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The Telehealth Playbook: Real-World Use of Tele-Ophthalmology

In today’s unprecedented times, the option of telemedicine has proved invaluable for diagnosing, managing, and treating patients. Between navigating this transition, staying up to date on billing and reimbursement, and tackling new technologies, physicians have had a lot to learn. While there have been both advantages and obstacles encountered along the way, telemedicine is enabling us to meet the No. 1 goal: treating patients safely and efficiently.

The evolution of telehealth now includes multiple pathways for virtual care delivery. At Bascom Palmer Eye Institute (BPEI), visit types range from entirely virtual to partial to online communication. Of note, each visit type is reimbursable under guidelines imposed by the Centers for Medicare and Medicaid Services (CMS) as of March 1, 2020. Let’s explore the many tele-ophthalmology virtual visit types at BPEI.

Outpatient Video Visits

Synchronous video visits are the traditional example of telemedicine. Although definitions have evolved, real-time video visits are now utilized at BPEI for a range of services for new, established, and postoperative patients. Examples include triage of new complaints, monitoring of chronic conditions like dry eye, and postoperative cataract and oculoplastic surgery visits.

Urgent Care Virtual Clinics

An urgent care virtual clinic was created to treat patients with low-acuity conditions remotely, while expediting treatment of high-acuity patients. This visit type minimizes crowding of our dedicated ophthalmic emergency department (ED) and keeps patients in the at-risk categories for contracting the severe form of COVID-19 at home. While common conditions such as chalazia and conjunctivitis are managed virtually, patients with more serious issues like new flashes and floaters, vision loss, or eye trauma are expedited for timely in-person evaluation.

Tele-Counseling Visits

Video visits dedicated to discussion and counseling lend themselves well to a virtual workflow. We observed that patients seem more relaxed in their home environments, and family members participate more often both virtually and in the patient’s home. Cataract and refractive discussions, as well as uveitis, neurologic, and genetics counseling, are some of the most successful visits.

Doctor/Doctor Consults

Consults between physicians prove critical, primarily by minimizing the number of physical encounters with multiple subspecialists. Real-time video slit-lamp examinations are also utilized at times. For example, a patient with an atypical corneal infection presented to the BPEI ED. A slit-lamp adapter was fastened to the slit lamp, and a smartphone was inserted. A Zoom call was initiated from the device and the screen was shared, allowing a corneal subspecialist to view the exam remotely and direct the referring ophthalmologist and patient through the treatment plan.

Hybrid Visits

For instances when in-person testing is necessary, a “hybrid” partial telehealth encounter was designed. This entails expedited testing at BPEI with a subsequent virtual visit. Patients are accommodated in one area of the facility whenever possible, limiting movement between floors or departments. After testing, patients immediately leave the facility. Physicians then perform a video or phone call to review results and discuss management. Hybrid visits significantly minimize wait times and exposure to patients, staff, and physicians. Retina and glaucoma patients requiring optical coherence tomography (OCT) imaging, IOP checks, and visual field testing are well-suited for this visit type, and patients who merit treatment, such as intravitreal injection, are scheduled for expedited procedure-only visits on a standard clinic day.

As hybrid visits have advanced, physicians are now able to manage patients at multiple BPEI locations virtually on the same day, limiting travel by all. After-hours and weekend clinics have been implemented for the backlog of canceled patients and for greater scheduling flexibility moving forward. Most recently, BPEI technicians are utilizing the video slit-lamp model described above for real-time virtual examinations by our physicians.

Hospital Tele-Consults & Tele-Staffing

In an effort to keep residents and attending physicians minimally exposed, inpatient consults are triaged with telemedicine first and followed remotely whenever possible. When inpatient exams are necessary, the attending physician utilizes tele-staffing. The relaxing of telehealth and tele-staffing restrictions by CMS has made this visit type possible.

Second Opinion Virtual Consults

Given travel restrictions, we perform both domestic and international second opinion consults. Patients are scheduled for telehealth appointments with the appropriate specialists and medical records are uploaded to the EHR. The physicians review the records and perform video consultations. Our service is available to help referring physicians as well, which allows them to keep and care for their own patients locally. These visits are essential as they are less costly for patients, avoid unnecessary travel, and allow patients in underserved areas to receive tertiary level care.

e-Visits for Online Communication

Though rarely recognized as virtual care, correspondence via email and portals has emerged as a necessity. Under CMS guidelines modified in March 2020, new and established patients became eligible for e-visits. Our physicians utilize this visit type most commonly for image review and triage, which has decreased the need for ED visits significantly. Remote monitoring bears mention here, and utilization will expand as home screening tools develop further.

The COVID-19 pandemic has induced a paradigm shift in the daily practice of ophthalmology. The diversity of telemedicine applications at our institute highlights excellent opportunities for ophthalmic care moving forward. Invaluable benefits to patient care, safety, patient and provider satisfaction, workflow efficiency, and decreased cost to the healthcare system at large will ensure the use of telehealth well after the pandemic resolves, resulting in a more evolved and nuanced model of healthcare delivery.

For New Patients

Some of our most impactful telehealth visits (to patients and the entire health system) are for new patients. We have seen countless examples of urgent triage visits, second opinion consults, and doctor/doctor consults that enabled timely care for serious conditions. Conversely, these visits minimize unnecessary emergency department (ED) visits and travel for subspecialty care. All of these visits are examples of telehealth for new patients. The impact to the healthcare system as a whole is priceless.

Types of Telehealth Visits for New Patients:

Urgent Virtual Care

An urgent care virtual clinic was created to treat patients with low-acuity conditions remotely, while expediting treatment of high-acuity patients. This minimizes crowding of our dedicated ophthalmic ED, minimizes unnecessary ED visits, and keeps patients in the at-risk categories for contracting the severe form of COVID-19 at home. While common conditions like chalazia and conjunctivitis are managed virtually, patients with more serious issues such as stroke, retinal detachment, vision loss, and eye trauma are expedited for timely in-person evaluation. Many of these patients would have sustained irreparable damage were it not for this virtual care.

Doctor/Doctor Consults

Consults between physicians prove critical, primarily by expediting treatment and minimizing the number of physical encounters with multiple subspecialists. Real-time video slit-lamp examinations are also utilized at times. For example, a patient with an atypical corneal infection presented to the BPEI ED. A slit-lamp adapter was fastened to the slit lamp, and a smartphone was inserted. A Zoom call was initiated from the device and the screen was shared, allowing a corneal subspecialist to view the exam remotely and direct the referring ophthalmologist and patient through a vision-saving treatment plan.

Second Opinion Consults

Given travel restrictions, we perform both domestic and international second opinion consults. Patients are scheduled for telehealth appointments with the appropriate specialists, and medical records are uploaded to the EHR. The physicians review the records and perform video consultations. Our service is available to help referring physicians as well, which allows them to keep and care for their own patients locally. These visits are essential as they are less costly for patients, avoid unnecessary travel, and allow patients in underserved areas to receive tertiary level care.

Ranya Habash, MD
  • Bascom Palmer Eye Institute

For further resources on billing and coding in telemedicine, please visit this enduring materials portal.