Feature, Report

Telehealth forges new path in patient management

The COVID-19 crisis has spurred a telehealth revolution that’s helping mitigate disruption for practitioners and patients. Leading professionals share their telehealth tips and discuss why the technology might be here to stay.

As the COVID-19 curve continues to flatten, parts of Australia are easing restrictions. There are also promising signs of a partial return to normality for the ophthalmic sector.   

While it is impossible to rule out another outbreak, eyecare practitioners are pondering how they will manoeuvre away from an ‘urgent care’ model and cater for pent-up demand. Many are also considering how they will deliver services in the event of further business disruption or if vulnerable patients are apprehensive to visit the practice.

Telehealth is one such solution and, in the previous issue of Insight, it was identified as a promising opportunity for the sector beyond the crisis. As it becomes increasingly mainstream, industry figures also believe the use of virtual consultations could drive new innovation and irrevocably alter current care models.

This month, the conversation continues as members of the ophthalmic sector offer practical tips on telehealth use and discuss its place in the future of Australian eyecare.

The current landscape

Before considering the potential of telehealth, it is important to note both sides of the telehealth coin. Teleophthalmology describes collaboration between optometrist and ophthalmologist and patient. Tele-optometry defines optometrist to patient consultations.

Ben Hamlyn.

Adelaide-based optometrist Mr Ben Hamlyn works in member support and is a policy advisor with Optometry Australia (OA).

He says the current MBS reimbursement, introduced in 2015, for a telehealth consultation requires the optometrist and patient to be present together while an ophthalmologist participates via online video technology.

“These MBS items are restricted to patients who are in ‘telehealth eligible’ areas which is non-metropolitan and outside a 15km radius from the treating ophthalmologist. This restricts use to those outside metropolitan areas, unless they are providing care in an aged care facility.”

Although Medicare Benefits Schedule (MBS) data over the past five years has indicated telehealth, or teleophthalmology, consultations are under-utilised in optometry, Hamlyn anticipates it has been adopted more frequently during the COVID-19 pandemic.

Subsequently, OA, Specsavers, Luxottica and Diabetes Australia have lodged submissions with the Department of Health to modify optometry MBS item numbers 10916 (brief initial consultation) and 10918 (subsequent consultation) for telehealth purposes.

At the time of writing, the government still had not approved this proposal, with the lack of progress frustrating the sector.

In the meantime, OA has released a Clinical Practice Guide on Telehealth in Optometry in March, and more than 470 members watched a webcast it hosted in early April to share advice on the topic.

Hamlyn fielded questions from members during the webcast on appropriate billing, record keeping and workflow requirements.

“We are emphasising that it is important for practices to decide under what circumstances, and when, is appropriate to use telehealth,” Hamlyn says. “Telehealth should be considered as an adjunct to regular care and not a replacement for face-to-face care.”

Optometry advocates have been lobbying for Medicare coverage for optometry services.

Without an MBS rebate, some optometrists are privately billing for telehealth services. Hamlyn says OA recommends charging a fee similar to a regular face-to-face consultation, commensurate with the duration of the consultation.

“Professional indemnity insurance is also a matter to consider. Members want to know whether they are covered. We can confirm OA’s professional indemnity insurance provider covers telehealth,” he says, adding that non-OA members should check their coverage before providing telehealth services.

According to Hamlyn, optometrists are typically choosing to deliver telehealth from their practice, but it is important that the location is secure and private. For example, ensuring the door is closed so others cannot overhear patient disclosures.

“Requirements on record-keeping are also the same as for a normal face-to-face consultation but optometrists need to be able to remote access patient records for history and note-taking if they are not in the practice physically,” Hamlyn says.

Optometrists have also faced the challenge of defining what constitutes ‘urgent care’ under the COVID-19 restrictions. This includes diseases that have a risk of progression, or a patient who has had their visual function impaired.

