Tackling COVID-19 with Telemedicine

Telemedicine is taking center stage in the current COVID-19 crisis. By mitigating the need for clinicians to be in the same place as patients, we protect patients by keeping them out of the crowded hospital environment, and we protect clinicians by reducing the time they spend in close physical proximity with patients.  

Much of the early discussion surrounding COVID-19 in ophthalmology has been about the 34-year-old Wuhan ophthalmologist Li Wenliang, who raised awareness of the risk to eye clinicians in the early outbreak of January 2020, and tragically died. We now understand much more about the disease, in particular about the danger of spread via asymptomatic patients or those presenting with conjunctivitis.

The close physical proximity between patient and clinician during the slit-lamp examination presents an opportunity for disease transmission – particularly if effective use of personal protective equipment and disinfection regimes aren’t observed. As our understanding of the disease continues to accrue – and with increasing strain on healthcare systems – the utility of telemedicine in a predominantly outpatient specialty, such as ophthalmology, needs to be addressed. How can we see our patients safely at a time such as this?

Telemedicine is a useful way to reduce face to face encounters at a time of mandated social distancing and self-isolation. Though no program can be created overnight, by definition, telemedicine is a resource to be shared – and we can harness what is already in place. Here is the practical utility of telemedicine for ophthalmology in the COVID-19 pandemic:

1. The power of virtual triage

“Forward triage” is a recognized strategy for managing healthcare surges – sorting patients for medical treatment on the basis of need before they present physically to a healthcare facility. Any reduction in face-to-face consultations at a time like this will protect patients, doctors, and the wider community. The utility and ambition of forward triage will grow with the increasing need for social distancing and self-isolation.

The key to successful implementation of forward triage is good risk stratification based on a clear required minimum dataset. In ophthalmology, this will include elements of clinical history, objective measurement (visual acuity, intraocular pressure), and imaging (photographs, OCT, visual fields). Triage protocols may be optimized by automated “smart” decision trees guiding structured data gathering, with or without diagnostic imaging. Big Picture Medical, a cloud-based telemedicine platform linking optometrists in the community to ophthalmologists at Moorfields Eye Hospital, is such an example.

It has previously reduced hospital attendances by more than 50 percent in some clinics, while further risk stratifying those that did need face-to-face review.  Last year, there were 7.86 million ophthalmology outpatient attendances in England alone, meaning that there is huge potential for this technology to relieve pressure on eye services in times of greatest strain.

2. Take the slit-lamp out of the equation

Advanced imaging and diagnostic techniques beg the question whether an ophthalmic slit-lamp examination is now needed in all cases. This examination requires the juxtaposition of clinician and patient – closer than that encountered in most face-to-face medical consultations.

Barrier shields may reduce, but will not eliminate, the risk of cross-infection between the two. A critical assessment of the benefits and risks of slit-lamp examination is now needed.ome clinics, such as repeat intravitreal injections and stable glaucoma, might dispense with it altogether.

3. The video eye consultation

The video eye consult is particularly suited for subspecialties, such as minor eye emergencies, oculoplastics and strabismus. Following in the footsteps of tele-dermatology, platforms such as Consultant Connect and Attend Anywhere are increasingly being used in the National Health Service (NHS) in the UK. Patients benefit from more convenient and often earlier access to specialist care. For example, a virtual waiting room system that mimics eye clinics and eases its incorporation into the clinical workflow.

Recently, a collaboration between the NHS Forth Valley and Moorfields Eye Hospital demonstrated the world’s first tele-examination of an eye in 4K resolution using 5G broadband, where a video of a slit lamp examination was streamed live between London and a conference in Edinburgh. This represents a turning point in tele-ophthalmology as we were able to deliver detailed video in real time, using readily available equipment.

The system is currently in use by NHS Forth Valley to allow remote examination of patients in community optometry practices and within Moorfields Eye Hospital to allow remote examination by senior on-call doctors. 

In the light of COVID-19, many routine visits to the eye clinic may have to be subdivided to reduce in-person contact; either diagnostic in-person visits (orthoptic assessment, biometry, OCT retinal scan), or video-based pre-surgery consults with the anaesthetist and surgeon. A combination of an in-person visit for OCT and visual fields, for example, and a video consult to discuss the results reduces the number of contacts for clinician and patient – and the time spent in clinic waiting areas.

Many other applications continue to be evaluated in ophthalmology, including post-operative care and monitoring of stable eye conditions, such as thyroid eye disease and diabetic retinopathy.

4. Self-Care

Reassurance and communication with patients who have chronic diseases, such as dry AMD or diabetic macular edema (DME), may be enhanced with home-monitoring of patient symptoms. Examples include the Alleye application (Oculocare Ltd), which enables monitoring of visual distortion on a mobile device and mobile phone-based, digitized patient reported outcome measure (PROMs) – both of which permit ophthalmologists to remotely monitor patients on a granular level; we should know how patients are faring daily between hospital appointments.

5. Communication

“Why are you ringing me?”

We live in an age of instant messaging, and yet clinically we still rely on phones, emails and pagers. A move to instant messaging apps allows easier team-based communication, which makes patient handover more robust – especially when individual team members unexpectedly have to go into isolation. Most of these apps allow photography within the app, and low-cost smartphone slit-lamp adapters (many telescope adapters cost less than $30) will allow clinical images to be taken using the clinicians’ own device, and sent for an instant specialist review. This technology provides a “rough-and-ready” store-and-forward solution at a time when certain critical skill sets might be physically unavailable.

Can’t go paperless? Go paperlite!

When it becomes impossible to access a set of paper records, even the briefest digital descriptor of clinical history (for example, scanned PDFs of letters) may facilitate management. Communication failure is a known key factor in patient harm. If clinicians are able to access electronic medical records via remote connections, eye clinics may still carry on albeit via telemedicine.

6. Systems developed in a crisis might persist

During a crisis, such as the current COVID-19 outbreak, it is inevitable that hospitals will rush to implement remote management systems that allow them to provide some care to patients unable or unwilling to come to hospital. We are already seeing some relaxation of the usual governance requirements in the UK, where NHSX (a unit responsible for implementing digital technologies to health and social care in the UK) has indicated that clinical need can outweigh usual standards of best practice.

Importantly, the Information Commissioner in the UK “has assured NHSX that she cannot envisage a situation where she would take action against a health and care professional clearly trying to deliver care.” As the crisis passes, however, we are likely to see many of the systems set up to meet short-term need, morphing into long-term solutions.

These new systems should be subject to constant scrutiny to ensure that they develop towards offerings that meet the standards expected during normal times. In this way, the current crisis could transform our healthcare systems towards the remote delivery of care upon which so many national strategies rely.