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Ensure quality patient care as telemedicine becomes commonplace
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As primary eye care providers we should be aware, alarmed and fully prepared to face an evolution that may disrupt the way eye care is delivered. The telemedicine train has already left the station and is on its way to you.
Lyft and Uber disrupted the transportation industry by making millions of dollars without owning a fleet of cars. Uber is expanding into ambulance services and driverless cars. Airbnb is disrupting the hospitality industry without owning a hotel. Health care is no exception, although it has been much more challenging and difficult to disrupt because of the stringent federal and state regulations.
DNA, lab testing
Numerous private ventures have succeeded in marketing their health care products; however, direct-to-consumer genetic testing offered by 23andMe and blood testing by Theranos have encountered obstacles to mainstream adoption due to pushback from the FDA.
For $199, 23andMe will test your DNA through a do-it-yourself saliva test without needles or blood. Results are available online within 6 to 8 weeks. You can receive 60+ personalized genetic reports; understand what your DNA says about your health, traits and ancestry; and find out your ancestry across 31 distinct populations worldwide.
Theranos’ marketing message is that you would not go to a grocery store that did not have price tags – why should getting a blood test be any different? It lists all the prices for the available tests, many of which are often less than the insurance co-pay. More than 140 of its tests cost less than $10. The testing centers are located ubiquitously at Walgreens stores, which increases convenience. For example, a search of Glendale, Ariz., yielded 45 Theranos Wellness Centers. Moreover, smaller needles and tubes (Nanotainers) are used to collect venous blood, and you can search for a nearby primary care physician to help interpret your results.
Image: Koh LV
Quickly maturing field
Disruptions in the laboratory testing arena are only the beginning of a broader wave crashing onto the health care shore because the concept of telemedicine is maturing fast with rapid advances in information technology. The American Telemedicine Association formally defines telemedicine as the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status.
Telemedicine is not new; it started more than 50 years ago as a way to extend care to patients in remote areas. In 1964, Norfolk State Hospital had an interactive video link to the Nebraska Psychiatric Institute, a distance of 112 miles. In 1967, Massachusetts General Hospital delivered medical care remotely to patients at Boston’s Logan Airport.
The two forms of telemedicine are the “store-and-forward” technique used in teleradiology and telepathology and the live interactive audiovisual technique used in teleconsultation in primary care and psychiatry. Now, telemedicine is an integral part of more than half of the hospitals in the U.S. and growing. Moreover, it is not limited to hospitals but spreading fast across all health care sectors.
The global telehome and teleclinic market is expected to grow from $23.8 billion in 2016 to roughly $55.1 billion by 2021. According to the firm Ken Research, the U.S. telemedicine market generated approximately $10 billion in 2013 and is expected to grow to $38.5 billion in revenue by 2018, with an annual growth rate of between 18% and 32%. Teladoc (NYSE: TDOC), a health care service connecting patients to one of 700 board-certified doctors via the telephone, became the first publicly traded telehealth company in July 2015 with a market capitalization of $450 million. SOCTelemed provides emergency teleneurology, telepsychiatry and teleintensivist consultations in partnership with local hospitals to improve access to specialty care.
Telemedicine in pharmacies
In the realm of primary care, in addition to Teladoc, national pharmacy chains are getting into the telemedicine arena. Walgreens offers telemedicine through the telehealth company MDLive, which provides access to board certified doctors, pediatricians and therapists. The cost per visit for medical conditions is $49 via the Walgreens MDLive mobile app or website. Walgreens has 8,177 stores in all 50 states, and many of them have Wellness Center clinics.
CVS Health works with three major telehealth companies to provide patient care: Teladoc, Doctor On Demand and American Well. American Well, a partner of the Cleveland Clinic, is in 7,800 retail drugstores, including 1,000 walk-in CVS MinuteClinics. They charge $25 for diet and nutrition advice, $49 for urgent care and $95 for online therapy. Doctor On Demand charges $40 for a visit with a medical doctor, $50 for a 25-minute session with a psychologist and $40 for a 25-minute session with a lactation consultant. Furthermore, Doctor On Demand also provides telemedicine kiosks in Wegmans Food Markets.
