Rethink Tele-Optometry: A Noble Choice to Provide Underserved Patients High-Quality Eye Exams
Conversations with Mike Rothschild, OD, and Sukumar Pandit, OD
WHAT IS TELE-OPTOMETRY?
Dr. Rothschild: Tele-optometry is simply, “the practice of optometry when the doctor and the patient are not physically in the same place when the care is being provided.”
So, if we reply via text or e-mail when a patient sends us a selfie of their eye and asks if they need treatment, we are practicing “tele-optometry.” It is important to note that our liability and responsibility is the same as it would be if we saw them in-person. As the professional, we owe it to the patient to make sure the information that we collect is adequate to provide proper care.
Dr. Pandit: In other words, tele-optometry is one more option in eyecare that increases choice for both the patient and doctor.
During the pandemic, most of us got used to doing things virtually that we had previously done in-person. In the world of optometry, patients may be more open than ever before to having their exam done by a doctor who is not in the same room with them, or even in the same office. The doctor, in fact, could be anywhere, and the patient would still get the same great, in-depth exam. This can be done via tele-optometry.
HOW DID YOU GET STARTED WITH THIS NEW APPROACH?
Dr. Pandit: I didn’t realize it at the time, but my first experience with tele-optometry was in 1999 at the Joslin Diabetes Center in Boston. We were assessing diabetic retinopathy remotely via fundus scans in Native Americans.
Since then, I have used tele-optometry to cover a satellite office with patients and no in-person doctor, to continue eyecare during the pandemic and to provide comprehensive eye exams while working from home.
Dr. Rothschild: I began a new practice in 2019, before the pandemic, with the intention of finding a way to deliver high-quality, comprehensive eye exams with a remote provider. My motivation was to help bring doctors, virtually, to underserved, rural areas. There is a growing problem in these areas to provide adequate coverage.
ANY READING RECOMMENDATIONS FOR ODS LOOKING TO GET STARTED?
Dr. Pandit: In her article “The Tele-Optometry Platform Expanding Reach without Compromising Quality of Care,” Dr. Noelle Tchang, our the Director of Professional Services at 20/20NOW, describes relatable scenarios for different clinic setup. The gist is: Tele-optometry is not for everyone and yet it is an alternate business model worth considering if it fits your business and practice model.
This is another great reference: American Telemedicine Association’s two-part statement about remote ocular health assessments, telehealth disease monitoring and the need for telehealth in the eyecare arena. The first part addresses the elements needed to provide high-quality remote eye exams, and the second part addresses the need for telehealth as a tool for eyecare delivery.
TRADITIONAL VS. TELE-OPTOMETRY, IS THERE A DIFFERENCE FOR THE PATIENT?
Dr. Rothschild: When I implemented tele-optometry in my practice years ago, the patient experience we provided was identical to a traditional eye exam; they were checked in at a front desk and then taken into a pre-testing room where a technician performed a variety of tests. Several instruments were used to capture images and take measurements.
When the patient was escorted into the exam room, the doctor entered via the computer screen instead of walking in the door. At this point, the doctor—who was online—had already read the history forms, reviewed the images and other data and could conduct the phoropter testing remotely.
Then, in a face-to-face conversation, the doctor talked directly to the patient and addressed any concerns they may have had. At the end of the exam, the remote optometrist turned the patient back over to support staff for eyewear selection, contact lens fittings, additional testing or referrals, if necessary.
SO, IT SEEMS LIKE THE DOCTOR STILL OWNS THE PATIENT EXPERIENCE.
Dr. Pandit: Absolutely. With 20/20NOW’s model, the process is essentially the same today. However, I would like to emphasize the role of the doctor at the center of a tele-optometry exam.
As Dr. Rothschild described, once the data collection is completed, I will remotely conduct the live clinical review with each patient. Based on the exam results and our conversation, I will give the patient a prescription or refer them to an in-person optometrist or ophthalmologist.
