his has been in the works for several years and it was finally released and published on the organization's website. The National Association of Vision Care Plans (NAVCP) is comprised of the managed vision care plans that provide routine eye care, glasses and contacts to their members; VSP, EyeMed, Versant, etc. They promote advocacy for vision care benefits, administrative simplification and industry collaboration.
A common question in teleoptometry is, "Do the VCP's cover telemedicine services?" and there hasn't been a very good answer because there hasn't been an official policy.
Yesterday (July 8, 2020) , the NAVCP put out this press release announcing the approval of a policy statement for the organization. There was input from a wide variety of stakeholders and I was able to contribute as a member of the Ocular SIG of the American Telemedicine Association and a member of Vision Source. While they didn't put in all of the suggestions from these groups, they did capture "Rule #1," which states that providers must use all available information to do whatever is in the best interest of the patient.
The various plans are not obligated to follow these guidelines, but are expected to quickly develop clear policies with this policy paper at the core.
This is a pretty big step. We would love to know what you think.
Video Presentation - TeleOptometry Today
This video message from Mike Rothschild, OD is an abbreviated version of our newest presentation, TeleOptometry Today. Watch this message about where we have come from, where we are now and why it is critical to determine where we are going now.
Telehealth Billing Rules
We get a lot of questions about proper billing and coding of telehealth visits. The truth is that the rules are changing so fast, that we are having a difficult time keeping up.
During the National Emergency related to the pandemic, many of the billing restrictions have been lifted. There is a lot of uncertainty about the continuation of these policies as the crisis ends.
For now, we are referring folks to the general (easy) overview article recently published by mend.com.
Day Four Report from the American Telemedicine Association
Day 4: The Lawyers Spoke
It turns out that there are still rules and they are being enforced.
This lecture woke me up to two facts:
1) Even the we received many waivers to the regulations that affect how we practice and bill, we still are responsible to know the law and to follow it.
2) They are people who use the expanding technology to blatantly violate the law and decency for their own benefit even if it hurts people.
It’s really hard for me to sit through a legal lecture, but it was good for me to hear all of these speakers deliver their messages.
It began covering some of the recent waivers from federal agencies that allowed and fueled the massive expansion of telemedicine services, including the addition of 80 new CPT codes and the relaxation of HIPAA while retaining “good and faithful efforts”.
It seems like we are being told, “just do right.”
The presentation also included an outline of the overlapping, and often conflicting, layers of regulations. As the rules change and (potentially) change back, there will be confusion and uncertainty.
The Bad Guys
Several case studies were presented on groups using telemedicine to cheat the system. Operation Double Helix investigated a Cancer Genetics company who allegedly paid doctors to order unnecessary tests and bill Medicare billions of dollars. These doctors never saw the patients when ordering the tests and never provider the results. All with telemedicine.
In April 2020 (middle of the relaxed restrictions) Operation Brace Yourself charged telemedicine companies with providing kickbacks for DME providers of needless neck and back braces.
Criminal telemedicine cases all have limited communication between the patient and doctor, provide prescriptions that are unwanted or not needed and route prescriptions to a specific provider.
Now What?
The Public Health Emergency was originally established for 90 days then extended for 90 more. It is scheduled to end in July. There is a great deal of speculation as to what will happen when the declared emergency ends. Some rules policies can be extended with a simple rule change, others require a literal act of Congress.
Nobody knows.
For those of you who like the details, you should read this.
Day Three Report from the American Telemedicine Association
Day 3: What’s in a name?
I have heard many lectures from experts in a wide variety of healthcare professions. “TeleCritical Care”, “TeleCardiology”, “TeleDermatology”, “TelePsychatiriy”, “TeleNutritional Coaching”, “TeleStroke”, “TeleMental Health” and “TeleOphthalmology” are terms that different professions are using to describe the services they are providing via telehealth.
