Since the COVID-19 pandemic, 77.4% of eye care providers are now providing telehealth, or teleoptometry, services.1 (See “Telehealth Platforms: An Overview,” p.15.) Although the initial shift to telehealth was driven by maintaining patient care while adhering to social-distancing measures during the pandemic, many optometrists have stuck with this technology because of its value:
• Increased accessibility. Teleoptometry removes barriers to care, making it easier for patients, especially those who live in rural or underserved areas, to access eye care services.
• Patient convenience. Teleoptometry allows patients to consult with their eye care providers from the comfort of their homes, should their car breakdown, a weather event, mobility issues, or transportation barriers keep them from the physical practice.2,3,4
• Continuity of care. Teleoptometry enables frequent and timely monitoring, early detection of disease progression, and rapid intervention when necessary.2
• Practice growth. Offering teleoptometry can attract patients whose conditions can be managed via this technology and prefer virtual consultations.
• Adaptability. Teleoptometry services can help practices adapt to future challenges, such as natural disasters, ensuring uninterrupted patient care.
• Collaborative care. The optometrist can collaborate with other health care providers, such as ophthalmologists, by sharing the data collected for additional patient management.2 Think retina photos and DED testing prior to refractive surgery.
For optometrists interested in participating in the benefits of teleoptometry, here are some best practices to get started.
Identify Ideal Patients/Methods
The optometrist should first identify current patients whose needs fall under teleoptometry. The present consensus in the medical literature is that teleoptometry and teleophthalmology are most commonly and robustly applied to the screening and management of diabetic retinopathy, glaucoma, age-related macular degeneration, and retinopathy of prematurity, as well as for triage and general eye care.2,5,6
Teleoptometry falls under 3 categories of use: (1) synchronous (real-time), (2) asynchronous (store and forward), and (3) a hybrid model. As a result, it makes sense for the OD to identify how they’ll use it effectively.
Synchronous use typically involves live video con-sultations, allowing for real-time interaction and assessment. For example, during a synchronous visit with a dry eye disease (DED) patient, the optometrist can discuss the effectiveness and tolerability of current therapies and adjust the management plan as needed. This interaction also allows for setting realistic expectations regarding the chronic and multifactorial nature of DED. This is essential for long-term management and patient satisfaction.2,7
Asynchronous use is the collection and transmission of patient data (such as images or test results) to the OD for review and feedback at a later time.2 In using the DED patient as an example, this can involve patients completing validated symptom questionnaires—such as the Ocular Surface Disease Index—remotely at regular intervals, with results securely transmitted to the optometrist for review and longitudinal monitoring of symptom trends. This approach enables the OD to identify early signs of worsening disease or inadequate response to therapy.2,8
The hybrid care model combines teleoptometry with in-person visits. For example, patients may undergo an initial in-person examination (eg a DED diagnosis) and assessments (eg, treatment efficacy) and follow-ups via teleoptometry.9,10
Relatedly, the optometrist must also be aware of state-specific privacy laws and international data protection regulations if they are providing teleoptometry services across borders. The OD can find state-specific privacy laws relevant to teleoptometry through the Federation of State Medical Boards (FSMB) and their own state’s medical or optometry board websites.11
Determine Related Reimbursement
The OD should familiarize themself with the re-quired codes for teleoptometry by communicating with both individual insurers and local Medicare Administrative Contractors.12,13 That said, codes 99201 to 99215 are commonly used for evaluation and management via teleoptometry. Specific examples: For remote retinal imaging and diabetic retinopathy screening, respectively, the American Telemedicine Association (ATA) specifies the use of Current Procedural Terminology (CPT) code 92227 (remote imaging for detection of retinal disease) and CPT 92228 (remote imaging for monitoring and management of active retinal disease), as well as CPT 92250 (fundus photography with interpretation and report) for some commercial carriers. Additionally, Healthcare Common Procedure Coding System code S0625 (retinal telescreening by digital imaging) may be accepted by certain private insurers, though requirements, such as pupil dilation, may apply and should be verified with each payor.
Choose a Platform
To determine which teleoptometry platform to invest in, the optometrist should conduct research, keeping in mind their existing technology infrastructure, in terms of space and compatibility. The OD should also consider crucial factors, such as Health Insurance Portability and Accountability Act (HIPAA) compliancy (eg, ensuring data encryption during transmission), ease of use, and must-have features (eg, video conferencing and scheduling).
