Balancing patient health, safety with technological progress

July 10, 2017
AOA panel addresses new technologies at Optometry’s Meeting®.

Optometry has long embraced the newest technologies that enhance and promote quality patient care, and continues to do so to this day. However, some of today's advances aren't designed with patient care and safety in mind, but technology for technology's sake alone. That's part of the message delivered in a panel discussion at Optometry's Meeting® on June 21 in Washington, D.C.

"This discussion is another example of AOA's unwavering commitment to patient safety. From urging the FDA to ensure that new technologies adhere to existing laws and regulations intended to protect patient safety to quickly and aggressively communicating accurate information to patients about the inadequate care these apps deliver, we remain vigilant," says AOA President Christopher J. Quinn, O.D. "While apps may provide disclaimers about what they can and cannot perform, if patients do not read and understand the small print, they are getting a false sense of security and potentially putting their health at risk."

Not all new technologies today enhance care; some technologies may have the opposite effect, creating barriers to patient care if users don't read the fine print and mistakenly believe that an in-person, comprehensive eye examination is no longer necessary to maintain good eye health. These technologies and their communications may have the effect of misleading patients, disrupting the doctor-patient relationship and may result in delayed diagnosis and treatment of eye and general health issues, noted Steven A. Loomis, O.D., AOA Health Policy Institute chair and past president during the "In the Pipeline: Disruptive Technology" continuing education (CE) session.

Comprised of panelists Dr. Loomis; Deanna S. Alexander, O.D., AOA State Government Relations Committee chair; and David A. Cockrell, O.D., AOA past president and AOA Advocacy Executive Committee chair; the disruptive technology discussion homed in on the question: Does increased access to care provided through non-OD or remote access points demonstrate improved health outcomes?

It's all about standard of care.

Citing optometric mission work in Sub-Saharan Africa, panelists discussed how new technologies in truly remote areas—where there are only 3.7 optometrists, or 2.9 ophthalmologists, per 1 million people—can deliver improved access for humanitarian reasons. But, Dr. Loomis stressed, in this case the standard of care "is essentially zero." That doesn't hold up in the United States where there are 133 optometrists per 1 million Americans, and the standard of care is already set high based on in-person, comprehensive eye examinations. It's a level that those same smartphone technologies will continue to fall short in, comparatively.

"There is a balance between advances in technology and patient safety," Dr. Alexander says. "Doctors of optometry are very versed in using technology in their own offices to advance patient care for both diagnosis and treatment. We will continue to see changes in technology, but the key is to have the technology improve the patient care and outcomes, and not put patients at risk for health issues that can be missed."

For instance, separating refractive tests from the complete eye health markup afforded by a comprehensive eye examination can entirely overlook telltale signs and symptoms of systemic disease or common eye maladies. A comprehensive eye examination can detect elevated intraocular pressure (IOP)—a potential risk factor for glaucoma—while a smartphone's interpretation of a refraction-only test cannot measure IOP.

Dr. Alexander stresses how these online app—based technologies are not telehealth, despite appearances.

"Appropriate telehealth should meet the standard of care of an in-person visit," Dr. Alexander says. "Not having an established doctor-patient relationship with these online technologies does not meet the standard of care."

Furthermore, that doctor-patient relationship afforded by an in-person examination bolsters the standard of care. But emphasizing that value is a challenge addressed by better awareness.

"Doctors of optometry are called upon to educate patients, regulators, legislators and policy makers on the difference between technologies that advance patient care and those which ultimately act as a barrier to patient care," Dr. Loomis says. "The tools available to protect patients are education, appropriate (enforced) regulation and appropriate (enforced) legislation."

Resolving action

Only days following the disruptive technologies session, the AOA House of Delegates passed a resolution that set a high bar for the application of telehealth services related to eye and vision care. The resolution effectively establishes a February 2017 position paper regarding eye and vision telehealth services as official AOA policy. In that position paper, the AOA Board of Trustees noted that telehealth is a rapidly evolving tool, but there are limits to the technology.

"The AOA supports the appropriate use of eye health and vision care telemedicine services to supplement access to in-person, high-value, high-quality eye health and vision care," the position paper states. "Eye health and vision care telehealth services, when used appropriately, can serve to improve patient care as well as communication among and between doctors of optometry and other primary care or specialty care providers."

The position paper stipulates that the "appropriate use" of telemedicine services takes place only when a series of important criteria are met. First and foremost, telehealth services cannot lower the already high standard of care delivered via in-person, comprehensive eye examinations, or replace such examinations, and cannot impede upon the doctor-patient relationship, among other points.

So, too, the use of direct-to-patient mobile apps or online vision tests raise additional issues. In addition to noting the limitations of direct-to-patient apps that only parse out the refractive portion of a comprehensive eye examination, the position paper states that such apps should never be used to diagnose eye health conditions and cannot be relied upon to deliver an accurate, objective refraction due to the lack of a controlled testing environment, subjective refraction and professional judgement.

In review of the panel discussion and subsequent resolution, Dr. Cockrell notes that it's critically important for technology to be an adjunct, not replacement, for provider-managed cared.

"There's an overlapping message here: The public's increased awareness of technologies that are occurring in telehealth/telemedicine today and the desire of our patients for options to utilize these technologies, while we, as their eye care providers, must stay focused on the critical need to review and oversee implementation of technological changes with the patient's best interests as our goal," Dr. Cockrell says.

"The challenge for us will be to assimilate the rapid change in technology and incorporate the 'proven technology' into our clinical practice to continue to improve the care we provide our patients."

Delegates unanimously approved the resolution, which now goes before the Judicial Council's final review before taking effect.

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