Medicine has been profoundly changed for the foreseeable future. COVID-19’s rapid spread and the extension of social distancing into our clinics has served as a catalyst to quickly resolve many of the outstanding issues surrounding telemedicine implementation. As such, telemedicine utilization has risen dramatically during the past few months. This rise has forced us to address several issues, including reimbursement, social acceptance of telemedicine as a substitution for clinic encounters and development of techniques to assess vital signs (ocular or systemic) at home to adequately follow our patients.
While health care as a whole has dramatically pivoted towards telemedicine encounters, some fields have not been able to perform this transition as easily as others. In particular, retinal practices rely heavily on imaging or an in-person examination to diagnose and manage pathology and adequately triage patients’ problems — no video-only substitution can fully replace a retina office visit. Yet, the impetus to remain home and avoid in-person visits has had a negative effect on those patients who self-quarantined despite our recommendations. For example, our practice has noted more hemorrhages in macular degeneration patients and more macula-off retinal detachments as patients defer examinations despite new symptoms. The need is great to ensure the ocular health of our patients, while keeping both patients and staff safe.
In this article, we review some of the elements of telemedicine that have already been implemented in our practice and identify some that are on the horizon. These include the use of imaging-only visits (whether during patient visits to other departments or specifically coming to the eye clinic for imaging only), the use of home testing/examination resources and the current modalities of conducting home telemedicine encounters through phone or video visits.
IMAGING IN CLINIC
Imaging is an essential part of a retinal evaluation and often the chief driver in clinical decision-making for macular pathology. Despite progress being made on home evaluation phone-based applications (discussed below), retinal imaging is still needed to confidently narrow a diagnosis and decide on treatment options. Retinal images can be obtained either in eye clinics or other settings such as primary care offices.
At Weill Cornell, we had already implemented outside testing for tele-retina patients prior to COVID-19. A number of ultra-widefield Optos cameras were set up in primary care and endocrinology offices throughout the Weill Cornell Medicine system for diabetic retinopathy screenings. Patients are able to take a quick non-dilated widefield retinal image, which one of our retina specialists interpret in the next few days along with appropriate management or follow up. Follow-up rates approach 100% for those patients with concerning pathology, and our department calls these patients to schedule an in-person evaluation. If no pathology is noted, the patients are reassured and can continue routine retinal imaging screening at their primary care or endocrinologist office.
COMBINING WITH TELEHEALTH
The second approach is one we implemented during COVID times. To minimize physical contact and face-to-face time, we have offered a combination of in-clinic testing and telehealth visit. A patient comes into the clinic, has their vision and pressure checked by a technician and then receives their retinal imaging, including macular OCT and widefield fundus photo. The patient can then leave the office and arrange for a later (likely same-day) virtual appointment with the retina specialist to review the results and discuss a plan. (See “The hybrid telemedicine approach”.)
This approach can be helpful for monitoring conditions that have a low likelihood of needing prompt intervention. We can monitor benign nevi, dry AMD or non-visually significant macular puckers. This minimizes the time the patient spends in the clinic and eliminates waiting time as well as crowding the waiting areas with patients ready for dilation.
This scenario can also be implemented if, during an examination, the conversation is expected to last for more than 10 minutes; then, the patient is given the option to discuss further over the phone. This can happen if a decision for surgery is made or if a patient has several questions that need to be addressed. The scenario minimizes the physical face-to-face time and prevents the practice from running behind, which could lead to a backflow and crowded waiting areas that it is presently important to avoid.
Video or telephone visits alone cannot supplant any form of examination, but what if there were means to conduct safe monitoring while keeping patients at home? One such device already available on the market is the ForeseeHome from Notal Vision Inc. As opposed to relying on patient comprehension and performance for the conventional Amsler test, this device allows users to more formally test for subtle visual field defects from home. Prospective clinical trials using this device (as published in Ophthalmology in 2014, by the AREDS2-HOME Study Research Group and Chew, et al) have shown that the device is sensitive in detection of central visual field changes secondary to active neovascular lesions in patients with wet AMD. While implementation of ForeseeHome was previously limited, perhaps a tool such as this might be useful now in the COVID-19 era for at-risk patients who wish to limit their clinic visits to only those that are absolutely necessary.
Nonetheless, the standard-of-care for evaluation of the macula in retinal practices remains OCT, which is more sensitive than even a clinical examination (perhaps except for that of Don Gass). Devices such as the ForeseeHome are still reliant on patient ability to adequately perform the test and to provide reliable responses. Notal Vision is actively working on a home OCT device for patients with scans evaluated using an artificial intelligence algorithm. Such a system would allow patients to defer in-person visits and would also permit retina specialists more meaningful context than the frequently asked question of “Do I really need to come in this week?” Hopefully, more patients would be coming back into clinics with small, reversible slivers of fluid rather than frank hemorrhages. Perhaps the current public health crisis may serve as a catalyst to bring such a device into our armamentarium sooner rather than later.
