COVID-19 has affected everyone and every industry, and our culture and society will likely be changed forever. Health care especially will feel the effects of the pandemic for decades. We are forced to rethink how we approach our clinics during these times, and we can either keep things the same or we can adapt and innovate, bringing forth a better, safer and more efficient way moving forward.

Prior to the COVID-19 pandemic, I was working on improving clinic workflows and efficiencies to enhance patient experiences by significantly reducing wait times. Through scheduling, staffing and operational changes, we were able to reduce end-to-end visit times to under an hour from an industry average of 90+ minutes. An important component of these changes was leveraging technology in the form of advanced retinal imaging, namely ultra-widefield (UWF) imaging. The quicker I can assimilate all the patient information to make complex retinal decisions, the less time I need to physically gather information and the more time I can talk with and educate the patient, with UWF images serving as excellent visual education tools for patients. This also improves my efficiency in the clinic.

Here I explain the increased benefits of utilizing UWF that we have seen during the COVID era.

OUR COVID TRANSITION

When COVID-19 struck in March, I was able to easily transition my clinic and staff into a more efficient and socially distanced model to adapt to the current situation. We quickly realized that we not only needed to make patients and staff safe, but we also needed to make them feel safe. We used to get away with crowded reception areas, close contact with patients, staff and physicians, longer wait times and lack of masks. However, it has been critical to screen for symptoms prior to entering the office, check temperatures, practice fastidious hand washing and sanitizing, minimize close contact and wear masks. Adding these measures helped create a safe environment for patients, but also made them feel safe and willing to continue to come to the office.

If we experience any breakdown in these policies, patients may express concern and be unwilling to return or find another doctor where they feel more comfortable. Personally, I have several patients who now come to see me after they were not happy with the safety policies at another practice.

THE ROLE OF UWF AND TELEHEALTH

Prior to COVID-19, I had already transitioned to obtaining UWF images and SD-OCT on all patients except procedure-only visits. I utilize a central workstation with two linked monitors to view EHR data, OCT images and UWF images simultaneously (Figure). In a matter of seconds, I can assess OCT comparison maps and scroll through OCT images, view a single UWF fundus photo that captures information anterior to the vortex veins and correlate with EHR data. Greater than 95% of the time, I have a diagnosis and treatment plan within seconds of reviewing the data and before I step in the room. I can then quickly perform any slit lamp and fundoscopic examinations focused on areas of interest based on the imaging and symptoms.

COVID-19 has only affirmed my approach as we aim to socially distance and minimize close interactions. Our practice began offering patients hybrid telemedicine visit options, which combine in-office imaging (UWF and OCT imaging) combined with virtual consultation with the physician. I now routinely utilize UWF imaging technologies to enhance my in-office workflow and often combine with hybrid tele-eyecare to augment my clinic, creating a parallel in-office/virtual clinic.

COVID-19 has required us to step back and assess our workflows. We can either continue doing things the same and just extend our hours to social distance our clinics or we can be innovative in our approaches to focus on safety, efficiency and efficacy.

OUR HYBRID APPROACH

Prior to COVID-19, we already identified the benefit of UWF imaging and made the decision to transition our offices into the use of this technology. We have 19 offices, and we currently outfit 12 of them with UWF. Early adoption of UWF imaging allowed us to easily adapt to using UWF-guided examinations and hybrid tele-eyecare.

For our hybrid visits, we first identified offices with an open day on the schedule. We send two technicians to these offices with patients scheduled 15-30 minutes apart. Patients only see and interact with one staff member, and they do not see other patients during their visit. The technician performs a standard work-up with history, visual acuity and IOP followed by UWF imaging and SD-OCT. UWF imaging allows for patients and staff to be distanced as images are captured with a remote control with staff several feet away.

Additionally, staff thoroughly clean and sanitize the devices between uses. All staff are masked, and close contact for examinations between staff/physicians and patients is minimized. We do not routinely dilate patients on these visits. The patients never wait in the reception area, and visits last 15-20 minutes.

We have been utilizing hybrid tele-eyecare for many chronic disease management patients, including dry macular degeneration, diabetic retinopathy, epiretinal membranes/macular puckers and other stable pathologies. If I identify patients that need treatment, I bring them back to clinic for treatment within 24-48 hours. For example, I recently evaluated a 6-month follow-up diabetic patient who had new neovascularization with pre-retinal hemorrhage indicating conversion to proliferative diabetic retinopathy. I brought the patient back for treatment the next day.

Our goal with offering hybrid visits is to provide additional ways for patients to be monitored in a safe and efficient way, especially if they are not comfortable coming to clinic with other patients and staff present. Surprisingly, many patients prefer this method and consistently ask to continue “seeing” me virtually.

Following the in-office data collection and image acquisition, we give patients the opportunity to connect with the doctor virtually either at the end of the visit while in the office or from the comfort of their home within 24-48 hours. Immediately following their imaging, patients are provided an iPad that allows them to have the virtual visit with me while I am at a different office. This allows patients to utilize these services even if they are not confident with their technical abilities or do not have access to a computer, smartphone, e-mail or internet. From a workflow standpoint, I either set aside an hour in the afternoon or during lunch to schedule video calls with patients or I often prefer to run parallel in-office/virtual clinics.

RESULTS

Combining the in-office practice efficiencies above and hybrid tele-eyecare, I now run parallel in-office/virtual clinics. As an example, I see 80 patients in-office at my downtown Orlando location between 7:30 a.m. to 4:30 p.m. on Fridays. Simultaneously throughout the morning, two technicians work up 12 patients at my Villages office. In between in-office patients, I connect virtually with these patients at the end of their visit after I remotely review their imaging. This allows me to effectively see 92 patients in the same amount of time while allowing better social distancing in clinic and enhancing safety and efficiency for the patients. Also, to improve on convenience for patients, we are starting to offer Saturday and after-hours virtual clinics.

CONCLUSION

As we transition into our “new normal” and we live and cope with COVID-19, the sentiments of Dr. David Parke II, AAO CEO, continue to drive us to think about the future and how we can adjust and adapt our clinics for years to come:

“The lessons learned from COVID-19 may mean that the normal of January 2020 may never approximate the normal of the future. We will have the SARS-CoV-2 virus with us for years. We will always have the memory of what it means to shelter in place for weeks on end, to furlough staff and to defer patient care. What we must do now is develop the processes to provide patient care in a ‘new normal’ … This will not be an issue of waiting for someone to signal the ‘all clear’ and turning on the lights.” OM

About the Author

S.K. Steven Houston III, MD, is a vitreoretinal surgeon and partner at the Florida Retina Institute. He is also CEO and co-founder of HealTheia, a telemedicine software company developing eyecare-specific software and workflows.

Disclosures: Dr. Houston is an advisor/consultant with Alcon and has equity in HealTheia.