For example, Hamlyn says a patient may have damaged spectacles, which means they are unable to drive to the supermarket. By definition, they need ‘urgent care’.

Telehealth also raises a host of questions for therapeutically-endorsed optometrists, which now account for 65% of the profession.

“Members want to know if they can issue a prescription or repeat a prescription, such as an expired contact lens or spectacle lens prescription, without looking at the patient’s eyes face-to-face,” Hamlyn says.

“There is no regulatory reason why an optometrist couldn’t repeat a prescription, provided they’ve considered the health of the eyes and the patient, and can potentially shorten the length of the prescription if it is reasonable to do so. We urge optometrists to consider all circumstances available and treat on a case-by-case basis.”

Despite the absence of an MBS reimbursement for now, OA has partnered with Oculo to provide its members’ practices access to the telehealth platform – including its real-time videoconference feature – for an initial six months at no cost. The platform is also used by Specsavers and Luxottica optometrists, among others.

“It’s designed for eyecare, offers a private and secure environment to transfer clinical data, and can work alongside practice management software to facilitate access to patient records.”

As of mid-April, OA reports more than 600 members had updated their online member profile to indicate their practice is offering telehealth, which is then displayed in the organisation’s ‘Find an Optometrist’ search function. It’s estimated some 200 practices would ultimately take-up the offer.

Alongside telehealth, OA is considering innovative ways to measure visual fields, such as the Melbourne Rapid Field (MRF) software that can be accessed on multiple platforms, including iPad.

According to the designers behind MRF software – which is registered with the Therapeutic Goods Administration as a perimetry device – it provides a portable, rapid and accurate threshold testing for patients with eye and neurological conditions. It can be used in clinical settings during COVID-19 instead of viewing-dome or goggle-type visual field devices that make direct contact with a patient’s face.

“Telehealth has proven it is useful to patients who live near services, not just those in rural areas. It has shown us all that maybe this is something that will become more part of our profession over time. Some changes are here to stay,” Hamlyn says.

“We see telehealth becoming an important adjunct to conventional optometry in the future, one that overcomes some barriers to care for the community enabling high quality care to be provided in an efficient manner that benefits both the patient and the practitioner. It is not a replacement for conventional clinical care, however it opens new ways to care for our patients.”

Hamlyn says the most challenging part of changing practice is the transition, and COVID-19 has accelerated this change. OA is also encouraging optometrists and ophthalmologists to work together and look at innovative models in how the eyecare system manages the backlog of patients that will result from temporary reduction in care.

“It has opened the eyes of practitioners and staff to other ways of practicing and given them experiences of working in a different way. The innovative approaches that provide benefit to the community are likely to stay. This may be as simple as incorporating regular telehealth for vulnerable groups, or upskilling staff to enable better triaging of urgent appointments.

“Technology in this area will continue to evolve and enable optometrists to capture more information remotely, and we should be open to these changes and utilise them to improve our profession and our care to patients. There is still a way to go, but COVID-19 has certainly kick-started telehealth.”

Speaking from experience

Dr Angus Turner is a name synonymous with teleophthalmology in Western Australia. He is the McCusker Director of Lions Outback Vision, part of the Lions Eye Institute in WA, which has run a state-wide teleophthalmology service to rural and remote communities in WA since 2011.

Angus Turner.

“Telehealth is an exciting area and the real-life restrictions put in place due to COVID-19 have placed it on the agenda. It is an opportunity to provide patient access to eyecare, to be as useful in urban areas as it has been in remote and rural  Western Australia.”

Speaking from nearly a decade of experience in teleophthalmology, Turner believes collaboration between optometry and ophthalmology is a necessity; both
professions are maldistributed and cannot afford to duplicate their efforts.

“There must be opportunities to work together better in the community. To that end, telehealth is an exciting prospect – it can elicit earlier, more timely access to eyecare, and certain conditions can be detected earlier.”

