Telemedicine for Dry Eye Care

Ranya Habash, MD; and William Trattler, MD, join Marguerite McDonald, MD, FACS, to discuss using telemedicine for dry eye patients.

Speaker 1: Informed Consent, Getting to Yes, is editorially independent content supported with advertising by Johnson & Johnson Vision.

M. McDonald, MD: Welcome to Informed Consent, Getting to Yes. I'm Marguerite McDonald of the Ophthalmic Consultants of Long Island and Oceanside, New York, and today we're going to change the format a little bit. Instead of talking to key opinion leaders about how they speak to patients to get them to agree to a proposed regimen, whether it's a new drug, an in-office procedure, or a premium IOL, for instance, we're going to talk about telemedicine and in particular telemedicine for the dry eye patient. So I've got two experts with me today.

M. McDonald, MD: We have Ranya Habash, MD. Dr. Habash is a consultant for Microsoft and Chief Medical Officer for Everbridge. She is also an assistant professor of ophthalmology and medical director of the Technology Innovation Unit at Bascom Palmer Eye Institute at University of Miami. Welcome, Ranya.

R. Habash, MD: Thank you.

M. McDonald, MD: And we also have Dr. Bill Trattler. He is director of cornea at the Center for Excellence in Eyecare in Miami, Florida, which is widely recognized as one of the very premier private practices in ophthalmology in the world. Welcome, Bill.

W. Trattler, MD: Thank you.

M. McDonald, MD: So I've been doing telemedicine since the pandemic started, and we all kind of shut down and went to just a skeleton crew, and it's my impression that it's easier to do a dry eye exam via telemedicine than say a retina exam or a glaucoma exam. What do you all think? Ranya, what do you think?

R. Habash, MD: Yeah, I totally agree. I mean telemedicine lends itself best to things that you can see just with the video, but you can actually tell and see way more than you think. I'll just hit sort of the retina and glaucoma use cases first, but with those, it's a simple. How's your floater doing? Do you have more floaters? Do you have some flashes of light? Oh, I see you're telling me you have a veil coming over the side of the vision. Okay, maybe we should bring you in. So it's stuff like that where I think in the first day of med school we learned that 99% of our decision-making actually comes from the patient anyway, from the conversation with the patient. So in those realms, I realize it's a little bit harder than an actual exam, but I do still think you garner a lot of information just by talking to the patients.

W. Trattler, MD: Yeah, I agree with Ranya 100%. I mean, I think we've actually been doing telemedicine for our whole careers because patients call up, you prescribe them a treatment for their dry eye, and they call you a month later saying they're not happy or there's an issue, and you talk to them over the phone. What's going on? How are you doing? And that's telemedicine. We're communicating with the patient, listening to what they have to say, asking important questions, and then making our suggestion for the patient to do next until they actually come to physically see you. And that's all we're doing again here with telemedicine except we may be incorporating video and some other aspects.

M. McDonald, MD: In your two wonderful ASCRS telemedicine webinars, Ranya, you mentioned that some docs are even teaching their patients to palpate their eyeball and give a gross estimate as to the pressure. And it was something about comparison to pieces of fruit, right?

R. Habash, MD: Yeah. The disclaimer here is, I'm not a big fan of that because I don't want a patient, and I said this during the webinar, I don't want a patient palpating their eyes and saying, well I think it feels more like a cantaloupe than a grape. So I just don't want that kind of misconception. But yes, that is one of the things that doctors are telling their patients to do to assess IOP. And then also there are lots of vision checks out there that people are trying to do. But I think the main point here that I want to impart is this is a paradigm shift in our thinking. We have to kind of find other cues in order to make an assessment about a patient, and we need to think of this more like wartime medicine. If we were on the battlefield, and we had to assess a patient really fast, we wouldn't pull out Ishihara plates to ask them to do, right? So this is kind of the same mentality. We just need to make a quick assessment about whether or not this patient needs to come into the ER or not.

