Our crash course in telemedicine will serve us well
If we resisted telemedicine in the past, COVID-19 changed that. It’s a change for the better.
In the past, although I appreciated telemedicine technology, the demand didn’t seem high enough for our practice to try it. When the coronavirus crisis began in March 2020, we started offering telemedicine as an option to help patients who needed us, and the relaxed government requirements to conduct this type of care made it possible for us to help patients via telemedicine.
Our task force laid out a plan, and we did our first virtual visit on March 19, 2020. Soon, we were doing 90 to 100 virtual exams per day. The strengths and disadvantages of telemedicine became clear very quickly — as did some likely applications of virtual visits for the future.
An efficient way to triage
Telemedicine’s strength as a triage tool was clear right away. We began grouping triaged patients into non-urgent and urgent telemedicine visits, which sometimes led to an urgent in-office visit. For less urgent needs we used virtual visits as a safe way to diagnose and treat via telemedicine. For more serious problems like flashes and floaters or vision loss, we gathered information and scheduled an in-office visit as soon as possible to explore whether those patients had a serious condition or exacerbation of a known problem.
Generally, diagnosis via video is best reserved for problems that can be easily observed or that can be reliably diagnosed based on the conversation. Non-urgent cases tended to involve chronic diseases like dry eye that we can diagnose with confidence through an in-depth history and then safely treat with warm compresses, changes in habits and environment, artificial tears and a trusted anti-inflammatory medication until we can see the patient in the office. Of the conditions we’ve diagnosed via telemedicine, the most common is dry eye disease, but we’ve also seen many patients with subconjunctival hemorrhages, allergic conjunctivitis, presumed viral and bacterial conjunctivitis, blepharitis and many other conditions.
Our virtual visits are much like in-person ones. A technician calls the patient and does the standard workup (chief complaint, signs and symptoms), gathers consent for a virtual exam and enters all that into the electronic medical record. Next, I call the patient over the phone or via synchronous video technology such as FaceTime or via a secure video application within our EMR.
Why dry eye?
Dry eye’s top spot among telemedicine visits likely stems from the condition’s overall prevalence, as well as the stress and demands patients have been placing on their eyes during the coronavirus crisis with increased screen time. If we see a patient in our office with a dry eye complaint, we can test osmolarity and inflammation and perform meibography, all of which are helpful, but we can just as easily diagnose this chronic and progressive disease state by talking to patients about their symptoms. We simply ask the right questions about symptoms, contact lens wear, activities when the eyes feel worse (screen time, reading), medications and health conditions. When a 40-year-old woman, for example, says she has decreased wear time in her contact lenses, and artificial tears no longer work, she likely has dry eye disease.
I do want to see patients back in the office at some point, but in the meantime, I want to manage their dry eye. I can prescribe a safe, trusted therapeutic and (now that coronavirus restrictions have lifted) see them in the office in 2 to 4 weeks just to confirm the diagnosis and make sure nothing else is going on. Once I’ve seen the patient face to face, dry eye is a great opportunity to continue long-term follow-up virtually, with only occasional in-office visits if symptoms change. EyecareLive is a telemedicine platform that focuses on treating dry eye using questionnaires that help quantify dry eye symptoms. This condition lends itself very well to virtual visits.
When to prescribe
My colleagues and I convened a 15-person consensus panel to discuss some of the ethical and medical-legal decisions encountered in telemedicine. For dry eye, we all agreed that prescribing a safe, trusted anti-inflammatory drug like Restasis (cyclosporine 0.05%, Allergan), Cequa (cyclosporine 0.9%, Sun Pharma) or Xiidra (lifitegrast 5%, Novartis) is within the scope of care. It’s appropriate and safe to prescribe it to new patients based on thorough questioning, as well as for any existing patient with a known history of dry eye.
We debated whether and how to prescribe corticosteroids based on virtual visits. The consensus was that it’s more acceptable to prescribe a corticosteroid to an established patient, but it can be considered for a new patient, if we follow up with a face-to-face exam within 2 weeks.
Following these guidelines, most corticosteroid prescriptions I have written have gone to dry eye patients. We saw some patients of ours with known histories of uveitis who had used a strong topical corticosteroid in the past and were prescribed the same during the COVID-19 pandemic through an urgent care facility’s telemedicine exam (without an eye doctor), and those patients actually had infectious ulcers from contact lens wear that were worsened by the steroid. That’s not common, but it shows some limitations of telemedicine as well as the necessity for eye doctors to take part in this arena, so patients get the right specialized care for their eyes.
The future of virtual eye care
Efficiency and ease of use make telemedicine a great patient experience. Although we’re all doing in-person eye exams now, we’ve seen a continued preference for virtual visits from people who are younger, traveling, very busy with work and parenting commitments, or have health or transportation challenges that make it hard to come in.
This is a very appropriate trend for eye care — one that is here to stay.
For more information:
Josh Johnston, OD, FAAO, practices at Georgia Eye Partners in Atlanta, where he oversees the Georgia Eye Partners Dry Eye Treatment Center of Excellence.
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