20/20 Vision Services, PC, employs or contracts with doctors throughout the U.S. to cover its professional operations in 38 states. Our doctors are responsible for driving test results assessment and a live clinical review with each patient.
My role as the clinician does not change; data collection is simply delegated to staff.
WHAT IF AN OD WOULD LIKE TO CONTINUE TO BE THE MAIN PROVIDER?
Dr. Pandit: I would defer to our business development team for specifics, but to my knowledge, this is not a setback at all. Tele-optometry services offered by 20/20NOW are highly flexible, with remote work options for optometrists or the option to work with our team of remote optometrists.
If this is something you are contemplating, take advantage of the complimentary consultations available to you because regulations may vary from state-to-state.
HOW COMPREHENSIVE IS THE DATA PROVIDED BY A TELE-OPTOMETRY EXAM?
Dr. Rothschild: Today’s diagnostic equipment captures incredible data and images that can be uploaded and reviewed by an OD anywhere in the world. We had an instrument that measured auto-refraction, corneal topography, wavefront-based abberometry, anterior segment analysis, pachymetry, tonometry and even pupil testing.
The anterior segment analysis is an important piece to assure that the angles are open when you can see the patient in-person. Our fundus camera doubled as a visual field, and we also utilized wide-field images. We also utilized auto-lensometry. Slit lamp images are taken by technicians in the exam room.
All of this was uploaded, so the doctor could review before logging in to see the patient. This is the same in most tele-optometry practices today with the addition of an automated phoropter that can be controlled online, so while the doctor is in a video call with the patient, they can conduct subjective refraction testing (“better, one or two”) just as if they were in the room.
There is an opportunity to enhance tele-optometry even further by using Visionix equipment. Multimodal diagnostic systems provide varying combinations of test modules including pachymetry measurements, angle measurements, autorefraction numbers, topography, tonometry, keratometry values, Scheimpflug imaging, as well as anterior and posterior segment photos.
VX 650 by Visionix anterior and posterior segment analysis combines data from 10+ standalone devices
CAN YOU SHARE A SAMPLE OF REPORTS TO SUPPLEMENT THE CLINICAL REVIEW?
Dr. Pandit: Yes. For example, here is a view of the fundus of a diabetic retinopathy patient using the Nexy fundus camera by Visionix.
Here is one example for anterior segment analysis using one of multimodal VX screeners. You can see the angles and anterior chamber depth.
If you are seeing many patients with dry eye symptoms, this is a great counseling tool to explain the cause for redness, why and how to manage it.
These are just a few examples. And, thanks to the recent strategic alliance with Visionix and 20/20NOW, all of this can be collected seamlessly with the doctor remote from the patient. You can even monitor eye disease progression for returning patients!
It is helpful to have everything I need to know during the clinical review.
SO, IN A NUTSHELL, WHAT IS THE “NOBLE PURPOSE” OF TELE-OPTOMETRY?
Dr. Pandit: Improving access to provide high-quality care for more patients. Tele-optometry, at its core, promotes healthcare equity and better treatment outcomes. It presents another way to address an inequality: # of eye exams > doctor availability.
The difficulty many patients have finding an eye doctor can be easily addressed via tele-optometry.
We have always worked in multiple locations to get to where the patients are. This gives us the chance to see a patient in California and Georgia within a few minutes, even if we are in the Northeast, or anywhere else.
Expanding access to care is vital, as ODs are often the first to catch sight-threatening and health-threatening conditions. I have been the first to tell patients they have hypertension, elevated cholesterol, diabetes, glaucoma and possible intracranial hypertension.
Tele-optometry provides a way to determine a patient’s treatment needs and eyewear prescription while still maintaining the ethical standards of ocular disease assessment.
Mike Rothschild, OD, is the Director of Practice Development for Vision Source and the founder of Leadership OD, a practice management consulting company. He can be reached at: mrothschild@LeadershipOD.com
Sukumar Pandit, OD, is the president of Pandit Optometric Corporation. He is also a tele-optometrist with 20/20Now. To contact him: spandit@for2020now.com
