Nelson: We will be discussing our experiences in using telemedicine for pediatric ophthalmology. Dr. Arnold shared information regarding his experiences with me in February 2020 before the 2019 novel coronavirus (COVID-19) pandemic took hold, and now more pediatric ophthalmologists have experience using it in their practices. Dr. Arnold, please tell us how you started using telemedicine.
Arnold: When I started using telemedicine for photoscreening, we would ship a Medical Technology and Innovations (MTI) photo-screener with paperwork to different locations for the staff to perform photoscreening. They would send us the results to evaluate and we would mail the results back to the parents.1 We were limited as to what types of data the patients could collect reliably on their own.The idea of having home visual acuity testing came later, probably in the early 2000s when the late Kurt Simons invented an HOTV surround top. He placed a stick as an axle in a box and then he had critical line 20/40 HOTV optotypes that he would rotate in a randomized fashion and then he would have the patient be able to somewhat identify or match. With his permission, I made one that I could print out on a piece of paper and we could fold one side to critical line 20/30 or the other side to critical line 20/40 and then the parents could fold that and hold it.2 The child would have a matching card with instructions on it. Since then, we've had good, reliable home vision testing capacity from parents who care about it ( http://www.abcd-vision.org/abcd-clinics/Telemedicine.html). So, essentially our Alaska efforts at telemedicine started out two decades ago as photoscreening and then moved to visual acuity screening.
Nelson: Dr. LaMattina, what has your experience been with telemedicine?
LaMattina: I had not used telemedicine prior to the pandemic. I was interested in it because we go to Lesotho twice a year to perform surgery and they don't have ophthalmology care long term. When the pandemic began, we formed a telemedicine committee to look at all of the different ways to do visual acuity screening. The critical piece that Dr. Arnold mentioned is having motivated parents.We haven't had great success with visual acuity testing. We have a package that we sometimes will send to the parents, particularly in our suburban office, that contains an eye chart and directions for using it so the parents can check the vision before the appointment, but, again, we've had mixed results with that. We also tried an app that Boston Children's Hospital was using called the Freiburg Vision Test (FrACT). All the parents need is a ruler. We control the screen display and they just have to measure the size on their screen. It doesn't work great on a phone, but is better on a tablet or laptop. You enter their distance from the screen and the size of that line that they're seeing on their screen as they measure it and then it calibrates. I've had some success with older kids with that.There are certain things that I find telemedicine helpful for. I find the video component really helpful because I can assess control in patients with intermittent exotropia or alignment in patients with accommodative esotropia and pseudoesotropia, and I can do a decent examination over video. But more complex issues such as uveitis are challenging and require a more in-depth examination. I've actually moved to doing a lot of my visits in person again now. I'm doing less telemedicine now than I was back in March and April.
Taylormoore: I also had no history with telemedicine before March 2020, but I had an interest in it because we were hoping to start using it for our annual trip to the Dominican Republic and also to establish a retinopathy of prematurity (ROP) telemedicine program. I have seven colleagues and none of us had used telemedicine on a regular basis prior to the pandemic, so there was a huge learning curve that had to be overcome. Within a 2-week period toward the end of March and the first week of April, everyone became comfortable with it. The hospital decided that we were going to use Zoom (Zoom Video Communications, Inc) as the platform and that has worked pretty well for us. I think each person does it a little differently. Some attending physicians are running visits completely on their own. Others are incorporating residents, fellows, and technicians into that visit using break-out rooms.
Nelson: Is Zoom the only platform that you use for telemedicine?
Taylormoore: The hospital had recently switched over to Zoom from GoToMeeting (Log-Mein, Inc) but there wasn't a lot of familiarity with it. When we initially started, we were actually using FaceTime (Apple, Inc) even though FaceTime and similar platforms were not HIPAA compliant. But then we increasingly used Zoom and it's worked very well for us.
Nelson: Have you encountered problems with parents knowing how to use Zoom?
Taylormoore: Yes, there has been great variability. Some families are really motivated and have the technical expertise and technology at home to make it happen, but others have to stand outside or drive around in their cars due to spotty Wi-Fi connections. I could write an entire book on the interesting Zoom calls I've had with parents. We have our technicians call the day before to walk parents through the set-up to make sure they're comfortable with it. If they're not comfortable with it or it's just not working, then we will reschedule them or figure something out.
Nelson: Dr. Arnold, what video platforms have you used, both before and during the pandemic?
