Solving Ophthalmic Telehealth Issues Requires New Tech and Regulatory Clarity, Surgeon Says

Telehealth’s future in ophthalmology is teetering between potential and uncertainty, according to Grayson W. Armstrong, MD, MPH, an ophthalmologist at Massachusetts Eye and Ear in Boston and instructor at Harvard Medical School.

The American Medical Association interviewed Armstrong on telehealth in a video posted Aug. 12 on the AMA’s website.

The pandemic propelled telehealth into mainstream use, but it also highlighted current technical and regulatory challenges in ophthalmology, which lagged other specialties in its ability to use telehealth effectively during the shutdown, Armstrong said.

Solving the technical challenges requires clarifying the regulatory environment so hospitals and other stakeholders know how much and where to invest, he said.

Current Technical Limitations

Topping the list of current challenges is the eye exam itself, Armstrong said.

“Ophthalmology is an exam-heavy specialty, and we really rely on all the clinical clues that we capture either at the slit lamp or looking at the retina or checking people’s vision and eye movements,” he said. “Those things don’t readily replicate into a telemedicine environment.”

Historically, ophthalmology was ahead in the telehealth game, Armstrong said, developing the capability for remote fundus imaging and implementing it in various environments. But it was asynchronous treatment, with the scan taking place at one time and the patient visit at another.

Ophthalmology was not ready during the pandemic to capture data synchronously in real time through Zoom or other video sharing software, he said.

Armstrong pointed to the slit lamp, which he described as a fancy microscope for the eye, as an example of such limitations, saying the slit lamp is used in nearly all ophthalmology exams, but it is not digitized, which would be more useful in a remote environment. He said his hospital is working with Massachusetts Institute of Technology to create a digitized slit lamp.

Potential Best Telehealth Model

Armstrong said he believes the best telehealth model will turn out to be a hybrid one, which puts eye care diagnostic tools in the heart of a community, allowing patients to go into any number of eye exam offices, get their testing done, and go home. An ophthalmologist will perform the telehealth visit later, reviewing the data from the testing and having an intelligent conversation with the patient.

This model improves health equity, providing access to care for patients who don’t otherwise have it, Armstrong said.

It also improves eye care for patients in general, cutting down their time at the office.

“I’ve been able to see patients while they’re at work or with their families or on trips, and it doesn’t take them away from their life to come into the office to see me,” Armstrong said. “Overall it’s more convenient for everybody.”

He sees the same model as a solution for emergency rooms, with emergency care providers performing initial testing and ophthalmologists remotely using that information to make some initial decisions on the fly.

Armstrong said ophthalmologists just have to get all the pieces in place to be ready to implement telehealth on a broad scale.

To that end, Massachusetts Eye and Ear has created a telemedicine curriculum for its ophthalmology residents that covers how to conduct a remote exam, create the appropriate environment as far as what appears in the video, evaluate which patients are best for remote visits, avoid inappropriate care (such as conducting an eye exam with a patient who is too far away from care to get that care), and manage billing.

Regulatory Hurdles

Regulatory issues that need to be clarified include whether private insurers will be required to pay for telemedicine once the pandemic is over; how rules may change regarding using video technology that is HIPAA compliant; and how phone visits will be reimbursed.

Armstrong said a lot of eye patients can’t see or are elderly, and his hospital has often used phone telehealth visits during the pandemic, which he said have been just as effective as video.

Licensing Restrictions

A challenge that Armstrong did not address but one that is pitting high-powered stakeholders against one another is licensing restrictions, Kaiser Health News (KHN) reported Aug. 31. 

US states are starting to roll back pandemic workarounds that allowed licensed clinicians to have virtual visits with patients in other states.

As a result, Johns Hopkins Medicine in Baltimore had to notify more than a thousand Virginia patients that their telehealth appointments were “no longer feasible,” due to Virginia returning to pre-COVID-19 restrictions, KHN reported. Johns Hopkins has hosted more than 1 million televisits since the pandemic began, with about 10 percent of visits in states where it does not operate facilities.

A doctor at NYU Langone Health told KHN that some patients are simply driving across state lines and make a Zoom call from their vehicle to get around such restrictions.

Stakeholders include medical boards that don’t want to cede authority; states that don’t want to lose licensing revenue; providers who are split over the issue, with some wanting to practice across state lines and others fearing the added competition of out-state practitioners; and consumers.

The AMA appears to side with the state border restrictions for oversight reasons (investigating incidents), KHN reported.

At least 17 states still have waivers in effect, allowing interstate visits, according to the Alliance for Connected Care, a lobbying group representing insurers, technology companies, and pharmacies.

Arizona and Florida allow out-of-state providers to register with the state to practice telemedicine in the state.