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The ECP’s POV: Decision Points and Considerations for Vision Care Telehealth

By Staff
Monday, April 16, 2018 12:23 AM
This VM Summit panel parsed important considerations for eyecare professionals and optical retailers weighing decisions surrounding telemedicine implementation, and featured several first-hand accounts. The following comments were prepared by the panelists but not presented fully, due to time constraints.

Jobson’s Andrew Karp (l) discussed telemedicine’s implementation with (l to r) Michael Dueñas, OD, AOA; Rupe Hansra, OD, For Eyes; Sukumar Pandit, OD, Philadelphia Eyeglass Labs; Jonathan Rosin, MD, Rosin Eyecare; and Daniel Stanton, Stanton Optical and My Eyelab.

Panelists
Michael R. Dueñas, OD, FNAP, American Optometric Association, Chief Public Health Officer
Rupe Hansra, OD, vice president of professional relations, For Eyes
Sukumar Pandit, OD, director of optometry, Philadelphia Eyeglass Labs
Jonathan Rosin, MD, owner, co-president, medical director of Rosin Eyecare
Daniel Stanton, founder of Stanton Optical and My Eyelab
Andrew Karp, moderator, group editor, Jobson Optical Group


Rupe Hansra, OD
We need a common definition of telemedicine. Some members of the OD community equate it to an online refraction. Others say it could be an objective measurement in-store, test at home app, or remote comprehensive eye exam with or without a conversation with the doctor. But is it truly telemedicine if we remove the doctors from the equation?

Patients are more informed in today’s information age, and they have a right to choose what course of action or treatment is right for them. So we need to be honest with them.

Some of the claims about telemedicine are misleading or confusing to the public. On one hand, some providers of online tests claim they are not offering an exam, yet they use the words test and eye exam fairly loosely, which causes issues and mistrust with doctors. Accreditation with standards we can all agree on, such as the American Telemedicine Association, is one answer.

Can the technology do what it touts? Is it accurate? There is a 60 percent drop in the Net Promoter Score—which is a measure of likelihood to recommend—when an Rx is remade, so there is a price for sacrificing the quality of the refraction.

Here are some questions telehealth providers must ask in order to determine if telehealth is right for the patient journey and the brand experience:

• Can it be commercialized and scaled?
• What does training look like?
• How long and how difficult is it?
• What is the role of the optician versus the role of the doctor?
• How has that changed?
• Are we asking opticians to perform slit lamp and/or retinal imaging?
• Is it appropriate for all demographics as far as age and socio-economic status?
• Can we perform contact lens fittings/evaluations (including toric)?
• What should OD follow-up look like?

Another big consideration for telehealth providers is to what extent will they be reimbursed by payers. I believe telemedicine will lower costs and could be a proactive means for screening and prevention.

Everyone is waiting for the two biggest players—VSP and Eyemed—to say “go.” Those companies should consider taking a leadership position.

Medical plans and Medicare Advantage Plans have demonstrated a strong interest in telehealth. Once the larger payers develop standards and begin reimbursement, it will open up access for many Americans seeking access to quality eyecare services.


Michael R. Dueñas, OD, FNAP
The American Optometric Association’s (AOA) focus is, first and foremost, to uphold and advance evidence-based standards of care that ensure patient health and safety. To that end, the AOA embraces telehealth and advanced technologies with ocular telehealth fitting into the matrix of patient care when it furthers patient health.

To accomplish these goals, telehealth technologies must:

1. Be responsible-science and evidenced based
2. Embrace patient health
3. Support the patient-doctor relationship


Importantly, ocular telehealth is not and should not be a substitute for medically-recognized eye health care, and most certainly should not (except in extreme cases) be considered a reasonable option for underserved communities to gain better access to eyecare, as they are already at higher risk for ocular disease, most often due to income disparities and excess environmental burdens.

As physicians, ECPs (e.g. optometrist, Doctor of Optometry) make critical diagnostic and treatment decisions about the care of their patients, based on patient attributes, standards of care, and the tools and technologies available to them. With this consideration, physician ECPs must be fully assured that “Virtual Eyecare Technology” used on patients is both safe and effective; being mindful that a manufacturer simply claiming safety and effectiveness is not definitive, and such claims may be misleading or biased.

