Telemedicine Principles and Practices: Speaking the Language

Telehealth has emerged as a rapidly evolving tool with a multitude of capabilities in the delivery of health care. Both established and newer doctors of optometry must remain diligent in recognizing contemporary patient health and safety influences, technological advancements, and policies involving applications and use of telemedicine that support patients, doctors, and the profession. This article explains why it’s important for us to remain diligent and how we can do so.

TELEHEALTH AND TELEMEDICINE IN OPTOMETRY

In October 2020, the American Optometric Association (AOA) issued a revised position statement regarding telemedicine in optometry as an important resource for supporting doctors of optometry and related stakeholders in the appropriate use of telemedicine to access high-value and high-quality eye, health, and vision care.¹ This statement, developed by leaders in eye health and vision care, artificial intelligence, telehealth platforms, and practicing physicians, features a concise glossary of useful definitions for terms such as telehealth, telemedicine, and telemedicine in optometry (see Key Terminology).

Telehealth and its technology are poised to revolutionize eye and health care, with some declaring it a natural evolution into the digital age.² Not only could its effects transform patient care delivery as we know it, but telehealth also holds promise for improving the lives of patients who experience barriers to proper treatment and services. Companies, researchers, and health care providers continue to investigate ways in which telehealth technology can be applied to achieve positive health outcomes.

To achieve desired outcomes, important criteria must be met to ensure that telemedicine in optometry meets the existing standard of care, is of high-quality, contributes to care coordination, protects and promotes the doctor-patient relationship, complies with state licensure and other legal requirements, maintains patient choice and transparency, and protects patient privacy.¹ Strong evidence to show these criteria are being met is essential. Keeping these references and helpful language in mind, let’s review several key optometric care delivery factors and patient-centered concerns involving telemedicine and optometric care.

KEY STAKEHOLDER CARE CONSIDERATIONS

When surveying the expansive health care landscape of telemedicine principles, practices, and other professional guidance to support its utility and effectiveness, one can be overwhelmed in recognizing the variety and strength of support in existing recommendations. To assist busy clinicians in further translating telemedicine into day-to-day practice, the AOA streamlined key considerations for delivery of high-quality patient care into three areas: patients, providers, and profession.

One of the most referenced issues across these three areas regarding telemedicine involves the concept of accessing care. As discussed in my last article, “Vision Screening and US Population Health, Part 2: What You Need to Know,”³ an understanding of the multitude of factors affecting health care access and utilization (ie, the five A’s of access) is important. The value of this knowledge is that it enhances daily delivery of quality eye and health care, and ultimately, overall health. When one sees access to health care stated from any one perspective, one can then quickly discern the context in which access is being referenced, recognize whether access is properly defined, and identify related factors that may require clarification.³ In short, it allows one to ask the proper questions for informing high quality health care–related decisions.

Additionally, it is not uncommon for patients to encounter roadblocks to telehealth services. Limited access to technology, inadequate or lack of network connection, and lack of familiarity with technology remain significant barriers to care. These disparities are more prevalent in rural populations, older adults, those of low socioeconomic status or with health literacy, racial ethnic minorities, and non-native English speakers.⁴ Ongoing assessment of the efficacy of telehealth services aimed to alleviate health care disparities is needed, as well as the evidence generated used to further inform policies, utilization, and applications that improve health equity.

As an example, it is important to educate patients and help families and caregivers to recognize that access to care differs from standard of care. The AOA states that “the standard of care for eye, health, and vision services must remain the same regardless of whether services are provided in-person, remotely via telehealth, or through any combination thereof.”¹

Another example involves incorporating patient preferences and ensuring patient autonomy so that “patients consent to receive telemedicine in optometry and understand their right to choose (at any point in the care continuum) in-person eye, health, and vision services provided by a doctor of optometry.”¹ If patients do not fully grasp limitations of specific care delivery methods and trade-offs that can occur between them, then they are not fully informed and are unable to share in making the best decisions for their own health care needs. Maintaining a standard of care is essential to achieving acknowledged health outcomes associated with contemporary, comprehensive optometric eye care.

Patients

The AOA states that, “use of direct-to-patient eye and vision health–related applications (including online vision tests and other mobile eye and vision-related applications) does not constitute telemedicine in optometry unless used under the direction of a doctor of optometry.”¹ This position reinforces the key role of doctors of optometry as the patient’s physician supervisor and appropriate knowledgeable professional directing the patient’s eye and vision care, while building patient confidence in the delivery and coordination of that care as an integral part of their health care team. Ultimately, the outcome is a strengthened patient experience.

