The Ins and Outs of ‘Tele-optometry’

My consulting work has given me the rewarding experience of being able to visit a wide variety of practices. Over the years, I’ve noticed that rural practices seem to enjoy a strong community presence and are often the only choice for eye care in their areas. These big, successful practices are not attracting new doctors, which often leads to high levels of burnout for these practice owners. My interest in “tele-optometry” was sparked as an exploration to help find a good solution to this issue.  

Before the pandemic, a small team led by Vision Source initiated a project to explore the possibility that tele-optometry could serve communities in a way that delivered quality care in a responsible way. I opened a new Vision Source practice in an underserved area with the primary focus of delivering high quality optometry care. This was 2019 and not everyone in optometry was open to the concept of tele-optometry. My plan for 2020 was to try to convince the optometric profession to think about the possibility.      

Since then, we’ve opened a new practice with the intention of providing Comprehensive Exams with a Remote Provider. This form of tele-optometry has the patient come into the practice and the doctor remotes in. We’ve learned so much about the strategies needed to deliver care this way. With the proper equipment and the right people, it can be done in a way that is as good (and in some ways better) than in-person exams. But it’s still different.  

Different Types of Tele-optometry
Tele-optometry is practicing optometry when the patient and the provider are not physically in the same location. Every time a “friend” texts you a picture of their eye and asks, “is this a stye,” if you answer and give advice or direction, you are practicing a very basic level of tele-optomety. This type of service is commonly called a VAHOV (Virtual, At-Home Optometric Visit) — and you can bill for it, by the way.

In addition to VAHOV’s, there is also Remote Monitoring, Supportive Care, and Comprehensive Exams with a Remote Provider. There is a wide variety of services that can be provided through tele-optometry, so it is important to clarify before you start any conversation about the topic. It is easy for a conversation to be derailed because we are talking about different forms of tele-optometry.  

The difference between synchronous and asynchronous care is the most important difference to understand, and it is determined simply by the timing of the connection between the doctor and the patient. Synchronous means the patient and doctor are talking in real time; asynchronous means they are not. The classic asynchronous visit is when a radiologist looks at an x-ray and diagnoses a broken bone, never seeing or talking to the patient. In eye care, we are doing the same thing when analyzing retinal photos for signs of diabetic retinopathy.  

The technology has upsides and downsides — it allows us to better care for our patients, but it also allows for negligence and cutting corners. It is our responsibility to make sure that it is used appropriately. Here’s a classic challenge: We all believe that diabetics should get yearly comprehensive eye exams, but this doesn’t always happen. One of the most critical tests that needs to be done at this exam is a retinal evaluation, which can be done with a retinal camera. Some of us agree that for a diabetic who can’t receive a comprehensive exam, a retinal photo is better than nothing. But it has to be presented in a way that doesn’t suggest that the photo is the same as the exam. Contact lens sellers need to respect the need for yearly exams and not substitute a photo and an old Rx as adequate.  

The quality of care still depends on the relationship and the connection between the patient and the doctor. The technology is plenty good enough, but it all boils down to how we use it to care for patients. If the connection to the patient is enhanced, with better attention to the patient or enhanced imagery, the quality of care is better. If technology is used to put up a barrier between the doctor and patient, the quality of care is diminished.  

Putting Technology into Practice
The equipment needed to perform tele-optometry depends greatly on the level of care that you plan to deliver. A VAHOV only requires a HIPAA-compliant way to connect with patients and a good internet connection. Remote Monitoring requires a device that the patient can take home to send measurements to the cloud. Comprehensive Exams with a Remote Provider require high quality equipment that allows internet connections. Digital phoropters and eye charts that can be operated remotely and imaging systems that can be uploaded to the cloud are the basis of this system.  

Similarly, the cost of setting up these services also depends on what level of care you intend to provide and what equipment you already have. If your office is already well equipped, you may not need to spend any extra money. If you are starting from scratch and you want to provide the highest level of care, the cost can be as high as $200,000 for the needed equipment.  

When it comes to billing patients for tele-optometry services, that all comes down to the location of the patient — not the provider. If the patient comes to the practice for a Comprehensive Exam with a Remote Provider, the billing is the same as with an in-person provider. For a VAHOV, the patient is in a different location, and there are many rules about this that are changing. During the COVID-19 Public Health Emergency, these rules were suspended, and billing was treated the same as it is for in-person exams. The Telehealth Expansion Act of 2023 is being debated in Washington right now to continue these relaxed regulations, so time will tell how billing for these services will change moving forward. 

Do What’s Best for Your Patients
As you consider adding tele-optometry services to your practice, commit to doing what is best for your patients. By keeping your patients at the forefront of your mind, insisting on quality care and demanding reliable data, you will enhance your delivery of care. If you are motivated only by making more money, it will eventually backfire.  

I am a little envious of the newest generation of optometrists because they will be the ones who determine how much we will utilize this technology moving forward. Optometry has a long history of adapting and shifting based on the needs of our patients. We are the primary eye care providers, and to keep that title, we need to adapt. My hope is that we keep our patients at the forefront of our decision making and develop processes that improve the care we provide.  

For more information on tele-optometry, Jobson Information Service’s research report is available for purchase here.