Unfortunately, many vision, and eye virtual technologies are based on medical devices or apps that have never been classified, cleared or approved by the FDA. In the AOA’s view, this situation poses risks to the public, for reasons described in the AOA’s April 4, 2016 letter to the FDA, Center for Devices and Radiological Health, detailing its specific concerns regarding the Opternative app.

The AOA and our member doctors across the country were gratified that the FDA took decisive action to address the urgent health and safety concerns the AOA first identified in the April 4, 2016 letter. It is our hope that we are a step closer to a regulatory approach that holds all companies in the eyecare space to the highest standards, for the safety and well-being of patients.

We also look forward to advances in technology that help improve patient health and strengthen the patient-doctor relationship.


Sukumar Pandit, OD
Philadelphia Eyeglass Labs is a five-location eyecare practice in the greater Philadelphia area. As its director of optometric services, along with director of operations Steve Hoffner, we have been beta-testing the DigitalOptometrics tele-optometry platform for the past six months. We have been involved in the oversights, developments, proper implementation and usage of this exciting technology platform.

We are using the platform as an equivalent to in-person comprehensive eye exams while scaling in such a way that both increases the efficiencies of our operations and helps to serve a larger segment of the underserved patients in our communities. Essentially it allows me to be in two places at once. Patients are seen as usual in our flagship location in Center City. And remote patients are seen from our satellite office in Bensalem, Pennsylvania.

From my live dashboard I can easily see the progress of the remote patients as they go through pre-testing with the on-site technician and a refraction with a remote refractionist. The remote doctor dashboard is essential in helping me juggle my daily schedule between live and remote patients. It’s a good amount of busyness! One thing I love is the efficiency of being able to review all the pre-testing, fundus scans etc., while the patient is going through their remote refraction. Finally, when I appear on screen to greet the patient, I can clarify any details, go over findings and allow the patient to ask any questions they may have.

A lot has evolved since last October when I saw my first remote patient. For example, toric contact lens fits are not an issue. There are many other ways to utilize and adapt the platform for other practice modalities as well. I can guarantee that no matter how it is used, it will be fun and exciting for both patients and eye-care professionals. I honestly feel as if we are bringing the future of eyecare to the present.


Jonathan Rosin, MD
My practice serves the Chicago metro area with 43 offices, 44 optometrists and four ophthalmologists. Two issues relevant to this discussion are: maintaining a cost effective, efficient professional staff (ODs and MDs) and being as convenient as possible for our patient base. There are times when we require several doctors at various locations leaving other locations without doctors for part of or all of a day.

Like most of our industry, walk-in traffic represents an important retail revenue source for us. When there is no doctor in the office, we attempt to pre-appoint walk-in patients for another day or send them to the next nearest location where we are staffed. In a city like Chicago, a patient will likely pass by six or seven of my competitors prior to arriving at my next location. Not a very satisfactory situation for us, but it is a compromise that we have had to live with.

Telemedicine is now at a stage whereby remote comprehensive examinations, using our own doctors in a video consultation can be reliably performed so that we can cost effectively and conveniently care for such patients.

We also have patients that require urgent subspecialty care. Using sophisticated and widely available high resolution digital retinal cameras and slit lamp videography, a fairly thorough evaluation can be performed remotely by a subspecialist in our group without the delay involved in scheduling a patient for a visit elsewhere or sending them to the emergency room. In this way, a convenient consultation is performed, a working diagnosis can be made and a treatment plan is set in motion immediately.

Now, there are several issues inherent to this process that need to be addressed:

• Cost: There are significant capital investments that need to be made in order to incorporate telemedical services into an eyecare practice.

• Patient acceptance: Will the public feel good about this? Well certainly, if we can demonstrate that this approach really does work (and it does), the data suggest they will. A study performed in Australia involving the Outback Lions effort examined patient satisfaction after a telemedical eyecare consultation and none of the patients surveyed rated their experience as being less than “very satisfied.”

