EVA virtual visual screening

Visual deficiency in childhood is mainly caused by reversible causes, such as amblyopia (lazy eye)  and significant refractive errors (need for glasses). Together they affect 20% of children around the world. They give few or no symptoms and are treatable if detected under the age of 7. 

Visual screening is needed for all children to effectively detect and treat the children at risk for these problems. But, on the other hand, there are not enough ophthalmologists to perform that, especially in underdeveloped countries. It is known that 50% of the ophthalmology visits are of kids with no significant visual problems. Therefore, a visual screening of children saves human and financial resources. It prioritizes and connects the children at risk for visual deficiency with adequate treatment at the right time. 

Our tool is a solution of virtual visual screening for children. It's a virtual platform that can be accessed through a smartphone with internet access. Through this tool, risk factors related to low vision are accessed through the use of a virtual questionnaire. Subsequently, the visual acuity (VA) is evaluated on the same screen, with scientifically validated optotypes suitable for each cell phone display size. Based on this information, children are stratified for risk of developing visual deficiency using artificial intelligence in low, average or high risk and based on scientific validated protocols suggests the urgency of a face-to-face ophthalmological consult. On the user side, the family receives a whatsapp message with the appropriate timing for an ophthalmology visit and can send information about the schedule of the in-person visit. If the child is stratified as low risk, the system will send messages annually to remind for a new test. 

On the backend, the manager ( a health care plan, clinic, or public system administrator) has the view of all screened patients and at what point of their journey they are. They can also access the number of children screened, severity classification, number of patients referred to the referral service, and details of post-consultation monitoring.

 The project relies on two existing digital tools that need to be integrated: the LauraCare platform and the EyeSpy app.The LauraCare platform is a multichannel platform that allows for the capillarization of virtual screenings, as well as the digitization and management of protocols for outpatients. To increase engagement and improve the patient experience, it is possible to use Natural Language Processing (NLP). A prototype with a questionnaire composed of sensitive questions that lead to the identification of the risk of developing low vision in children. The registration and storage of patient data, virtual ophthalmic anamnesis, analysis of responses, stratification of the risk of developing low vision, suggestions for referral to reference service, and evaluation of the outcome are carried out by the platform structured in a relational database. EyeSpy 20/20 is a vision testing app. It was released after conducting a study with children comparing its software with the traditional validated method of visual testing protocol. EyeSpy tests VA in children over 3 years of age, using validated optotypes that automatically conform to the screen size of the smartphone on which the exam is being performed.

Data is stored in a database and together with the information of the questionnaire at Laura, children at risk for visual deficiency can be accurately detected. Also such data will enable the constant improvement of processes and make the impact of actions measurable, as a learning health system. 

Therefore, EVA virtual visual screening is a complete virtual tool that will help public and private services to guarantee the visual care for children, connecting the right child to the ophthalmic service, eliminating unnecessary visits that overloads the healthcare system. 

This solution is designed for children up to 7 years old, in order to detect and treat in an adequate time the main pathologies that are treatable and can cause visual deficiency. The children that are not diagnosed and treated in time, remain the rest of their lives with visual difficulties, have a negative impact on their education, economic income and in their quality of life.

In Brazil, the Unified Health System (SUS) is the government public health system and is in charge of 80% of the population. Therefore state and municipal health secretariats are potential partners. There is a dramatic reality today in ophthalmology, especially in the pediatric subspecialty. Data from the vacancy regulation system (SISREG) in the city of Rio de Janeiro (RJ), indicated an accumulation of 15,845 patients with pending appointments for an ophthalmological consultation in October 2015. According to SISREG, in 2020 the waiting list is of 6 months up to 2 years for a consult of pediatric ophthalmology and it totals 5,361 children.

There is also data showing that up to 56% of the  495,149 ophthalmological consults were of patients with no ocular alteration. Therefore screening would be equivalent to a savings of about USD 500.000  in 12 months to the healthcare system of Rio de Janeiro. 

In this system, there is no categorization of risk of low vision for patients.

Another potential user of the tool are the private health insurance providers, which seek greater efficiency in the allocation of resources and the lowest number of routine consults (children without visual/ocular changes).

