Ethically providing telehealth/telemedicine services in your practice

Over the past weeks, virtual care visits have become the new normal with much of America under lockdown. Medicare's emergency expansion of telehealth services, which includes doctors of optometry and was the subject of two #AskAOA webinars in March and April, has provided an important connection point with patients.

While telehealth cannot replace all elements of an in-person, comprehensive eye exam by an eye doctor, it can serve as a critical tool for physicians as doctors of optometry work to identify patients necessitating in-person care and those who can be provided physician direction remotely as the COVID-19 public health crisis continues. When it comes to telehealth, though, doctors of optometry must be aware of the ethical considerations. How can they ethically incorporate its use into their practices to benefit patients?

In a thought-provoking case study by the AOA's Ethics and Values Committee available in the Ethics Forum, published in July 2019, authors Kenneth Lawenda, O.D., and Robert Moses, O.D., explore the dilemmas created by the rise in telehealth/telemedicine services. Drs. Lawenda and Moses are past and current members, respectively, of the AOA Ethics and Values Committee.

The Ethics 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 AOA Standards of Professional Conduct and Code of Ethics.

"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 provide education to patients thereby improving understanding and compliance," Drs. Lawenda and Moses write.

"Conversely, when telehealth services are improperly applied, care can become segmented, resulting in failure to diagnose concurrent health issues," they add. "Inappropriate technology inappropriately applied can lead to inappropriate care."

'Setting the direction'

The case study covers such topics as patient protection laws, the proper and improper use of telehealth, the standard of care, preservation of the doctor-patient relationship, and attempts by optical retailers to undermine that relationship and undercut state telehealth laws. The case study also lays out the AOA's Position Statement Regarding Eye and Vision Telehealth Services, approved by the AOA Board of Trustees in February 2017, which is being reviewed and revised by the AOA's Telehealth Council. The use of telehealth during the current public health emergency will undoubtedly be considered as the council and, ultimately, the AOA Board of Trustees finalize the policy revision.

Typically, Medicare restricts telehealth services, allowing only for reimbursement of telehealth services when provided in locations outside of metropolitan statistical areas and in Health Professional Shortage areas. However, an emergency aid package signed into law March 6 gives the U.S. Department of Health and Human Services the power to suspend these rules, keeping Medicare beneficiaries—an age group particularly susceptible to the virus—at home. Read more about Medicare and telehealth services during the COVID-19 emergency.

Eye telehealth is transforming the delivery of eye care and the AOA stands to influence its evolution through the position statement and advocacy. The revised AOA statement on telehealth is expected later in 2020.

"Together with our partners, we are setting the direction of responsible eye telehealth and ensuring that those who place profits ahead of patient safety and undervalue the benefits of a comprehensive eye exam provided in-person by a doctor of optometry cannot continue to undermine the highest standard of comprehensive care," says AOA President Barbara L. Horn, O.D.

"With the introduction of this new technology, doctors will need to assess its value to enhance the care provided," Dr. Moses says. "These resources should not become a substitute for traditional, in-person care. Incorporating telehealth/telemedicine services must not lead to a reduction in the standard of care patients require and deserve."

Says Dr. Lawenda: "Doctors should have a better understanding of the ramifications and how best to discuss these issues with their patients and their peers. Through this case study, doctors will hopefully be able to better understand the pros and cons of telehealth/telemedicine and open further discussion on the topic."

COVID-19 impacting care

Doctors of optometry should be cognizant of the COVID-19 situation in their communities and stay attuned to the latest care recommendations. Read the AOA's guide to telehealth-based care during COVID-19, and review the webinar on billing and coding for telehealth-based care and COVID-19.