Caring for patients via telehealth isn’t a new concept, but until 2020, widespread adoption was slow.¹ As the COVID-19 public health crisis worsened—and minimizing the risks of exposure to the virus became an urgent priority—virtual visits surged accross the country.

In mid-March 2020, CMS expanded telehealth benefits for Medicare beneficiaries, accelerating acceptance. In the last week of April 2020, nearly 1.7 million beneficiaries had received telehealth services, compared with approximately 13,000 in an average week before the pandemic.²

At Bascom Palmer Eye Institute in Miami, the increase in telehealth utilization has been dramatic. The number of virtual visits skyrocketed from three in February to almost 1,500 by the end of April (Figure 1).

“Even when we were able to perform elective surgeries again, the number of telehealth visits stayed high, and we saw an uptick in October,” says Ranya G. Habash, MD. “To patients and physicians, this became a critical new line of service that has persisted and thrived.”

Urgent Initial Response

Immediately after the initial shutdown, some cataract surgeons at Cincinnati Eye Institute in Ohio turned to telehealth to see patients for their 1-week post-op visits.

“We shut down our typical day-to-day operations on March 17 with strict orders to minimize all face-to-face visits whenever possible,” recalls Kavitha Sivaraman, MD. “Several of us did our 1-week post-ops via Skype or doxy.me for patients who’d had routine, uncomplicated cataract surgeries and were doing well, just to review their instructions and the red-flag symptoms that would require an in-person visit. If there was any hint of an issue, we would have had them come in for an examination.”

The surgeons at Williamson Eye Center in Baton Rouge, LA, had never used telemedicine before the pandemic, but as Blake K. Williamson, MD, says, “If necessity is the mother of invention, then crisis is the father. We had to figure out something quickly.”

Virtual Day-1 Post-Op Visits

The in-office day-1 post-op visit has been a long-standing practice for outpatient ophthalmic surgeons. Since COVID-19 restrictions were imposed, Dr. Habash and Dr. Williamson have found that converting these visits to telemedicine is safe and efficient for patients who’ve had routine, uncomplicated cataract surgery. Both surgeons will continue these virtual visits for selected patients after the public health crisis has subsided.

“This has raised some questions in the ophthalmology community,” Dr. Habash notes, “but consider what we’re actually looking for the day after routine surgery. If a patient has severe pain, headache, or nausea while you’re talking to them, or if they’re seeing flashing lights and floaters, obviously you’re going to bring them in. This is when we must rely on our good old-fashioned clinical judgment rather than the obligatory box-checking.”

Dr. Williamson also heard from colleagues with concerns, chief among them IOP spikes. “I always emphasize that only patients without glaucoma who had routine, uncomplicated cataract surgeries are candidates for virtual visits,” he says. “In addition, every patient has a pressure check at the end of the case and is given acetazolamide not only at the end of the case but also to take that night at home.

“I have an extremely low threshold to have patients come into the office if I detect something amiss during a virtual visit,” Dr. Williamson says. “If I open up that video feed and see a swollen eye, excessive tearing, or a cloudy cornea, or if the patient reports severe pain or blurry vision, I have them come in. In my experience, however, the vast majority of these patients are bright-eyed and doing just fine.”

Efficient Patient Communication

Telehealth has also emerged as an effective tool for various types of communication between patients and the surgical team.

“We spend a lot of time going over pre- and post-op instructions in the ASC,” Dr. Habash says. “Those tasks should be done via telehealth. We’ve found that patients understand the information much better, and they’re able to make a more informed decision because they’re not rushed, overwhelmed, or struggling to understand someone who’s wearing a mask.”

Dr. Williamson has noted similar advantages when, for example, patients “meet” with a refractive counselor via telemedicine for a surgical consult on advanced IOLs or laser vision correction.

“Patients appreciate being in the comfort of their own home, and having their spouse or children, frequently the decision-makers in the family, right there with them,” Dr. Williamson continues. “We’ve actually seen higher adoption rates from these virtual consults, as patients are choosing to have surgery and choosing premium technologies more often than they were before.

“At the beginning of the pandemic, telemedicine was a practice savior, because it was the only thing we could do to bring in income,” Dr. Williamson says. “Now, I think we can use it as a practice-builder.”

Benefits Beyond the Pandemic

It may have taken a deadly pandemic to bring telehealth into the mainstream of medical practice, but physicians and patients are appreciating that virtual visits can be vital links between providers and patients. As they become more comfortable with the technology, they are discovering new ways to take advantage of it.

“I was amazed how much could be accomplished from an audio-visual encounter,” Dr. Sivaraman notes. “It doesn’t replace an in-person examination, but there are some great tools available to facilitate these visits.

“For example, the American Academy of Ophthalmology released a printable eye chart that patients can use at home to check their visual acuity. Although not done at our practice, some ophthalmologists in our region have been offering hybrid-type clinics. Patients report their history, chief complaint, and visual acuity via telehealth, and then drive to the office where a technician or physician meets them outside for a drive-by IOP check.”

At Bascom Palmer, the scope of telehealth utilization has expanded quickly to encompass triage.

“When a patient calls our office with an acute issue or a medical question, that call is converted to a telehealth triage visit,” Dr. Habash says. “We’ve found that roughly 70% of these patients have not required an ER visit, and we could start care virtually. The other 30% or so who did need an emergency visit were expedited and managed in a much more timely way. This type of value to a patient, to a facility, and to the health system as a whole is priceless.”

The efficiency of virtual visits, specifically the transition from in-person day-1 post-ops to telehealth, has created opportunities for practice growth.

“The day after surgery, I would typically see between 30 and 40 cataract patients in clinic for post-op evaluations,” Dr. Williamson says. “Now, most of those patients are in my virtual waiting room when I arrive in clinic, and I can see all of them in about 30 minutes. Telemedicine has literally opened up 30 slots in my post-op day for surgical consults.”

Will the interest in telehealth persist once the public health crisis has been contained?

“There’s no question telehealth is here to stay,” Dr. Habash says. “That has been demonstrated by the fact that even when our offices were reopened, the number of telehealth visits stayed high and have been increasing ever since. Telehealth has become recognized as one of our tools for better, faster, smarter patient care.” ■

REFERENCES

1. Centers for Disease Control and Prevention. “Using Telehealth to Expand Access to Essential Health Services during the COVID-19 Pandemic.” June 10, 2020. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html# . Accessed November 30, 2020.
2. Verma S. “Early Impact Of CMS Expansion Of Medicare Telehealth During COVID-19,” Health Affairs Blog, July 15, 2020. Available at: https://www.healthaffairs.org/do/10.1377/hblog20200715.454789/full/ . Accessed November 30, 2020.