By Mike Rothschild, OD
April 1, 2020
Updated Nov. 19, 2020
During the lockdown of the spring, eyecare practices called people who were on their schedules to cancel or postpone most appointments. Imagine if each of those appointments had been converted into a Virtual At Home Office Visit. Each patient’s current situation could have been evaluated by an optometrist after a brief conversation with a limited “evaluation.” Here is how I was able to do this in my practice.
What Is Telemedicine?
During a Virtual At Home Office Visit visit, the doctor can inquire about any problems the patient is experiencing and review the record for details about the patient’s eyecare status in much more detail than just looking at the schedule. Any needed treatments can be initiated and a clinical decision about next visit can be made while considering everything – including the current COVID crisis.
Your patients are made up of an intricate mix of complexities. Many successfully wear daily disposable contact lenses and have a good pair of backup glasses. Depending on their age, they could be very low risk for a sight threatening eye problems, but their eyes could be feeling dry. Others are elderly with active eye disease that you are monitoring or treating, but could die if they are exposed to COVID-19 in your practice.
Telemedicine Quick Tips
• To qualify as a synchronous telemedicine office visit, you and the patient must see each other. You need to look like a doctor who is “at work.” Put on a good shirt (pants are optional) and arrange your camera in a professional manner. Put the camera at eye level and look into the camera. If you are using a laptop, put in on a stack of books. Do not sit on the couch with the laptop on your lap.
• It usually takes a few tries for patients to get this connection made. Be patient and keep smiling. WiFi connections will vary, people will have trouble hearing you and being heard. They usually can figure it out, just give them a minute. Don’t stop because of this.
• Debrief after every visit. Every question the patient asks about the process is a chance to improve the instructions.
• Keep a journal. We are being thrust into telemedicine and this crisis will end. There can be some lasting impacts that can help us make our practices even better when things return to normal. Learn what you can.–Mike Rothschild, OD
These are tough clinical decisions that don’t need to be made simply by looking through the schedule.
Telemedicine visits can be billed to insurance and to the patient. But, let’s forget about that for a second and concentrate on taking good care of the patient.
Once you realize the benefit of incorporating telemedicine into your practice, you want to make sure that it meets your high standards of patient care.
Set the Protocols
First, decide who qualifies for these types of visits. This is a moving target and will expand as you get more comfortable and as restrictions increase. The less variables you set, the easier it will be to convert your appointments. You can use age, complaints or diagnoses as variables to determine who you are willing to see this way and who must come in and who you will just cancel to be rescheduled later.
I encourage you to convert every patient on your schedule to a VAHOV. Whether you bill them or not, you will connect with the patient to show them that you are still concerned, and you will make sound clinical decisions for the patient. Plus, it allows the staff to stay engaged in patient care from home and stay employed.
Write the Script
You will need to think carefully about the words you use to convert an appointment to a VAHOV. Through experimentation, we have found that there is less confusion if we use all the words in the name of this visit.
• Virtual (on the internet)
• At Home (NOT at the office)
• Office Visit (more than “just a phone call”)
These messages can be phone calls or e-mails or text messages, but they have to be managed by a person. There is too much variability for an automated program to do this.
Here is the script we are using today, but it was a little different yesterday. Start with this and continue adapting until it fits your situation:
“Hi Mr. Johnson, this is Mayeli calling from Vision Source Villa Rica. We have you scheduled for an eye exam tomorrow at 3:00. Dr. Rothschild has asked that we convert that exam to a Virtual – At Home – Office Visit. (The “-“ reminds you to say it slowly.)
“Is that time still good for you?”
Notice there is no mention of the COVID-19 pandemic. They know. Also notice, that we do not ask, “Do you want to do this or wait until later?” Finally, notice the VAHOV is discussed like an office visit, not “just a virtual call.”
Speak confidently about this to the patient. Answer all questions assuring them that this is a great way to make sure we are able to take the best care of them that we can. The toughest one is the first one, so go ahead and get that one out of the way.
Pick a Meeting Platform
I use a HIPAA – compliant version of Zoom because I already have that account through my existing telemedicine practice. Zoom has a free version and several inexpensive versions that work while the HIPAA restrictions are relaxed. Zoom encrypts the conversations on both sides of the conversation and is secure. Even with relaxed restrictions, we need to continue to make good faith efforts to protect the patients’ privacy.
Other platforms are being used successfully by ODs. Do your research and find one that works for you and your team. It is important that you settle on one means of communication so you can send your patients clear instructions as they work to connect with you.
Communicate with the Patient
People are not reading these days. There’s too much coming at us. Keep your instructions simple and use as many pictures as you can. Your goal is to set the patient’s expectations and try to have them ready for your VAHOV. Every time something goes wrong, it is an opportunity to make the process better.
