Implementing telemedicine during the pandemic

Saya Nagori, MD, has been preparing for ophthalmology’s telemedicine revolution for some time. Anticipating that it would come amid a global pandemic, however, was never part of the plan.

Over just a few short weeks, Dr. Nagori transitioned from utilizing telemedicine technology on any given day to relying on it exclusively every day, for nearly every patient. “My telehealth usage in the office has skyrocketed,” says Dr. Nagori, owner of Vision MD Eye Doctors, in College Park, Md. “I am not seeing anyone in person currently, unless it’s an emergency.”

Dr. Nagori is among a growing list of providers attempting to expand on or initiate telemedicine for their practices during these difficult circumstances. The spread of COVID-19 has unofficially ushered in an era of digital health care, along with a fair share of unpredictability and confusion about the “new normal.”

The transition to telemedicine could be eased by recently implemented waivers for HIPAA compliance and changes to state-level and federal regulations that govern telemedicine’s usage. These changes, which were started in response to COVID-19, are intended to increase access to patient care while expanding reimbursement scope. However, these changes are not without untenable provisions that could pivot, depending on the pandemic’s path. Dr. Nagori and other experienced telemedicine providers suggest that their peers take a calculated approach to the beginning and broadening of their services. Being mindful of the fluid nature that today’s reality brings while establishing roots for longterm telemedicine adoption will be significant for businesses as the industry adjusts.

“This is a scary time, but there is some good that can come out of practices essentially being forced to start these technologies, both from a doctor and patient standpoint,” Dr. Nagori says.


Regardless of the extent of pre-pandemic services that providers have offered, the need to establish telemedicine habits is perhaps more important than ever. “Caring for our patients while keeping them safe at home is critical right now,” says Ranya Habash, MD, medical director of technology innovation and assistant professor of clinical ophthalmology at Bascom Palmer Eye Institute of the University of Miami.

Physicians who are introducing telemedicine at this time should preemptively identify those patients most likely to require this method of care. “Be proactive and go through your existing schedules,” says Dr. Habash, who also suggests sending email announcements to patients and engaging office staff to let the community know telemedicine is being offered during this time of need. “Patients will really appreciate that instead of hearing that the office is closed.”

Along with reimbursement and HIPAA compliancy, a significant drawback to initiating telemedicine in ophthalmology has been the patients’ use of technology, according to Michael Trese, MD, clinical professor of biomedical science and ophthalmology at Oakland University William Beaumont School of Medicine, Auburn Hills, Mich.

“One of the reasons that telemedicine has been used sparingly is that it wasn’t being paid, but the biggest limitation, even in this time of crisis, is the age of the patient,” says Dr. Trese, who serves as chairman of the AAO’s telemedicine taskforce. “The patient has to know what the interactive technology is, own it or have access to it and be able to use it. In many cities, they don’t.”

Conducting an initial phone call to educate patients on telemedicine modalities can help encourage older patients and vet whether their family could assist with devices, although nationwide social distancing could be a complicating issue.

The patient’s age aside, Dr. Habash says focusing on appropriate use cases, such as patient triaging and acute care visits, will lead to more successful follow through of telemedicine delivery. “When a patient calls with a red eye, you can have them send a picture. A picture is worth a thousand words, and a video is worth a thousand pictures,” she says.

There is a limit to the timing of telemedicine postop sessions related to reimbursement, however. “You cannot charge for telemedicine when there was a procedure or face-to-face examination within 7 days of that interaction,” Dr. Trese says. “You would need to be able to push that appointment back if you want to be paid, if that re-scheduling would be clinically appropriate.”

Triaging through telemedicine is worthwhile for a few reasons, one of which is to calm patients’ fears when acute issues might otherwise lead them to the emergency department (ED), Dr. Habash says. “Telemedicine is very important at this time for something as simple as asking, ‘Does this person need to go to the ED? Should that patient spend the day possibly being exposed to COVID-19?’ This decision could change the course of a patient’s life.”

Dr. Nagori, who estimates that she has triaged patients online for at least five years, says she recently helped to keep a patient with subconjunctival hemorrhage at home. “He was very anxious and would have likely gone to the ED if we weren’t able to see him,” she says. “He thought the problem was far worse because of the appearance of his eye.”