Schools would also be great places to screen as the visual deficiency can impact on a child's school performance.

Concerning health care providers, pediatricians could offer a virtual visual screening to their patients, regardless of their practice activity. General ophthalmologists working in clinics can also promote screening activities, helping in the early detection and directing patients at risk for a face-to-face consult, reducing visual impairment in childhood and allocating resources to patients who need to be seeing.

With all these efforts, performing visual screening of the entire population is possible to reduce the prevalence of amblyopia, for example, from 2% to 0.2%, as in of Europe nordic countries, where universal screening performed shows. It also saves resources to the health system allowing to better allocate them.

The EVA founders are women, mothers, pediatric ophthalmologists, MD and Ph.D. graduated in Brazil and trained in US, currently working in both private and public healthcare systems in Brazil. We are also involved in the board of directors of the Brazilian Pediatric Ophthalmology Society.  We are located in three different regions of the country, northeast, southeast, and south of this continental country so we have the knowledge of different aspects of national health in diverse realities. In our practice we deal daily with late diagnosis, long waiting lines, and the lack of system resources. 

We are supported by the Brazilian Council of Ophthalmology and some municipalities of Brazil are interested in our solution. We also worked with some non-governmental organizations that perform eye care health campaigns for underdeveloped communities which have great interest in using our tool. So, we have both support of entities that do the strategic thinking of healthcare and the possibility of delivering the care for the right population.

We need to develop a better and sustainable business model, expand our team and guarantee the integration and implementation of our solution with financial resources, in large scale. Until this moment we have used our own resources and our capacity of establishing partnerships to design the entire solution, create the prototype and perform a pilot project where we screened, gave an ophthalmology exam and provided glasses for those in need, for 600 children.

There are some barriers to integrate the 2 technology partners, mainly concerned with the cost of the IT team and the API. We also need to find partners to help to run the business itself and open the potential market. We expect to find a mentor to help us develop an adequate business model and connect us with possible partners to be integrated to our team. 

We need financial support to integrate the platforms, run analysis of the collected data and go to the market to test our MVP. 

Virtual visual screening is still not available and not scientifically validated even in places such as the US or Europe. Telemedicine in pediatric ophthalmology has several barriers and is still a big challenge to implement. Our solution is simple because relies on a technology that is accessible to many people, even in middle/low-income countries such as Brazil, where 81% of the population has a smartphone with internet access. It is also possible to be accessed in different points of contact of the child with health care system (both public or private) schools, or self-testing by parents. The manager of the healthcare system can track the tested children  and understand which part of the journey the patient is in the system. It saves resources for the technology buyer, who will be avoiding unnecessary ophthalmology visits and delivering earlier care to those in need and, otherwise, would be waiting for a spot in line, for months. 

Impact goals for next year: 

Decrease the current waiting line of children for ophthalmology consults in the municipalities of Curitiba and Rio de Janeiro, screening all children already in line.

Screen children between 4-7 y.o. from the municipality of Joinville using EVA visual virtual screening (25.000 children)

Impact goals for the next 5 years:

Implement EVA visual virtual screening in the national public health system of Brazil as a way of stratifying all children for low vision risk.

Open to the private market and screen children to give better orientation on how to refer children exclusively to pediatric ophthalmology. 

Get to know other Latin American countries' public health systems, to adapt the screening tool to their reality and help them to screen and refer children to pediatric ophthalmologists. 

Results: 

• The completion of an efficient unified virtual tool (Laura plus EyeSpy) that is able to identify and stratify the risk of low vision in children with good sensitivity and specificity in relation to the gold standard that is the complete ophthalmological exam.
• The development of a database organizing the pediatric ophthalmology department
  • Reduction of the queue for a pediatric ophthalmology visit;
  • Early consultation for children with a high-risk of low vision, ensuring equity.
• Generate a database on the epidemiology of complaints and measurement of VA in a large scale, provide data with the entire patient's journey to evaluate the performance of the manager, in addition to enabling remote VA monitoring in cases of amblyopia being treated.

