Keeping the 'medicine' in telemedicine

Excerpted from page 36 of the March/April 2021 edition of AOA Focus.

Informal consults are nothing out of the ordinary for doctors: family and friends calling for off-the-cuff opinions on benign subjects. But when the father of his daughter’s friend texted Chris Wolfe, O.D., a picture of her newly developed internal hordeolum, the stakes were a bit different.

Normally, an office visit would be warranted, but this was early in the #FlattenTheCurve months of the global coronavirus pandemic with stay-home orders in place and Dr. Wolfe, like other doctors of optometry, was limited to emergency eye care. So, to ensure the girl wasn’t subjecting herself to unnecessary infectious risk at an urgent care or emergency department, Dr. Wolfe suggested an option perfect for this unique situation—a remote consult.

“Sure enough, she ended up with her entire eyelid swollen so we jumped on a call to determine the best options with oral medications,” Dr. Wolfe says. “After a couple days and another follow-up, things resolved, and she turned out just fine. We got her scheduled back for an in-person, comprehensive eye exam for several weeks later when everything opened back up.”

The situation casts a stark contrast on what might have happened had telemedicine not been at Dr. Wolfe’s disposal, namely the family resorting to a general “teledoc” appointment with a non-eye-care specialist or upping their risk at a clinic. Dr. Wolfe says it just goes to show the power of having an established, trusted, doctor-patient relationship.

“If you participate in telehealth services with a patient who is your patient, there is no reason for that patient to consult an urgent care or establish new care elsewhere for their eye disease,” Dr. Wolfe says. “In my opinion, there’s no reason for them to see someone they don’t know.”

Over a quarter of doctors of optometry reported using telemedicine services during the COVID-19 public health emergency, reinforced by temporary allowances that may have changed not only public payers’ but also private payers’ willingness to leverage telemedicine.

Like it or not, the pandemic accelerated technology’s adoption several years as Americans’ interactions became increasingly digital. In fact, a report from strategic management consulting firm, McKinsey & Company, found that the COVID-19 crisis accelerated digitization of customer and supply-chain interactions by 3-4 years; sped up the creation of digital offerings by 6-10 years; and, now, customers are three times more likely to say at least 80% of their customer interactions are fully digital in nature than they were before.

It’s no stretch to say that patient hesitancies toward telemedicine have started dissolving, too, revealing an opportunity for optometry to bolster its patient care toolkit while also carefully educating stakeholders about the appropriateness of such technology.

“Unfortunately, there are companies out there using the idea of ‘telehealth’ that’s confusing to the public in order to sell a product,” Dr. Wolfe says. “But when you’re utilizing telehealth as a continuum of care for your patient, that does place the patient at the center of health care decisions, and when you do that it’s easy to recognize.”

Telemedicine in COVID-19

Telemedicine, the exchange of medical information from one site to another through electronic communication to improve a patient’s health, is hardly anything new, but the sudden emergence of the pandemic prompted an emergency expansion of its utility criteria.

In March, while the AOA worked to ensure doctors of optometry were fully recognized as physicians in the nation’s COVID-19 response, the Centers for Medicare & Medicaid Services (CMS) broadened access to telemedicine services for Medicare beneficiaries in order to keep this at-risk population home. Under 1135 waiver authority, CMS suspended requirements that Medicare only pay for telemedicine on a limited basis (when beneficiaries live in a designated rural area), as well as clarified how these visits will be furnished and paid.

Although temporary—the 1135 waiver is to remain in place for the duration of the public health emergency—the expansion of telemedicine services is increasingly looked on with favorability as other payers looked to CMS’ example and similarly expanded or adjusted their policies. And in fact, CMS recently noted it will reevaluate care covered via telemedicine following the public health emergency; however, to truly eliminate the geographic limitations will take congressional action.

“There may be certain exceptions going forward, and I could be totally wrong, but I would be surprised to see that rolling back in a significant way,” says Dr. Wolfe, AOA State Government Relations Committee chair. “I think reimbursable telehealth is probably here to stay.”

Based on use alone, that would seem to be the case. Per a Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR), telemedicine visits increased 154% (March 2020 vs. March 2019) for care and conditions other than COVID-19, likely indicative of the change in telemedicine policy and public health guidance. All told, some 1.62 million telemedicine encounters occurred in the first three months of 2020, or about a 50% increase from 2019.

The MMWR notes this “marked shift” in practice patterns would seem to have implications that extend far beyond the pandemic, and that continuing telemedicine policy changes and regulatory waivers “might provide increased access to acute, chronic, primary and specialty care.” Toward that end, health care advocates, such as the American Medical Association, avowed to actively support the continued expansion of telemedicine and infrastructure to support greater access to such services going forward.

True, the CDC data indicate a departure from the norm, but it doesn’t tell the whole story. After telemedicine visits peaked in April 2020 at roughly 70% of all U.S. ambulatory visits, such services declined to only 21% of total encounters by July as COVID-19 cases also declined, per an August 2020 study by Epic Health Research Network (EHRN). Although EHRN also identified regional differences in use—the Northeast is far more likely to use telemedicine than the South, the former decreasing only 25% off its peak-April volume vs. the latter’s 53% decrease—telemedicine visits were expected to rebound as COVID-19 cases surged at year’s end.

While the data might suggest patients’ caution and adherence to public health guidance, it also could suggest that patients seek options in how they access care. That being the case, the CMS’ decision to expand reimbursement and the increased use likely represent an inflection point for telemedicine adoption, says Kenneth Lawenda, O.D., AOA volunteer and an optometric regulatory specialist who’s served on three regulatory boards. In other words, there’s no going back now.