• Payment for services: This is a fairly new technology and several third-party plans fail to recognize the importance of this mode of patient care. However, given the large population of patients who value more convenience and those that require significant levels of eyecare (Baby Boomers that are coming at us like a locomotive with eye disease), I believe that providing easier access to providers through telemedical services will register positively with insurers.

What’s more exciting is what is to come by combining Artificial Intelligence systems that employ pattern recognition and deep learning software, high resolution photographic imaging, OCT imaging and perhaps digitized abberometry to telemedicine platforms. You end up with automated systems that can make diagnoses and correctly stage disease as accurately if not more accurately than human observers (doctors).

And, it is happening now. Such systems are being used in the area of diabetic retinopathy. It is not a quantum leap to envision retinal exams being performed in the endocrinologist’s office or even comprehensive examinations taking place at the local pharmacy.

This is disruptive and it may be threatening to some but, I strongly recommend that we, as eye-care professionals, take the lead by embracing these technologies and creating relationships with the industry to help further develop this important mode of care, thusly securing our role as the best custodians for our patients ongoing eyecare needs.


Daniel Stanton
Before I jump into the subject of telehealth I want to share with you my journey that ultimately lead to our telehealth solution.

I’ve been a student of the industry for the last 17 years. Most likely, I’m an admirer of you or your respective companies’ accomplishments. Early in my career, I realized that while the optical industry is complex and reports to many different governing bodies the purpose of the industry was to provide eyecare to individuals allowing them to see clearly.

At first, I thought this was just being able to provide them with a place to buy eyeglasses. What I have come to learn, however, is that the eyeglass purchase only addresses the customer need and while a person buying eyeglasses is a customer they’re also a patient.

Over the next decade, I worked directly with the idea that the customer is also the patient. Over these 20,000 hours it was clear to me that the patient was restricted to servicing their vision care because of one thing—access.

The patient has to go through such a journey, at such a cost, to see clearly. Unlike other countries where seeing clearly can be done during a lunch break, seeing clearly in the U.S. takes so long or is not available in the surrounding area that some opt out of vision screening all together. Also, unlike most countries where people update Rx and glasses frequently, in the U.S. we do it once every two years.

Obviously, like most, I thought if I can make glasses faster and sell them cheaper I’m providing the accessibility to the patient, however, that isn’t the case. I’ve learned the accessibility need is not providing them a place but rather a service. The service includes both eyeglasses and a vision treatment plan.

The treatment plan, the result of the exam, is and will always be the beginning of the journey to see clearly. That said, we’ve found telehealth to solve the industry issue of access. With telehealth the patient data can be accessed more efficiently. Efficient in both a timeliness and cost factor.

With telehealth a patient can simplify eyecare which we believe will encourage more frequent visits, as seen in other countries. The telehealth solutions need to uphold the same standards that the patient has become accustomed to. We’ve found not only in our results of patient surveys but also in our vision treatment plans that with the proper setup and execution we can provide the same experience and care to the patient via telehealth. We’ve found that with the right doctors you can exceed the patient’s expectations as well.

So, today, Stanton Optical and My Eyelab are executing this concept of easy eyecare not only through faster and less costly eyeglasses but also with telehealth solutions. The telehealth solution has allowed our doctors to focus on the clinical evaluation of the patient more so than the mechanical operation of tools. With much more complex health care procedures such as drawing blood, orthopedic knee replacement, LASIK eye surgery and hair transplants already using smart machines, it makes complete sense for the basic eye exam to evolve.

Telehealth has allowed patients more access to care at a lower cost. And, while telehealth scares the same naysayers that found it impossible for a machine, such as the non-contact tonometer (NCT), to replace the physical evaluation intraocular pressure, telehealth really is just another milestone in the adaptation of technology in medicine.

At Stanton Optical and My Eyelab we’re reducing our retail price by as much as 32 percent while adding more access to the patient. With telehealth, both the industry, and more importantly, the patient, are winners.

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