Virtual Visits in Ophthalmology: Timely Advice for Implementation During the COVID-19 Public Health Crisis

Introduction

Virtual visits (VVs) decrease patient cost,¹ increase satisfaction,^2,3 and allow ophthalmologists to care for patients efficiently.³ With massive disruptions in health care caused by COVID-19, interest in VVs for ophthalmology and across medicine is increasing. Numerous national and state agencies recognize telehealth as vital during this emergency,^4–7 lifting regulatory boundaries such as utilizing Health Insurance Portability and Accountability Act (HIPAA)-non-compliant audiovisual platforms for VVs⁷ and adding temporary pay parity between in-person and telehealth visits to facilitate social distancing while simultaneously maintaining access to health care. Prior to the COVID-19 outbreak, we had already conducted hundreds of VVs dating back to 2016 leading to an understanding of best practices that are transferrable to other subspecialties beyond pediatric ophthalmology and strabismus. We hope that these best practices will be helpful to others, and we believe that this dialogue will spur innovation among colleagues.

Technological Platforms

We use a commercially available HIPAA-compliant platform that integrates with our scheduling software. This platform provides a virtual waiting room that scrolls through a series of customizable screens, which we use to inform patients of best practices to optimize their VV and their estimated wait time. Disadvantages are that it requires a software download by the patient and a link within an e-mail to access the virtual waiting room. The aforementioned regulatory changes now allow ophthalmologists to use prevalent and intuitive audiovisual platforms that are not compliant with HIPAA. Although use of these systems may need to cease after the state of emergency, in the interim they may allow some providers provide services quickly.

Etiquette and Best Practices

Many interpersonal skills and procedures providers have mastered do not translate intuitively to best practices in virtual encounters. Table 1 outlines best practices for VVs. As with any appointment, it is vital to first obtain explicit permission to conduct the visit. This permission is built into commercial systems as a requisite for entrance into the virtual waiting room. If an ad hoc system is used, informed consent must be obtained and documented.⁸

Second, the provider must find a private space with a professional backdrop and attire. The provider must also make the patient aware of all of the parties present to ensure the right to privacy.

Third, VVs are most successful when the audio–video feeds are of high quality. Video feeds are optimized by ensuring that the computer, tablet, or phone is stabilized on a flat surface at eye level on each side. The patient should be stable as well (setting babies on laps and toddlers in highchairs is ideal). Most critical is good lighting on the face without backlighting; natural light from windows is ideal. Not only is good lighting critical for the patient but also important for the provider side. Well-lit providers allow patients to ascertain nonverbal facial cues during conversation. Also, placing the video feed of the patient close to the camera or looking slightly below the camera during discussion facilitates “eye contact.”

Fourth, the virtual examination is most successful in pediatric patients if completed first when the novelty of the virtual encounter is in play. History and counseling may be addressed later when the child can “leave” the discussion.

Fifth, there are benefits to clumping VVs together at the beginning or end of the clinic day. This minimizes the mental effort of “task-switching” (and timing synchronization) between VV and in-person visits. Morning VVs also provide the option for a same-day clinic visit if a concerning element is identified.

Virtual Examination

Many providers express incredulity that an ophthalmic examination might be performed virtually. Our experience shows that much can be gleaned to facilitate medical decision-making and counselling.³Table 2 describes the methods that we have found useful. This listing is not exhaustive and evolves with experience. Asking patients to provide videos, pictures,⁹ and even home-based visual acuity measurements may be helpful, increasing efficacy of the virtual examination. If the history or examination is worrisome or unclear, we have a low threshold for a same-day clinic visit; this allows us to use VVs without concerns of jeopardizing patient safety. In some cases, VVs, by way of limiting our ability to examine, enhance the utility of a careful history, which can be very powerful from a diagnostic perspective.

Documentation and Billing

Each VV should be documented in the same manner as an in-person visit, with qualifiers that make the limitations clear. For example, we document “estimation via video observation during virtual visit” for various elements of the examination. We also describe exactly how we performed the examination (e.g., visual acuity in a baby: fixes and follows a toy moved side-to-side by parent). At the end of the note, we append that the VV was necessitated by the social distancing mandate, the location of the patient and provider, the individuals present, and the length of the visit highlighting the percentage time in face-to-face counseling. We bill VVs with Current Procedure Terminology evaluation and management codes, adding the GT modifier. We recommend checking with billing and compliance in your local environment to understand the appropriate approach.

Proposed Indications by Subspecialty

Our experience in VVs has been in pediatric ophthalmology and adult strabismus clinics, but we believe our breadth of practice translates well to other subspecialties. Table 3 presents a list of suggestions that is certain to expand as the field of ocular telemedicine innovates. In some cases, a hybrid model where testing is performed in the office and history and review of results are performed virtually may limit exposures during a time of social distancing.

Conclusions

The current public health crisis necessitates innovation and shared development of best practices to allow for safe and efficient implementation of VVs. We hope this collation of experience inspires further creativity, and we believe that our field will emerge with new skills to deliver better care for our patients.

Disclosure Statement

No competing financial interests exist.

Funding Information

This study was funded by the Innovation and Digital Health Accelerator, Boston, MA, and the Children’s Hospital Ophthalmology Foundation, Boston, MA. The funding organizations had no role in the production of this article.