“Once you’ve gotten that genie out of that bottle, so to speak, it’s going to be hard putting it back in, so I do believe we’ll see an increase in telehealth going forward post-pandemic now that the CMS has accelerated it,” Dr. Lawenda says. “I think we’re at a point where we’re going in the right direction, but the profession has to be able to adapt, adjust and incorporate this into its regimen of care.”

That’s the key: overall, health care is becoming much more patient-centric. Patients demand more transparency in how they access care and greater input in how their care decisions are made; hence, the increasing reliance on technology, Dr. Lawenda argues. So, too, accessibility and convenience are fast becoming greater determinants in patients’ own decision-making.

However, there are clear pitfalls in letting convenience be the driving factor in patient care. Serving on regulatory boards, Dr. Lawenda knows full well how telemedicine is a delicate balance in accessibility and patient protection. There must be a way for patients to get care when and where they need it, without sacrificing the standard of care and risking patients’ health and safety.

“The profession is moving slowly and judiciously forward, and ultimately, the doctor-patient relationship has to be maintained,” Dr. Lawenda says. But outside actors also are seizing on this opportunity to subvert the doctor-patient relationship and home in on that convenience aspect, divorced of the continuum of care, to promote their own services or products.

Adds Dr. Lawenda: “Now, you’re going to have these competitive, for-profit companies that aren’t necessarily drivers of what will happen, but they serve to push and push. The AOA is pushing back in a good way because they’ve found that the claims these companies are making are false and the instruments they’re using haven’t been FDA-approved.”

Finding balance in technology

Technology, alone, isn’t disruptive. It’s about the application. Consider autorefraction in the 1970s or, now, visual fields on an iPad; technology that’s labeled “disruptive” yet incorporated directly into the doctor’s toolbox. But therein lies the rub: Technology is a useful tool and one that should be used to promote, enhance and protect—not supplant—the doctor-patient relationship.

Companies that play fast and loose with that line, think Visibly (formerly known as Opternative), purport to provide an online vision test to generate a contact lens prescription. Yet, the AOA repeatedly faulted the company for marketing its test as an exam, thereby further blurring patients’ understanding of what they are—and, more importantly, are not—receiving: a comprehensive eye examination. The AOA argued this separation of traditional refractory tests from a true, comprehensive eye exam seeded patients a false sense of security that their eye health needs were adequately addressed. Then, three years after the AOA first raised such safety concerns about Visibly, the Food and Drug Administration cited the vision test’s failure to gain formal authorization prior to marketing and issued a recall.

But Visibly, for instance, was clearly an attempt by a for-profit company to exploit the gray area in the public’s understanding of consumer technologies focused on users’ health and true telemedicine that promotes patient care. That space will only become more crowded as technology’s promise becomes reality.

“Technology should be a tool for the doctor as opposed to a replacement, something that provides data or information that should be consistently checked against a doctor’s own experience, observations and conclusions,” says Annabelle Storch, O.D., AOA New Technology Committee chair.

A patient is more than a single data point, she notes, with many factors relating to the patient’s life and circumstances that factor into the medical decision-making for appropriate diagnosis and treatment. That said, technology can bolster the doctor’s understanding of a disease state and inform the treatment plan. Continued innovation is only going to further hone technology into a tool that supports—not supplants—doctors’ input. Dr. Storch admonishes that the profession would be remiss not to make use of the technologies available but says finding that balance is critical.

“Adapting to the changing times is important, though in my opinion, we cannot lower or change the standard of care in the long term,” Dr. Storch says. “We are primary care practitioners, and we have a responsibility to our patients to find a way to maintain the standard of care that our patients deserve.”

AOA supports telemedicine in optometry

In 2020, the AOA’s Telehealth Council took these realities in mind as it gathered input from leaders and innovators within the eye and vision care field and wrote a new position statement that dictates the AOA’s stance on telemedicine, the criteria for ensuring its high-quality application, emerging legal and privacy considerations, as well as a reaffirmation of the in-person, comprehensive eye examination as optometry’s “gold standard” of care. The 2020 statement supplants a 2017 version and offers a more concise north star to how the AOA will approach developments in telemedicine—and it doesn’t mince words.

“The AOA supports the appropriate use of telemedicine in optometry to access high-value, high-quality eye, health and vision care,” the statement reads. “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.”

Additionally, the statement emphasizes that one standard of care must remain constant regardless of whether services are provided in-person or remotely; telemedicine is appropriate to bolster doctors’ decision-making; and direct-to-patient eye or vision apps do not constitute telemedicine and cannot replace or replicate a comprehensive eye exam provided by a doctor, based on current technologies.

Importantly, the AOA believes a fundamental, doctor-patient relationship must be established and maintained, while “physicians must act as advocates on behalf of the patient and are obligated to discuss necessary and appropriate treatment alternatives, and in good faith to fully inform the patient of all treatment options.”

Christopher Quinn, O.D., AOA Telehealth Council chair, says the forward-looking changes included in the 2020 statement and approved by the AOA Board of Trustees fully acknowledge the evolving role of telemedicine provided by optometry.

“The policy carefully recognizes that care delivered remotely can improve immediate patient access in some circumstances, but that remote care can’t completely replace in-person care or deliver the gold standard, comprehensive eye examination,” Dr. Quinn says.

“The policy also carefully makes clear that a comprehensive eye examination can’t be deconstructed into components delivered separately, in whole or in part, and that attempts to do so are detrimental and deceiving to patients.”

As technology progresses, optometry can and should make the best use of the tools available to advance quality patient care.