities on Vancouver Island. During these clinics, 524 clients were screened and 140 of those clients were referred to a general ophthalmologist, family doctor, retinal specialist, optometrist, or other provider. Ratings of teleopthalmology system quality, information quality, service quality, and system usage were positive. Satisfaction with the teleopthalmology project was high among clinicians involved with the project. Satisfaction was also high among health providers in First Nations communities, with clinic scheduling identified as a potential area of improvement moving forward. The average cost savings per client, taking project costs into consideration, was calculated to be CAN $28.16, which was largely due to the elimination of client travel costs.
  
  
  CONCLUSIONS
  Teleophthalmology was a welcome addition to health services by the First Nations communities on Vancouver Island, as evidenced by the 100% rate of interest from those communities. There was no evidence of dissatisfaction by clinicians involved in the teleopthalmology project or by First Nations community health providers. The now-operational teleopthalmology program is a testament to the early success of the project.
authors.affiliation: University of Victoria, Victoria, BC, Canada. juliekim@uvic.ca.
authors.forename: Julie
authors.identifier: http://orcid.org/0000-0002-2197-5400
authors.initials: J
authors.lastname: Kim
authors.forename: D Dean
authors.identifier: http://orcid.org/0000-0002-5659-5862
authors.initials: DD
authors.lastname: Driver
keywords: Diabetic Retinopathy; Mobile Health; Ophthalmology; Telemedicine; underserved populations