I have searched for eye care lectures, posters and research was disappointed by one word conspicuously missing word, “TeleOptometry.” Look at this list of titles:
Advancing Adoption of Teleophthalmology in Primary Care through Stakeholder-Engaged Implementation (Oral Presentation) - Yao Liu, MD
Cloud-Based Improvement of Patient-Provider Communications Regarding Free-Clinic Retinal Screening (Poster) - Andrés Eduardo Guerrero Criado, MD Candidate MSIII
Diabetic Retinopathy & AI: Machine Learning in Ocular Health (Panel)
Key Attributes for Implementing Teleophthalmology to Improve Diabetic Retinopathy Surveillance (Poster) - Flaum Eye Institute, Department of Ophthalmology, University of Rochester Medical Center
Telemedicine with an Ultra-widefield Camera for Diabetic Retinopathy Screening (Poster) - Patrick Le, University of North Carolina School of Medicine
Validation of computer-aided diagnosis of diabetic retinopathy from retinal photographs (Oral Presentation) - Dr Sheila John, Head of Teleophthalmology Department
“Tele-I-Care,” a population-based program, increases access to eye exams for diabetic patients (Poster) - Mohammad Bawany, Medical Student
I find myself marveling at how much potential there is in this concept and wonder why optometry has been so hesitant to get involved in this movement.
Some other terms that are being used frequently that could leave optometrists behind are “artificial intelligence”, “virtual front door”, “data sharing”, “consumerization” and “simulations.” Also, “bots” are different that “robots” and “computer vision” means something different to these people than it does to an optometrist.
The future is here and optometry needs to be a part. If you are reading this and you are an optometrist, will you consider becoming a member of the ATA?
Day Two Report from the American Telemedicine Association
Day 2 - Tuesday, June 23: The Point of No Return
The question was asked by the representative from the National Health Service of the UK really stuck with me. She explained that before COVID, doctors were paid less (reduced the tariff) if they utilized telemedicine technologies. Since the pandemic, the technology has become a major part of the healthcare system to protect patients and to protect vulnerable providers.
The question: Has the benefit been so great, that the technology will continue to be a part of the healthcare system? Most feel the answer is “Yes.”
Today, the focus seemed to be on brining back the joy that providers can get by truly caring for patients. Removing barriers from that relationship improves all aspects of the care. The need for mental health care for providers during these stressful times was also highlighted and we were encouraged to find ways to provide peer-to-peer support.
In eye care, I attended a session about Artificial Intelligence specifically designed to detect diabetic retinopathy from retinal photos. One speaker said, “this is designed to keep patients out of eye doctors’ offices.” I must admit, that bothered me some, but the next speaker highlighted the need to be “clear and accountable” in AI. The purpose must be to keep doctors connected to their doctors because “people trust people.”
However, there IS a significant access problem in the world. We have to do something!
Day One Report from the American Telemedicine Association
Day 1 – Monday, June 22: COVID! COVID! COVID!
As you can imagine at the International Meeting of the ATA, the shutdown from the pandemic was centerstage. It is commonly said that telemedicine has advanced 10 years in the last three months.
The big topic of conversation was the testimony of the ATA president, Dr. Joe Kvedar before the full Senate Committee on Health, Education, Labor and Pensions (HELP) Telehealth: Lessons from the COVID-19 Pandemic. During his testimony, he urged policymakers to “take specific actions before the end of the public health emergency to make access to telehealth services permanent.”
There were strong presentations and discussions throughout the day that discussed the “transformative time due to this healthcare crisis.” The point was made over and over that the power of the technology is here and it is up to us, as healthcare professionals, to make sure that we use it to provide safe, effective and appropriate care. We saw some utilization metrics that shows just how far telehealth has come since last year’s meeting.
Today’s keynote was delivered by Jennifer Schneider, the President of Livongo which delivers remote monitoring coupled with virtual coaching. They got their start in diabetes care and have moved into hypertension, weight management and behavioral health. Imagine a platform that not only tells you that your glucose level is too high this morning, but also suggests that you drink some extra water and go for a walk before work.
Speakers made us think of what it will take to be ready for the next disaster, how to make sure that we don’t use technology to make the disparity problem worse and piqued our interest with “conversational agents” (like Siri and Alexa) in healthcare.
COVID has made “telehealth” a household name and demonstrated that it is ready. Everybody recognizes that this is an Opportunity for Real Change.
Consultative Synchronous Care
All OD’s have worked with those specialists in eye care that you know will have your back. The ones that you can ask stupid questions and they won’t treat you like it was stupid. These are the same ones that tell your patients that you are the best eye doctor they have ever met. If you aren’t working with a tertiary care specialists like this, keep looking.
These doctors give a level of expertise that bring the patients (and us) comfort and ensure we are giving them the best care. Through the American Telemedicine Association’s Ocular SIG, these specialist often collaborate on finding ways to reach more patients. Often concentrated in cities with jam-packed schedules, it is a barrier for many patients who need them.
