Issue: July 25, 2020
Disclosures: Parekh and Kontos report no relevant financial disclosures.
July 21, 2020
7 min read
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Telehealth a popular option for eye care during COVID-19 pandemic

What does the future hold for in-person vs. telehealth appointments?

Issue: July 25, 2020
Disclosures: Parekh and Kontos report no relevant financial disclosures.
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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a joint society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.

Ken Beckman
Kenneth A. Beckman

While the concept of telehealth has been around for a while, it came to the forefront during the COVID-19 pandemic. There are many obvious benefits to telehealth, but there are also some pitfalls. This month, Jai G. Parekh, MD, MBA, FAAO, and Mark Kontos, MD, discuss their thoughts on telehealth in ophthalmology. We hope you enjoy the discussion.

Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor

Telehealth is here to stay

I attended the American-European Congress of Ophthalmic Surgery meeting earlier this year, and there was so much discussion in terms of innovation for our field. Since then, who would have thought that the country and the world would be swept away with the intricacies of COVID-19, its morbidity and mortality, and the impact that it has had in almost every aspect of what we do?

In health care, COVID-19 has had amazing implications for our first responders at the hospital level for sure, but also on the outpatient level, where patients tend to be afraid and circumspect about going to the doctor; telehealth, no doubt, has been invaluable. In states, early on, where stay-at-home mandates were issued, patients had to curtail travel unless for acute medical issues or for food and groceries. It is here where telehealth technology offered patients a new option to discuss their myriad issues with their physicians.

Jai G. Parekh, MD, MBA, FAAO
Jai G. Parekh

Now, here we are today, still in the middle of COVID-19, while chasing a flattening and making sure social distancing is in place. There has been a gap in health care access for the last several months, and luckily telehealth has helped mitigate that gap and provide access to doctors and health care professionals as much as possible. Recently, CMS reported the average number of telehealth visits before the pandemic was around 11,000 visits a week. Now, CMS reported the average is up to 1.4 million a week. Telehealth has surely accelerated digital medicine by at least 5 to 7 years. It is here to stay, and many of us in the health care community are happy about it. We almost have no choice.

Telehealth has provided a solution for patients to talk with physicians in a safe-guarded fashion, allowed us to make sure our patients are taking their drops, and helped us maintain communication for both acute and chronic issues. Patients contact us to discuss issues such as dry eye symptoms, or they have questions about their glaucoma drops, or they have a history of diabetic retinopathy and are now experiencing blurry vision. We now have the ability to counsel our patients through a virtual platform, whether it be iPhone FaceTime, Google Hangouts or, my personal preference and more HIPAA-compliant platform, Doxy.me. It has been wonderful and has evolved over the last 4 months.

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In our practice, we have done more than several hundred telehealth visits during the crisis, mainly with patients who have had emergencies or, more commonly, issues related to the anterior segment, including glaucoma, dry eye, blepharitis and ocular allergies. Almost every single one of our patients has commended us for providing telehealth and are thrilled that we will be providing it in the future. I definitely see telehealth as an option on the upward swing. I do think, in the acute term, there are some lower regulatory barriers, and because of that, it is easier to facilitate and implement. For example, due to the fact that a significant number of patients may not have video capabilities or cannot comprehend the steps to get that video, a qualified phone call may be just as good, and reimbursement, for now, is on par with a video call.

Telehealth is now ubiquitous, and for you to not embrace it, someone else down the street will. It is as simple as that. It has also offered a fair financial revenue stream for many of us who went down to almost little or no revenue to support the rent and utilities, and it allowed us to have some employees on hand in the office to support our telehealth endeavors.

I think telehealth technology will also improve as time goes on. It is tech-savvy and tech-centric, so it will force the industry to come up with scenarios in which we can perform better diagnostics, more than just looking at a patient’s eyes and looking at their anterior segment.

The potential is huge, and telehealth is here to stay. I know for a fact that many of my colleagues in other specialties are embracing it on the societal level, hospital level and certainly on the provider level. I am happy with telehealth as a viable option to communicate with our patients, and for us to not offer it would be a huge disadvantage to our patients, limit their access and reduce the goodwill of our specialty.

