Table 1.

Summary of major challenges in the implementation of tele-ophthalmology for diabetic retinopathy screening.

Quality of care	Quality of care appears to be causing a significant degree of skepticism for ophthalmologists. This derives from the fact that tele-ophthalmology interferes with the classic attitude of a physician’s clinical examination and personal interaction with his or her patients.
Liability	Possible standard malpractice considerations have to be taken into account, especially in cases where there may be relevant gaps in the laws of each country
Image quality	Teleophthalmology programs must take into account that the ungradable rate is a critical issue. In cases of an ungradable image, that encounter becomes unusable. The patient will not benefit, and it drains resources from the program. Reduction of ungradable images will increase the financial sustainability and clinical effectiveness of the program.
Workflow	Validated protocols are required in order to clearly delineate workflow and roles/responsibilities. Additionally, the time burden on physicians needs to assess all cases should also be estimated.
Security	Data encryption, password protection, and adherence to federal regulations, compliant backup and archiving must to be in accordance with all devices, from workstations to mobile devices.
Financing and reimbursement	Financial sustainability can be a substantial challenge, especially for programs that are not university-based or are not part of a federal program.
Patient perceptions	The patient’s attitude, satisfaction and compliance to a tele-ophthalmology program should be assessed at regular intervals.
Training of health care providers	All professionals involved in such screening programs must receive appropriate training regarding DICOM [Digital Imaging and Communications in Medicine] standards and compliance, regulations, as well as hardware and software that will be used.
Confusion of scope	Every tele-ophthalmology project should clearly define its scope, objectives and targets regarding the health care services provided.