Emory Eye Center ophthalmologists April Maa and Alexa Lu collaborated on the just-published guide
Physicians seeking to increase access to eye care have a new tool to help them. The recently published Ocular Telehealth: A Practical Guide
is a compendium of best practices and emerging trends in ocular telehealth that have been tested, reviewed, and revised by working ophthalmologists and optometrists for the better part of a decade.
Chief among those experts is the book's editor, Emory University ophthalmologist Dr. April Maa, whose Technology-based Eye Care Service (TECS) program in the Veterans Integrated Service Network (VISN) 7 is the busiest in the VA enterprise.
We've been practicing in this space [telehealth] for years, so we were excited last year when Elsevier [Publishing] approached us about putting this book together,
said Maa, who solicited and edited contributions from more than two dozen practitioners, including her Emory colleague, Dr. Xiaoqin Alexa Lu (also an ophthalmologist).
The work we've already done - setting up new billing strategies, monitoring patients, investigating technology - will make it easier for other providers to start a telehealth practice. They can use this book to get started.
Defining ocular telehealth
Telehealth
is a term that describes a wide array of approaches (and technologies) that allow some portion of a patient's health care to be processed or delivered remotely. Ocular telehealth has been finding its way into mainstream vision care for years.
For instance, depending on the complexity of the eye condition, patients might find themselves alternating between in-person examinations and video-assisted wellness checks with their physician. In between, they may visit a satellite site to have a technician perform specific eye diagnostic tests, such as Humphrey visual fields. The results of that test can be electronically transmitted to the physician who can, on their own schedule, analyze them and determine next steps. Those next steps might include an in-person visit or a Zoom call.
A common thread, throughout, is the use of technology - in particular, telecommunications - to remove geographic distance from the equation. For ophthalmologists like Maa and Lu, whose practices cater to far-flung rural populations, that's a huge help. But they are not alone.
Previously, ocular telehealth was typically reserved for rural or underserved populations,
writes Robert Morris, OD, in chapter 1 of Ocular Telehealth
.
During this pandemic, everyone became remote and underserved, making telehealth mainstream.
Getting beyond the School of Hard Knocks
Ocular Telehealth: A Practical Guide
analyzes the field from multiple angles, both practical and philosophical. There are chapters devoted to remote patient monitoring, the legal and ethical considerations of setting up an ocular telehealth practice, and billing/coding issues. A good deal of the book focuses on best practices for a broad spectrum of eye conditions. Each chapter author did extensive literature reviews to back their findings, but they also derived valuable data from what Maa and Lu sometimes refer to as the school of hard knocks.
Experience can really tell us a lot. The VA system has a lot of physicians who've been incorporating telehealth into their practices for a while. They wrote a lot of this book. They've experienced and gotten beyond a lot of the barriers and challenges - experiences others don't need to repeat,
explains Maa.
One thing all telehealth practitioners need to do is accurately assess their technology needs. Sufficient bandwidth for data-hungry diagnostic instruments, uber-secure data storage, and efficient transmission channels are just the beginning of this challenge. Each vision subspecialty has its own array of telehealth tools and instruments that need to be assessed and carefully coordinated to make the entire system work. The book's authors shared their experiences doing just that.
The anterior segment of the eye can be difficult,
says Lu, a cornea specialist. To get a good exam, you need better magnification, something more than a 2D photograph. You need a modality that will give you the ability to do 3D interpretations.
In her own research, Lu discovered that drone slit lamps offer a promising solution. Physicians can use these instruments to conduct an examination of a patient miles away, at a satellite clinic near home. Any time travel is reduced, access is improved.
You get the magnification you need and you get that videography that allows you to better understand what you are seeing,
she said.
Change is in the air
Both Maa and Lu are excited about the future of ocular telehealth. They've already seen it expand access to traditionally underserved populations, particularly in rural areas of the country, including Georgia. Last year, the VA enterprise conducted more than 21,000 patient visits remotely using TECS. And, even though Maa and Lu do not bill Medicare for their VA-based telehealth services, both are encouraged by the fact the Medicare granted a waiver during the pandemic that allowed telehealth billing.
We hope it will continue after the pandemic,
says Maa. We're advocating for it.
Meanwhile, Lu is personally and professionally invested in expanding access to telehealth. She heads up the national training curriculum for TECS readers and manages the VISN 7 TECS teaching rotation for non-eye and eye providers. She devoted an entire chapter to this subject in the book because she strongly believes in teaching others to become future eye telehealth practitioners.
And we know that this is just volume 1,
adds Maa. Once physicians read this book and have their own experiences, we know they'll come up with new ideas for implementing telehealth. That will be in volume 2. We can't wait to see what they teach us.
Eventually, both physicians foresee a time when more patients can comfortably alternate between in-person and telehealth exams. More tests can be run by technicians at satellite sites, with the results being evaluated by physicians miles away.
But at the end of the day, neither Maa nor Lu is suggesting a one-size-fits-all approach to ocular health care.
You need to select the right patients for telehealth,
says Maa. If you try to force it on a person who is not comfortable with it or who really needs to be seen in-person, you will not get compliance. Quality of care may suffer. Our most important skill will always be our ability to judge our patients needs and then meet them where they are.
-Kathleen E. Moore