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ANSWERING THE CALL OF TELEOPTOMETRY
Only a few decades ago, the idea of a video phone call -- even a basic one -- sounded like science fiction. Today, this technology not only exists, but also has been incorporated into the lives of most Americans. Video conferencing is common and allows people to see and speak to one another in real time with crystal-clear audio. The possibilities for this technology are vast. Healthcare has become a part of this conversation, with stakeholders wondering if telehealth could offer high-quality remote diagnosis and treatment to patients.
Several professions are wrestling with the idea of telehealth, including optometry. To develop sound professional opinions on this topic, optometrists should first know the differences between a few key words.
• Telemedicine is a wide term encompassing all healthcare professions. It is often used interchangeably with the word telehealth. This is a new way to offer exams and other services- remotely, via webcam.
• Teleservice is a more negatively-connotated term. It describes attempts by patients and companies to secure prescriptions, verifications, or products without doctors. At its worst, teleservice can eliminate the role of doctors by circumventing their authority. Many have referred to Opternative and its ilk as teleservice.
• Teleophthalmology exists separately from teleoptometry. It is already practiced in the VA system, where it has received positive reviews and has been incorporated into a study about detecting diabetic retinopathy.
Teleoptometry is offered by multiple companies using different methods. According to an August 2019 article by Invision Magazine, “There are about 200 different telehealth models being run these days in the U.S. and abroad.” An OD may be more comfortable with some of these than others. Players in the field currently include DigitalOptometrics, Smart Vision Labs, D-EYE, 20/20NOW, RightEye, and EyeNetra. Some of these offer only refractions, while others are attempting a more full-service product. The degree to which doctors are directly involved varies between brands. Contrary to some stereotypes, not all teleoptometry involves smartphones or apps.
At the time of this publication, the Illinois College of Optometry has completed the first stage of its inaugural research study into teleoptometry. “This pilot study aims to evaluate the teleoptometric exam vs. the traditional in-person comprehensive eye examination,” says Jaymeni Patel, OD '16, one of the optometrists currently evaluating the data. For scientifically-sound conclusions to be made, however, “further investigation is required, given the size and patient selection used.” This initial study by ICO is a proof of concept, meant to “kick the tires” and responsibly decide whether to conduct deeper research.
The study was conducted at ICO in partnership with DigitalOptometrics. Our campus offered space, doctors, and patients, while DigitalOptometrics lent refractionists and equipment. DigitalOptometrics currently serves over 100 locations and plans to be in over 400 by the end of 2020.
For this research, ICO used a pool of 30 of our own students as “patients.” Each subject received two eye exams- one traditional comprehensive exam with an in-person optometrist and one including a remote component. For the teleoptometry exam, an on-site technician performed all entrance testing locally. Explains Dr. Howard Fried, founder of DigitalOptometrics, “This is comprehensive. We’re getting retinal photos, we’re getting anterior seg video, we’re getting visual fields, OCTs.” The tech saved their findings to the cloud, where the information would be retrieved by an OD. This OD appeared on a television in the exam room to check the technician’s work. This method, combining in-house and remote healthcare professionals, is the model most used by DigitalOptometrics’s clientele. Options with remote technicians are also available but were not tested by ICO.
Upon completion of both eye exams, two major comparisons were made between formats. First, ICO’s researchers compared the resulting prescriptions for accuracy. Second, each patient responded to a subjective survey documenting their feelings about both experiences. Preliminary results have been gathered and will be shared across two posters at the 2020 Association for Research in Vision and Ophthalmology (ARVO) conference in Baltimore.
As we excitedly await these conclusions, Dr. Fried offers some insight into why he, an optometrist, founded his company. “This is not a replacement of the on-site doctor,” he insists. “I wouldn’t have started this business if that’s what this is about.” From his perspective, DigitalOptometrics products are “a supplement for the in-person experience,” not a replacement.
If executed well, teleoptometry has the potential to strengthen doctor-patient relationships. Rural patients could gain more access to providers they trust, and, in turn, doctors would not necessarily have to choose where they live based on the location of their patients. Optometrists could detect disease and intervene earlier in a patient’s journey.
Though many are aware of the upsides, some optometrists share hesitations about teleoptometry. Doctors do not want to succumb to teleservice, missing out on optical sales as they pass off remote prescriptions. Dr. Fried responds that, with DigitalOptometrics, “conversion to sales rates are higher than with on-site doctors.” Additionally, despite occasional news stories about the technology failing, he says “the redo rates are a fraction of 1%.”
Technical failures are also a common fear when it comes to new tools. No tech behaves perfectly 100% of the time, including equipment used during in-person exams. While a connectivity hiccup could hinder an exam, data is stored in the cloud and will not be lost forever. A practice could, theoretically, continue to staff in-house doctors to replace the tech during rare downtimes.
Some of the larger hurdles facing telemedicine are complex pathology, insurance, and legislation. Dr. Fried acknowledges that a slit lamp is still needed for diagnoses such as corneal abrasions and ulcers. For complex cases, DigitalOptometrics encourages (and assists with) referrals to trusted colleagues. As for insurance, he admits that vision insurance plans are currently less receptive to teleoptometry than general medical insurance. As of February 2020, EyeMed is running pilot studies, but neither EyeMed nor VSP has reimbursement scheduled for teleoptometry.
Most states have laws clearing the way for teleoptometry. Exceptions include New Mexico, which mandates that a patient’s first exam must be in-person. Kentucky has received similar recommendations from its state optometry board. Regulations like these are put in place with patient safety in mind. Doctors should take care, then, to apply the same level of caution to even their most trusted forms of technology. For example, texting information to patients could easily result in a HIPAA violation.
Caution is healthy, but so is the responsible and ethical exploration of new ideas in the profession. “With the increase in digital exposure across all professions to meet the needs of consumers, it is likely teleoptometry will continue to be adopted,” says Dr. Patel. If optometrists do not stay at the forefront of this research, some other sector will inevitably take the reins- and they may or may not have patients’ best interest in mind.
Dr. Fried agrees, adding, “Other technologies that are currently out there are run by businesspeople. [Teleoptometry], to me, is much bigger. It's about much more than being a profitable business. There’s nobody that’s more qualified than optometrists to determine where the profession of optometry is going. We are the best gatekeepers in the healthcare system.”
“I do appreciate the fact that ICO took a step in this direction,” says Dr. Fried. “Without endorsing the product or the technology, they understood that they need to be the ones to go ahead and introduce this and do their due diligence. I think what’s most important is that students learn what is coming out there in the profession. Then, they can determine as new doctors of optometry whether these are tools that they want to use in their own practices.”