Consulting with your EHR vendor is a good first step to assessing in-house telemedicine capabilities, according to those interviewed. For example, Modernizing Medicine and NextGen Healthcare announced expanded services and resources during the pandemic.

Other digital applications are available, and many are free or offer free versions. Among the options, Dr. Nagori says she has regularly used ConnectOnCall, a platform built by three retina specialists. “They take your phone calls and emails and follow up with you,” she says. “Providers can be part of the process that leads to the next version of the application. And I think it’s important that we do that.”

In addition, during the pandemic, government officials have scaled back penalties connected to telemedicine and HIPAA privacy and security. These “relaxed” regulations make popular everyday apps such as Skype, FaceTime, Zoom and Google Chat available temporary options for telemedicine when they would normally be fraught with concerns

Dr. Nagori does caution that the use of free apps could result in connectivity issues, as many users try to utilize free services at this time and support systems are not as strong as for fee-based programs. “Unfortunately the free versions of most platforms are going to give you glitches, so people probably have to invest in something,” Nagori said. “The free versions were fine when there weren’t so many providers trying to use them. But now that many more people are trying to access them — there’s a bit of an overload.”

The AAO published guidelines for evaluating telemedicine considerations ( ).


Patients still have to be seen in the office occasionally, says Dr. Habash. Telemedicine can be used to reduce face-to-face contact in these situations. “But we want to be very careful, and we don’t want to risk potential exposure unless there’s a sight-threatening condition,” she says.

For example, a glaucoma patient may require an IOP check after beginning new eye drops. Conducting an in-office targeted exam and then immediately sending patients home for a video or phone session to discuss results limits contact for a billable service. In addition, for retina patients using a ForeseeHOME device (Notal Vision) that triggers an alert about changes in their Amsler grid, an expedited visit for OCT can be performed by a designated technician onsite and the patient can get the results from home.

“These are short, targeted visits,” Dr. Habash says. “This allows for minimal exposure while keeping staff members employed. Dedicated teams can conduct these tasks so that not all staff members are onsite, and teams can work in rotation. The physician reviews the results and plan with the patient later, from home.”


The pandemic has led the government to scale back penalties connected to telemedicine and HIPAA privacy and security ( ). Along with the regulation changes for video chat applications, the Coronavirus Aid, Relief, and Economic Security (CARES) Act allows for advance payments during the pandemic ( ).

“This is a time of emergency, and emergency rules are in place,” Dr. Habash says. “The whole point here is to take care of patients.”

That said, quick rollouts of legislation are causing procedural and legal questions. Alissa Smith, a partner at the international law firm Dorsey & Whitney and co-chair of its Health Transactions and Regulations Practice Group, represents individual providers and health systems. Ms. Smith says clinicians should not assume their care will be legally protected, especially pertaining to telemedicine for out-of-state patients. State law holds precedent, so clinicians must research law before conducting any telemedicine service. “Simply waiving HIPAA enforcement does not impact state laws,” Smith said. “There are legal risks in general.”

Also, Dr. Trese warns about industry rumors. “There seems to be information going around that all state regulations for practice of medicine are being removed — and that is not necessarily true,” he says. “There is ‘crisis appreciation,’ but you have to confirm that with each state.”


To protect providers and patients, informed consent and thorough documentation are necessary. Patients should be made aware of the mode of telemedicine and its functionality. “You should have telemedicine consent forms ready to go,” Dr. Habash says. (For suggested language for forms, visit the National Consortium of Telehealth Resource Centers ( ).

Sessions should be conducted in settings where no one else can overhear conversations or see photos and videos. Also, thorough documentation must include the patient’s name, communication method, how consent was obtained, service date and total time spent in session.

Dr. Nagori, the physician founder of the telemedicine company , which she launched in 2016, urges providers to think about licensure and to avoid the temptation of acting hastily in response to the pandemic.

“Some of the more risky parts of telehealth during the pandemic, for example, the lack of a requirement for a HIPAA-compliant platform, should be dialed back when this pandemic is over,” she says. “The changing rules and regulations have allowed us to start seeing patients we couldn’t see before. However, it is important to think long-term and to keep up with the proper guidelines for appropriately delivering telemedicine once the pandemic subsides.” OM

Ophthalmologists who are in need of guidance on how to set up telemedicine for their practices are invited to connect with Dr. Nagori, who provides instruction through InnovateHealth and is available through email at