Telehealth: an eyecare access breakthrough or dangerous gamble?

There are few countries in the world that are better positioned to both benefit from, and further develop, teleophthalmology than Australia. With our wide expanses, far-flung communities, and technical excellence, millions of people both at home and abroad could benefit from its increased use and evolution.However, it is also a relatively new phenomenon, one which comes in many different forms, and whose scope and practical use has been the subject of much debate.In Australia, telehealth has been promoted as part of the solution to rectifying the probl of underserved regional and rote areas, where treatable yet blinding eye diseases such as glaucoma, cataracts, and diabetic retinopathy are prevalent.Nowhere has this gap in eye health been more obvious than Western Australia, where studies have shown that ophthalmology coverage in some areas is 19x lower compared to major cities.Perth serves as the only major centre providing tertiary level ophthalmology services in the state, yet it is more than 3,000 kilometres away from some towns and communities in its most rote corners.{{quote-A:R-W:450-I:2-Q: Teledicine as a tool to help a doctor better care for a patient is absolutely acceptable to most doctors including myself, -WHO:Dr April Jasper, President of the Florida Optometric Association}}A 2016 study published in the Australian Journal of Rural Health found that teleophthalmology is underutilised in Australia, despite its potential for improving eye health services for regional and rote patients.The findings called for advocacy geared towards funding regulatory, training, and infrastructure programs to support teleophthalmology.Such an investment could potentially support 15% of urgent patient transfers and 24% of outreach consultations, equating to cost savings of around $1.1 million per year.According to the study authors, the real-world savings could even be higher.Aside from the economic advantages, the study also found significant benefits related to teleophthalmology in terms of enhancing service delivery for rural patients, reducing wait times and non-attendance for consultations, and also improving access, quality of care and outcomes.Online eye testsWhile telehealth has succeeded in providing improved access to better eyecare, businesses – mostly in the US – are using similar technology and applying it in situations outside of rote and rural settings. Such an approach has proved divisive, with proponents of these often smartphone based applications arguing it improves screening rates, while critics have charged it will lead to patients avoiding essential in-person eye examinations that can only be performed by optometrists.One of those businesses leading the charge is Smart Vision Labs, a start-up that has developed technology that allows a person to complete an eye exam in minutes without the need for an eye specialist.