Rite Aid Corp. collaborates with HealthSpot, a telemedicine provider, to provide telehealth kiosks at Rite Aid stores in Ohio. The service offers a 15-minute video conferencing visit with a board-certified physician for $59 to $79. Similarly, Rite Aid also has RediClinics and operates nearly 4,600 stores in 31 states.
The common denominator shared by these companies is to move into a new paradigm of health care that gives more power to the patients, as discussed in a recent book by Eric Topol, director of Scripps Translational Science Institute, The Patient Will See You Now. The ultimate goal is to make health care as accessible as coffee, within 5 miles or on your couch.
Telemedicine in optometry, dentistry
Dentistry and optometry are not spared. Virtudent, a Harvard innovation lab company, has developed a new dental care delivery model that brings the dental office to patients with basic diagnostic and preventive visits bi-annually. It handles all logistics and directly bills the dental insurance carrier.
A similar model is marketed for eye care by Pupil, which provides on-demand mobile vision screenings to prescribe eyeglasses for customers in its coverage area. It claims to advocate for optometry via its networked optometrists and recommends comprehensive eye exams be done at least once every 2 years. It refers patients to local practitioners if needed. Each exam takes about 30 minutes. The eye exam is free, but it costs $75 for the spectacle prescription and doctor review.
By now most optometrists have heard about Opternative, a Chicago start-up that provides an app to estimate customers’ refractive errors, which are then sent to a licensed, local ophthalmologist to sign as a new prescription for glasses or contact lenses. The online refraction, albeit marketed as an eye exam, is available in 33 states, and the cost is $40 for each prescription or $60 for both glasses and contact lens prescriptions.
Moving beyond online refraction are online spectacle and contact lens services, including 1-800 CONTACTS and Lens.com in the contact lens arena, and Warby Parker, GlassesUSA and Zenni in the spectacle arena.
Recently, Opternative forged a partnership with 1-800 CONTACTS to bypass a contact lens exam at the doctor’s office altogether, which is disconcerting because contact lenses are a medical device. Multiple risk factors need to be ruled out, and advanced training and education are required to ensure that the patient experiences safe contact lens wear.
Regulatory oversight
The health care industry is being bombarded by disruptive forces fueled by advances in technology to deliver care directly to patients. All of these new ventures, however, have not been smooth because of stringent health care regulations to protect the public and resistance from medical organizations who are concerned that some of the new technology undervalues the importance of the patient-doctor relationship. Suspicions abound regarding the profit motivations of venture capitalists as the primary driver over patient care.
For example, the FDA issued a warning letter to 23AndMe in November 2013, and the company halted its service for a few years. The FDA called Theranos Nanotainer vials an “uncleared medical device” in October 2015. Walgreens has since rescinded its relationship, and Theranos lost its certification for its flagship lab in Newark, Calif., and had to void 2 years of its test results. The Texas Medical Board and Teladoc have been entangled in a battle over telemedicine rights and services in the state since 2011. The American Optometric Association filed extensive FDA complaints against Opternative in April 2016. Despite the numerous hurdles these companies have faced, they have raised millions of dollars in venture capital to overcome such challenges.
Current health care trends are moving more toward a direct-to-patient model via telemedicine or at mini-clinics. Telemedicine has become an extension of the traditional model of medicine and is being integrated across U.S. hospitals. Many patients have already experienced the convenience of having genetic tests in a kit, blood tests using Nanotainers, video medical consults, smart phone vision tests and online purchases of eye wear. The business model of Starbucks, Airbnb and Uber is spreading to the health care industry as patients are facing higher deductibles and reduced access to the traditional health care delivery model.
As primary eye care providers, we need to be aware of what is happening, how it may impact our profession and, most importantly, know what we can do to provide timely, quality and affordable care to our patients and ensure the health of our profession in the future.
- References:
- Global Markets for Telemedicine Technologies. BCC Research website. Updated May 2016. http://goo.gl/f2Yxu3.
- Ken Research, The U.S. Telemedicine Market Outlook to 2018 – Rising Penetration of Telehome Care and mHealth. Ken Research website. Updated June 2014. https://goo.gl/p2ycX1.
- MDLive website. www.mdlive.com/consumer/getapp.html.
