Teleophthalmology: An Essential Tool in the Era of the Novel Coronavirus 2019

Meghana Kalavar; Hong-Uyen Hua; Jayanth Sridhar

Disclosures

Curr Opin Ophthalmol. 2020;31(5):366-373. 

In This Article

Abstract and Introduction

Abstract

Purpose of Review: The aim of this article is to assess the current state of teleophthalmology given the sudden surge in telemedicine demand in response to the novel coronavirus 2019 (COVID-19).

Recent Findings: Recommendations and policies from government and national health organizations, combined with social distancing, have led to exponential increases in telemedicine use. Teleophthalmology can be integrated into ophthalmic care delivery. In the emergency room, teleophthalmology can be utilized to triage patients and diagnose common ophthalmic eye diseases. Ophthalmology practices can utilize real-time medicine to conduct many parts of an in-person exam. In cases where more complex diagnostic tools are warranted, a model incorporating telemedicine and focused in-person visits may still be beneficial. Innovative technologies emerging in the market allow for increased remote monitoring, screening, and management of adult and pediatric patients for common eye diseases.

Summary: COVID-19 created a demand for healthcare delivery that limits in-person examination and potential viral exposure. Teleophthalmology allows ophthalmologists to continue caring for patients while keeping physicians and patients safe. Although challenges still exist, the pandemic has accelerated the adoption of teleophthalmology. As a result, teleophthalmology will play an integral role in providing high-quality efficient care in the near future.

Introduction

The novel coronavirus, SARS-CoV-2 (COVID-19), has been considered a pandemic by the WHO.[1] Considering there is no effective vaccine or treatment, the primary response has been to slow transmission via patient isolation, promote social distancing measures and enforce public health quarantine.[2] These changes have tremendously impacted many aspects of our world, including healthcare.

Ophthalmologists are at high risk for contracting COVID-19 because of high patient volumes and the close proximity between patient and physicians during the standard visual examination.[3] COVID-19 may be spread via tears and conjunctival secretions, further increasing ophthalmologists' risk.[4,5] In line with government recommendations, the American Academy of Ophthalmology has recommended postponing all elective services during the COVID-19 pandemic,[6] resulting in a significant decrease in clinical and surgical volume. According to a recent analysis, ophthalmology case volume dropped 81% during the pandemic, the largest drop in cases as a result of COVID of all specialties studied.[7] Alternate avenues of eye care must be explored to ensure that all patients, regardless of COVID status, can continue to receive the ophthalmic care they need.

Telemedicine is formally defined as 'the use of medical information exchanged from one site to another via electronic communications to improve a patient's health status.'[8] It provides a platform for clinicians to continue providing healthcare to patients while helping limit contagion. Many healthcare systems had invested in this technology and laid down infrastructure enabling its use prior to the pandemic. According to a 2019 report by the American Hospital Association, 89% of health systems have a computerized telehealth system.[9] However, patient utility of the technology had been relatively slow before the COVID pandemic.[10,11] Studies have shown nationwide consumer adoption of telehealth ranged from 8 to 18% prior to 2020, despite consumer satisfaction surveys with telehealth being very high.[12–14]

The most commonly cited barriers to the adoption of telemedicine include limited reimbursement, unfamiliarity with the technology by both physicians and patients, and no urgent need to replace in-person care.[10,14–16] The COVID-19 pandemic presents an unprecedented challenge for healthcare systems to efficiently deliver care and necessitates the adoption of a model of care that limits exposure to the virus. Consequently, major health organizations, including the Centers for Disease Control (CDC), and American Medical Association (AMA) have advocated the use of telemedicine and taken measures to address the aforementioned barriers.[17–19]

In light of the COVID pandemic, efforts have been made to decrease barriers to telemedicine adoption such as limited reimbursement, health insurance portability and accountability act (HIPAA) compliance, physician training, and patient awareness. Previously, Centers for Medicare and Medicaid Services (CMS) limited reimbursement of telehealth medicine to only designated rural areas.[20] In 2019, only 10 out of 50 states had 'true payment parity' between telehealth services and office visits.[16] However, in response to the COVID pandemic, CMS made telehealth available to many more beneficiaries by stating that Medicare would reimburse for professional services at the same rates as in-person visits, regardless of the location and setting.[21] With this initiative, a wide range of providers can provide care through remote video consultations and preventive health screenings. Additionally, CMS removed penalties against providers for HIPAA violations during this period. Technologies that were previously considered non-HIPAA compliant such as Facetime, Google Hangout, and Skype can now be used as platforms to provide remote care. Furthermore, providers can now see new patients and provide care for patients in other states via telemedicine.[21] Many private payers have followed Medicare's lead and are similarly offering payment parity between telehealth and in-person visits and $0 copays.[22] Lastly, there have also been many efforts to train physicians to utilize teleophthalmology. Physician education for rapid deployment must include information on how to use the technology, remote patient examination techniques, and 'web-side' manner.[23] Some healthcare systems have been impressively quick in catching their physicians up to the learning curve; one institution onboarded over 1300 providers in three weeks using a 'train the trainer' model.[23] Many organizations, such as the AMA, are also providing remote learning modules and toolkits for clinicians online.[24,25] These efforts, combined with a necessity of an alternative way to deliver safe care, were the perfect catalyst for the expansion, transformation, and promotion of telemedicine.

In the months since COVID-19 first entered the United States, there has been widespread adoption of telemedicine in many healthcare systems.[26] Demand for telemedicine has surged throughout the country, with some reports stating telehealth claims were 5100% higher in March this year compared with monthly averages in 2019.[27–30] As physicians and patients rapidly shift to engaging in care digitally during this pandemic, it is critical to consider the current state of teleophthalmology, previously described as 'in its infancy'.[31] The rest of this article will focus on the current capabilities of teleophthalmology, the integration of teleophthalmology into ophthalmic care delivery, previously established strengths in diagnosing certain eye conditions, and opportunities for growth in the context of the COVID pandemic.

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