Objective: to reduce the prevalence of treatable visual impairment in children:

1. Parents and guardians can easily answer the questionnaire and perform the exam on the child
2. Schools, health facilities - periodic screening of all children, without special equipment or logistics.
3. Government Health departments or health ensurance companies or pediatricians and general practitioners: add visual screening to periodic exams

All screened children enter the system and are visible to the manager, already with their risk classification.

The manager can then know the size of the demand at each level of complexity and allocate resources to the highest risk cases and beyond, depending on the resources.

The project relies on two existing digital tools that need to be integrated: the LauraCare platform and the EyeSpy app.

The LauraCare platform is a multichannel platform that allows for the capillarization of virtual screenings, as well as the digitization and management of protocols for outpatients. To increase engagement and improve the patient experience, it is possible to use Natural Language Processing (NLP). A prototype with a questionnaire composed of sensitive questions that lead to the identification of the risk of developing low vision in children. The registration and storage of patient data, virtual ophthalmic anamnesis, analysis of responses, stratification of the risk of developing low vision, suggestions for referral to reference service, and evaluation of the outcome are carried out by the platform structured in a relational database.

EyeSpy 20/20 is a vision testing app, well known in the US, and scientifically validated for testing visual acuity both in adults and children. 

Both technologies work on smartphones with internet access. 

Any healthcare professional in basic units of health (nurses, technicians, pediatricians, family doctors) - Can better refer children to ophthalmologists based on data that provides a probable risk of vision problems. 

School teachers - They can screen all children, including the one with possible difficulties in learning to understand the reason for so. 

Guardians of the children - They can be aware of the eventual urgency of ophthalmic visits. 

The solution is led by 3 women, doctors, with little experience in technology in search of an accessible and scalable solution that meets all the diversity of the public, without distinction of social class or geographic location. The company, once incorporated, will favor the inclusion of diversity, for underdeveloped areas, where there is a population of children who doens't have access to an ophthalmologist,  especially to make the tool accessible to the visually impaired.

We are a software as service that can monitize as monthly fee for the municipalities for example, to screen the intire population of a certain district or population.  We can also progress to risk sharing as we gather data of the screened population and understand the percent of unnecessary visits that were avoided. 

Once the tool is operating, we expect the public authorities (municipal and state health departments and the ministry of health), private health insurances (supplementary health), and private institutions (large hospitals and eye clinics) as potential buyers. Other potential partners include health professionals, schools, and the optical sector industry. There are two main ways to monetize: monthly recurrence and risk sharing, which will be detailed below.

Considering that the single public health system in Brazil (SUS), includes 5,570 municipalities and approximately 150 million users. Furthermore, ophthalmology is the third largest federal budget when ranked by specialty. If we consider only municipalities with more than 100,000 inhabitants as potential users of the tool, we are talking about 236 potential customers, who, by paying a monthly recurrence rate of R$15,000/month, would generate annual revenue of R$42.5 million/year.

This considering only the use by municipalities, if we take into account that the SUS also has state and federal bodies, the number of potential customers in this remuneration model is even greater.

Speaking of supplementary health in Brazil, the private health insurance system includes about 700 health operators, which hold 48.5 million lives. This is a growing market in the country, between 2020 and 2021 alone, it accumulated 1.7 million new users. We estimate that only the 10% largest health insurance companies might have an interest in saving resources through virtual screening. In a monthly recurrence system, charging the same R$15 thousand in a monthly recurrence system, it would mean annual revenue of R$12.6 million.

It is estimated that the annual expenditure of health insurances is something around R$62 billion/year, with R$5.7 billion/year spent on ophthalmology alone. As mentioned above, based on the fact that a pre-screening could save up to 50% of resources, we would be talking about savings of up to R$2.3 billion/year. This, in a "risk sharing" remuneration scheme, could generate an income even higher than that assessed in the monthly recurrence scheme described above.

As for the other potential buyers, large hospitals and ophthalmic clinics, other health professionals, schools, and the optical sector industry, we would design an active client search strategy to also be hired monthly.

As mentioned before, so far our team is formed by 3 doctors, with no experience in business financing. We understand that we still need a solid financial plan and that this is one of our greatest weakness. therefore, this is one of the main reasons we are applying for this challenge.

We haven't got to that point in business yet.