Arnold: If the parents are initiating the communication with me, HIPAA compliance during the pandemic has never been an issue and some suspect I'm much more interested in patient care than some of the rules. If a parent wants to text me with a picture or FaceTime, I believe that's legal. There's nothing as good as Face-Time in terms of video if the families have it. They're already good at it and the quality of the video is superior to anything else. We ended up using Doxy.me (Doxy. me, LLC) because that has the potential to be HIPAA complaint and that worked okay but maybe 50% as well as FaceTime.
Nelson: Of course, the parents have to have an iPhone and not an Android device to use FaceTime.
Arnold: Correct. So for approximately 80% it was easy to use FaceTime and for the others I used Doxy.me.
Nelson: Dr. LaMattina, what is your telemedicine platform?
LaMattina: I also use Zoom primarily due to privacy issues. With FaceTime, we tried having an email account that we set up specifically for the department for telemedicine to protect the physician's privacy. We used FaceTime mostly for patients who were struggling with Zoom. For my pediatric population, I didn't really have Zoom problems. By April most of them were familiar with it because it had become how everyone was doing homeschooling and work communication.We didn't have the technology support to contact the families in advance because half of our staff was furloughed. We developed instructions to send the parents the day before, such as trying to use a larger screen if they have access to it (as opposed to the phone) and then putting it on a stable surface so that there's less noise in the background and using natural lighting. I had to call a couple of people and talk them through it, but they just clicked on the link and it was pretty straightforward for the most part.I tried to use the breakout rooms with my orthoptist, but we realized that we couldn't do high-volume visits that way. Generally I would only do a handful of Zoom calls in the morning or afternoon to enable us to get through all of the different components we would try to do. But it varied due to the socioeconomic barriers. One mother couldn't find a quiet room in the house and so I was trying to examine the child on the lower bunk of a bunkbed and we had to keep having the child move so I could actually see the eyes, and the surface wasn't stable so the quality was terrible. Overall, Zoom worked well for those who could use it. For those who couldn't, we used Doxy.me because it just dials them and links up to their video on their phone, which also eliminates privacy issues because it shows the hospital phone number.
Nelson: How many patients were you able to schedule, especially during the pandemic when you weren't seeing patients very often in the office?
LaMattina: I would do 4 or 5 in the morning and another 4 or 5 in the afternoon. It often depended on what they were being screened for. For example, patients who had a symptomatic form of uveitis that had been well controlled with low-dose topical steroids would not require a video visit and I would just call them. Similarly, I rescheduled patients who needed vision screening because I couldn't check whether their myopia had progressed, so there wasn't much I could do for them on the phone. Some parents just wanted a phone call to touch base, which did not take as long as a video examination, so I could see more patients in a day.
Arnold: We scheduled approximately 45 minutes for each visit, but most of the time we needed 20 minutes or less. It was not the same as a regular comprehensive examination, but more to tide them over until we could start having in-office visits again. Our experience with telemedicine is mainly coverage of the families that have the capacity for telemedicine. We don't know how many patients we have missed compared to what regular examinations would have been. I probably saw 8 patients a day using telemedicine.
Taylormoore: We had one physician covering the hospital every day of the week. On those days, I was seeing all of the emergency patients and consultations and so I would see 5 to 10 patients in person and I would intersperse maybe 5 telemedicine visits on those days. Then we had separate days that were just telemedicine days, working from home and doing telemedicine all day. On those days, we scheduled 6 patients in the morning and 6 in the afternoon. We basically would do three in a row every half hour, then have a break and do another three. However, it was unusual to actually see all 12 patients because there were always a couple who signed in an hour late or totally missed the appointment or couldn't get their video to work. On average, it was probably more like 9 or 10 per day.
Nelson: What is your experience with the billing process for telemedicine?
LaMattina: That was one of the big questions we had when we first became involved with telemedicine. The guidelines weren't really clear when we started so we relied a lot on the emails from the American Academy of Ophthalmology (AAO) and American Association for Pediatric Ophthalmology & Strabismus (AAPOS). I had created templates that essentially prompted me or my technician to make sure that we got all the information we would need. Boston Medical Center also had someone available to offer advice on billing. Initially, I think we were billing primarily at level 3, because a lot of the initial examinations were just coding and billing a bit lower until we became more comfortable with the guidelines and were able to start billing more based on time spent. We haven't had any issues with reimbursements for any of the telemedicine appointments that we've been billing.