Maintaining required legal and administrative patient-related issues is also of concern. It is critical to meet patient privacy and confidentiality standards. Photographs obtained by patients or stakeholders outside of a clinical setting may not meet quality standards or contain enough information to accurately evaluate a patient’s eye and visual system and health status. Another example involves risk assessments and potential outcomes of using technology to screen for specific eye health issues to replicate or replace a dilated eye examination based on technology uses and limitations.

Telehealth diagnostics, or telediagnosis, in eye care is a timely example of an emerging field that requires diligent exploration and methodical evaluation by health services researchers and other clinical investigators to ensure quality care and its equitable delivery. Because telediagnosis differentially affects the steps in the diagnostic process, careful consideration must be given to how these steps are redefined. Clinicians are also faced with challenges created by the rapid evolution of the field as new tools and systems are constantly being introduced. However, maintaining needed focus on key factors, such as access, engagement, and follow-up, can strengthen the foundation for a desirable iterative and practice-driven approach.⁵ These considerations are of utmost importance for all emerging technologies to ensure telehealth systems can demonstrate health equity and reduce health disparities.

Providers

As far as the role of the physician regarding standard of care, the AOA states that, “doctors may not waive the obligation or require patients to waive their right to receive the standard of care.”¹ The following considerations demonstrate the challenges and obligations doctors face on a daily basis in meeting this fundamental objective.

One of our key roles as physicians involves successfully helping patients, staff, and other stakeholders to fully understand the selective nature and differences in care delivery/patient populations targeted by available technologies. Doctors of optometry have a long history of quickly and efficiently adopting emerging technology. The current landscape requires this continued embrace of technology, but in a way that best supports and enhances the optometrist’s clinical decision-making and is in the best interest of patient care.

Evolving technologies will continue to provide new ways of gathering health–related data but cannot replace optometric expertise in evaluating it. Technology alone cannot fully predetermine next clinical care options, especially from a primary care standpoint. Available technologies cannot yet predetermine patient preferences, weigh cost benefits, or incorporate all available evidence to support optimum patient–centered care. For example, as industry recognizes, available remote technology does not yet support the detection of all possible systemic and ocular conditions to arrive at important comprehensive clinical findings, where doctor and patient can discuss how to achieve optimum health outcomes.

Conversely, another important consideration involves risk of fearing technology or misusing it when not fully informed of technology capabilities within the telemedicine landscape. Anxiety can be created when eye and vision-related technology is used in primary health care and other professional settings outside of optometry. Doctors also face complexity in reimbursement issues for telemedicine, regulatory and scope issues (ie, practicing across state lines), and in attempts to reach all patient populations requiring equitable optometric care, especially when addressing geographic and other access-related challenges.

Profession

There are many outside influences to consider that affect the profession as a whole and the care that optometrists provide. As for standard of care, the AOA position statement indicates that, “a payor may not require either the doctor or patient waive the right to receive the standard of care.”¹ Decades of optometric advocacy continue to elevate legislation, policy, reimbursement, and the value of care provided by doctors of optometry. The position statement also points to criteria for ensuring high-quality telemedicine and presents considerations for professional organization, training, and implementation of telemedicine. This important advocacy further highlights the significance of the doctor–patient relationship and the unique role our profession plays in improving the nation’s health, one patient at a time. It acknowledges unknowns and existing gaps in our knowledge of telemedicine, including a need for data to better understand potential positive and negative health outcomes resulting from promoted telemedicine and technology applications.

One key consideration facing all of health care involves the horse and cart analogy: Will doctors allow technology to overinfluence the direction of professional care delivery (ie, put the cart before the horse), or will doctors continue to drive patient care by embracing technology that works while avoiding approaches to care that are not shown to be beneficial? For example, during the pandemic the disparate use of telemedicine across specialties ranged from 68% of endocrinologists to only 9% of ophthalmologists.⁶ The potential for telemedicine to help reduce health disparities exists, yet there is a lack of evidence to support the best approaches to achieving health equity within the national landscape. Another consideration involves evidence of bias in artificial intelligence and retinal machine learning models.⁷

BE VIGILANT

Evidence supports the adoption of many telemedicine procedures, including video conferencing, providing rehabilitative therapy, capturing images, and managing prescribed treatment refills.^8-10 However, limitations in telemedicine functionality for full-scope diagnosis and treatment from a population health perspective still exist. For example, there are generational differences with technology and preferences for convenience, speed, and remote engagement. Exactly how these choices will affect future professional care delivery, professional training, and the long-term health of the public are not yet fully understood.

It remains in the hands of optometrists and others who recognize the value of optometric eye care to preserve, protect, and promote the doctor–patient relationship that is so essential to health. Vigilance is required for the successful navigation of the changing telemedicine environment and the adoption of evolving care delivery choices.