Comprehensive Eye Exams with a Distance Provider
A quality comprehensive eye examination can be done without a doctor being physically present. The quality of this exam can exceed all standards of care presented list by the American Optometric Association and the American Academy of Ophthalmology. The quality of care given is ultimately the responsibility of a licensed professional utilizing their clinical judgement based on all of the available information.
Rule #1 is that a responsible clinician is making decisions that are best for the patient after considering all related factors that could affect the patient’s care – including the quality of the available data.
In considering incorporating a Distance Provider service into your practice, the step is to list the tests that are essential for you to consider the exam “comprehensive.” Consider it from the perspective of delivering responsible care to your patient and requirements to get paid by 3rd party payers.
List the tests you need:
History
Visual Acuity
Lensometry
Pupil Reactivity
Extra Ocular Motilities
Visual Field
Keratometry
Corneal Topography
Tear Osmolarity
Blood Pressure
Height and Weight
Binocularity
Objective Refraction
Subjective Refraction
Irideocorneal Angle Measurement
Slit Lamp
Posterior Pole Evaluation
Peripheral Retinal Evaluation
Stereo View of Retinal Structures
Dilated Fundus Exam
Conversation with Patient
Others
Many of the tests listed have specifics that need to be considered as well, like the structures that you need to evaluate with the slit lamp or the levels of visual field testing required for a standard exam.
Once your required testing is defined, determine how to collect that information and upload it to a place where the doctor can evaluate it. The most efficient method of for a system when digital information is automatically uploaded. The technology is here, but it is also expensive.
Most practices have already invested in sufficient equipment that will allow for data to uploaded directly into a patient’s record, such as autorefractors, autolensometers and other data devices. Digital retinal cameras and other imaging devices are relatively common in modern eyecare practices and Optos now allows viewing images from anywhere.
Today’s slit lamp cameras, in the hands of a skilled technician, can effectively capture high quality, detailed images and videos from a slit lamp. All of this equipment varies widely in quality and the necessary skill needed from the onsite staff.
Subjective refractions can be delegated to an on-site staff member using traditional manual phoropters. With digital phoropters that can controlled by a control panel, this test can be done by a technician or doctor who is not present in the room with the patient. Most manufacturers of digital phoropters now can be operated remotely.
Once the equipment requirements are mapped out, a tool to upload the data is needed. A cloud based EHR is a fairly essential component for this. A place to upload the data and images that can be viewed by the doctor and a place to document the findings.
And finally, a connection tool like Zoom for Healthcare. The exam room will need to be equipped with a quality webcam and speaker to talk to the patient. Consider the position of the doctor’s image in relation to the patient. Put the monitor as close as possible to where a doctor would sit if they were in the room.
Develop a technique that enhances your relationship with your patient. Typically, we talk with our patient and continue the conversation while we conduct a variety of tests and the conversation directs the testing to some degree. In this “data-driven” exam, all the data has been collected and evaluated and your treatment decision may be mostly made before you ever talk to the patient. The point is it’s different.
An effective technique is to begin with open-ended questions first. Then review the findings with the patient and show them something with a screen share, retinal images are always good. Review the plan and make recommendations.
As you can see, the set up is complex, but once you establish your system, the exams can be smooth and effective.