However, we need to keep in mind that whereas telehealth in no way replaces the live doctor and patient interaction in the office, it manages to serve as a bridge of comfort and clinical exchange that patients feel satisfied with until that next “real” visit. Telehealth will only grow in the foreseeable future and will now become a significant part of our practices, even past the pandemic, which has only accelerated its arrival. We certainly embrace it, and it will only get better with more patient, physician, payer, regulatory/government and industry input.

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Telehealth may have unintended consequences

I do see value in telehealth, and it is not that there is not a place for telehealth in ophthalmology. There certainly is, but during the pandemic, our rush to embrace telehealth as an aspect of patient care and using it as a significant part of our practices may have unintended consequences.

Mark Kontos, MD
Mark Kontos

There is no doubt that in the era of COVID-19 telehealth can be helpful in certain circumstances. It can save patients from unnecessary visits to the office, but ultimately it does not replace the doctor and patient face-to-face visit. We had the ability before the pandemic to talk with our patients via telehealth and to conference them using FaceTime and other forms of technology but rarely chose to do so. There is nothing new in terms of technology that was created during the pandemic with telehealth. Its use never represented more than 1% of patient interactions in ophthalmology before COVID-19.

Office closures and dramatic loss of revenue due to the pandemic drove us to telehealth. The motivating factor for generating telehealth visits was not necessarily patient care but generating revenue when our offices were closed. I think it is important to be aware of what primarily drove this decision.

Once CMS decided to reimburse telehealth with rates commensurate with an office visit based on time, it became a financially viable option. Before that, it was not anything that we embraced in any significant way. I have concerns about how CMS is now reimbursing telehealth at the same rate as an office visit. If they look at telehealth and decide the doctor does not even need to be in the presence of the patient, then how valuable is the relationship? CMS is always looking for ways to diminish reimbursements over time, so this may be a way for it to do this. I see this as a potential way for CMS, although it has increased the reimbursement for telehealth currently, to rationalize a reduction of total reimbursements for all visits, be it telehealth or live.

I do not feel that telehealth is much of a time-saving device for physicians. By the time you factor in all of the preparation that is required to get a patient ready for the visit and the time you spend with the patient in order to bill properly for a telehealth visit, you have lost any real efficiency compared with seeing patients in the office. That is with not even taking into account the difficulty some patients have managing the computer needs involved. Also, telehealth billing issues (and there are plenty) are a great way to anger your billing staff and upset your patients. Telehealth is not a particularly efficient way to deliver care for patients, at least for ophthalmology.

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However, two factors concern me the most about telehealth and embracing this in the field of ophthalmology. In our specialty, and certainly in my practice, we have spent many years trying to create what we feel is a patient experience that is of genuine value. We have honed our interactions with patients down to a science to create a unique experience. When they leave the office, they feel they have received the best care possible and want to refer our practice to others. I think that is of enormous value in terms of generating referrals for a practice and helping a practice grow. It is almost impossible to do this in a telehealth environment.

The second factor, and possibly most concerning, is that we leave ourselves open to possible medical liability issues with telehealth. It is not possible to perform an exam that is complete or of any real value in most telehealth settings. There is nothing that can replace a full in-person exam of a patient. Sometimes we can give patients the impression in a telehealth visit that they have had a normal exam, but they most certainly have not. Patients may then put off needed in-office visits in which they would receive a more complete exam. We identify asymptomatic serious pathology during these exams every day in the office that we may otherwise miss in a telehealth visit. Practices that use telehealth for a large number of patients will likely miss pathology. It is possible to miss serious issues in a face-to-face full exam, but making a mistake in a telehealth environment is much more likely. It only takes one overlooked condition to create a bad scenario for a practice.

During the pandemic, telehealth was better than nothing, but now that we are moving toward more normal operations, I am not sure how useful it will be to practices in the near future. As technology advances and we can perform virtual exams that are meaningful, telehealth will become more impactful, but at this point, doing FaceTime or Zoom with a patient leaves a lot to be desired.