M. McDonald, MD: As cornea anterior segment experts, do you or, Bill, do you do telemedicine for dry eye now?

W. Trattler, MD: Yes. So I think that the main difference again is we've been doing telemedicine for years. We just haven't been charging patients or charging insurance. We've been talking to our patient on the phone. We're communicating with them all the time. I mean, I'm sure we all have gotten so many calls over the years. So we're doing the same thing. We're just being more organized, entering the information a little bit more in detail in our medical records, and you can bill it now. So I think that's the main difference.

M. McDonald, MD: Do you have your patients either fill out in advance or verbally or somehow go through one of the quick little psychometric questionnaires about dry eye, like the SPEED test, or do you do it verbally with them once you've engaged?

R. Habash, MD: I mean, I feel the simpler the better. I do think that, over time, we'll refine the process of the telemedicine visit where we can add ancillary things like apps to check visual acuity or Amsler grid or that sort of thing, but for right now, yeah, I just talk to the patient. I mean, I think that the dry eye exam is probably the easiest thing in the world to do via video, just by talking to the patient, and then you can clearly see a lot about what's going on in the eye.

R. Habash, MD: If they tell you their eye's red and irritated, it's very easy to see. Are they having an allergic conjunctivitis or some sort of a conjunctivitis? Is it more that horrible ectropion scleral show that they're having? Is it the recent eyelid surgery where they've got a bunch of scleral show? Those are all symptoms and signs that we can work with to make a really good assessment. And then you follow that up with, “Okay, well, what have you tried? How about putting in artificial tears? Oh, you mean everything gets better after you put in the artificial tears? Okay, well then this is the next route we're going to go.” The dry eye exam is just the easiest of all exams to do this way.

M. McDonald, MD: Now most of my dry eye patients, and at OCLI I'm the director of the Dry Eye Center of Excellence, the established ones that are doing great, that just call in for a renewal of their medicine, their Restasis, Cequa, Xiidra, whatever, that gets handled by the skeleton crew of techs. They don't even talk to me. And most of the patients that are established and stable are just going to wait to come see me when all this is over with, the pandemic. But the ones who are really suffering do reach out, and most of them are older. And I've found that most of them can deal with an iPhone photograph of their eye, but much more than that the older patients get confused. What has your experience been?

W. Trattler, MD: Well, I agree that certainly I've been surprised that some of my older patients are happy to even try the iPhone video and FaceTime because they've done it with their family members, but most have not. But I don't think the dry exam needs the video. I mean, I agree that the eye exam is important, but actually the history and discussion you could learn so much from a patient and really at least get patients started in the right direction. I think we have to remember Ranya shared some great pearls on different symptoms, but the symptom that we also see a lot is the patients that are asymptomatic but have fluctuation in vision. So we can't forget that one. But I think if you just go as Ranya suggested, just ask all those questions, you can come up with a treatment plan for today. Follow up in a couple of weeks. See how they did, and then you can always modify each time you speak to them on how they're doing, how their symptoms are getting better. This is a great tool. Telemedicine is a great tool for our dry eye patients.

M. McDonald, MD: For the patients that are willing to somehow share an image with you, do you ask them to pull down their lower lid and take a snap up close or start the video up close? What exactly do you tell them to do, Bill?

W. Trattler, MD: Well, so I mean most patients I guess they take a picture of their eye itself, and you could see in their palpebral fissure, the conjunctiva, is there obvious injection? But I think a lot of dry eye patients don't have significant redness. They have maybe a tinge of redness. It's not much. If we're able to examine them on a slit-lamp exam, we'd see they'd have a rapid tear breakup time. They might have a little bit of corneal staining. They might have a little bit of blepharitis or MGD. These are all subtle things that are maybe hard to pick up on a typical photo. So that's why we have to rely more on history and then also the experience of how patients do on our regimen we prescribed.

M. McDonald, MD: Ranya, I know that Bascom Palmer has this amazing remote-controlled slit lamp where the patient goes to the office but you're not there, but the tech puts them at the slit lamp. Have you been using that technology?