Telestroke care is one of the big success stories in telemedicine. We all know that quick diagnosis and initiation of treatment is essential to quality outcomes. Hospitals across the world are incorporating “stroke robots” that connect patients with stroke symptoms to specialist around the world. This technique has saved countless lives and the approval rating is through the roof.
While glaucoma loss is much more ominous and slower than dangers from a stroke, glaucoma specialists are in high demand. Sometimes, OD’s just need another set of eyes on an OCT, a visual field, a pressure history and the current treatment plan. Without telehealth, a family member often needs to take a day to take a patient into the city to see the specialist who takes the same tests that were taken by the optometrists.
With telemedicine, the specialist can come right into the exam room, with the OD and the patient, look at the entire record, talk to the patient to determine if a trip to the big city is even necessary.
There are codes available for the specialist to use to rightfully allow them to be compensated for this care. Many healthcare specialists enjoy this type of patient connection and comment that it is a great way to get to know referring doctors.
Teleoptometry "Supportive" of In Person Care
I am having a hard time talking to my patients wearing a mask. I never knew this about myself, but I do a fair amount of communication with facial expressions. It turns out, we all do!
Studies are also showing that reducing the amount of time in close contact with another person seems to reduce the risk of passing along COVID-19 to each other.
These two facts have led me to make some fairly significant adjustments to my in-office eye exam technique. In a recent whitepaper, we call this method “Supportive Teleoptometry”. We define it as a portion of the in-office exam being done through synchronous remote communications. In other words, part of the exam is done by someone who is not in the room with the patient.
At Leadership OD, we work with a variety of clients adapting their process for Supportive Teleoptometry:
Case History before the patient comes in.
“Filling out paperwork before you arrive” has been a technique to improve efficiency for a long time. It dates back to the days when paperwork was actually on paper.
When the paper forms come in already completed or if the online form is filled out before arrival, there should always be a conversation about the answers. “On your form, you checked that you had cancer. Can I ask you a few questions about that?”
This conversation can happen from the patient’s home or car safely parked in the parking lot. In our office, we are bringing the patient into the exam room, inviting them to remove their mask and the doctor connects from across the hall, also maskless.
The conversation is way better via Zoom than masked in the same room.
We also have the capability to refract remotely.
We utilize a proprietary technology that allows us to control our automated phoropter and digital eye chart from a computer screen. This allows us to sit back from the patient, refract from across the hall, or delegate the refraction process to the skilled refracting technician from our partners at 2020 Now.
A high quality slit lamp camera allows me to sit back from the patient and look at the images on the computer monitor. This also allows me to capture images or videos of anything that I need to document quickly.
Review the treatment plan.
I have a really good script for explaining lid scrubs to my patients but I can’t catch my breath when trying to do it behind a mask. I also do a lot of demonstrating when explaining the importance of a good technique when instilling eye drops.
For all of the same reasons that I like beginning the exam with a virtual connection, instead of a masked conversation, I like wrapping it up the same way. I like to smile when I say thanks for coming in.
To explore how these ideas can benefit your practice, feel free to Contact Us at Leadership OD.
Bonus: If you decide to implement the virtual case history and then walk into the room with a mask, you can steal this joke if you want……… “If a masked man walks in there in just a minute, don’t let it scare you. It’s just me.”
-Kills every time.
Comprehensive Eye Exams with a Distance Provider
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.
Remote Monitoring
Imagine if you prescribed a new glaucoma drop to a patient and were able to get 4 IOP readings per day for the next month.
We have all treated a glaucoma patient whose “numbers” all looked good, yet they continued to lose vision. We wonder about the IOP diurnal variations. What if we could track that?
Do we really have to get an ambulance to bring that patient from the nursing home for an IOP check every month?
The American Telemedicine Association states defines Remote Patient Monitoring (RPM) as: including home telehealth, uses devices to remotely collect and send data to a home health agency or a remote diagnostic testing facility (RDTF) for interpretation. Such applications might include a specific vital sign, such as blood glucose or heart ECG or a variety of indicators for homebound consumers. Such services can be used to supplement the use of visiting nurses.
iCare now offers a home tonometry unit that has been approved by the FDA for home use and measurements of IOP by the patient in their home. It is safe, easy and highly accurate. The measurements can be uploaded to a portal in your practice and the patient can keep the unit as long as need for you to get the needed data.
