Issue: March 2017
March 16, 2017
9 min read

Educating patients essential in the age of disruptive technologies

Issue: March 2017
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By nature, the term “disruptive technology” can elicit fear of losing the status quo or a change beyond recognition. New technologies in eye care are challenging the way patients find information, purchase eye wear and address their ocular health.

Author and Harvard Business School professor Clayton M. Christensen first coined the term “disruptive technologies” in a 1995 article. He said an early example of disruptive technology was the first mass-produced, affordable automobiles, which changed the transportation market in a way that the first 30 years of automobiles did not, as, previously, only the upper class could afford them.

The eye care industry has yet to see how innovations such as online refraction, telemedicine and wearable technology will affect patient care in the long term.

April Jasper

“Disruption is fine as long as we understand how we can embrace the technologies for the benefit of our patients and not have it confuse them,” April Jasper, OD, FAAO, of West Palm Beach, Fla., said in an interview with Primary Care Optometry News.

Jerome A. Legerton, OD, MS, MBA, FAAO, said there is no need to fear impending technological advances.

“The sustainable elements and value of our licensure is not our refracting skill or our conduct of any clinical measures. The irreplaceable value of our licensure is our professional judgment and our consultation,” he told PCON.

It will be a long time before artificial intelligence will replace patient-centered consultation, according to Legerton, chief clinical and regulatory officer at Innovega Inc. and cofounder of Myolite and SynergEyes Inc.

Ryan Corte, OD, said educating patients about the value of a comprehensive in-office exam can convince them to avoid shortcuts when it comes to their eye care.

Image: Corte R

“New technologies will create the need for doctors to do a better job of telling their story, explaining the importance of an eye exam and why regular exams are important,” Jasper said. “Doctors need to be willing to embrace the technology if it’s for the betterment of our patients.”

Online, remote refraction

Jasper is concerned that developers of remote refraction technologies are not working diligently to ensure that users understand that the technology does not equate to a comprehensive eye exam.

Ryan Corte, OD, who practices at Modern Eye Care in Concord, N.C., agrees that while the technology cannot be relied upon for a complete eye exam, it may have potential as a preliminary screening tool for in-office use and might be a timesaver for practitioners, streamlining the traditional in-office exam.

He suggests that a patient could utilize online refraction technology in office as a preliminary refraction that they can perform themselves, then the doctor could confirm that the refraction meets their vision demands and individual needs and perform the actual binocular and ocular health assessment.


“We need to understand the value of what we provide,” Corte said in an interview. “Technology is only as good as the people interpreting the information, and the reality is that errors could lead to poor outcomes. There is a lot of liability in providing a prescription based only on a refraction when the other aspects of eye health are removed.”

“Remote refraction is confusing to patients,” Jasper added. “Patients assume that since it’s on the Internet, it’s OK. Unless someone gets the story out there as to why it’s not the same as an in-office exam, patients won’t know any different. I don’t think any remote refraction will come out in the next 10 years and take the place of what we can do in the practice.”

“While I personally want optometry to be able to hold onto refraction because it drives eye health examinations and all the wonderful consultation that optometrists offer to enhance quality of life,” Legerton said, “I forecast that the consumer force to have the right to refract their own eyes will be tough to beat in a 21st century America.”

New apps will continue to hit the market, according to Joseph P. Shovlin, OD, FAAO, PCON Editorial Board member and private practitioner at Northeastern Eye Institute in Scranton, Pa.

“I think it’s something that is here to stay and will probably only expand moving forward,” he told PCON.


“There are parts of telemedicine that we need to embrace,” Jasper said, “as a screening tool, for a better way to screen patients or as a way to talk to your doctor. Where it gets confusing is when patients see it as a substitute for a comprehensive eye health examination.”

Ryan Corte

The Veterans Administration has been using telemedicine as a screening tool for diabetic retinopathy for years, Corte said.