The hybrid telemedicine approach
By Timothy G. Murray, MD, MBA
The “hybrid” telemedicine model allows ophthalmic technicians to perform an ancillary examination and imaging, such as ultra-widefield fundus imaging coupled with swept-source OCT to image the patient’s retina. The patient is then scheduled separately for a virtual examination with the retina specialist.
Similarly, GlobeChek brings a unique approach to eye care that has been immediately applicable during the pandemic. GlobeChek kiosks incorporate a focused, technician-driven examination that delivers an all-in-one experience including assessment of VA, IOP and, most importantly for the retina specialist, fundus imaging with OCT. This process occurs without dilation or touching the eye and typically takes 10 minutes to perform. This information is sent to a GlobeChek doctor, who will review it and deliver to the patient any diagnoses or recommendations for follow-up care.
GlobeChek has initially focused on broadening access to eye care for those without an existing ophthalmologic relationship. Clearly though, this approach enhances access during unique times such as our COVID-19 pandemic.
Importantly, the “hybrid” telemedicine approach eliminates the need for hands-on physician evaluation in cases where patient symptoms require more comprehensive evaluation, such as symptomatic retinal tear/detachment, intraocular tumor, or peripheral retinal disease outside of the scope of imaging.
Home testing does not mean only imaging obtained at home. Rather, it also includes adjunct testing of “ocular vital signs” to help qualify image interpretation. For example, at Weill Cornell we have been experimenting with a number of downloadable applications to facilitate patient’s checking their own visual acuities, color vision and Amsler grid, and we provide specific instructions in conjunction with the application. With the assistance of a device lending program, we have even been monitoring IOP.
All of the above modalities serve as adjuncts to a phone or video visit with a doctor or an advanced care provider to discuss the implications of the findings, to reassure and check-in with the patient or to ask them to come for an in-person visit. The “ocular vital signs” obtained by the patient help guide management of the pathology identified on a home imaging device. The combination of both elements (ocular vitals and imaging) allow for a more comprehensive evaluation and discussion with a retina provider. At the very least, such an encounter more adequately triages any pathology and informs the acuity of any necessary in-person follow-up.
There are varying degrees of reliability with an aging cohort utilizing mobile devices and their applications, let alone performing the tests; however, their use at least adds the potential of acquiring sufficient information to form meaningful clinical decisions, with the patient kept away from the office.
The declaration of the public health emergency (PHE) — and the subsequent requirement of social distancing — accelerated the implementation and acceptance of “virtual care.” This increased acceptance was true for both providers and patients. Although the ability (in theory) to perform telemedicine and telehealth visits has been around for several years, the archaic and overly restrictive rules that governed such visits made their use nearly nonexistent. Very few CPT codes were billable via telemedicine, geographic restrictions limited the localities in which televisits were allowed to be performed and, even for virtual visits, patients needed to be in an approved facility.
As part of the PHE, federal regulatory rules (from HHS and CMS) were relaxed to allow for more than 250 CPT codes to be used for telemedicine encounters. The geographic and specific location restrictions were also eased, so that patients could be sitting in their own homes while speaking with their doctor. Importantly, modification of state medical licensure requirements allowed doctors to care for patients who live in a neighboring state, which was especially significant for practices like our own. Not only do we typically draw from a catchment area that includes four states (New York, New Jersey, Connecticut and Pennsylvania), but many of our patients also decided to temporarily leave the New York area altogether and ride out the PHE in places as far away as Hawaii. Notably, the updated reimbursement methods from third-party payers also allowed virtual care to become part of a viable business model for medical practices.
Along with the easing of regulatory requirements, wide availability and ease of use of real-time audio and video technologies, such as Facetime, Zoom, Webex and Doximity, has allowed even those who are technologically unsavvy to connect with their doctors.
Perhaps the greatest impact of COVID-19 on the future of health-care delivery will be that of telemedicine. During the PHE, in-person outpatient visits across the New York-Presbyterian health-care system dropped by more than 75%; in contrast, our televisit volume with no in-person component, increased by nearly 4,000%. Virtual care for retina patients can be provided on a spectrum, from retinal imaging in a primary care office to testing-only visits followed by a conversation with a retina specialist as well as home monitoring with virtual check-ins and no in-person component. The hope is that regulatory burdens and barriers will not be reinstated and payment models not negatively realigned as the PHE is lifted.
The era of telemedicine arrived along with the COVID-19 pandemic. Managing expectations for provider, administrative staff, patient and patient family, as well as knowing the limitations inherent in virtual care, will allow this to become an integral component of health-care delivery. OM