The ATA recommends that telehealth systems conform to applicable U.S. Food and Drug Administration regulations and national/local statutes. Additionally, the ATA suggests that equipment and software meet standards, such as Digital Imaging and Communications in Medicine and Health Level 7 (electronic health information exchange standards), for interoperability and data security. Further, the organization emphasizes that telehealth programs should ensure compliance with privacy, security, and credentialing requirements, though platform selection and validation remain the responsibility of the provider or institution.2
Examples of search terms for researching teleoptometry platforms include: “teleoptometry platforms,” “asynchronous teleophthalmology,” “store-and-forward telemedicine eye care,” “synchronous video consultation optometry,” “hybrid telehealth models optometry,” “retinal image transmission telemedicine,” “optometry telemedicine software,” “digital referral optometry,” and “remote optometric care technology.”
The optometrist can also seek input from colleagues on their experiences regarding a teleoptometry platform’s usability, integration with existing workflows, medico-legal considerations, and more. However, it is essential to verify the information provided against peer-reviewed medical literature and regulatory guidelines.14
Develop Protocols and Policies
The OD should establish clear protocols for teleoptometry visits, including how to handle emergencies, documentation requirements, and follow-up procedures. Regarding policies, this should include informed consent. Privacy and informed consent are central medico-legal considerations. Explicit informed consent for telehealth must be obtained and documented, including discussion of telehealth-specific risks, such as limitations of remote assessment, and potential data privacy concerns. This way, the optometrist and patient are on the same page regarding appointment expectations and the limitations of teleoptometry.
Set It Up
The optometrist should set up the teleoptometry platform where video consultations can be physically separated from public or high-traffic areas, with soundproofing or white noise. Additionally, computer screens should be positioned to prevent inadvertent viewing by unauthorized individuals.12 This is necessary for patient privacy.
Also, the platform’s camera should be positioned for maximum eye contact for direct communication.
Train Staff
Hands-on, scenario-based practice allows staff to develop proficiency, optimize communication, and address challenges unique to telehealth, such as privacy, technology disruptions, and adapting clinical skills to the virtual environment. Also, practicing in a controlled setting helps identify workflow gaps and ensures all staff become comfortable with the technology and protocols before patient-facing implementation.11,15,16
For smooth telehealth platform operation, the OD should have a list of technical support contacts readily available for staff and review with staff protocols for handling technical issues during a teleoptometry visit. These protocols:
• Immediate troubleshooting. If a technical issue (eg, loss of video/audio, poor image quality) arises, guide the patient through basic troubleshooting (eg, checking internet connection, etc.) Then, document the nature of the issue and steps taken.
• Time tracking. Accurately record the start and stop times of the teleoptometry session, including time spent troubleshooting, as this may be relevant for billing if the visit is billed based on time.
• Contingency plan. If the issue cannot be re-solved within 5 to 10 minutes, offer to switch to the practice phone, or reschedule the visit. Also, document the transition and its reason.
• Documentation. Clearly document the technical issue, its impact on the clinical encounter, the resolution or alternative plan, and the final modality used for the visit. This is essential for compliance and reimbursement.
Market the Teleoptometry Service
The optometrist should inform existing patients about the teleoptometry platform through newsletters, emails, and/or social media posts.
Also, the optometrist can include information about teleoptometry options and how to schedule appointments on the practice website.
Determine Workflow Integration/Documentation
Initially scheduling teleoptometry visits for the same time allocation as in-person visits can account for potential issues, such as portal-entry difficulty.
Regarding documentation, the OD should employ standardized electronic health record documentation templates for teleoptometry encounters. These templates must capture the modality of the visit (video, phone), clinical findings, uploaded images, explicit patient consent (see above), and any technical issues or troubleshooting steps.
Additionally, the ATA guidelines emphasize that telehealth documentation must meet the same standards as in-person care (accurate and complete entry of the modality used, clinical findings, uploaded images, explicit patient consent, and any technical issues or troubleshooting steps). Doing so supports clinical decision-making, continuity of care, legal protection, and compliance with HIPAA.11
Prepare Patients
The OD should instruct patients on how to use the teleoptometry platform, ensure their internet connection stability, and conduct test calls if necessary. Doing so minimizes technical difficulties.
