Eyeworld

18 Ophthalmology Business • March 2017 private payers to reimburse physi- cians in states with this legislation as if an e-visit were conducted in person—comes into play. Accord- ing to the American Telemedicine Association, 29 states plus Washing- ton, D.C., have telemedicine parity laws, one has a partial parity law, and several have proposed legislation. In states that don't have a parity law, Dr. Habash said it is up to the private payer to decide whether or not tele- medicine services will be covered. "In my experience, it has been widely covered," she said. "Some of the payers are making telemedicine contracts with the physicians at the hospitals and other telemedicine ser- vices because they realize it cuts costs for the health system if you can keep patients healthier without having them come into the hospital." What about liability if, for instance, a patient argues that a mis- diagnosis occurred because an eval- uation was performed remotely via telemedicine rather than in person? Dr. Habash said most malpractice carriers offer telemedicine coverage. Dr. Weng predicts liability standards will become more defined over the next decade, but for now she stressed the importance of informed consent from the patient, HIPAA-compliant storage and data transfer, and knowl- edge of state regulations if services cross state boundaries. While telemedicine might be increasingly demanded by the highly connected millennial generation and beyond, Dr. Weng thinks it will be a necessity just to meet the needs of the aging population as fewer eyecare professionals are available. "Telemedicine can be tremen- dously helpful in these circumstances by identifying patients at greatest risk for vision loss, thereby opti- mizing the utilization of in-person evaluations. Still, in-person visits will always be the core of medicine. Oph- thalmologists should not be fearful In addition to expanding care, Dr. Habash explained how telemedi- cine can help the health care system, using the orbital fracture patient as an example. "[That patient] would have wait- ed 5 hours for me to finish my clinic and then come to the hospital to as- sess. Instead, the patient was able to have orders started and get an answer within 30 seconds. That's invaluable. Not only is that beneficial for the patient—and for me—it's also a ben- efit to the hospital because there are CMS Core Measures that the hospi- tals need to follow, and one of them is the ED throughput time. That means they have a finite amount of time to see a patient from presenta- tion to the ER to discharge from the ER or admission into the hospital. The biggest chunk of time that is lost is in waiting for the providers to call back or waiting for orders to be started. When you can expedite that, you are helping the workflow of the whole system, which decreases costs and increases efficiency for the pro- viders, the hospital, and the patients themselves." Possible barriers While there are more than 30 CPT codes that apply to telemedicine, Dr. Weng said only two codes are specific to teleophthalmology: one for re- mote imaging for detection of retinal disease and another for remote imag- ing for monitoring and management of active retinal disease. "Sadly, the current reimburse- ment levels preclude many smaller practices from offering teleophthal- mology services," Dr. Weng said, noting that the capital for some equipment and personnel to con- duct telemedicine programs can be substantial. On the flip side, how are doctors reimbursed for "e-visits" using free, yet HIPAA-compliant, apps? That's where a parity law—one that requires Telemedicine is already helping close this gap and is expected to increase screenings for these patients as well. According to Dr. Habash, Bascom Palmer offers teleretinal screening for diabetic patients at the time of their primary care visits. Massachusetts Eye and Ear partnered with Massachusetts General Hospital to do the same. "Trained radiology technicians capture images with a flash-based, non-mydriatic fundus camera using the Joslin 3-field technique," said Brian Song, MD, Massachusetts Eye and Ear, Boston. "These images are uploaded to a secure server where they are read by a Mass Eye and Ear ophthalmologist or optometrist, and a note describing the findings is placed in the patient's electronic health record. The patient's primary care doctor is copied on the note and made aware of the findings. If a face- to-face examination is needed, then the readers work with the primary care doctor to facilitate an appoint- ment with an ophthalmologist." Dr. Weng said she thinks there is great potential for telemedicine to branch into glaucoma, too. "Glaucoma is another silent blinder and one of the most common causes of vision loss in the world. The optic nerve's cup-to-disc ratio is fairly simple to image. Better yet, if retinal nerve fiber layer optical coher- ence tomography could be integrated with the camera technology, screen- ing for glaucoma would become even more reliable and potentially save countless people from blindness," she said. Telemedicine is already being used in some cases to expand access to specialist care for those in rural settings or underdeveloped countries and also for second opinions. "Its applications are even being evaluated by NASA for use in outer space. The possibilities are endless," Dr. Weng said. continued from page 17

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