In 2014, Lions Outback Vision demonstrated that providing a reimbursement to optometrists for providing a teleophthalmology consultation led to significantly more consultations being performed. This research evidence was used to successfully lobby the Australian Government to provide funding for a reimbursement through the MBS.

A year later, the Federal Government introduced an MBS reimbursement for optometry-facilitated teleophthalmology consultations under specific circumstances. It was made available to optometrists to provide real-time teleophthalmology consultations with ophthalmologists for patients that comply with the 15km rule, and are based at an Aboriginal Medical Service, or in an aged care facility.

Dr Angus Turner, pictured here speaking with optometrist Dr Alex Craig, says restrictions due to COVID-19 have placed telehealth on the agenda across the broader sector.

“Real-time teleophthalmology consultations, as per the MBS descriptor, has an inherent problem with lining up three people – optometrist, ophthalmologist and patient – for a video conference,” he explains.

“It depends on availability, and we’re still facing that roadblock because, in my experience, optometrists and ophthalmologists work on a different rhythm, although it does have real-time benefits for the patient, because they are in the conversation, and can give their consent to surgical procedures.”

Turner says teleophthalmology in WA has adapted and evolved with time. The eventual introduction of on-call services provided immediate access to the specialist ophthalmologist for telehealth at the time of the initial optometry visit, instead of the need to schedule for a future date.

“This availability has led to a ten-fold increase in uptake for Indigenous communities in remote areas where optometrists are only visiting for a couple of days at a time,” Turner says. 

The Lions Outback Vision telehealth model has been audited regularly since its inception in 2011. According to research published in Clinical and Experimental Optometry, during 2018 there were 953 patients referred to the Lions Outback Vision teleophthalmology service. This resulted in a total of 1,028 teleophthalmology consultations, an increase of 50.5% compared to the previous biannual audit.

Additionally, a systematic review of real-time teleophthalmology versus face-to-face consultation, also published in the journal, determined that in terms of diagnostic accuracy, real-time teleophthalmology was considered superior to face-to-face consultation in one study and comparable in six studies.

Optometry-to-optometry telehealth?

Independent optometrist Dr Alex Craig graduated from the University of Melbourne in 2015 and accepted a position with OPSM in Karratha, in the Pilbara region of WA.

Alex Craig.

“I grew up in Zambia in Africa and I wanted to work in a rural environment where I’d be exposed to a plethora of eye health conditions and could use my full scope of diagnostic skills.”

With no resident ophthalmologist in Karratha, Craig soon became acquainted with the visiting ophthalmologists with the Lions Eye Institute mobile van and, by extension, Dr Angus Turner.

“Working with Angus Turner, we were able to set up telehealth through the OPSM practice in Karratha. That was a great start. It allowed us to ensure that patients that required chronic care who needed to be seen, were seen.”

Through managing patients that required acute care, Craig forged a stronger co-management relationship with Turner. The pair have used Facetime to connect with patients to plan for their care in real-time.

“It was more efficient, there was less lag time. Things were as ‘live’ as they possibly could be. I could take current OCT scans in the practice with the patient and send them immediately to Angus,” Craig says.

After four years with OPSM, Craig resigned and locumed interstate for six months, including in Swan Hill and Cairns before returning to the Pilbara and opening his own practice – Karratha Eyecare – in November 2019.

Dr Alex Craig (left) and Dr Angus Turner (on screen) with a patient.

Due to travel challenges associated with the region, telehealth is an integral part of his practice.

“Recently I had a patient email me in the evening; the very next morning I saw them in clinic and diagnosed a retinal tear. With same day telehealth accessibility, I Skyped with Angus, and we created a targeted management plan, taking into consideration whether the patient needed to travel to receive immediate tertiary care.

“Telehealth can provide simple assurity. It can ensure I’m covered and the patient knows they are receiving top quality care.”

Craig also runs monthly telehealth clinics from Karratha and Port Headland hospitals.