R. Habash, MD: Yeah, but it's not even that necessary in all honesty. I mean I agree with Bill that a history just on the phone is actually just fine. The reason I really like to do the video exam and kind of push them a little bit to make sure that they are up for the video exam is because it may be a little bit difficult for some of them at first, but I'll tell you, like with this whole pandemic, they're all getting way better at Zoom calls and FaceTime calls and that sort of thing because they've had to. It's out of necessity. But when I'm able to connect with them face-to-face on a video call, not only do I get to see a little bit better, even though, like Bill said, you can really do a great exam just with the history itself, but I do it actually more just to connect with the patient.

R. Habash, MD: Those patients are in isolation right now. They're not talking to many people. This is basically their one interaction with another human being all day, and they really love it. And I just find that interaction alone just helps them so much. I've always been a proponent that 30% of medical improvement is actually the placebo effect. And I think that is so true and I feel like it really comes into play here when you're positive and they can see your smiling face on the other end and when you can give them some encouragement. So that's kind of more the reason why I pushed for the video call instead.

M. McDonald, MD: That's so true. There was a study about 8 years ago showing that 15% of all Medicare visits to doctors are due to loneliness, and now it's just so much worse.

R. Habash, MD: Yeah, exactly.

M. McDonald, MD: We have to get permission to do telemedicine now, and I think it's wonderful because we're getting paid for things we used to do for free for many years, but I find it's a little awkward. What's the best way to ask gracefully? Because these patients are used to receiving care for free over the phone. Do you know what I mean? This is something new for them, too. How do you gracefully say we're going to invoice you for this? Is that okay with you?

W. Trattler, MD: Well, I know at my end what I'm explaining is that I know you see me [for] just a quick call, but I'm really going to enter this all into the medical record. So we're going to actually do an online visit, and so it is something we would call a telehealth visit. And I explain that the process means I'm going to have to ask the history and be a little more detailed, but it's going to go all in their medical records, and we're saving all this information. So it's not just a telephone call. It's more than a telephone call. I try to explain that, and I get their permission to do that. And I do let them know that we do bill insurance for their call.

M. McDonald, MD: Oh, Bill, you mention that. Good. Is that pretty much what you say, Ranya, is something along those lines?

R. Habash, MD: Yeah, I mean, I never think it's a good idea for a physician to get involved in the insurance talk at all, so I always try to have a buffer as much as possible. And that's how we've set it up at Bascom is we have them scheduled properly, and then they are logging in through MyChart, which I realize a lot of practices might not have, but the point is to have a buffer of some sort. And so our administrator gets insurance information or verifies it all and then confirms their appointment and says, “Okay, you have an appointment tomorrow with Dr. Habash for a video call. Let me help you get set up. And also, just so you know, this is going to go through your insurance like a regular visit due to these pandemic circumstances now.” And that's it. So it's something as simple as that.

M. McDonald, MD: See the way we're set up right now at OCLI, I check my OCLI mail constantly, and I'll get a message, Mrs. Smith needs to talk to you about this, this, and she's got eye pain and blah blah, and here's her phone number. And I can log onto her charts from home, but it's sort of up to me to say something. So I liked the way you said that, Bill, since I'm the one who has to present this information.

M. McDonald, MD: And when they send images, of course, you store them in EMR, both of you, I would assume.

R. Habash, MD: Yeah, that's the best medical-legal way to do things. And going back to your question, I also get a lot of email requests, too, but I still try really hard to have my secretary respond and say, “Dr. Habash thinks she can help you better with a formal video visit, and these are the instructions.” But you can still create that barrier even if they email you directly. And then the last-ditch, if I'm responding to an email is, by the way, this will go through your insurance, just like a regular office visit due to these pandemic times.

