Arman Mosenia, MD: Insight into the Feasibility of Telehealth in Ophthalmology

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A new Q&A focuses on hybrid telehealth in ophthalmology and subspecialty-level care, and its potential to create new opportunities and increase access for patients.

New research published in JAMA Ophthalmology indicated the COVID-19 pandemic led to increased telehealth use across clinical specialties, with the lowest utilization observed in ophthalmology.

However, study investigator Tyson N. Kim, MD, PhD, Department of Ophthalmology, University of California, San Francisco, is quick to point out that while the rate was low relative to other specialties, ophthalmology relies heavily on exams and testing. An asynchronous testing approach proved effective for some subspecialty-level care.

“What is perhaps more interesting is that teleophthalmology was actually feasible with the hybrid approach,” Kim said.

Although his department returned to mostly in-person visits, he noted that test-only visits were performed at the same location as in-person visits. Thus, it became logistically easier to return to regular in-person visits in most situations as COVID-19 restrictions eased. Testing at other locations in the future could help determine the sustainability of the telehealth model.

In an accompanying Q&A with HCPLive, study coauthor Arman Mosenia, MD, Department of Ophthalmology, Dell Medical School, The University of Texas at Austin, discussed the greater context of the team’s findings and the importance of innovative solutions to improve patient care in ophthalmology.

What factors played into the low use of telehealth observed in ophthalmology during the COVID-19 pandemic compared to other specialties and its greater subsequent return to in-person settings? How do these trends suggest the feasibility of alternative care or telehealth within the larger ophthalmic arena?

Ophthalmology relies heavily on examination and testing. These data are typically acquired through in-person encounters, creating intrinsic barriers for telehealth in ophthalmology. While our study did find that voluntary utilization of telehealth by physicians was lower in ophthalmology than other specialities, an important finding was that asynchronous testing actually did make telehealth evaluation feasible. A limitation of our study was that it was not designed for continued use of telemedicine in ophthalmology beyond COVID-19 restrictions, as asynchronous testing was performed in the same buildings as in-person appointments. It was simply more convenient in most cases to return to the traditional care model when COVID-19 restrictions were eased. Using remote sites for asynchronous testing will be a better way to assess if this telehealth care model is feasible long term.

Your data show subspecialties like retina and glaucoma were the lowest users of telehealth but were some of the highest users for asynchronous testing. Moving forward, will hybrid care/asynchronous testing fill the niche of telehealth and benefit patient care for these subspecialties? Does the nature of these specialties requiring instrument-dependent eye examination lend credit to the hybrid model?

Physician participation in the hybrid telehealth model in our study was voluntary so we tried not to draw absolute conclusions on its utility. For example, our retina division was a low utilizer of telehealth, but ophthalmic telemedicine has traditionally been used most successfully in screening for retinal diseases. Nevertheless, we found that combining asynchronous testing with telehealth enabled the evaluation of certain conditions that had not previously been cared for remotely, highlighting new opportunities that lie ahead. Our work suggests that the hybrid model will be useful for most if not all subspecialties, and we suspect the degree will be correlated with the quality and range of data acquired.

Accessibility is obviously a big question in any medical specialty. What are ways to better increase access to both asynchronous testing and greater eye care for underserved populations who may benefit from this approach? What is the takeaway message on this topic?

The potential for telehealth to improve access to care is exciting. This could have significant impact in reaching underserved areas, particularly in screening for certain diseases and providing follow-up care. One potential approach would be to bring testing sites directly to these communities to facilitate teleophthalmology, and then to refer abnormalities for in-person evaluation. It will also be important to learn and be cognizant of the blind-spots associated with telemedicine, since we certainly don’t want to cause harm by missing disease.

Your findings highlight that the asynchronous testing approach may differ outside of the singular institution which included trained professionals in a fully equipped setting. Although feasible, what more is required to evaluate the topic and expand its reach into these subspecialties?

This is an important question and area for innovation. The accessibility of remote testing is likely inversely correlated to the complexity and cost of acquiring subspecialty-level data. Fortunately, there’s been a lot of progress in making tools for getting this data more affordable and user-friendly. Additionally, the infrastructure on where to perform remote testing will need to be worked out. One possible way to expand testing in a controlled fashion may be to bring this testing to the primary care setting.

Moreover, why is this topic important, particularly given the far-reaching effects of the COVID-19 pandemic on patient care?

The COVID-19 pandemic forced us and the world to re-think healthcare delivery. This has catalyzed tremendous interest and discussion in telemedicine, and it’s a particularly impactful time to consider models which may or may not work.