• How to Set Up Telemedicine in Your Practice

    Ophthalmic telemedicine holds a lot of promise and, when used properly, can help decompress your busy in-person clinic, triage patient complaints and improve communication with patients and their families. 

    Telemedicine has become more common since the onset of the COVID-19 pandemic across all fields of medicine, and ophthalmology is no exception. If you’re interested in being at the cutting edge of technology and innovation, here are a few useful tips to setting up telemedicine in your own practice. 

    Ways to Use Telemedicine

    Triage. Telemedicine is a useful tool for triaging patient complaints. Set aside time each week where staff can schedule patients to meet with you virtually. At the appropriate time, connect with the patient on a synchronous video call and discuss any questions and concerns. This takes the guesswork out of whether patients will pick up when you call back, and a video-based platform provides more information about their eye health than an audio visit.

    Screening. It's possible to serve your local community by providing ophthalmic screening for eye disease through telemedicine. Through partnerships with primary care and endocrinology offices, fundus photography can be used to detect diabetic retinopathy and other pathology prior to the onset of symptoms. While manual fundus photograph review can be a daunting task depending on volume, novel fundus cameras equipped with Food and Drug Administration-approved artificial intelligence algorithms (Digital Diagnostics and Eyenuk) capable of autonomously detecting diabetic retinopathy can also be employed. In either case, your services in detecting eye disease or serving as a reliable referral source can be beneficial to your community and your practice.

    Appointments. You can also use telemedicine to replace the in-person component of a patient appointment if the patient is able to undergo their regular ophthalmic testing. This is especially true for patients with eye diagnoses that warrant frequent testing, such as glaucoma (visual fields, OCT, intraocular pressure), age-related macular degeneration (fundus photos, OCT) and hydroxychloroquine screening (fundus photos, OCT, visual fields, fundus autofluorescence). 

    In this model, the patient comes in for a testing-only visit with your technicians and schedules a virtual visit with you at a later time. As an added perk, you can share screen and show patients the results of their tests, which may lead to better compliance and informed decision-making.

    Family calls. Setting up joint telemedical calls or video visits with patients and their family members can help when discussing preoperative planning, complex diagnoses or to monitor ongoing therapy. It can be helpful to have the support system for patients on board when discussing the risks and benefits of cataract or glaucoma surgery. 

    It can also be useful to check in virtually with a patient or their loved ones when discussing complicated decisions like choosing between various multifocal intraocular lenses. Lastly, virtual group discussions revolving around the treatment of diseases like glaucoma or dry eye can yield insights into medication compliance and changes in patient symptoms.

    Potential Challenges

    Choosing which patients are appropriate for virtual visits can be a challenge. A large proportion of our patient population is older, which poses limitations in the uptake in novel technologies like video visits. Other patients may have poor insight into their disease processes and their symptoms or may be prone to respond as ‘pan positive’ on review of systems making virtual care difficult, while others have better insight into their eye health and symptoms. Additionally, cultural differences, language barriers and poor health and technology literacy can make virtual visits a challenge for certain segments of your patient population. As a result, it is critical to be mindful as to which patients you offer virtual appointments and which you need to see in person.

    Choosing and implementing a virtual telemedical platform can also be tricky. Ensure that any telemedical technology you employ is HIPAA secure and is easy to use by your patients. Additionally, take time to educate your staff on the use of the virtual platform so that they can help train patients prior to your telemedical appointments. Although some platforms like Doximity have been available for a long time, the hardest part may be choosing which platform from an ever-expanding laundry list of telemedical vendors to employ. 

    Lastly, obtaining reliable ophthalmic exam components virtually can be tricky. Something as simple as having a patient take a picture of their eye can be difficult without proper lighting or the help of an assistant. Ophthalmic vital signs like visual acuity can also be challenging, though websites like Farsight.care, the Academy’s printable at-home visual acuity test, and a large number of online smartphone apps can be useful. 

    Fortunately, coding and billing doesn’t need to be a challenge. While time-based billing using E/M codes is always an option, the addition of ophthalmic testing from testing-only visits, at-home testing, and remote patient monitoring allows for more complex encounters and billing through medical decision making. The Academy offers resources to help with coding and billing for telemedical visits. 

    The Promise of Telemedicine

    Although ophthalmic telemedicine may not replace your busy in-person practice, it can be seen as a useful supplement. With a bit of innovation and thoughtful implementation, the use cases for telemedicine in your own practice are limitless.

    Grayson W. Armstrong, MD, MPH About the author: Grayson W. Armstrong, MD, MPH, is a comprehensive ophthalmologist and director of ophthalmic emergency services at Massachusetts Eye and Ear in Boston. He is a Harvard Medical School ophthalmology instructor who served as director of the eye trauma service from 2019-20. Dr. Armstrong completed his residency, chief residency and fellowship in ophthalmic telemedicine at Massachusetts Eye and Ear and Harvard Medical School. He joined the YO Info editorial board on Jan. 1, 2022, and was selected to participate in the Academy’s Leadership Development Program XXIV, Class of 2023.