- For more information:
- Kevin Helmuth, OD, is assistant director of clinic operations and an assistant professor at Midwestern University, Arizona College of Optometry in Glendale, Ariz. He can be reached at khelmuth@midwestern.edu.
- Len V. Koh, OD, PhD, MBA, FAAO, is an associate professor at Midwestern University, Arizona College of Optometry. He can be reached at lkoh@midwestern.edu.
Disclosure: Helmuth and Koh report no relevant financial disclosures.
Acknowledgment: The authors would like to thank Dr. Joshua Baker, who dedicated his time and expertise to reviewing this article.
Perspective
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Justin Bazan, OD
I havent been around for other medical or technological evolutions, but Im pretty sure all of them brought heated debates and high emotions. The technology revolution that we find ourselves in surely creates much drama. I myself have struggled with just how much of this new technology is safe to utilize and embrace.
Despite my reputation as being an early adopter of new technology, Im cautious to embrace any technology that does not have the support of the American Optometric Association. Current technology, such as Opternative, does not have their endorsement.
There are numerous reasons for a telemedicine company not to gain their endorsement, but for me the most important ones are that many of these emerging technologies dont allow for care to follow current AOA guidelines or optometric standards of care. Im definitely not in favor of any technology that allows for a patient to receive a contact lens Rx without a slit lamp examination of both the eye and the contact lenses. In my opinion, many of these first-generation telemedicine apps and programs will be utilized to help patients circumvent optimal care. People are put at risk.
Right now it feels to me that many of these companies are putting their wallet before their concern for whats best for the patient. Id like to ultimately see the emphasis on providing technology that does not sacrifice care, but truly enhances it.
Telemedicine will continue to evolve. It needs to do so at a pace that keeps the patients best interest at heart. One day I can foresee it reaching the point where proper care can be provided; however, we are not there yet.
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Kim Castleberry, OD
All I ever wanted in practice is an unfair advantage. Technology has afforded my practice just that. Telemedicine is an opportunity to advance care for my practice beyond my four walls. It makes no difference to me if its examining a posterior vitreous detachment patient remotely with my 3-D Wave (Marco), OCT and Optomap (Optos) or using portable refractors to manage optical needs in another location. I will utilize any tool I can to advance and improve accessible care to my patients both on site and off.
They say it takes a village to raise a child. I think the same is true for telemedicine. It takes a village of telemedicine devices working in concert, managed by doctors, to provide a competent level of care to an increasingly demanding, mobile and aging population. I think these new developments can also assist care givers in mission fields and provide countries without adequate doctors a way to deliver vision care to those who otherwise would suffer. I am more concerned with finding accurate valid devices that work than any perceived competitive threat.
Give me the technology and I will find a way to compete. I have learned to feed between the feet of giants over the past 34 years utilizing technology. Telemedicine will continue to give me all I ever wanted in practice: an unfair advantage.
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Andrea P. Thau, OD, FAAO, FCOVD, DPNAP
The American Optometric Association upholds high-quality patient care and supports evidence-based innovations that further patient health. Proven technologies such as OCT have changed the practice of optometry and enhanced the ability for doctors of optometry to provide superior patient care.
The fact is the current online/app options are not tested and do not deliver a proven care model. They give patients a false sense of security and potentially miss serious eye or health conditions, and these concerns were validated in a recent media investigation on Good Morning America, when a volunteers risk factor for glaucoma elevated intraocular pressure was completely missed by Opternative.
The potential for significant health consequences underscores why AOA has taken a strong stance against online vision tests and filed a formal complaint to the FDAs Center for Devices and Radiological Health, citing Opternatives continued marketing to consumers without federal approval and without the FDAs formal review of the products claims under the Food, Drug and Cosmetic Act. And AOA is not alone. Key members of Congress are joining states and the AOA in the call for the FDA to act. To date, 11 states have enacted laws regulating the usage of these unproven technologies.
Online eye tests rely on unproven technology that has never, to our knowledge, been shown to be safe or effective in accurately determining a lens prescription. Use of this unproven technology could result in the forgoing of an in-person comprehensive eye examination by an eye doctor that is designed to diagnose and treat a variety of conditions that, left undiagnosed and untreated, can result in permanent vision loss or ill effects on a persons health.
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