“This advancement is important, as not everyone has access to care in underserved areas or areas outside of the U.S.,” he said.

Telemedicine can help bridge the gap in treating these patients, but Corte does not think it is entirely needed in areas where providers are able to perform the full assessment.

Moving forward, private insurers will aggressively adopt telemedicine to reduce the costs of health care, Karen F. Perry, OD, FAAO, a private practitioner based in Orlando, Fla., and director of professional relations and training at Compulink, said.


Compulink is working on scheduled/on-demand video teleconferencing with image capturing capability to enable audiovisual communications from provider-to-provider and patient-to-provider, Perry explained.

Telemedicine is an adjunct to traditional medicine, she stressed, and not a replacement, helping improve accessibility to care for the elderly, disabled and homebound.

The United Kingdom Hospital Eye Service (HES) employed an electronic patient record utilizing a virtual glaucoma specialist to determine if they could lower the number of patients requiring an in-office visit to a glaucoma specialist, according to a study by Wright and Diamond. HES was struggling to review glaucoma patients at their planned interval.

Patients underwent testing and clinical examination at mobile clinics and were triaged into one of five groups: normal, stable, low risk, unstable and high risk. Patient data was uploaded to an electronic medical record to facilitate virtual review by a glaucoma specialist.

“Virtual review allows the glaucoma specialist to remain in overall control while reducing the risk that patients are treated or followed-up unnecessarily,” researchers concluded.

“Mobile health is a huge entity already,” Perry said in an interview. “Using smartphones in health care and driving telemedicine is something the government is starting to endorse aggressively. When we adopted ICD-10 billing methodology, there were several new codes for telemedicine.”

Karen F. Perry

She added that telemedicine will also help providers meet Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requirements.

“We can truly help reduce the burden of health care in the future the sooner we can think outside the box and embrace this technology, and we will have better care and outcomes in the future,” Perry said

She suggests that the reimbursements will come as the technology gains popularity and credibility, but practitioners will also see an ancillary benefit.

“Driving efficiency will provide us with a quality of life balance that we all seek in our lives,” Perry said.

A 2016 Ophthalmology study reported the health outcomes and cost savings of a telemedicine-based diabetic retinopathy (DR) screening program in Singapore. The Singapore Integrated Diabetic Retinopathy Program provides real-time assessment of DR photographs by a centralized team of trained and accredited graders, supported by a tele-ophthalmology information technology infrastructure, according to Nyugen and fellow researchers.

The retinal images were captured in primary care settings and transmitted to an ocular imaging center via a secured, web-based tele-ophthalmology platform. The trained graders assessed the severity of DR in the images and sent the results back to the primary care office within a 1-hour turnaround.


The telemedicine-based system yielded a cost savings of S$173 per person while eliciting quality-adjusted life-years similar to the traditional physician-based model, according to the study. These cost savings represent S$30 million when considering the current volume of Singaporeans with diabetes over a patient’s lifetime, the researchers wrote.

“The ophthalmic equipment industry has enjoyed good margins while failing to price for penetration or, let’s say, failing to price for telemedicine,” Legerton added. “Even so, lower cost instruments will be implemented. This is all that is required as a catalyst for telemedicine. The roadmap is drafted with systems theory, instrument packaging and economics as the critical path issues.”

Wearable technology

Another growing area of disruptive technology is wearables.

“Consumers’ appetite for information, entertainment and connectivity will drive them to wear their information, entertainment and connectivity,” Legerton stated.

Currently, Perry sees wearables as more a part of the gadget and entertainment world, but she believes over time they will transition to health care.

Legerton said technology developers believe eye-wearable technology will be the next computer console.

Facebook, Microsoft, Google, Samsung, Sony, Magic Leap, Innovega, Zeiss, Lumus, Vuzix, Meta, ODG and many others are spending billions to develop lightweight, stylish, high-performing, wearable computer eye wear, he said.