Hubble Contacts has already expanded into Canada and Europe

As alluded to earlier, the technology is packed into a smartphone- powered device a fraction of the size of traditional refractors, and all that’s needed by the patient is to answer some questions on personal health and history, then sit through a simple passive test by staring into the device’s camera. It then runs three different tests – visual acuity, papillary distance and refraction error managent.The information derived from the tests is transmitted to optometrists or ophthalmologists partnered with the company, who send the results back via ail within 24 hours of the patient taking the exam.The US Food and Drug Administration (FDA) have cleared the technology and the company claims a high level of accuracy, with a 1% rake rate compared with the 10% average for traditional optometry practices.Multiple companies have already integrated the technology into bricks and mortar stores, including Warby Parker in New York. It also found its way into stores in San Francisco, Los Angeles and San Diego.However, the developers concede that the syst does not provide a complete work-up as, for example, it cannot dilate pupils and there are still question marks regarding its ability to comprehensively detect eye probls. If the syst does detect something, the company advises the patient should consult an optometrist or ophthalmologist.Another startup, Simple Contacts, has followed closely on the heels of Smart Vision with a similar technology that allows people to record thselves taking a eye test, by using their phone as a virtual eye chart while wearing their current prescription contact lenses. It is followed by an exam where the camera is positioned to check the eyes for visible signs of infection or damage.Both videos are then sent to an ophthalmologist for analysis. If the vision quality rains the same and no signs of probls are detected, the prescription lenses are reissued. It is also substantially cheaper than the traditional option in the US – it costs just US$10 (AU$13), whereas a visit to the optometrist or ophthalmologist can be 10x that amount.The company has stressed that the process is not a full eye examination and there are restrictions. Patients are limited only to the renewal of prescriptions, and even then they have to have had a full check up within four years prior to completing the virtual test.Yet another startup, Hubble Contacts, has attpted to make the process even more convenient, by giving patients access to contact lenses via an innovative subscription method. The company’s daily lenses are available in America for US$30 (AU$39.20) for a month’s supply, while the company also recently branched out to Canada and the UK.Hubble Contacts already has a strong subscriber market of around 25,000, and revenues could hit US$20 million (AU$26.1 m) this year.{{image5-a:l-w:500}}{{image6-a:l-w:500}}Safety concernsThe technology is not without its skeptics, with some eyecare professionals expressing concerns about the autonomous nature of the technology.“Teledicine as a tool to help a doctor better care for a patient is absolutely acceptable to most doctors including myself,” Florida Optometric Association president Dr April Jasper said in an interview with Business Insider.“When teledicine is advertised and promoted as a substitute for a comprehensive eye health examination, most doctors are going to have serious concerns for our patient’s safety.”Jasper pointed out while there’s still no teledicine technology that could substitute for a comprehensive eye health exam, such technology could lead to patients becoming complacent, or worse misled, and therefore bypass a visit to the optometrist.Regulatory challenges{{image9-a:r-w:300}}Online eye test companies have faced opposition from powerful lobbying groups such as the American Optometric Association (AOA), which has resulted in multiple legislative challenges. Three states have already banned ocular teledicine companies, and as such most of the US$8 million (AU$10.45 m) that Smart Contacts was able to raise in its most recent round of funding will go toward governmental affairs in order to get ahead of regulatory battles.Woolfson Eye Institute clinical director Dr Tom Spetalnick believes such challenges are vital to protecting the public.“Eyecare patients tend to think that an eye exam is just a measurent for glasses, and that is a real important test because people want to see well out of their glasses. But it’s a fairly small part of an overall comprehensive eye examination and has no impact, or very little impact, on assessing the health of the eye,” Spetalnick told CNN.“There is a standard of care when an eye doctor is expected to perform an eye exam, and the eye exam is expected to determine if the patient does or doesn’t have things like glaucoma, retina probls – even diabetes can be detected.”Aside from safety, Spetalnick also worries about efficacy: “Even if you’re talking about nothing but assessing the proper eyeglass prescription for an individual, a single test isn’t the way a doctor ought to be determining what to prescribe for that patient. You need to collect multiple data points,” Spetalnick said.But while many professionals are still not convinced about the real value of online eye tests, their comparatively lower costs make th more attractive to the lay population.Yet, despite its obvious price advantage, Spetalnick still believes the online eye tests are not value for money, explaining, “first of all, you’re not getting an eye exam, and you’re talking yourself out of getting proper eye healthcare.“For $40, $20, $1, it’s a bad call if you’re getting an eye test instead of a comprehensive eye examination. If you want an inexpensive eye exam, they’re out there.”However, notwithstanding the criticism over safety, there is also an another incentive for optometrists to speak out against online optometry tests – money.Money talks{{image10-a:r-w:300}}Potentially disruptive teledicine has become a threat to the current business model of bricks and mortar optometry practices, and as mentioned earlier, this has seen teledicine opponents enlist lobbyists to discredit the practice and encourage lawmakers to restrict the new technology through legislation.In 2017, New Mexico Governor Ms Susana Martinez vetoed anti-ocular teledicine legislation that was being pushed through by state legislators backed by optometry lobbyists, citing the need to protect the potential benefits the technology had in terms of patient access. Similarly, former South Carolina Governor Ms Nikki Haley also vetoed a bill that would have restricted access to online eye tests, arguing that the technology would “stifle competition for the benefit of a single industry.”The conjecture surrounding the contact lens industry and its relationship with telehealth prompted the FTC to explore “issues regarding competition”, which led to multiple stakeholders participating in a workshop in March addressing the future of the sector.One of the loudest voices at the workshop was the AOA.{{image11-a:r-w:300}}“Through the delivery of personalised healthcare, doctors of optometry assure precise and healthy vision, identify and treat glaucoma and serious infections, and ensure early diagnosis of immediate threats to overall health, including hypertension, stroke and diabetes, which may have no obvious signs or symptoms,” a statent presented to the FTC read.“Some have used it as a smokescreen to try to mislead the public and undermine very basic quality care standards. Patients can receive inaccurate or misleading information when relying on an app for an eyeglass or contact lens prescription.”The National Eye Institute (NEI) and the Centers for Disease Control and Prevention (CDCP) also agree that existing technologies still cannot match a comprehensive eye examination to effectively determine healthy eyes and vision.Australian perspectiveBack home, Optometry Australia (OA) has welcomed teledicine as a new approach to help bridge the gap for underserved communities. However, OA also maintains that safeguards need to be in place through legislation to ensure it is not abused.“While erging technologies are something that Optometry Australia continues to observe and welcome, we must ploy caution to uphold the highest standards when it comes to patient health and care,” an OA spokesperson told Insight.{{image12-a:r-w:300}}“We believe legislation should be strengthened to ensure that online dispensers are required to site a valid prescription from an optometrist prior to supplying contact lenses and to ensure that virtual eye exams are not able to give patients a false sense of security.”The concerns OA has with telehealth are similar to those voiced by its counterpart in the US, in particular with regard to its potential to ineffectively replace comprehensive eye exams.“This is an erging situation that OA has been watching closely. We have concerns regarding the accuracy of such tests and the impact this may have on a patient’s vision and eye health,” the spokesperson said“Typically online tests assess vision but do not provide a comprehensive consultation that may identify underlying pathology that may be associated with a visual change or that may be present but not yet symptomatic. If patients aren’t aware of this and don’t also access a comprehensive consultation from an optometrist, early signs of eye disease may be missed.”The lack of companies such as Hubble Contacts and Smart Vision Labs operating in Australia means related legislation has not yet been drafted or likely even considered by lawmakers. However, given the ubiquitousness of technology and the increasingly global nature of society, their arrival is surely a matter of when, not if, which means Australia and its ophthalmic sector need to be prepared.{{image7-a:l-w:1010}}