May 2020


Covid-19 News You Can Use
Bringing telemedicine into practice

by Ellen Stodola Editorial Co-Director

Telemedicine in practices has grown exponentially in light of the COVID-19 pandemic. EyeWorld spoke with ophthalmologists around the country about their implementation of telemedicine and how it’s allowing them to help patients while clinic and surgical services are limited.

Deborah Ristvedt, DO
Vance Thompson Vision
Alexandria, Minnesota

Brandon Baartman, MD
Vance Thompson Vision
Omaha, Nebraska

Having not previously used telemedicine, Dr. Ristvedt said that Vance Thompson Vision began diving into best practices in mid-March, learning how to make it work for their patients, especially for the elderly patient population. Doctors at the practice strategized and broke into teams, each addressing different issues, with Dr. Ristvedt focusing on how to make the best telemedicine program possible.
The practice now has a “robust telemedicine program,” seeing patients in the office for testing only; a doctor follows up later via a video or phone call.
For glaucoma patients, Dr. Ristvedt said there may be a possibility for virtual visual field tests or IOP checks. Similarly, plastics patients could potentially do a virtual visual field test. While photographs can be taken and analyzed with telemedicine, Dr. Ristvedt said, one hurdle is pressure monitoring. There are technologies available for remote IOP monitoring, but they haven’t been implemented across the nation.
Telemedicine services are keeping the practice moving during the pandemic, but Dr. Ristvedt added that there is some concern about volume when practices reopen as well, and these methods may still be useful then.
Dr. Ristvedt said that patients being seen in the office are those who require a slit lamp exam or retina evaluation. These could include patients who recently had glaucoma surgery or those who are experiencing flashes or floaters after cataract surgery.
Dr. Baartman said that he’s still seeing patients scheduled for essential postoperative care (like glaucoma surgical patients or corneal transplants) as well as ongoing, sight-threatening issues like corneal ulcers.
One of the goals moving forward is to limit not only the number of in-person visits but also the amount of time each patient spends in the office. A lot is dependent on in-person diagnostics and slit lamp examination, making a true “telemedicine” program challenging, he said.
Dr. Baartman described a “hybrid program,” where necessary testing is done in person but follow-up with the doctor is conducted afterward by phone or video. They’ve also implemented a system so all new patients can elect to be seen by a doctor virtually. “In creating this hybrid program, we want to implement something that can be sustainable,” Dr. Baartman said. “We do not know for how long we will need to be instituting some of these changes, so we think it’s important to create something that is functional and not onerous to staff or doctors.”

Blake Williamson, MD
Williamson Eye Center
Baton Rouge, Louisiana

In response to COVID-19, Dr. Williamson quickly transformed his practice into a virtual eyecare center with 10 of the 14 doctors at Williamson Eye participating in telemedicine. From day 1 his goal was to make this a robust, patient-friendly experience that allowed the doctors to take care of a relatively high volume of patients. By the second week, they were approaching around 100 telemedicine consults per day.
“At first, we had some issues with patient acceptance as many were intimidated by the technology,” Dr. Williamson said. “Our call center also struggled somewhat with how to explain the benefits of telemedicine to patients. But with careful scripting of our teams working the phones, we were able to overcome this, and our patients have enjoyed the opportunity to get their eyecare needs and prescription refills taken care of from the comfort of their homes.”
Williamson Eye is using, which Dr. Williamson chose because he found it to be the simplest platform. “We like that Doxy is web-based, which means it doesn’t require the patient to download an app. Instead we can simply text them a link to my waiting room vs. spending time teaching them how to find the App Store. We also like that it’s device agnostic, Apple and Android are both supported, and it allows us to invite multiple patients at once into a virtual waiting room,” he said. “This way patients can wait for us to bring them from the virtual waiting room to the exam vs. my team spending time trying to call each patient and invite them in the waiting room one by one, which is inefficient. We can take anterior segment photos with it, and all of our providers have been able to take to it easily.” So far, they’ve even caught a COVID-19 patient who presented with conjunctivitis.
“A lot of physicians wonder, if you can’t do a slit lamp exam or check pressure, is it worth it?” Dr. Williamson said. “The answer is yes. It doesn’t replace an in-person exam, but when you are practicing what we call ‘wartime ophthalmology,’ anything is better than nothing. We think checking on patients to make sure their family is safe and not in need of medical attention is important. Refilling medical prescriptions is of great value as well. If nothing else, just reaching out to your patients and making sure they know you’re thinking about them and are still open for emergencies is important. Often we are the only doctors who have called them, so we take a moment to discuss general safety guidelines for COVID. Keeping our practice in patients’ minds and keeping our doctors’ minds on their patients is critical during a crisis.”

