Communication with Ophthalmology Consultants and Telehealth

Communication with Ophthalmology Consultants and Telehealth

Sophia Mirza Saleem

Emergency providers request specialty consultation to seek opinions and expertise to provide high-quality care for patients. This request is made with expectations of minimal or no delay in care, but, increasingly, seeking a consulting physician prolongs lengths of stay and exacerbates volume dilemmas.

Similarly to most emergency providers, covering consultants also face higher patient volumes and several global and specialty-specific disincentives to cover call. The Emergency Medical Treatment and Active Labor Act (EMTALA) guidelines, established to protect uninsured patients who need acute care, have also increased nonreimbursed and nonurgent care being delivered in emergency departments (EDs). Increasing malpractice insurance costs and low or nonexistent compensation for taking call further deters specialists from participating in call pools.1 This creates an even larger burden for surgical specialists who might need to perform emergency procedures that are not reimbursed.2 Related to these reasons, surgical specialty coverage is demonstrating a well-documented decline across the country.2 The lack of specialists available to EDs may result in negative outcomes for patients owing to delays in definitive care or increased number of transfers to tertiary centers.3

The limited literature suggests serious gaps in ophthalmology coverage for EDs.4 An analysis in Florida indicates that ophthalmologists take less call than other surgical subspecialists.5 The American Academy of Ophthalmology also published an editorial to describe the reasons why the ophthalmology coverage gap exists and why they speculate it will continue to expand. The article suggests the growth of ambulatory surgery centers, which reduces private practice surgeons’ dependence on hospitals, outdated ED equipment, and growth of specialization, which reduces the number of ophthalmologists who feel clinically comfortable taking call.6 This same update indicated that consultants rarely need to physically come in because most calls are for advice or follow-up.

Many ophthalmologists who take call will often remotely discuss a patient and make a recommendation. A conversation between two physicians about a patient without examination, review of the chart, or consultant documentation of their findings and recommendation is defined as a curbside consult. There are several perils in performing curbside consults. First, providing an opinion about a patient without knowing the individual details of the case can lead to unsafe decisions by the care team and may result in delay of appropriate care or patient harm. This can also lead to wasted resources to correct the care plan or manage complications. There is also liability that the consultant incurs during a curbside consult. Often, the requesting physician will document the consulting physician’s name and whether a curbside or formal consult was performed. This puts the consultant at risk for recommendations that they might not have made after examining
the patient or reviewing diagnostic testing. Additionally, without a documented request and written recommendation, the consult is generally not billed and reimbursed, reducing revenue for the hospital that is potentially paying the physicians to take call. Although ophthalmologists are accustomed to giving opinions over the phone as an alternative to coming to the ED, this method of practicing medicine can be unsafe and lead to poor quality yet more costly care.

Specialty coverage inconsistencies, especially when there is no physician to take call, are particularly problematic, resulting in delays, potential errors, or excessive and costly transfers. The poor availability results in significant clinical, financial, and operational impact for patients, providers, and health systems.

Background on Tele-ophthalmology

Several strategies are being employed to help increase the attractiveness for specialists to take call. Taking call was previously required and uncompensated when affiliated with a hospital. Over the last two decades, physicians are expecting remuneration for call, whether they are employed by the hospital or not. The acquiescence of hospitals to reimburse providers for call has given rise to many models of call compensation, which often depends on the specialty, the regional availability of that specialty, payer mixes and facility types, and the use of telemedicine at reduced physician payment to cover call.

Several cost-reduction methodologies have been shown to improve the gap7; however, it has been difficult to demonstrate how these changes immediately make it easier for specialists to deliver care quickly and handle volume more efficiently. Leaders in health care policy believe that crowded EDs have been a long-standing issue and look to innovative solutions such as telemedicine to expedite care.8

The COVID-19 pandemic exacerbated existing ED specialty coverage gaps, while also creating new gaps related to social distancing and initial scarcity of personal protective equipment. Solutions were quickly needed to continue to provide basic and specialty care to patients in all care settings, especially in the ED. Telemedicine, in all its forms, was quickly implemented to fill these gaps. After the emergence of SARS-CoV-2, relaxations in telemedicine regulations, improved reimbursement, as well as the need to reduce exposure to health care workers prompted increased usage of telemedicine across all care settings.9 What might have taken 5 to 10 years to accomplish to advance telemedicine was implemented in a mere 9 to 12 months. By integrating telemedicine into ED workflows, hospitals are poised to improve access to specialists, increase throughput, reduce wait times and transfers, standardize care quality and access, and maneuver future pandemics. The final memorialization of current regulations and reimbursement structures will dictate the extent to which telemedicine may become more ubiquitous.

The concept of telemedicine use in the ED is not new. It is used to expedite specialty care access, including burn and trauma transfer decisions, acute stroke management, psychiatric evaluation, and even tele-ultrasound support. A meta-analysis of telemedicine use in the ED reported positive findings for services like triage, treatment of minor illness or injury, and connecting providers to specialists. Telemedicine also added value in terms of productivity for the EDs.10 These studies were reported prior to the COVID-19 pandemic, and since 2020, telemedicine has expanded and grown exponentially, with thousands of articles describing the value-add of telemedicine to support ED clinical operations.

Telemedicine in ophthalmology has evolved over several decades, yet its use in the ED has been fairly basic and unstructured. Prior to the COVID-19 pandemic, the use of telemedicine in ophthalmology was mostly described in the ambulatory care settings. Opinion surveys of telehealth prior to 2020 indicate that most ophthalmologists already practice store-and-forward telemedicine, meaning they received photos of patients and were asked to provide a clinical opinion. Additionally, the survey indicated that most of them are amenable to using telemedicine for consultations.11

Rudimentary forms of acute care telemedicine currently employed by ophthalmologists and emergency providers help close the ED coverage gap. Although many eye physicians do not consider themselves telehealth providers, ophthalmologists taking ED call over the last few decades often practice telephone-based telemedicine (a curbside consult). The use of the curbside consult in ophthalmology demonstrates that triage can occur remotely. In fact, most ocular-related visits to the ED are nonacute and unrelated to trauma.12 Of patients who present to the ED for ophthalmic complaints, 97% are treated and released. Table 27.1 lists the most typical reasons for ocular complaints in the ED.

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Apr 18, 2023 | Posted by in OTOLARYNGOLOGY | Comments Off on Communication with Ophthalmology Consultants and Telehealth

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