By Brian Chou, OD, FAAO
May 13, 2020
Not long ago, telemedicine was widely panned by optometry. Remote refraction and online prescription renewal drew ire. Yet with COVID-19 bringing optometric practices to a standstill, eyecare trade media now portrays telemedicine as a lifeline. Does the rapid embrace of telemedicine expose hypocrisy? Or was optometry’s previous denouncement of telemedicine ill-informed?
Telemedicine refers to a diverse range of health technologies used at a distance. The various forms of optometric telemedicine are frequently conflated, but they are hardly monolithic. Here are examples:
Live video chat. Think of FaceTime or Zoom. There are HIPAA-complaint and professional-grade apps for healthcare (e.g. doxy.me). These require the patient and doctor to each have internet access and a computer, tablet or smartphone.
Data-driven image diagnosis. Image-recognition software and artificial intelligence can diagnose with high sensitivity and specificity dermatological lesions and diabetic retinopathy.
Synchronous (real-time) remote refraction. A digital phoropter is controlled from elsewhere. 20/20 Now and DigitalOptometrics are competing systems currently embroiled in litigation. The patient must go to an equipped facility with trained staff, but the doctor is remote.
Asynchronous (store-and-forward) imaging. External eye videography (e.g. Simple Contacts app’s “redness test”) that is recorded and reviewed later by a remote doctor.
Specialized hardware for mobile health (mHealth) platforms. Low-cost adapters that connect to a smartphone assessing refractive error, like by EyeQue for self-administration. Or adapters by EyeNetra or SVOne administered by a traveling technician.
Remote contact lens and eyeglass prescription renewal by duplicating or slightly modifying an old prescription uploaded by the patient. A remote doctor can review the old prescription alongside self-administered visual acuity measurements. Examples include Prescription Check by Warby Parker and Visibly (formerly Opternative).
There are also hybrid models combining features. For example, the eyecare-specific app, EyecareLive, combines capability for synchronous video chat with self-measured visual acuity, digital photos and video for asynchronous review by their doctor.
With many shapes and sizes of optometric telemedicine, the validity of one does not automatically bestow another with the same. Rather the merits of each deserve individual inspection.
Physical Distancing Underlies Today’s Move to Telemedicine
The longstanding impetus for telemedicine includes improving access in under-served areas, convenience, cost savings and increasing profit. However, with the COVID-19 pandemic, telemedicine interest is spurred by aspirations for physical distancing. Just as coronavirus has catalyzed business for Instacart, Zoom and DoorDash, it will do the same for telemedicine. Yes, this virus is a boon to online prescription renewal for Visibly, Warby Parker, Simple Contacts, 1-800 Contacts and their ilk.
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Which forms of telemedicine allow physical distancing? Many do not. For example, scleral profilometers can transfer data remotely to a lab to generate custom scleral contact lenses. But this form of telemedicine requires the patient to come into the office for profilometry whereupon at least one staff member has close and extended contact with the patient. The same goes for remote-controlled digital phoropters.
The patient still needs to go into an equipped facility where a technician positions the phoropter in front of the patient. If the telemedicine technology cannot get readily distributed to the patient for self-administration in their home, it will not enhance physical distancing. Technologies that lend themselves to physical distancing include video chat, asynchronous user-captured photos and video, mHealth with adapters and self-administration and online prescription renewal.
Clinical Limitations of Optometric Telemedicine
There are eye exam components that are not readily and effectively evaluated using the current telemedicine offerings. To name a few, take palpating for adenopathy, tonometry, upper lid eversion to evaluate the palpebral conjunctiva, use of vital dyes, corneal topography, corneal esthesiometry, Seidel testing, ocular coherence tomography, wide-field retinal imaging, prism dissociation vergences, threshold visual fields, Van Herrick angle estimation, evaluation for transillumination defects, visualization of cells and flare, dilated fundus examination with binocular ophthalmoscopy and scleral indentation.
Having a complete diagnostic tool-set facilitates appropriate care. Without it, the clinician is at a disadvantage to serve the patient. The clinician may not be able to meet the community standard of care of face-to-face interactions, thereby under-serving the patient while concurrently increasing their own medico-legal exposure. Worse, the practitioner’s professional liability policy may not protect the clinician when they are working remotely (check your insurance policy). Finally, optometric telemedicine may not fulfill minimum exam requirements for third-party reimbursement. Even future improvements in telemedicine technology may not overcome these limitations.
Today, optometric telemedicine can complement in-office eyecare. It is useful for triage, diagnosing and treating garden-variety conditions like chalazion, allergic conjunctivitis, blepharitis, simple bacterial conjunctivitis and subconjunctival hemorrhages. These can often be diagnosed through video chat or user-submitted photos, even with limited image quality. Yet other conditions, including corneal foreign bodies, retinal detachment, angle closure and infectious keratitis, require in-office examination and treatment.
Video chat can help in situations where the doctor would otherwise call the patient as a check-up, for reviewing test findings (e.g. threshold visual field, OCT results, genetic test results, etc.), providing instruction and reviewing contact lens handling. Reducing the number of in-office visits through video chat helps reduce office traffic, enhancing physical distancing. But to be sure, these functions will not replace most optometric services.
Before committing to a fancy telemedicine system, first have your IT professional set up secure remote access to your computer network. That way, if one of your patients contacts you when you are not in the office, you have capability to review their electronic exam record and call in a prescription if necessary. Once you have this foundation set, you can increase other telemedicine capabilities.
Consider video chat for patient triage, reviewing results and low-stakes progress visits. You might proactively offer prescription renewal to your patients. Finally, realize that video chat telemedicine often does not generate revenue. A more reasonable goal is to improve efficiency and convenience to your patient, so you have greater capacity to see more in-office patients. If your goal is to reduce contagion in the office, you may have better success making other changes in your office.
Careful Embracing Telemedicine
While telemedicine’s role in optometry is emerging, it may not burn as brightly as we would like during the darkness of COVID-19. An over-reaching enthusiasm for telemedicine rooted only in physical distancing may instead open Pandora’s box to online refraction and prescription renewal, redirecting traffic out of the office to the unchecked virtual world of online retailers.
Brian Chou, OD, FAAO, is the owner of ReVision Optometry in San Diego, Calif. He co-developed the first doctor-led smartphone app for self-administering visual acuity. Launched in 2010 it amassed over a million downloads in iTunes. He was also a retained consultant for two start-ups developing new refraction technologies with remote capabilities.