Monitor and Evaluate
The optometrist should collect patient and staff feedback staff to evaluate the platform’s effectiveness and identify areas for improvement.
Joining the Revolution
By implementing teleoptometry services, the OD can meet the needs of a variety of patients and position themselves at the forefront of a rapidly changing healthcare environment.
References
1. Capitena Young CE, Patnaik JL, Seibold LK, Kahook MY. Attitudes and Perceptions Toward Virtual Health in Eye Care During Coronavirus Disease 2019. Telemed J E Health. 2021;27(11):1268-1274. doi:10.1089/tmj.2020.0424
2. Massie J, Block SS, Morjaria P. The Role of Optometry in the Delivery of Eye Care via Telehealth: A Systematic Literature Review. Telemed J E Health. 2022;28(12):1753-1763. doi:10.1089/tmj.2021.0537.
3. Ramchandran RS, Yilmaz S, Greaux E, Dozier A. Patient perceived value of teleophthalmology in an urban, low income US population with diabetes. PLoS One. 2020;15(1):e0225300. Published 2020 Jan 9. doi:10.1371/journal.pone.0225300.
4. Sharafeldin N, Kawaguchi A, Sundaram A, et al. Review of economic evaluations of teleophthalmology as a screening strategy for chronic eye disease in adults. Br J Ophthalmol. 2018;102(11):1485-1491. doi:10.1136/bjophthalmol-2017-311452.
5. Rathi S, Tsui E, Mehta N, Zahid S, Schuman JS. The Current State of Teleophthalmology in the United States. Ophthalmology. 2017;124(12):1729-1734. doi:10.1016/j.ophtha.2017.05.026.
6. Caffery LJ, Taylor M, Gole G, Smith AC. Models of care in tele-ophthalmology: A scoping review. J Telemed Telecare. 2019;25(2):106-122. doi:10.1177/1357633X17742182.
7. Amparo F, Dana R. Web-based longitudinal remote assessment of dry eye symptoms. Ocul Surf. 2018;16(2):249-253. doi:10.1016/j.jtos.2018.01.002.
8. Wolffsohn JS, Travé-Huarte S, Craig JP, Muntz A, Stapleton FJ. Appropriateness of Questionnaires for the Diagnosis and Monitoring Treatment of Dry Eye Disease. J Clin Med. 2024;13(11):3146. Published 2024 May 27. doi:10.3390/jcm13113146.
9. Newman-Casey PA, De Lott L, Cho J, et al. Telehealth-based Eye Care During the COVID-19 Pandemic: Utilization, Safety, and the Patient Experience. Am J Ophthalmol. 2021;230:234-242. doi:10.1016/j.ajo.2021.04.014.
10. Mosenia A, Li P, Seefeldt R, Seitzman GD, Sun CQ, Kim TN. Longitudinal Use of Telehealth During the COVID-19 Pandemic and Utility of Asynchronous Testing for Subspecialty-Level Ophthalmic Care. JAMA Ophthalmol. 2023;141(1):56-61. doi:10.1001/jamaophthalmol.2022.4984.
11. Bozkurt, T., Flórez-Arango, J. F., Levi, M., & Norton, S. (2020). Telemedicine. CDC Yellow Book.
12. Horton MB, Brady CJ, Cavallerano J, et al. Practice Guidelines for Ocular Telehealth-Diabetic Retinopathy, Third Edition. Telemed J E Health. 2020;26(4):495-543. doi:10.1089/tmj.2020.0006.
13. Yeramosu D, Kwok F, Kahn JM, Ray KN. Validation of use of billing codes for identifying telemedicine encounters in administrative data. BMC Health Serv Res. 2019;19(1):928. Published 2019 Dec 3. doi:10.1186/s12913-019-4753-2.
14. Mazzuca D, Borselli M, Gratteri S, et al. Applications and Current Medico-Legal Challenges of Telemedicine in Ophthalmology. Int J Environ Res Public Health. 2022;19(9):5614. Published 2022 May 5. doi:10.3390/ijerph19095614.
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16. Pfeil SA, Shellhaas CS. Using simulation to train clinical providers in the effective use of telehealth. Nutr Clin Pract. 2023;38(3):520-530. doi:10.1002/ncp.10977.
