Dr. Mina Massaro in a telemedicine appointment.
By Alexandra Brodin
Scheie Vision Annual Report 2020
In March, the Scheie Eye Institute began offering telemedicine services as an option to non-urgent patients in order to practice social distancing and limit the spread of COVID-19. All urgent patients were still seen in-person.
Telemedicine refers to clinical services, such as diagnosis and disease management, that are offered through telecommunications technology, including consultations and follow-up visits over videoconference. Telemedicine is distinct from telehealth, which is a broader term that includes non-clinical services, such as continuing medical education.
At Scheie, all non-urgent appointments (including elective services, non-urgent follow-ups, routine eye screenings, and optical shop appointments) were cancelled starting on March 16, 2020. Patients who had their appointments cancelled were given the option to have an appointment via telemedicine.
The most evident advantage of practicing telemedicine during a pandemic is that patients and physicians do not risk exposure to the virus through an in-person visit. Ophthalmologists were at an especially high risk during the height of the pandemic, when personal protective equipment (PPE) was more limited, because proper eye examination often requires close proximity to the patient. Telemedicine became an alternative option for Scheie physicians to continue to care for their patients. “I was really quite surprised at how much I could see on the surface of the eye through the video,” said Scheie dry eye disease (DED) specialist Mina Massaro-Giordano, MD.
Although social distancing was the primary benefit, several other advantages to using telemedicine have emerged in the last several months. The standardization of telemedicine creates new options for patients with chronic disabilities and immunodeficiencies, who may have been hesitant to come onsite for care even before the pandemic.
Telemedicine also provides a unique opportunity for physicians to see inside their patients’ home environments. This insight allows physicians to advise patients on ways to improve their environment and day-to-day activities. For example, Dr. Massaro can observe whether a patient is looking up at the computer screen, which forces the eyes to open wide, or looking down, which allows the eyes to partially close. With DED, keeping the eyes fully open can lead to greater dryness and irritation, so Dr. Massaro can advise patients to adjust the angle of their computer screens.
Physicians can also learn more about how patients are managing their eye care at home. With telemedicine, Dr. Massaro has the opportunity to see the eye drops that patients are using at home, which they usually would not bring to an in-person appointment. They can show her how they are using the drops, and she can instruct patients in the best way to administer them.
In the same vein, Thomasine Gorry, MD, MGA, Associate Professor of Clinical Ophthalmology, has found that discussing test results with patients is often simpler over videoconference. “It is so clear to the patient what we’re talking about, and there are no other distractors in the room,” said Dr. Gorry. “I find that, in terms of conveying the message of what the illness is or what the patient’s medical status is, telemedicine visits are actually very efficient.”
Telemedicine can also provide isolated patients with a social outlet. For some patients, seeing their regular physician over telemedicine can be comforting when they are unable to do their regular activities. “Many patients have been closed in their houses for months,” said Dr. Massaro. “It’s very isolating. To all of a sudden see a friendly face at the other end of the computer—I think it’s very empowering for patients.”
Though the advantages outweigh the disadvantages, telemedicine does present some unique challenges. Some patients have limited access to technological devices or are unfamiliar with the channels of communication required for a virtual visit. Physicians may connect with patients by telephone, if videoconference options fail.
Another limitation is that telemedicine cannot support most ophthalmic testing and procedures. To be able to offer in-person testing while also limiting the spread of the coronavirus, Scheie developed the Telemedicine Enhancement Pathway (TEP). Along with Eydie Miller-Ellis, MD, Chief of the Glaucoma Service, Dr. Gorry led the development of the TEP.
The TEP is a process for seeing patients with well-known eye diseases that require consistent monitoring, such as glaucoma. The process involves two main steps. First, patients who have been identified as appropriate candidates for TEP come to Scheie to receive testing ordered by their physicians. They wait in an area specifically designated for the TEP, and are seen by a technician who has been assigned to the pathway. Patients do not typically see their physician during this in-person visit.
Usually within two weeks, patients on this pathway meet remotely with their physicians to review the results and discuss treatment plans, if applicable. The structure of this pathway maximizes efficiency and reduces potential exposure to COVID-19, since the patients do not have to wait to meet to with their physician in-person.
Innovations like the TEP can become bright spots amid the crisis, and give physicians and leaders something inspiring to work towards. “We’re still at the hard work stage, but one triumph has been the ability to connect with my colleagues over a great idea,” said Dr. Gorry. “You can’t overestimate what that means when you’re otherwise isolated. So we had a great opportunity to reconnect and bring this forward.”
The TEP is currently serving primarily glaucoma patients. Dr. Gorry and her team are working to expand this pathway for patients with other diseases that require consistent monitoring, including diabetic retinopathy and macular degeneration.
Leaders in telemedicine at Scheie believe that telemedicine care will persist in various ways beyond the pandemic. Conditions like DED lend themselves well to telemedicine, as the surface of the eye can readily be examined through a video camera. Moving forward, physicians will be able to decide how much to integrate telemedicine into their workflow, based on what works best for their individual practices and patient bases.