W. Trattler, MD: Right. Well, I will say that the main challenge we have is that many offices in practice have actually, unfortunately, had to furlough their employees, so we're really on a skeleton staff. So we don't have quite the number of people in our office to help us. So even many of the doctors in my office, including myself, we're working up a lot of our patients just because we have to really right now minimize costs and make sure we make it through this challenging time. So I love, Ranya, your suggestion, but for other practices where the doctor has to call, I mean just trying to explain it, but also you're going to be on the phone a little bit longer, whether it's video or not, because they're entering the information into the medical records. So the patient will also understand this is not the typical 3-minute phone call. There's that much more detailed call overall.

R. Habash, MD: Yeah. I like how you put it, where you said, “We're going to document all this into the medical record.” I think that makes them feel better, and then that does show value in the visit.

W. Trattler, MD: Right.

M. McDonald, MD: And it shows that it's a more formal encounter.

R. Habash, MD: Exactly.

M. McDonald, MD: Than just, “Hey, how you doing?”

M. McDonald, MD: When they say, “When can I see you again?” That's a hard one to answer, and if I feel that they're really stable, and they don't need to come in, I'll say, “We all have to play this by ear, and it seems that it's going to be state by state.” And I'll say, “Just periodically try the office, but as soon as you hear that our state or our region is opening, you can assume we'll be open too, and we'll be glad to see you as soon as possible.” How do you respond to that?

W. Trattler, MD: I agree. Right now we really don't know. And, so I always tell patients, kind of like what you were saying, if it's important, then we're still seeing our urgent and emergency patients. So if a patient with dry eyes is just miserable, maybe they've somehow developed an abrasion overnight and are really in pain, they can come see us. We have myself and other doctors are available to see them for emergency and urgent cases, but for now, if it's just relatively something that can be controlled over the phone with a video conference call, telemedicine call, let's try to do that for now. We can do a follow-up, as Ranya suggested, and make it a little more formal. I think you guys mentioned that you can actually put a telemedicine visit on the schedule a month from now and say, “Let's do a follow-up formal visit,” and be organized. Actually, who knows? Six months from now, even when your office is open, you might have a morning or an afternoon a week that you're just doing telemedicine calls, and I know that Ranya has been sharing a lot of information on that.

M. McDonald, MD: And Ranya and Bill, do you think that, going forward, we'll be in a way like the attorneys? Every time you interact with an attorney, they start the clock. How many minutes they're spending with you, a half an hour, an hour, whatever. I guess going forward we'll maintain the ability to bill for all the things we used to do for free. Usually, takes me an hour a day to answer all the calls and interact with all the people who tried to reach me from outside the office. Do you think we'll be able to do this going forward, or will it go back to the old way where we just did it all for no charge?

W. Trattler, MD: Not only do I think the same, I think the other thing that's interesting is that insurance actually will cover the call. Marguerite, not that you ever need to call me for advice, but if you ask another doctor for advice outside of your practice, there's actually ways to bill for your request of information from a provider. And also if you give advice to a provider, which we've never ever done, we're always so used to giving that for free, taking our time about our patients, but Ranya has shared a lot of information about how doctors who are communicating, spending their valuable time trying to help a patient with the patient, not in front of them, can actually bill insurance appropriately get paid or compensated for all this extra work they're doing on their own time.

M. McDonald, MD: Well, I've done that twice already, billing for an interaction with another doctor, but what I'm afraid of is the insurance companies, as soon as the pandemic is sort of under control, they'll say, oh, that's over. Or do you think it's here for good?

R. Habash, MD: I think we've been through this because I've been actually at this telemedicine game for over 4 years now, and we have been successful in certain areas if we're trying to show an ROI for the insurance companies. We've had groups of physicians, for instance, who've done telemedicine visits, and then we’ve presented all that to the insurance companies, and we've said these are all the visits that would've gone to the emergency room and run up the bill for health care, but instead, they were able to be seen by telemedicine for this amount instead. So if you can show an ROI, then I think that they will be able to listen to that.

R. Habash, MD: And I really think that, with this whole pandemic, the CMS will also learn that there were so many patients who didn't get sick because they didn't have to go to the hospital or to the ER or to one of our clinics and could stay home and get care. So I think it's just going to be a matter of just showing the evidence, and the evidence speaks for itself, which is we've been able to keep a lot of patients outside of our doors and just help them pretty significantly just from home. So hoping that they listen to that and take that as a sign of the times.

