Leading the charge: AOA recommends care standard for telemedicine use amid rapid change

When the AOA Board of Trustees adopted and updated its profession-leading Position Statement Regarding Telemedicine in Optometry last fall, there was plenty new, such as sections on appropriate use of artificial and augmented intelligence (AI) and case studies. But it stuck steadfast to its No. 1 stance: telemedicine can’t replace in-person, comprehensive eye examinations by doctors of optometry.

Upfront, in the 12-page policy statement, the AOA maintains that the standard of care for patients must be preserved and identical in quality, whether delivered in the practice of a doctor of optometry or via telemedicine. The new, revised policy statement was developed after input from leaders in eye, health, vision care, artificial intelligence, telemedicine platforms and practicing physicians and was approved by the AOA Board of Trustees in October 2022.

The statement was the result of study, input and recommendations by the AOA Telehealth Council over several months.

“Our ultimate goal is to make sure that patient care is delivered in a safe and effective manner,” says Christopher Quinn, O.D., past AOA president and chair of the Telehealth Council, which met over several months in order to provide the update. “The policy is widely recognized by industry and providers as important. I think it’s why we had such broad participation from stakeholders who wanted to have their voices heard. These are important topics to give guidance to our providers.”

Adds Terri A. Gossard, O.D., M.S., member of the AOA Board of Trustees and liaison to the Telehealth Council: “The AOA’s Telemedicine Policy is valuable to the optometric profession and the patients we serve. As technology continues to evolve, criteria must be set to ensure that optometric telemedicine meets the existing standard of care, is of high quality, contributes to care coordination, protects and promotes the doctor-patient relationship, complies with state licensure and other legal requirements, maintains patient choice and transparency, and protects patient privacy.”

A key statement in the policy reads:

“The AOA supports the appropriate use of telemedicine in optometry to access high-value, high-quality eye, health and vision care. Telemedicine in optometry can serve to expand patient access to care, improve coordination of care, and enhance communication among all health care practitioners involved in the care of a patient. The AOA supports coverage of and fair and equitable reimbursement for telemedicine in optometry. The AOA also affirms that efforts are needed to ensure health equity in telemedicine. All individuals should have the opportunity to receive the standard of eye health and vision care regardless of location, socio-economic status, or any other social determinants of health.”

Specific criteria for use of telemedicine

After that, the policy statement details the appropriate use of telemedicine in optometry. Among the criteria for achieving proper use:

• The standard of care for eye, health and vision services must remain the same regardless of whether services are provided in-person, remotely via telemedicine, or through any combination thereof.
• Fundamental elements of the doctor-patient relationship must be established and maintained.
• The decision to use telemedicine in optometry should be made by the doctor of optometry in consultation with the patient.
• While technology has advanced and continues to advance, in-person care, provided by a doctor of optometry, is the criterion standard for the delivery of a comprehensive eye exam.
• Unless otherwise permitted by law or regulation, doctors of optometry delivering telemedicine in optometry must be licensed in the state which is the originating site and must abide by that state’s licensure laws and regulations.
• Patients must be informed of the limitations of telemedicine in optometry when present.
• The patient’s relevant health history must be collected as part of telemedicine in optometry. Appropriate health records should be available to the doctor of optometry prior to or at the time of the telemedicine encounter. Doctors of optometry should have a good understanding of the culture, health care infrastructure, and patient resources available at the originating site.
• In the absence of an existing doctor-patient relationship, services which, remote or otherwise, offer a prescription for glasses or contact lenses without including all the elements of a comprehensive eye exam, would not meet the current standard of care.

Additionally, the report dedicates space to (1) Organization, Training and Implementation and (2) The Doctor-to-Patient Relationship and the Use of Direct-to-Patient Technology and (3) Administrative and Legal Considerations.

AI, case studies

Artificial and augmented intelligence are evolving areas as well.

“As AI in health care expands, AOA believes that important criteria must be met.” Among those criteria are an evaluation of whether AI can improve patient outcomes and whether high sensitivity and specificity can be attained.

“Systems using AI to identify patient risk of disease must be held accountable to ensure that referral loops are closed,” the report continues. “The value of AI cannot be based solely on the accurate identification of disease risk. Value of AI must be assessed based on whether or not patients identified with potential disease risk receive necessary care and follow up.”

“Because artificial intelligence and augmented intelligence is becoming recognized as a potential tool to improve the delivery of care, we thought it was important to mention that,” Dr. Quinn says. “It’s not really mature but certainly at the end of the day any tool that helps doctors provide better care to their patients, as a result of technological advances, is a good thing for patients. We wanted to specifically make sure that we called out these augmented and artificial intelligence in the technological delivery of care.”

The policy statement also recommends that efforts be made to identify and address bias in AI and educate patients and doctors on its limitations and potential. Under certain conditions, telemedicine may provide value to patients and doctors of optometry. Those instances?

• Patient management, including triaging to identify emergencies and need for immediate in-person care.
• Remote patient monitoring for previously diagnosed chronic conditions.

“Every doctor who provides care ultimately has to decide for themselves how to best provide care to their patients,” Dr. Quinn says. “What’s important in describing some of these advances that are technologically based, including delivery of care through telemedicine, is that we inform the doctors of what’s out there and then give them guidance should they decide to embrace this as a mode to deliver care. What are the important guardrails to assure we are always focused on what’s best for the patients?

“It’s a matter of education, informing, making people aware of what’s out there and then giving them guidance on some of the guardrails that are important,” he says. “If they do decide to embrace this mode of delivery of care, then how do we do it safely, how do we make sure that we always keep the patients’ best interests in mind.”