As some of the bigger companies such as Google expand their offerings, optometrists will be called upon to provide prescriptions, dispense these products and help patients adapt to the devices, Shovlin said.

“I think there are opportunities as well as challenges,” he said.

Jerome A. Legerton

Certain companies are targeting low vision as a priority, Legerton said, as well as using wearable displays in vision therapy, with potential applications in binocular vision, amblyopia and vision development and rehabilitation.

“It puts a different perspective on being able to treat patients with disabilities,” Perry added. “The low vision world may be the first to adapt to it.”

ESight, for example, is a wearable device that can aid those with macular degeneration, diabetic retinopathy, ocular albinism, forms of glaucoma and many other sight-threatening conditions.

Innovega plans to deliver a contact lens-enabled wearable display system that will require optometrists to fit the iOptik or eMacula contact lenses, Legerton added.

Moreover, he sees more optometrists using wearables to manage images and data collected while face-to-face with a patient, instead of turning their back to face a computer monitor.

Artificial intelligence in EHR

Artificial intelligence (AI) is set to disrupt the electronic health record (EHR) world, Perry said, where the current focus is better patient outcomes.


AI can help improve outcomes and reduce costs by eliminating redundancies, she explained. The AI-aided component is being called “clinical decision support,” with the goal of helping doctors make decisions and complete some of the analysis so they can achieve faster results within the system.

“That will translate to other programs such as remote refracting and virtual try-on, all tied in through interfaces that are automated and can work together,” she added.

For example, if a patient is using a remote refraction but does not want to order glasses online, that information can be sent electronically to the provider, who can assess the patient’s measurements and dispense the appropriate eye wear.

AI can also make billing and coding decisions for the provider, eliminating the need to know multiple diagnosis and procedure codes and how and when the tests can be ordered, Perry said.

Virtual try-on

Corte sees virtual try-on technology as a creative innovation that offers a large range of frame and color options, “but there is always that important aspect of being able to touch and feel it on your face.”

“I like patients having the opportunity to try on colored contact lenses online,” Jasper added.

While she likes the idea for virtual try-on for frames, she sees room for improvement.

“This technology is not going to hurt anyone; it bothers me less than the confusion we are creating through online testing,” she said. “The worst that will happen is patients won’t be happy with their lenses and they come to a brick and mortar and get a pair that are a better fit for them.”

Future progress, adjustments

The more the industry rejects these technologies the more difficult it will be to move forward, Perry concluded.

However, as online spectacle and contact lens sales have increased, so have incorrect prescriptions and inaccurate measurements, which practitioners need to deal with, according to Shovlin. He recommends establishing a policy for this in-office.

Joseph P. Shovlin

There may be battles ahead, such as with online refraction companies and their ability to provide contact lens prescriptions, he added.

“Considering there are more creative ways of individuals trying to circumvent a complete eye exam, we must continue to educate our patients,” Shovlin continued. “We don’t want any technology continuing at the expense of patient care.”

These experts agree that instead of fighting many of these new technologies, using and adapting them to an in-office setting, when possible, can be beneficial for the patient and the practice.


Corte believes patient education is a step many providers can improve upon to explain the depth of the in-office eye exam. Many patients simply are not aware of the testing and technology utilized during a comprehensive eye exam and why it is essential to their eye health, he said.

“If they don’t understand the actual care you are providing and the quality of care, it is easy for them to be misled through online marketing techniques to seek out shortcuts,” Corte added.

Having up-to-date, in-house technology is key, he said, as is training your team to educate patients to the highest level.

“If you don’t train them to provide that message to your patients, it is easy for your patients to get lost in exactly why they are there,” Corte said.

Disclosures: Corte is founder of Jasper is a paid consultant to Alcon. Legerton is founder of Myolite and co-founder of Innovega and SynergEyes. Perry is director of professional relations and training at Compulink. Shovlin is president of the American Academy of Optometry.