M. McDonald, MD: Ranya, if you don't mind, would you share with us the story about how you got into all this? It's a fascinating story.

R. Habash, MD: Yeah. It's so funny how the one fateful day can just change your whole career. So I was in private practice like Billy, and I was seeing patients one day in my office, and the ER doctor—I was on call at the hospital—and he said, “Habash, we need you down here right away. There's a patient with an orbital fracture. Get down here right away.” And I said, “Well, there's patients in my waiting room, so I can't. So either the patient waits 4 hours, or you text me a picture of the CT scan, and we'll do a quick FaceTime call with the patient, which we did, and we learned within about 30 seconds the patient wasn't entrapped, didn't need to stay at the hospital, could leave on oral antibiotics and come see me. I hung up my phone and went about my business. Didn't think anything of it.

R. Habash, MD: But then, about 2 days later, the compliance officer at the hospital called me and said, “What the heck do you think you're doing?” She actually didn't say heck. She said, “You're going to get us a $1.5 million fine for what you did. It's not HIPAA compliant.” I said the same thing that any doctor would say: “I just helped a patient, so I actually thought you were calling to congratulate me.” But instead she was berating me. And I said, "Well, how did you find out about this anyway?" And she said, "Oh, that's easy. The ER doctor was so happy he got up through the consult on a patient so fast, he told everybody, and it got back to me." So anyway, long story short, my response was, well, this is BS. There has to be a better way for us to communicate around our patients and help our patients that doesn't involve all these bells and whistles and logins and portals and all this other stuff. We need to be able to do it very simply.

R. Habash, MD: So I got my brother who's a Microsoft software engineer, at the time he was, and we wrote software that was HIPAA compliant. I designed it, and he wrote it, but it was so simple and easy to use because it was designed by a physician. And that's the one thing that's different from every other piece of software we use. It's like they don't even ask the doctor what we want. So when we were able to design something that was just ridiculously simple, my one caveat to him was, if it takes more than one brain cell to use, I'm not going to use it, and neither will anyone else. So we made it really simple. Put it on the app store in Google Play. It became one of the top used apps, according to Becker's Hospital Review, and then our company got acquired by a global communications company called Everbridge, which is the same company that sends all the Amber alerts and all the emergency notifications that you get on your phone. So I've been working with them as the chief medical officer for that company for 4 years now as well as being at Bascom.

M. McDonald, MD: And you left obviously after that. You left private practice and joined Bascom, right?

R. Habash, MD: Right.

M. McDonald, MD: So when your brother first wrote the software, was it for ophthalmology only or for general medicine or ….

R. Habash, MD: Nope, it was like iMessage or FaceTime but HIPAA compliant. And people would ask us, they'd say, “Oh, can we use this for dermatology? Can we use this for orthopedics? Can we use this for neurology?” And I'd say, “It's just like language. You can use it for anything. It's like fire. You can cook your food. You can stay warm. You can use it as light. You can do whatever you want. It's just communication.” That's it, except it was HIPAA compliant, and that was the game changer, and 5 years ago we really didn't have any good tools to do that. So we were very lucky. Just hit at the right time.

M. McDonald, MD: Does that compliance officer at the hospital know that she launched your international career and launched telemedicine?

R. Habash, MD: This is the most important part of the story. That hospital was our first customer, and they're still a customer to this day.

W. Trattler, MD: That is great.

M. McDonald, MD: Wow, that is a fantastic story. Well, I really learned a lot about telemedicine and telemedicine for dry eye. I thank you both so much. Promise me, Ranya and Bill, you will come back in the future when we ask you, which will be all the time.

R. Habash, MD: Thank you so much for having me.

M. McDonald, MD: Thank you.

W. Trattler, MD: Thank you.

Speaker 1: Informed Consent, Getting to Yes, is editorially independent content supported with advertising by Johnson & Johnson Vision.