The Coronavirus Preparedness and Response Supplemental Appropriations Act (“CPRSA Act”) (https://bit.ly/2yeiFD0 ) authorized the Department of Health & Human Services to allow health care providers to use non-HIPAA-compliant, non-public facing (e.g. FaceTime, Skype, etc.) platforms to provide telehealth during the COVID-19 pandemic. As such, optometrists, among other health care providers, are interested in learning how to implement telehealth appointments in their practices. This is particularly the case, as such appointments will enable patients who have nonurgent ocular issues to continue to receive care and private-practice O.D.s to keep their businesses viable.

Y. Shira Kresch, O.D., M.S., F.A.A.O., who practices at the Columbia University Irving Med-ical Center in New York City, a hotbed for the life-threatening coronavirus, has been performing telehealth appointments through the University’s EMR for roughly three weeks at the time of this writing.

“Initially, we developed a system to manage patients who called complaining of red eye via telehealth to limit the number of patients with possible COVID-19-like symptoms coming into the clinic, since conjunctivitis is one potential early sign of the virus,” she explains. “Now, we continue to expand our telemedicine service with more sophisticated methods to accommodate more types of patients, although telemedicine by nature remains limited.”

Here, Dr. Kresch discusses the steps she and her colleagues took to make these appointments successful — steps she says also can be taken by optometric practices.

1 LEARNING THE RULES

Telehealth appointments under the COVID-19 legislation require items such as documentation (e.g. patient consent) and specific billing and coding protocols.

The April 6 AOA webinar “Medicare Telehealth Billing and COVID-19” covers the rules and can be accessed at https://bit.ly/2US56SC . Additionally, this link contains a guide to telehealth-based care during the pandemic.

Other links to check out: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes and https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html .

“I recommend having a staff member conduct a 100% internal audit review, as our department has done, so every single telehealth appointment is tracked for accuracy, and staff can determine early on what may be missing or need to be done differently,” notes Dr. Kresch.

2 BUILDING A TEAM AND INSTITUTING A LEADER

One person should lead the effort, in terms of developing protocols, understanding the chosen telehealth software and educating others, Dr. Kresch says. There should be frequent updates communicated amongst the team, she adds.

“Additionally, telehealth appointments, or televisits, should be structured in such a way that there is designated personnel to schedule and provide education to patients on access to the tele-platform. Also, a reminder system is helpful to be sure the patient is prepared for the visit. All this will encourage a successful visit and save a lot of time,” she explains.

3 PLANNING AHEAD

Dr. Kresch recommends optometrists look over their patient appointments for the next couple months to determine which patients can be rescheduled for telehealth appointments rather than be cancelled, and have the designated scheduler contact those patients to reschedule.

4 CREATING A TRIAGE PROTOCOL

At the Columbia University Irving Medical Center, the eye care team developed a triage system to determine whether patients who call with a visual complaint need to be seen in the clinic or via a telehealth appointment — something, again, that can be implemented by optometric practices, Dr. Kresch explains. She says most of these patients are converted to some level of a televisit, utilizing either audio or audio/visual means. Dr. Kresch adds that it is essential to obtain and document patient consent before conducting any kind of televisit. There are then essentially four components to the decision-making:

1. Consider the patient’s chief complaint. Things like flashes, floaters and acute changes in vision will need to be seen.
2. Request patients send a photo of their eye or eyes through the EMR or another secure platform. (Emailed smartphone photos also work, for now, Dr. Kresch says.) Try to conduct a video visit.
3. Choose basic visual function tests that are downloadable or up on your website for patients to use to measure VA, check amsler grid, test color vision, etc. “One example of an app is the Eye Handbook app,” she offers. “Remember to always document what you use, as these are ‘gross’ and not exact measurements.”
4. Be sure you are aware of the patient’s systemic and ocular history to the best of your ability before deciding on a management.

“We are finding that at least 60% of the patients we speak to can have a telehealth appointment. Such patients have some form of ocular surface disease, be it dry eye syndrome, viral conjunctivitis, allergic conjunctivitis and even contact dermatitis now because we’re getting into allergy season,” she describes. “Those patients who call with complaints related to a sudden acute change in their vision, such as double vision, or those who have flashes, symptoms of retinal detachments and acute angle closure, among others, are scheduled to come to the office. It’s important to remember that telemedicine is not sufficient for all patients, even amidst a crisis. It has limitations that need to be respected.”

As a brief, yet related, aside, Dr. Kresch says Columbia University Irving Medical Center has a protocol of protective measures, including having patients answer a COVID-19 symptom and travel questionnaire and wearing a mask, before they can enter the eye clinic. Additionally, doctors instruct any patient who has possible COVID-19 to discuss it with their primary care provider.

IT CAN BE DONE!

“Telehealth appointments can be very simple to do, but implementing them requires a solid understanding of the rules and solid organization,” Dr. Kresch says. “Once the O.D. and staff learn these items, the actual visits themselves are easy and greatly appreciated by patients.” OM