“Patients are streamlined, their eyecare needs addressed, they have access to tertiary care, for cataract, for AMD, for diabetic retinopathy. Telehealth offers better intervention, treatment, and follow-up. Compliance and intervention rate is better, it’s a lot more targeted,” he says.

From his post in the Pilbara, Craig is well-acquainted with the use of telehealth between the ophthalmologist, optometrist and patient, but he see’s potential for a third side, from optometrist to optometrist.

“In teleophthalmology, between optometrist and ophthalmologist, the Medicare rebate has restricted the service to rural areas. Here in Karratha, immediate ophthalmology care accessible to patients and practices gives massive peace of mind. We have on-call a tertiary care provider who can give some form of interactive care and intervention,” he says.

“In tele-optometry, between optometry and patient, there are some limitations. You cannot always tell through a telehealth consultation if red eye is conjunctivitis or uveitis. In these cases, you would need some form of minimal investigation of the eye face-to-face to make a clinical decision. However, even though there are some cases where tele-optometry would be suitable this does not apply globally to most patient consultations.”

Interestingly, Craig believes there is potential for an optometry-to-optometry telehealth service.

“Theoretically, an optometrist could consult with another optometrist who has expertise in a certain area of primary care, such as glaucoma, ortho-k, or behavioural optometry. This peer-to-peer telehealth consultation would contain diagnosis and treatment within the primary care sphere, and not unnecessarily elevate it to tertiary care, a system already over-burdened.”

He added: “It’s a way to create a telehealth ‘Rolodex’ of optometry leaders in their sub-speciality fields, and ensure the profession is growing. It could help bring awareness to the need for appropriate referral, such that cases are elevated to tertiary care only when needed.”

Telehealth to gather pace post-pandemic

Rapid uptake of telehealth amid COVID-19 is energising research focused on new ways to remotely diagnose and monitor eye disease, according to the Centre for Eye Research Australia (CERA).

“Video communication has moved into the mainstream and this is an irrevocable change that will also translate into the health system,” CERA deputy director Associate Professor Peter van Wijngaarden says.

“New technologies have the potential to detect the early signs of disease – without the need to attend an eye clinic – and determine who needs to be referred for a more detailed clinical assessment. Research is now revealing the potential to test patients at locations that suit them – in their own home, a photobooth in a shopping centre or during a visit to another healthcare    provider like a GP.’’

Professor Robyn Guymer, CERA. Image: Anna Carlile.

Van Wijngaarden is developing a simple eye test to detect the early signs Alzheimer’s disease. He is also clinical director of KeepSight, a national eye check reminder system for people with diabetes. He says new screening technologies needed to be accessible and convenient, and people need to be motivated to use them.

For example, Professor Robyn Guymer, deputy director and head of macular research at CERA, is helping develop a digital application for neovascular age-related macular degeneration (AMD) patients.

It is hoped new tests will replace the Amsler grid, and involves patients taking a weekly test on an electronic tablet at home to monitor for early signs of disease.

She hopes it will incorporate an electronic test that could be accessed remotely by specialists. Patients with noticeable deterioration would be alerted to take action.

Guymer hopes it will reduce the number of review appointments, minimising pressure on the health system. The next challenge is to ‘gamify’ the digital tests to ensure they’re engaging so patients continue to use them.

Professor Mingguang He is trialling the use of an artificial intelligence (AI) tool to identify people at early risk of blinding eye diseases, including diabetic retinopathy, glaucoma, AMD and cataract.

It’s being trialled in real-world setting, including remote Indigenous communities in the APY Lands in Central Australia with the Nganampa Health Council and The Fred Hollows Foundation.

The next step will be to compare the AI tool against current telehealth models and measure accuracy, cost-effectiveness, ease of use and patient and   clinician acceptance.

“After COVID-19, face-to-face consultation will become increasingly challenging. AI integrated with automation and robotic technology will enable us to develop a virtual clinic as a new model of care,” He said.

Seperately, He has led the development of an app which enables people to measure their visual acuity at home.