Welcome to the Ethics Forum! The optometric profession has long recognized its ethical responsibilities to patients, colleagues, other health care professionals and the public. This forum provides an opportunity to review a hypothetical case study containing potential ethical challenges and includes suggestions on how one might handle the situation based upon the American Optometric Association Standards of Professional Conduct and Code of Ethics.

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If you have any questions on ethics, please submit them to EthicsQuestion@aoa.org. The AOA Ethics and Values Committee will respond to your questions as soon as possible. If you have an ethical challenge you wish to share, please feel free to submit a case description to ethics@aoa.org. The case description will be reviewed by the AOA Ethics and Values Committee and may be featured in a future Ethics Forum.

TELEHEALTH CARE / TELEMEDICINE

Authors: Kenneth Lawenda, O.D., past member of AOA Ethics and Values Committee

Robert Moses, O.D., member of AOA Ethics and Values Committee

Case Study No. 17

Legislatures in many states have passed laws that prevent the separation of refractive assessments from overall comprehensive eye examinations provided by an eye doctor. One reason for these patient protection laws is to protect patients who may unwittingly neglect their overall health because the use of an online app allows them to skip regular visits to their eye doctor. For patients residing in states where online refractions are permitted, ultimately, it is up to the individual whether to utilize these services. As doctors of optometry, is there an ethical dimension to our interactions with telehealth technology?

We as professionals have all benefited from technological advances in eyecare delivery systems. We have utilized in our comprehensive eye examinations instruments like auto-refractors, topographers, visual field instruments, retinal cameras, OCT’s and electronic health records. They have all dramatically improved patient care when combined with professional knowledge and judgment.

Telehealth, including telemedicine, when properly executed by licensed professionals, can provide a valuable service to patients. As health care providers we should use these services when appropriate to benefit patient care. However, when improperly used, patient health can be adversely affected.

These services can increase availability to specialty care for patients in rural and underserved areas, improve monitoring of patients with chronic disease, as well as providing education to patients thereby improving understanding and compliance. Conversely, when telehealth services are improperly applied, care can become segmented, resulting in failure to diagnose concurrent health issues. Inappropriate technology inappropriately applied can lead to inappropriate care.

The American Optometric Association has published a position statement on Vision Telehealth Services and how these services should be utilized to benefit patient care. The position statement states that “(t)he AOA supports the use of eye and vision telehealth services provided by licensed eye doctors…and other appropriate, licensed professionals in certain instances,” when certain criteria are met. Among the criteria listed are these critical points:

  1. The standard of care provided to the patient must stay the same;
  2. Telehealth is not appropriate for establishing the doctor-patient relationship or for an initial diagnosis or other types of care where face-to-face interaction is indicated;
  3. Patients must be made aware of the limitation of telehealth services and should be given the option of in person care;
  4. Eye doctors must abide by state licensure laws and regulations when delivering telehealth services;
  5. At its current stage of development, telehealth is not capable of replacing all elements of an in-person comprehensive eye exam by an eye doctor.


In the AOA’s view, telehealth services can bring increased access to care for patients requiring consultation or a specialist's assessment. When used properly, patients can be directed to appropriate services in a timely manner, improving outcomes. In person, initial assessment by a licensed vision care provider, with appropriate technology and experience, insures a more comprehensive evaluation of all critical data needed to support the distant consultant’s diagnosis and subsequent monitoring and treatment, which may incorporate telehealth elements.

Currently, optical retailers are attempting to use aspects of telemedicine to market eyewear and contact lenses directly to consumers without the need for a comprehensive eye exam and eye health assessment. These sellers suggest that separating refractive error determination from comprehensive care would benefit the consumer. In our view, this approach is not consistent with a basic principle of telemedicine in that the standard of care delivered must remain the same regardless of how telehealth services are provided. A visit to an eye doctor to receive a comprehensive eye exam in order to obtain a prescription for glasses or contact lenses may result in the diagnosis of asymptomatic conditions such as glaucoma and early diabetic eye disease, something that a remote, refraction-only test would miss. Thus, in our view the cost to impacted patients and to society far outweighs any perceived convenience advantage to an individual. The first line of the Optometric Oath states “I affirm that the health of my patient will be my first consideration.” We believe that the responsible use of telemedicine should adhere to that principal.


A question arises – if rules and regulations have been established by state legislators to protect the public, how will regulatory bodies enforce those laws when they are not followed? The answer to this question appears on the surface to be quite simple. If the mandated level of care is not being delivered by a licensed professional, then regulations applicable to professionals can be enforced by the appropriate professional board to protect the public. However, as more and more non-physician companies offer services that were once the exclusive responsibility of licensed professionals, the picture is not so clear. Over the past few years, we see have seen multiple states being faced with litigation by these for-profit online companies who are challenging the notion that professional rules and regulations apply to them. So far the outcome of these lawsuits has been mixed, leaving the scope of professional licensing boards’ authority in question.

Understandably, the current state of affairs might leave a doctor confused about whether or how to appropriately incorporate the use of telehealth technologies into his or her practice. It is perhaps easiest to think of this as a two-part question. First, is the technology permitted by the laws and regulations in your state? Doctors can look to their state licensing board websites for answers. These sites are a useful resource and typically contain copies of statutes and regulations governing the practice of optometry. Your AOA affiliate state optometric association can assist if you have difficulty interpreting state statutes or rules.

Assuming a particular technology is legal, the other question then becomes whether the doctor feels that its use complies with the current standard of care in his or her state, and the doctor can appropriately incorporate it into his or her practice. Ultimately, each doctor must answer this question for him or herself. Materials like AOA’s Clinical Practice Guidelines or the Position Statement Regarding Eye and Vision Telehealth Services can serve as guides, but they are not replacements for individual professional judgment.

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References

  1. https://www.aoa.org/Documents/Legal/Position%20Statement%20Regarding%20Eye%20and%20Vision%20Telehealth%20Services%20-%20Referenced%20in%20HOD%20Resolution%201989.pdf
  2. https://www.aoa.org/documents/about/Standards-of-Professional-Conduct_Adopted-June-2011.pdf
  3. https://www.healthit.gov/telehealth
  4. https://www.aoa.org/about-the-aoa/ethics-and-values/the-optometric-oath
  5. https://www.aoa.org/advocacy/state-advocacy/state-by-state-breakdown/consumer-protection/consumer-protection-map

About the Authors:
Dr. Lawenda, OD, presently serves on the Vermont State Board of Optometry and has served on the California State Board of Optometry. He is a Past President of the California Optometric Association and has served on various AOA and ARBO COPE committees and is presently on the COPE Audit Committee and Chair of the COPE Judicial Council/Resolutions Committee. He currently practices in Vermont and in group practice in Beverly Hills, California.

Dr. Moses, OD, FAAO, is the owner of a multilocation full-scope primary eyecare practice in Northwest Indiana. He is a Past President of the Indiana Optometric Association and has served as Chair of the IOA's Third Party Care Committee for over 35 years. Dr. Moses was appointed to the AOA Ethics and Values Committee in 2016.