Is telehealth the ‘new normal’ in neuro-ophthalmology?
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COVID-19 has propelled new models to forefront
Before the COVID-19 public health emergency, I was excited about incorporating video visits into my practice. Multiple times a day I had patients who had driven for hours, many of whom had stayed overnight in a region known for expensive accommodations because of lack of access to neuro-ophthalmologists near their home. Others shuttled between the neurosurgery clinic, MRI scanner and my clinic, getting in their car and re-parking, re-registering and waiting multiple times. Everyone faced a multi-hour appointment, shuttling from waiting room to exam room to photography to exam room, before waiting for a physician running late because of providing care to patients with complex disease. The system was broken for patients and this provider.
Many of my patients had seen an ophthalmologist recently with relevant vision measurements, examination and ancillary testing. Others were stable established patients. Video visits intrigued me as a tool through which to provide high-quality care for these and other selected patients, improving convenience for them, while facilitating growth of my practice without consuming more physical resources. However, barriers of lack of IT infrastructure and limited telehealth reimbursement made incorporating these into my practice a long-range proposition.
During the COVID-19 public health emergency, patient and staff safety concerns have propelled new models of care delivery to the forefront. IT infrastructure implementation has been accelerated and reimbursement broadened. Over 1 week in March, my clinic transitioned from 100% in-person to 90% virtual visits. This has not been easy, with the clinic support systems remaining set up for in-person visits and IT challenges on both patient and provider sides, but these get better daily. I am proud that we have continued delivery of high-quality neuro-ophthalmic care through video visits and other telehealth approaches during COVID-19. Video visits are especially useful for triage to figure out who needs to come for an in-person visit, for second opinions and for stable established patient visits. As having patients in clinic becomes lower risk, the advantages of telehealth remain, and we must not lose sight of these as we return to business as usual. Tele-neuro-ophthalmology improves patient access to care and patient convenience while reducing congestion in the clinical space and maintaining delivery of high-quality care. Continuing to provide care using diverse methods will better serve our patients, referring providers and ourselves. I hope that reimbursement and institutional support allow us to continue to do so.
Heather E. Moss, MD, PhD, is an associate professor of ophthalmology, Byers Eye Institute, Stanford University.
Telehealth has utility now, but maybe not in long term
During this unprecedented COVID-19 pandemic, Americans have to face the reality of a “new normal.” In our profession, telehealth has emerged as a possible strategy for providing patient care when face-to-face eye care is not possible or severely limited by either public health fears or public health mandates. The degree of adoption by neuro-ophthalmologists has recently been quantified, and although the trends suggest increased awareness and early adoption by some, the new normal for neuro-ophthalmology likely will remain a hybrid of care modalities despite the risk for infection to both patient and physician.
Moss and colleagues recently surveyed telehealth utilization pre- and peri-COVID-19 among practicing neuro-ophthalmologists in and outside the U.S. using an online platform. The utilization of all telehealth modalities jumped pre-COVID-19 to peri-COVID-19 in video visits from a tiny 3.9% to a whopping 68.3% (P < .0005); remote interpretation of testing went from 26.7% to 32.2% (P = .09); online second opinions increased from 7.9% to 15.3% (P = .001); and interprofessional e-consult went from 4% to 18.7% (P < .0005). The majority of the respondents stated that access, continuity and efficiency were benefits of telehealth, but the main barrier was data quality.
In my own practice, telehealth was most helpful to me when someone else had done the exam and my expertise was being called upon for examining the history and reviewing the prior tests (“chart biopsy”) or when the external exam or motility was the issue. Amazingly, anecdotally we were able to diagnose a wide array of neuro-ophthalmic conditions during a virtual visit, including demyelinating internuclear ophthalmoplegia, myasthenia gravis with ptosis, orbital lymphoma with lid fullness and ischemic sixth nerve palsy. We also were able to use an at-home visual acuity and visual field test for many of our stable follow-up patients with idiopathic intracranial hypertension or known homonymous hemianopsia. In my experience, however, most of our new virtual visits in which the fundus exam (eg, rule out papilledema on OCT) was required ended with the caveat and apology: “We need to see you for a face-to-face exam.”
In conclusion, I believe that telehealth has some potential in neuro-ophthalmology, including triaging new patients with neuro-ophthalmic conditions, evaluating stable follow-up patients, making a preliminary working diagnosis in cases in which the external or motility exam (efferent neuro-ophthalmology) is the issue or providing a chart biopsy. Although the adoption of such telehealth platforms by neuro-ophthalmologists has increased during the COVID-19 pandemic, it is unlikely that telehealth will be the new normal for conditions requiring a fundus exam or ancillary posterior segment imaging (eg, OCT). So, is masking and distancing our new normal in the COVID-19 era? Probably in the short term, yes. Is telehealth our new normal in neuro-ophthalmology? I hope not.
Andrew G. Lee, MD, is OSN Neurosciences Section Editor.