Christina Weng, MD
Associate professor of ophthalmology
Cullen Eye Institute, Baylor College
of Medicine
Houston, Texas

Working as a surgical retina specialist in an academic setting, Dr. Weng finds several challenges that telemedicine can’t quite overcome: 1) patients who need injections, 2) urgent and emergent pathology, and 3) cameras and equipment needed to assess the retina and posterior segment.
Dr. Weng still sees most of her injection patients, critical postoperative follow-ups, surgical complications, and patients who are experiencing acute symptoms (flashes, floaters, pain, vision loss, or eye redness). The clinic is taking precautions when carrying out those visits.
Dr. Weng champions a large teleretinal screening program for diabetic retinopathy in Houston, Texas, but telemedicine in the COVID-19 era is different. The ultimate aim is to provide contactless care, she said. Ophthalmologists are turning to platforms like FaceTime and Zoom that allow for video calls. At her institute, they are using televisits built into the EHR system and are able to bill for these exchanges. Additionally, the EHR has a mobile version that can be downloaded. Most of the “visits” involve the patient describing their symptoms and history, but people are getting innovative with evaluation methods, she said. “While the quality of images across a phone or computer camera will not parallel that from a slit lamp, it does allow for a general assessment and more-informed triage,” Dr. Weng said. Another challenge is some elderly patients are not familiar with computers, smartphones, and apps, and some may not have access to these. For these patients, phone calls may be a better option than video chats, Dr. Weng said.
“This type of telemedicine has been available for quite some time, but it was seldom used until COVID-19 forced us to change the way we work and live,” Dr. Weng said, adding that she thinks this shift in providing care will be a permanent one. “I hope that this brings a heightened awareness to the value of conventional, fundus-based teleretinal screening, a cost-effective way to prevent blindness in millions of people.”

April Maa, MD
Associate professor
Emory Eye Center, Emory University School of Medicine
Clinical director of TECS, VISN 7 Regional Telehealth Service
Atlanta VA Medical Center
Decatur, Georgia

Dr. Maa works with the VA, which had a telemedicine screening program prior to the pandemic, Technology-based Eye Care Services (TECS). The goals of TECS were to prescribe glasses and identify patients requiring an in-person eye exam at the primary medical care home. Challenges in the VA system pre-pandemic included geography (patients living far away from the main eye clinics) and access (not enough appointment availability).
However, since the COVID-19 pandemic, her focus has shifted, since many of the veterans are high risk, and TECS requires a technician to be present in person with the patient. “Routine eye screenings don’t need to be done during this time,” Dr. Maa said. “We’ve shifted our experience in telemedicine to helping the field find another way to see patients during the pandemic.” She mentioned a newly designed video protocol to connect with patients and added that they are piloting a protocol for ophthalmic urgent care, which allows for a specialist to be patched in through the VA Video Connect system if, for example, a primary care doctor has an eye question when seeing a patient via video appointment.
Post-COVID-19, there’s going to be a substantial backlog because many patients who need care but are not having acute problems are not being seen at this time. There may be the possibility to do a “digitally integrated visit,” where a technician could perform tests and check on the patient in the office, even if the physician isn’t present, and the physician could follow up with the patient after all the information is gathered, Dr. Maa said.
“It’s unfortunate that the pandemic is here, but at the same time, it’s a good opportunity for practices to incorporate telemedicine as part of their toolbox for taking care of patients,” Dr. Maa said, adding that it’s an important tool for being successful in the long run.



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