There are newly recognized CPT codes for remote monitoring and they can be billed monthly. So this begs the question if it is better for a patient to come into the office every 3 months for an “IOP Check” or a monthly evaluation of 30 days of multiple IOP readings?
Eye Care Live promotes a visual acuity test that can track the VA of a patient undergoing myopia management. When reliable testing of VA can be done, is that comparable to in-office refractive testing for the purposes of tracking progress? (Remote monitoring of VA does not qualify for billing purposes as remote monitoring.)
Both of these methods require patient training and rely on proper technique, but they data received allows significantly improved ability to decide when intervention is needed.
If not us, then the ……… internists?
Great opinion piece from Mary Kane at Vision Monday today. Read this story where she shares her real-life decision to seek help for her eyes. While I am glad this story has a happy ending, it is a wake-up call to who will fill this void if not us, optometrists.
Best Practices for a VAHoV
A VAHoV is a “Virtual, At-Home Visit.” Anytime you see (and hear) your patient through a remote (virtual) connection, they are not in your office and you are discussing their optometric care, you are performing a VAHoV. These types of visits were virtually non-existent prior to the COVID-19 national emergency, but quickly adopted as a device to help us stay in touch with patients during the crisis.
How to Do It Right
Recognize that it is a different way to see your patients. It’s not designed to be comprehensive eye care and has its limits — although in many ways, it is better than seeing the patient in the office. While you can’t see the various layers of the cornea, you can see the patient in their natural environment.
Have a defined system that your team operates so that you seem to know what you are doing. Walk through a typical visit with a trial patient or two. Define how you will connect, communicate with your patient and deal with misunderstandings. There are a variety of connection tools like EyExam Virtual, Eye Care Live, Doxy.me and Zoom for Healthcare. Pick one and learn how it works.
Treat it like a doctor’s visit, not a phone call. It is important to work out details like insurance, billing and demographics before these visits, just like in-office visits. We recommend a “check-in” with a staff member who confirms or collects any needed data, including credit card information. (They won’t be mad if you talk about money.)
Define how this visit will be documented. We recommend that the staff-person who checked in the patient become the scribe while the doctor is talking to the patient. She can simply turn off her camera, open the patient’s record in the cloud-based EHR and enter the findings. Doctor can turn it back over to her for orders or scheduling, while the doctor logs into the record to review the entries and sign off. Done!
Don’t be late. When a patient is in your office, you have to make them wait a pretty long time before they give up on you. When they are at home, it’s not unheard of for them to go get a sandwich if the wait exceeds a few minutes. Keep up, but have a really good plan for communicating with the patient if time gets away from you.
Moving Forward
Prior to the national shutdown, VAHoV’s were being successfully incorporated into a few practices and we expect it will remain a part of practices as we return to “normal.” The hardest part is actually working it into your normal scheduling techniques.
Under normal circumstances VAHOV’s can be the first visit for any after hours call. Currently, we receive a call from the emergency line and we call to speak to the patient for free. On that call, we decide to see the patient now or later and sometimes we treat the patient by calling in a drop. Utilizing TheTeleOp.com, that same patient can complete a form that identifies several factors about their condition, direct the patient to a VAHoV and once connected – you have performed a VAHoV (a legitimate service).
VAHoV’s are great for Contact Lens Progress Exams (CLPE). Today’s contacts are really safe and easy to fit yet we still like to see them after they have been in a week before we prescribe them. Consider just how inconvenient this is for your patients when you really just need to know if they can see good, they feel good and if the eye looks ok. All of this can be done with a VAHoV. Today’s cell phone cameras give a really good few of contact lens movement and even toric lens rotation.
Dry Eye Follow-up’s are great with a VAHoV. Same as with CLPE’s, the biggest part of the visit is the conversation with the patient about symptoms and compliance and a general look at the eyes. Tear meniscuses can be seen in a VAHoV, if the lighting is right. Dr. Brittany J McMurren is developing a technique to visualize staining through a VAHoV.
There are other follow-ups that can be done through teleoptometry, depending on a variety of factors surrounding the patient’s condition and your comfort level seeing it remotely. Consider allergic conjunctivitis, contact dermatitis, corneal abrasions (little ones), chalazions, headaches, trouble with these progressives …
You can do a lot with virtual visits with your patients, but you also can take it too far, like this guy. Remember that your liability remains the same and you have to do what is best for the patient.
While VAHoV’s don’t keep people away from utilizing us, it keeps us in touch with them and helps us take better care of them than we ever did Before COVID (BC).