Establish a program in your practice during this Wild West phase of tech.
Reviewed by Rebecca Wartman, OD
Telemedicine is not a new concept; it has been around for decades but generally restricted to use with patients in rural areas with no or limited health care practitioners. However, the technology has been forced to take great leaps forward during the COVID-19 pandemic to meet the eye care requirements of patients who were isolated.
As a result, caregivers have entered this Wild West phase of this technology, according to Rebecca Wartman, OD, retired from private practice in Asheville, North Carolina, now working as a consultant; and Harvey Richman, OD, in private practice in Manasquan, New Jersey.
In optometry, telehealth provides synchronous/asynchronous technologies and non–face-to face telehealth (eg, virtual check-ins, e-visits, and telephone and telehealth services) for the eye, adnexa, visual system, and related systemic health care services.
However, these capabilities do not replace the face-to-face interactions with the doctor and patient—telemedicine does not, in and of itself, replace the standard of care.
The current standards of care typically require face-to-face interactions in order to adequately perform comprehensive ophthalmic evaluations.
Technologies available are not sophisticated enough, at this point, to be able to meet state and federal standards of care. Specifically, services such as refractive tests, photographs, and screenings do not replace direct contact between the doctor and patient because of inherent limitations in the technology. Optometrists are bound to abide by their respective state laws.
The goals of establishing a telehealth program are staff efficiency, patient compliance and convenience, improved access to care, streamlined schedule, addressing downtime issues, and examining the value of the system to the patients, staff, and practice.
Such considerations include access to care, chronic and postacute care management, triage for emergencies, and many communication channels.
The bottom line for patients who love the technology is the convenience it provides. In the 2021 US Telehealth Satisfaction Study by J.D. Power, 51% of respondents listed convenience as the No. 1 benefit. This was followed closely by safety at 46%, quality of care at 30%, and their condition being covered by the telehealth visit at 28%.1
During the post–COVID-19 period, the rules about telehealth are in flux regarding who will be allowed to offer certain services, when the services will be allowed, what payers will participate, and what payers will exclude eye care. The rules likely will tighten.
Once the dust settles, Wartman advises all individuals be educated on benefits, including staff and patients. In addition, options should be provided that include telemedicine visits, virtual check-ins, and portal access for any questions they may have.
Office staff can be involved in scheduling, patient intake, ensuring the timing of visits and patient set-up, connectivity, and what to do when connectivity fails. Other considerations are that patients must be prioritized for telehealth, educated with a script, and converted to telehealth.
Wartman underscored the importance of maintaining a professional office appearance during telehealth visits. Perhaps the most important is having a backup plan for when the technology fails.
The clinically appropriate care provided during telehealth visits include glaucoma compliance, follow-up of patients with dry eye and acute infections, and checkups of patients with age-related macular degeneration, among others.
Given the nature of virtual evaluations, physicians cannot conduct deep anterior segment and posterior segment examinations, refractions, and IOP measurements. Physicians can evaluate the anterior segment and the pupils to a certain degree, the extraocular muscles, and collect history symptoms; however, evaluation of the visual fields is uncertain.
Patients can also conduct an at-home visual acuity test with appropriate instructions regarding lighting and distance to the chart. Additionally, they can perform Amsler grid self-testing at home and measure their IOP using the iCare tonometer (iCare Finland Oy) and the SENSIMED Triggerfish contact lens sensor (SENSIMED) to monitor glaucoma.
Other devices, such as smartphone retinal imaging systems and portable vision, color, visual fields, and contrast sensitivity devices, are also available to facilitate examinations. Other testing abilities include the pupils, eye movements/alignment, penlight anterior segment evaluations using a camera, patients’ selfie images, and medical discussions that include patient and family questions. Physicians should document the length of each visit.
“Telehealth will become more common in our practices and [must] be properly and effectively implemented,” Wartman said.
This article is based on Wartman and Richman’s lecture titled “Telehealth and remote care: what is possible and what is not!,” presented at the Annual American Optometric Association (AOA) Optometry’s Meeting held June 15-19, 2022, in Chicago, Illinois.