We have found that people look at text messages far more frequently than they look at e-mails. We have also found that Zoom contact info is better through e-mail. So, we send a text that says, “We look forward to seeing you for your “Virtual At Home Office Visit” tomorrow at 3:00. Please watch your e-mail for connection instructions. The e-mail will come from Elizabeth at Vision Source and may go to your spam. So look for it there.”
The goal of the first e-mail is to establish an e-mail connection and set expectations for what to expect next. We show our logo that is familiar to them and the Zoom logo, which may or may not be familiar. (It still has too many words – we are working to decrease this.)
In the second e-mail send the contact information, including the password and the time.
We send a text message to the patient (and the staff who are all working from home) 30 minutes prior to the visit reminding them that it is coming up. Time gets away from us all sometimes.
Map out the Visit
A synchronous telemedicine visit requires the presence of the patient and the doctor who can see and hear each other in real time. It can include others on the call too, like staff members. It is important that the patient is told who is there and they are all part of the team. With the patient’s permission, a family member who is at a different location can also join the VAHOV. Pick a platform that allows others to join the meeting for more efficient and thorough care.
Decide how you will document the visit. If you have a cloud-based EHR or if you are working at the office, just log in and document directly into the record. If you are working from home and have a server based EHR, put it all on paper and transfer it to the EHR when you can.
Other Pieces to Explore
Walk through the ideal “script” of your VAHOV and decide who plays what part. Every practice is different and the situation can change on a daily basis. We have changed something about our process every day and it keeps getting better. The same will happen for you.
Establish a Process for Your Virtual At Home Office Visit (VAHOV)
Our office manager is the Zoom host and the meeting starts when she logs in. Everyone who logs in before her can wait, check audio, etc. Our entire staff is working from home too.
Once the connection is made, we all leave our cameras off, except for the office manager who begins the conversation. She assures that this is a secure connection, confirms all demographic information, discusses fees, insurance, etc.
I turn on my camera and she turns hers off and I begin the office visit. I am able to see the patient record and review all previous tests while the demographics are being updated. I resist the urge to talk too much about “how crazy things are,” greeting the patient as if they were in the practice.
Usually, the patient will make a comment about how “neat” this type of visit is.
I discuss the patient’s history and review what I know about their status. If they have glaucoma, I ask if they are using drops and if they have plenty. I can ask about contacts, glasses, sugar levels, blood pressure, anything.
A word about Visual Acuity. I acknowledge that a good VA is important for a normal office visit and there are ways to get it done virtually. I acknowledge that looking at a VCR clock is not a VA measurement. But I can compare the eyes to each other, I can ask the patient if it seems “good” and I can watch them slowly tilt back their head with progressives to see if they need more plus. I document what I can evaluate into the record. I document these notes into the “Notes” section of the VA. Be creative to find ways to evaluate vision the best you can during these extreme times.
We have found that the best images of the eye can be captured in the bathroom. Lighting is good, they can wash their hands and that is usually where the drops and contact lens solutions are kept. Talk to them the entire time they are capturing the images with their phones – “up a little, left, back – good.“
I get all the information that I can reasonably obtain and make a clinical judgement (Assessment)and decide something (Plan). We always make a plan for reconnecting with the patient through another virtual visit, in-office visit, or a referral to another specialist.
Communicate the plan to the patient and the staff, and “Leave Meeting.” Caution: don’t leave if you are the host. The staff deals with any check-out issues, like billing, scheduling, prescriptions, orders, etc.
I enter my findings into the EHR and sign the record.
Remember Rules for Clinical Judgement
Rule #1 in telemedicine is that the doctor must be the one to make the clinical decisions based on available information and data. We have to weigh the reliability of the data, the concerns of the patient, the potential risks to the patient and available treatment options. During this time, clinical decision making is tougher than ever. Take your time and think it through.
Make a few clinical decisions before you are faced with them during a live visit.
Example: 80-year-old patient treated for glaucoma scheduled for an OCT and a pressure check. Consider the significant risk for a visit to your practice based on her age and the fact that someone will likely have to drive her.
Next, consider her most recent glaucoma control levels. You may make different decisions if her pressures have been controlled over the last two years compared to someone who just started a new drop due to uncontrolled pressures. The most recent OCTs and Visual Fields may dramatically influence how long you can go before needing to measure the IOP. What else does this patient have besides glaucoma? Diabetes? ARMD? Cancer? COVID-19?
Also consider what questions you may need to ask during the visit that can affect your decision making. Status of refills on drops, how the eyes feel, overall health, changes in vision, on and on. While testing VA may not be reasonable, what if covering one eye reveals that the microwave clock numbers are distorted when covering the right eye?
Do not take these decisions lightly. It is perfectly reasonable to end the virtual visit and consult with specialists and research the best solution. Remember, you are responsible, and you are liable. Give every patient your best – just like you always do.