Telehealth-based Eye Care During the COVID-19 Pandemic: Utilization, Safety, and the Patient Experience

In the era of a global pandemic, the demand for telehealth services has expanded across all fields of medicine, including ophthalmology. While general telemedicine services have demonstrated favorable patient feedback from ease of use and decreased wait time, there is limited data on telehealth based eye services. Conducted during a shelter-in-place order during the COVID-19 pandemic, this study investigated the safety of triaging eye care through telehealth and evaluated the overall patient experience and satisfaction.

In this cross-sectional study, the authors interviewed 1,720 participants who received in-person, video, or telephone visits or had deferred their appointment between March and May 2020 at a single tertiary, multispecialty care practice (University of Michigan Kellogg Eye Center). During this time a clinical policy was instituted to provide in-person care for “urgent or semi-urgent patients” and defer care or offer telehealth for all other patients. Each interview consisted of five questions: two open-ended questions, including “how is your eye problem doing?” and “how did you feel about your virtual or in-person visit or deferring your visit?”; and three more quantitative questions about perception of eyesight, degree of concern about eyesight, and satisfaction scale with their eye care. The qualitative data from the open-ended responses were coded into categories and summarized, while the quantitative data from the latter three questions were analyzed with frequency and percentages. The authors also selected quotes from the interviews to further highlight patient experiences. 

Out of 24,455 scheduled visits between March and May 2020, only 5.7% (n=6,542) were completed. Within the completed visits, 74.3% were in-person, 4.8% were video call, and 20.9% were telephone visits. A stratified sample of 3,274 patients were called, of which 1,720 (53%) agreed to participate in the survey. The authors report oversampling video and telephone visits to obtain more feedback and data to analyze. 
The majority of participants were Caucasian (82.6%), and the median household income was $75, 387. Of those surveyed, in-person participants were significantly older (66.8) than those receiving video (59.8) or telephone (62.6) visits. Caucasian patients were more likely to have in-person visits than minority participants. Cornea specialists provided more phone visits than other subspecialists, and retina providers were more likely to have in-person visits.

Most patients (88.1%) rated satisfaction of their eye care at or greater than 8 out of 10. Participants who underwent in-person or video visits were significantly more satisfied than those who deferred their visit or had a telephone visit. Participants with in-person visits worried more about their eyesight compared to those who had virtual visits or deferred their visits. Participants who underwent tele-video care provided mixed feedback from positive (39.4%) and negative (45.7%) perceptions on quality of care, convenience (30.9%), and technology factors (21.3%). Telephone visits were reported to have poorer quality than in-person visits (33.9%). In-person, more than half were pleased with the COVID-19 precautions (mask, social distancing) taken by the university. Within the cohort of patients who deferred, the majority felt it was appropriate to push off their appointment given the risk of COVID-19 exposure. 
Only 1.5% of participants resulted in an in-person visit within 1 day of virtual visit, and 2.9% required in in-person visit within 2-7 days. These results suggest a safe and effective triage process. Moreover, of the 24% who had in-patient visits, many had positive reviews of the low waiting room occupancies. Triaging the more routine or less urgent cases to virtual visits or deferring them to a later date freed up the waiting room for high-risk patients.
The greatest concern that most patients had with virtual visits was the lack of ancillary testing. While the center offered drive-through eye pressure checks, other testing such as imaging and visual field testing were not performed. The authors suggested that hybrid models of in-person testing followed by a video or phone call with a clinician may result in more effective patient care and improved patient satisfaction.

There are a few limitations to the study. This study did not evaluate patient outcomes of telehealth (missed eye pathology or progression of ocular disease), rather it investigated the utilization, safety, and patient feedback of different methods of eye care. Second, while it is difficult to categorize qualitative data that was surveyed, the authors provided a comprehensive overview of patient’s feedback through quotes and categories. Third, this study was over a short period of time of 2 months. The results may have varied if conducted over a longer period of time. For example, patients may not have been as satisfied with deferring visits further. Finally, the authors admit that the demographics were not very diverse, suggesting that either minority patients were not interested in participating in the survey or that current telehealth system may not be as accessible to everyone. 

This study proposed a safe and effective triage system. Furthermore, patients were more satisfied with in-person or video visits than telephone visits or deferring their visit, emphasizing the value of the face-to-face (virtual and in-person) interactions. Additional video platforms coupled with future home monitoring devices to check eye pressure and provide external eye and fundus photos and optical coherence tomography may help augment the telehealth domain of ophthalmology. Finally, the authors suggest that as clinicians become more confident, they will be more likely to continue telemedicine in the future.