As ophthalmic practices reopen in the COVID-19 era, telehealth will play a major role. Presenters at the ASCRS Virtual Annual Meeting 2020 discussed how virtual technology can be integrated into revised patient flow to reduce infection risk.
Not every aspect of ophthalmic practice can be virtualised, especially advanced diagnostics, slit-lamp examinations and, of course, surgical procedures. So, the first task is determining what steps can and cannot be done remotely – and explain to patients what will be done at home and in the office and why, said Vance Thompson MD, of Sioux Falls, South Dakota, USA.
For a refractive cataract practice, talking with patients, educating them in real time or with videos, reviewing information from referring physicians, registration and insurance, and counselling them on their vision needs and premium lens choices can all be accomplished remotely, Dr Thompson said.
“That is a lot of time in the office that can be done at home.”
Before COVID, most of these steps took place in the office, Dr Thompson said. Now, educational videos must be watched, and technician interviews and counselling done remotely.
Inside the clinic, half of waiting room chairs have been removed to ensure safe social distancing. The parking lot and patients’ cars are now the first stage of the waiting room. The office texts patients when they are ready for the waiting room.
On surgery day, testing is double checked in the clinic only as necessary and patients are counselled in person and signed consent forms collected before surgery, Dr Thompson said. He suggests mapping out the patient’s journey before and after arriving at the office to ensure a positive experience. Satisfied patients are more likely to choose a premium lens that better meets all their visual needs, he added.
Trial and error
Ranya Habash MD, medical director for technology innovation at Bascom Palmer Eye Institute, Miami, USA, outlined steps for integrating telemedicine based on her institute’s experience to date.
“New telehealth visit types have been key to adapting to a changing healthcare environment,” she said.
First, providers should go through the patient schedule and proactively determine which patients and which types of visits can be done remotely. These include urgent care telehealth visits, pre-procedure counselling, routine follow up and consultations with other physicians, Dr Habash said. A quick look at a televised image can help an ophthalmologist determine if redness can be treated at home with artificial tears or is a condition requiring immediate attention that may not be apparent to a general practitioner.
Choosing a telemedicine platform is important. Many commercial options are available including Doximity, Skype, Zoom, FaceTime and Microsoft Teams. In the USA, some privacy regulations have been relaxed to allow these platforms to be used.
Be sure to include technicians and scribes in telemedicine practice and create templates for each kind of visit to ensure no important points are overlooked, Dr Habash said. At Bascom Palmer, registration personnel call patients to schedule them, and a technician calls 24-to-48 hours in advance to confirm the appointment and ensure the patient has the video platform needed. A coordinator schedules technicians and scribes 24 hours in advance of the visit, and initiate calls and workups before patients speak to a physician.
Safety is particularly important consideration, said Elizabeth Yeu MD, of Eastern Virginia Medical School and ASCRS Secretary. In a recent survey of 5,500 patients, depending on location, about one-quarter to two-thirds expressed nervousness about receiving elective health services. She recommended contacting patients and communicating with them prior to their appointments about what your clinic is doing differently to protect them, what they should expect, and any differences with future appointments.
“Traffic jams” at patient check-in and check-out and within the testing and diagnostics area challenge physical distancing. The check-in and out areas in her clinic have thus been separated, and there are also free-standing check-in kiosks within a check-in tent directly outside of the office. Patients are advised to show up no sooner than 10 minutes prior to their scheduled appointment, and family and caregivers now wait outside in their cars, or in tents or a gazebo.
Initially, Dr Yeu’s clinic tried to split three-hour appointments for new cataract and glaucoma patients into two shorter appointments. But patients overwhelmingly preferred one longer appointment. To accommodate, clinic schedules now start earlier and end later with fewer appointments scheduled per hour. Remote telehealth visits for post-op day-one appointments for routine cataract surgery have proven very popular. The perioperative kit has been adjusted to include Diamox immediately after surgery and brimonidine for one week after surgery to prevent IOP spikes.
Dr Yeu believes even more services, including panretinal photography and possibly even slit lamp exams may one day be possible remotely. “We believe the technology will allow it soon.”
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