Managing expectations: Telemedicine’s next step

There is a simple mantra R. Tracy Williams, O.D., abides by: When everyone else says nothing more can be done, that’s when he gets started.

As a guiding principle, it’s at the heart of his 30-year career in low-vision rehabilitation. So, when the COVID-19 public health emergency called for a sudden pivot in how Dr. Williams provided his low-vision care, he stayed true to his instincts.

“Telehealth was a response and, while we weren’t really into that field, we approached this opportunity to continue to address the needs of our patients from the standpoint of isn’t this possible,” he recalls. “Everyone said you can’t do it.”

So, Dr. Williams and his multidisciplinary team got started. Telemedicine, both then and now, doesn’t have the capability to allow the full range of vision rehabilitation services, yet the technology does excel at one aspect of care critical for low-vision patients—communication. From the moment a patient receives a diagnosis for permanent vision loss, immediate intervention and referral for vision rehabilitation services can give them the earliest chance to develop new strengths, Dr. Williams explains. Telemedicine consults in advance of in-person visits allowed Dr. Williams not only to set patients’ frame of mind and expectations for care but also to share a sentiment oft lacking during the pandemic.

“Hope is a big thing for patients with vision loss; it’s emotional and you have to honor breathing and giving a person the chance to cross the bridge of acceptance,” Dr. Williams says. “Even before they first come in, we can use telemedicine to talk to them and get them to understand why they have to reinvent themselves.”

The pandemic forced many health care providers to reinvent their own approach to telemedicine, too. As the Centers for Medicare & Medicaid Services (CMS) temporarily expanded access to telemedical care under a 1135 waiver early in the pandemic, telemedicine usage initially spiked to a third of all office and outpatient visits and, even after plateauing, remains at levels 38 times higher than pre-pandemic, notes a 2021 McKinsey & Company report.

Also changed are patients’ attitudes toward telemedicine, once solely an option born of necessity and now one that’s to be expected. About 40% of consumers state their willingness to continue telemedicine use going forward—up from only 11% pre-pandemic. And the venture capitalists have taken note with three times the level of digital health investment in 2020 than 2017.

The game is changing—and fast. How patients expect to receive the continuum of care offered via telemedicine and where this technology is taking the eye care industry remain questions that the AOA and stakeholders are striving to stay atop. For many doctors, such as Dr. Williams, it’s no longer a question of if they’ll offer telemedicine services but how best.

“In my mind, telemedicine shouldn’t go away,” he says. “Here, there’s a need and if it’s the best option, then we have to continue.”

The evolving regulatory environment

The COVID-19 public health emergency accelerated telemedicine with the CMS making regulatory changes providing for greater access and reimbursement—taking the list of approved telemedicine services from 101 to 238—and many commercial payers following suit. Such is the case; telemedicine remains a popular issue regardless of presiding administration.

“[T]he pandemic accentuated just how transformative [telehealth] could be, and several months in, it’s clear that the health care system has adapted seamlessly to a historic telehealth expansion that inaugurates a new era in health care delivery,” noted then-CMS Administrator Seema Verma in the 2020 Physician Fee Schedule (PFS) final rule.

Not even a year later, Health & Human Services (HHS) Secretary Xavier Becerra announced $19 million toward expanding telehealth services: “Telehealth is crucial to providing convenient and sustained care for patients. ... I will continue to support innovative solutions that will strengthen our health care system.”

In November, the 2021 PFS prolonged the list of expanded telemedicine services through Dec. 31, 2023. Over these next two years, the CMS intends to gather data and analyze requests for services to be permanently added to the telemedicine services list, as well as adopt coding and payment for a longer virtual check-in service on a permanent basis.

While the fate of these telemedical services is tied to the duration of the public health emergency, indications suggest reimbursable telemedicine is likely here to stay. In November, President Joe Biden signed into law a $1.2 trillion, bipartisan investment in U.S. infrastructure that included $65 billion for broadband access. The funds would go toward improving internet services for rural areas and low-income families, likely hastening telemedicine options for these traditionally underserved populations.

Kenneth Lawenda, O.D., an optometric regulatory specialist serving on three state boards of optometry over the past 14 years, notes telemedicine has made great advances over the years with even greater potential for growth as administrations press developments. Now is the time for clinical optometry to see that the path forward is to ensure patients’ health and welfare and that any technology aligns with this mandate.

As Dr. Lawenda explains, the way regulators have historically viewed the issue regarding patient care is that the standard of care has been in-person. Yet, major advances in technology and communication have resulted in additional ways to communicate with patients, no doubt providing alternative ways to evaluate patient care. Increased access may result in better health outcomes, but Dr. Lawenda adds a stipulation.

“Telemedicine is increasingly considered to be one of the more impactful tools to increase access when done responsibly,” Dr. Lawenda says, adding the caveat that telemedicine is just another “tool in the toolbox” for doctors to utilize.

“Going forward there are many cases that can be handled where telemedicine can be of extreme benefit and improve patient outcomes.”

But telemedicine shouldn’t be viewed as a patient care panacea, in and of itself. While telemedicine visits initially spiked in 2020 for specialties and services, such as psychiatry, substance-use disorder treatments and endocrinology, ophthalmology lagged far behind. A 2021 Health Affairs study of 16.7 million commercially insured and Medicare Advantage patients showed a range of telemedicine use from 68% of endocrinologists to 9% of ophthalmologists. As for optometry, an AOA Health Policy Institute survey found a quarter of respondents in November 2020 providing telemedicine services.