Taylormoore: I am thankful for all of the guidance that was given out by the AAO and AAPOS during those first few weeks because all of us were confused about what we could and couldn't bill and whether billing was the same for a telephone call versus a video call. We were billing based on time primarily, level 2s and 3s for the most part. As Dr. Arnold said, it's hard to get more than 20 minutes out of a lot of these families.The challenge of working in the DC metro area is that we have patients from Maryland, Virginia, and DC. Some of us are licensed in all three locations, some of us are only licensed in two of them, and each state had a different restriction. For example, one of my colleagues who normally practices in DC or Maryland couldn't see any patients from Virginia. Sometimes the schedulers wouldn't realize that and they would mis-schedule patients. We also had issues with billing patients who were coming from outside our immediate geographical area, such as from West Virginia and Pennsylvania. I could see return patients, but I couldn't see new patients. So making sure the schedulers were on the same page was a challenge. Unfortunately, we had to cancel a lot of visits because we weren't going to be able to do any billing whatsoever. Then we would put them on the schedule for someone who had a license in a different state.
Nelson: Dr. Arnold, as someone who has had a long experience with telemedicine, what are your overall thoughts on using it long term?
Arnold: I think telemedicine helps patients, but it is not sustainable economically, especially if you have an office for which you have to pay rent and staff. The telemedicine model that has the potential to be successful is when you have highly technical, digital information such as ROP photographs that have been collected by an expert and you can quickly review them using an electronic platform that ideally also helps you schedule. But, for the most part, pediatric ophthalmology will not survive as a sustainable occupation if we have to depend on telemedicine.When you look at children's eyes, refraction is a critical component and it is not easy for telemedicine. Our colleagues who focus on adult optometry or ophthalmology are using an automated refractor, but we are still relying on retinoscopy. Some day there may be a consumer app for smartphone photoscreening that might be able to address refraction. But currently, the main company focusing on photoscreening, GoCheck Kids, is careful to understand what its camera capacity is. They are not following every model of smartphone, but using photoscreening in pediatricians' offices in well-defined cameras for which they know the camera capacity. When performing examinations on new patients, as opposed to patients we've seen once or twice, the refraction is the one part of a pediatric examination that I don't think you can live without and we don't currently have another way to estimate the refractive error.
Nelson: Do you have any pearls to share that would add to the success of telemedicine from your perspective?
LaMattina: The AAPOS webinar mentioned the importance of natural lighting to improve the quality of the video on the call. Also stressing to the parents that they should have a stable surface for the device, because the image quality, and therefore examination, is worse when the device is being held and is unsteady. I would also consider the feasibility of drive-by retinoscopy for cases of failed vision screenings, which I found difficult to triage. It would have been helpful to have my staff be able to check whether the child had gross strabismus and just check refraction to know how urgent it was for the child to be seen. If we had continued to limit our capacity to 15% or 20% of what we normally see, I might have tried to push for something like that, because I would have worried that we were missing a lot of children who had potential amblyopia risks.
Taylormoore: We found that having one of our technicians call the family the day before improved the quality of the visit. After watching the AAPOS webinar and evaluating the available resources such as Dr. Arnold's website, we decided to use either the Eye Handbook app or the HOTV printout that Dr. Arnold created and we made an email that would explain the process to the parents ahead of time. But even with that, at least 50% of the time you would get on the Zoom call and they hadn't checked vision yet. So having a technician call the day before to walk them through it and teach them how to really cover the eye appropriately improved the compliance and then we didn't have to waste our time during the actual video walking them through that.Dr. Nischal and others have some really good videos on YouTube about doing alignment checks at home with wooden spoons and household items. I was surprised at how much I could get with a motivated family over video, even when the quality of the video itself wasn't that good. They could actually do a decent alternate cover and cover-uncover test at home. I think having the parents watch that video ahead of time improved the quality of the visit. Of course, it takes a motivated family, which is the major factor in all of this.
Nelson: This is an important topic that we will be hearing more about in the future. Thank you all for sharing your experiences.
This Eye to Eye session was conducted on July 20, 2020.
- Arnold RW, Gionet EG, Jastrzebski AI, et al. The Alaska Blind Child Discovery project: rationale, methods and results of 4000 screenings. Alaska Med. 2000;42:58–72.
- Tsao Wu M, Armitage MD, Trujillo C, et al. Portable acuity screening for any school: validation of patched HOTV with amblyopic patients and Bangerter normals. BMC Ophthalmol. 2017;17:232.