How is Telemedicine Being Done by Retina Specialists?
Richard Garfinkel, MD and Michael Singer, MD
As the country responds to coronavirus, the term telemedicine or telehealth has been used as an alternative to conventional office visits. There have been some excellent presentations on the subject by both Rishi Singh and the American Academy of Ophthalmology. However, in terms of implementation, it may be challenging for some private practice retina specialists. For this month’s column I have interviewed Dr. Rich Garfinkel who is part of the Retina Group of Washington. The Retina Group of Washington is one of the largest private practice retinal groups in the United States. I wanted to better understand how the pandemic is affecting his practice and how he is integrating telemedicine into his patient encounters.
1. Rich, how have you been affected by COVID in terms of patient volume and what have you done to adjust to it?
The numbers in our practice are down through April. The doctors designed a very safe system with three phases. In the first phase, we were restrictive to patients, seeing patients who really needed the care—primarily exudative age-related macular degeneration patients and others with a variety of urgent or emergent retinal problems. That limited us to about a third of our patient population. We wanted to make sure we could see our patients safely, having over 300 employees in all locations. In phase 2, we increased the number of patients safely and Phase 3 will be starting soon when we will be open to all patients. To my knowledge, we’ve had 4 employees, out of more than 300, test positive for coronavirus (2 were from the call center and didn’t enter any of our offices). There has been no employee to employee spread that we are aware of but the real test is when we don’t restrict the schedule starting next week.
2. How did you implement each phase and what was the response?
In phase 1 we tried to limit the number of patients coming through. We removed many chairs in the waiting room. We gave patients the opportunity to wait in their cars to limit the number of people in the office at any given time. The number of doctors in the office was limited as well. Everyone had to wear a mask, including patients. Every surface that is touched, especially equipment, is heavily cleaned and disinfected. When we get to phase 3 and see more patients, we will begin temperature checks prior to the patient entering the office. Most of our offices have remained open. We had rotating teams of doctors and techs in case someone became infected, but luckily, this has not happened other than the two instances I already mentioned.
3. How do you define telehealth in your practice? What is the objective of a telehealth visit?
Telehealth in our practice means being able to communicate with patients primarily through video conferencing. We use the Doxy.me platform, which has been great. Patients seem to be able to use it easily. With some patients who are older without access to the internet, we have initiated telephone calls. Telemedicine allows you to connect in a different way with patients, sometimes in a deeper way than what we have time for in the office. It allows me to learn a bit more about my patients. We can ask them about symptoms and get a good idea of when they will need to come back in. It provides for a more educated way of rescheduling patients.
4. What technologies are you using for an exam to enhance the telehealth experience?
Some of my partners use eye charts and use Amsler grids. What I do is ask people to pick up reading material on their desk to assess their near vision. I test their eyes separately. You can assess symptoms by asking specific questions, especially if you are familiar with the patient’s history and problem list. Many of our patients can detect changes in their vision. Home monitoring for dry AMD is another telehealth vehicle. As retina specialists, we have fallen in love with anti-VEGF drugs. I am appreciative of the ability to improve vision with these injections, although modestly. Clearly, anti-VEGF treatment is revolutionary. However, we have largely ignored using home monitoring such as ForeseeHome® for early detection of wet AMD. In pandemic parlance, we don’t want to flatten the anti-VEGF treatment affect, but we know that this happens after about 3 months of treatment regardless. Instead, we want to move the curve toward better long-term vision. Home monitoring has shown that this can be achieved, especially in the absence of new and improved drugs. This was highlighted by Allen Ho with his review of the IRIS Registry data. We have failed to come far enough over the years, even with the widespread application of OCT. If you analyze the data carefully, without home monitoring, we are really no better off detecting early conversion from dry to wet AMD than we were 15-20 years ago.
5. Have you been proactive in terms of reviewing ForeseeHome® with patients before their telehealth visit? What percentage of your patients are currently using the device?
When you write a prescription for the device, Notal Vision sends a device to the patient and educates them about use. We can access the data, but they perform the monitoring. The more frequently the patient tests, the more accurate. Based on data from the HOME trial, testing 2x per week will achieve a 94% success rate that choroidal neovascularization will be detected with the patient’s vision 20/40 or better. That’s all accomplished without the patient necessarily seeing their results. If there is a series of test results that are concerning, the physician is alerted and the patient is be called in to be examined. There are some patients who can’t use the machine, so they return it. In the beginning, this was not an approved Medicare device so a number of patients could not use it because of the cost. Once it became Medicare-approved, we saw an increase in its usage. About 20% of my dry AMD patients use the device.
This pandemic has reopened my eyes to a technology that we should all be embracing because it makes a huge difference to our patients. All you need to do is look at the compelling data. The way things are going with uncertainty of patients coming in, we don’t need to wait until a second wave of the virus hits. Early detection is important when we’re talking about improving a patient’s quality of life. The pandemic has given each of us a chance to reflect. If we are practicing medicine the same way a year from now, we will have wasted a great opportunity to better ourselves as physicians.
Thank you so much Dr. Garfinkel for your thoughtful insights. Everyone agrees the pandemic has reshaped life as we know it. As retina specialists we strongly believe that our care is an essential service, as retinal disease can lead to blindness if not treated promptly. As more states are loosening restrictions, we will start to see and treat more patients again. The concern is if there is a second wave, we need to have more tools available to remotely treat our patients effectively. By incorporating the suggestions of Dr. Garfinkel, Dr. Singh and the AAO, as well as having our patients embrace technology proactively, such as home monitoring and vision testing phone apps, we may be better prepared to do more effective telehealth if and when the next wave of this pandemic returns.
About Our Editor:
Dr. Michael Singer is a board-certified Vitreoretinal Specialist and Director of Clinical Research at Medical Center Ophthalmology Associates in San Antonio, TX. He is currently the Clinical Professor of Ophthalmology at the University of Texas Health Science Center in San Antonio.