So, too, evidence suggests factors, such as tech literacy and patient demographics, might directly have bearing on telemedicine usage.

The evolving patient experience

Like any care modality, telemedicine isn’t for everybody in every situation. But Dr. Lawenda says now that the “genie is out of the bottle” the challenge becomes how to define telemedicine’s next steps and address the standard of care and newfound expectations of that care.

The McKinsey & Company report found 40-60% of consumers expressing interest in expanded virtual health solutions post-pandemic. The buzzy catchphrase for this is the “digital front door,” an approach that provides multiple opportunities for patients to access and engage their health care when and how they want. Telemedicine is an essential piece of this puzzle with possibilities ranging from virtual first visits to ongoing monitoring and post-care engagement.

So, where does optometry fit into this paradigm shift? Lori L. Grover, O.D., Ph.D., AOA trustee, emphasizes that as primary providers of the continuum of eye health care services, doctors of optometry must continue to embrace technology in a way that supports and enhances doctors’ clinical decision-making.

“One can effectively videoconference, triage, provide rehabilitative therapy, refill prescriptions and capture images. What has emerged is stunning. But not everything can yet be obtained due to limitations in functionality for full-scope diagnosis and treatment from a population health perspective,” Dr. Grover says. “Our biggest challenge is making sure colleagues and the public understand the selective differences in delivery of care and the patient populations targeted.

“Technology tools assist with clinical decision-making but can’t replace optometric expertise or predetermine what should happen next.”

Even in the case of artificial intelligence (AI), while the sensitivity to certain retinal changes may be making strides, the technology doesn’t make the clinical decision about what care is needed or the best way to treat a specific patient.

“Technology and AI are improving in assisting us in gathering health data, but as industry acknowledges, the continuum of primary optometric eye and health care still requires direct human interaction and the shared clinical decision-making that delivers optimum health outcomes,” Dr. Grover says. “Technology, as it currently exists, doesn’t deliver patient preferences, weigh cost benefits, or incorporate evidence for shared decision-making. Available remote technology doesn’t yet support the same standard of eye care, such as detecting all systematic and ocular conditions, to arrive at those important comprehensive findings where doctor and patient can discuss where next steps in care can best deliver health outcomes.”

In other words, advances in technology shouldn’t come at the expense of that doctor-patient relationship for the sake of convenience or short-cutting the process of comprehensive assessment and diagnosis. Advances should augment doctors’ expanding care repertoire for the benefit of patients’ overall health outcomes.

Dr. Grover says the preliminary evidence finding broadening gaps in care among those unable to use telemedicine or the delays in care that could be precipitated by virtual-only visits suggests the telemedicine expansion needs to be carefully considered.

“Health equity matters. At-risk populations are often targeted by tech supporters as current beneficiaries, yet millions across the country still cannot access reliable internet. Key factors like these remain, and until there is equal internet access and tech literacy, an evidence gap remains for understanding tech-related benefits and risks to health. The early data puts us on guard, on notice, that this often overly enthusiastic support for telehealth in certain populations and settings could really be less than beneficial,” she notes.

“Our continued focus must be to ensure that our voice is heard, and we bring relevant thought-leaders and evidence together to show what we can support and what doesn’t work.”

AOA’s Patient Experience Summit

The mission that Dr. Grover describes is the driving factor behind the AOA’s years-long commitment to learning, interpreting and defining telemedicine’s role in optometry. Pre-pandemic, the AOA Telehealth Council convened industry leaders and stakeholders for a listening session that influenced landmark changes to the AOA Position Statement on Telemedicine in Optometry. In it, the AOA affirmed its support of appropriate telemedicine in optometry to expand access to high-value, high-quality eye health and vision care with the standard of care clearly defined as an in-person, comprehensive eye examination.

In December 2021, the AOA Telehealth Council reconvened with stakeholders to build on nearly two years’ perspective of telemedicine use to see what has changed, what is working and what is coming. In addition to influencing the next iteration of its telemedicine statement, the AOA’s Patient Experience Summit, Dec. 9-10, in Washington, D.C., gained new learnings from industry to provide doctors with tools and resources to meet patients’ new expectations.

“From the AOA’s perspective, it’s about the quality of patient care,” says Jerry Neidigh, O.D., AOA Telehealth Council member. “Making sure that any telemedicine that is being delivered equals or exceeds the level of care you get from an in-person visit. It can be accomplished, but we need to identify those companies that may have the technology to do this.”

Dr. Neidigh points to the high adoption of telemedicine in other medical specialties, e.g., psychiatry or radiology, that are driving health IT innovators’ and investors’ products to capitalize on a demand. But he emphasizes that optometry is a vastly different field with vastly different requirements. Therefore, the summit provided the AOA an opportunity to hear directly from industry about technologies they may be working toward and ensuring the conversation stays squarely on what’s best for patients.

Lessons learned will be condensed into a patient experience guide that will provide members with insight into the potential technologies or processes that doctors may want to incorporate into their practices. The end goal is to ensure optometry emerges from these past two years with the action-able information and guidance to influence patient care going forward.

“Telemedicine is here; you’re either going to be a part of it or be cut out of it,” Dr. Neidigh says. “Wisely, the AOA has taken the position that we need to shape what it looks like for our profession and ensure our patients’ care doesn’t suffer.”

Interested in learning more?

Join Rebecca Wartman, O.D., and Harvey Richman, O.D., at Optometry’s Meeting® in Chicago for their lecture, “Telehealth and Remote Care—What is Possible and What is NOT! It is a Brave New World!” on Thursday, June 16.