Dr. Freeman: Hello and welcome to PracticeUpdate. I'm Paul Freeman, co-editor of the eye care site on PracticeUpdate. Today, it's my pleasure to interview a good friend and colleague, Dr. Tim Petito. Dr. Petito has been in private practice in St. Petersburg, Florida, for 30 years, where he specializes in complex contact lens fitting and helping people who are visually impaired. He was an assistant professor at the State University of New York College of Optometry and a chief of primary care services at the Optometric Center of New York before entering private practice. Dr. Petito is an author and lecturer on various topics relating to ocular care and is a consultant to several industry-leading companies across the spectrum of eye care. Dr. Petito is currently a member of the American Optometric Association Federal Relations Committee, and is the AOA representative to the physician consortium for performance improvement, and currently serves on his screening and preventative care technical expert panel. Dr. Petito is a fellow of both the American Academy of Optometry and the National Academies of Practice and a diplomate of the American Board of Optometry. Welcome, Dr. Petito.
Dr. Petito: Hi, Paul. Good to see you again.
Dr. Freeman: Good to see you. I have a couple of questions as it relates to telehealth and telemedicine. Given the pandemic and the extraordinary circumstances that it's created, including relaxation of government regulations for patient communications, there's been an increase in telemedicine- and telehealth-based healthcare over the past four to six months. I have a two-part question. The first is, what is the difference between telehealth and telemedicine? The second part of that is, do you think this is going to be a permanent technological advance in healthcare communications? Or are we going to go back to what we did before this pandemic?
Dr. Petito: Well, the first part, let's talk about telehealth versus telemedicine. The World Health Organization makes a pretty easy split between the two. Telehealth includes all computer assisted telecommunication-based access to health information. It's not specific to a patient or a patient's own information. Basically, if you Google, what's a hiatal hernia, and you get that answer back over your computer, that's in the broad definition of telehealth.
However, telemedicine, according to WHO, revolves around management, diagnosis, and treatment of specific patients. If I get my prescription for my blood pressure medication specifically from my doctor in a face to face, or now with the relaxed communication standards, even on a phone call, that would be considered telemedicine because it's specific to treating me and me being the specific patient.
Secondly, dealing with whether this is going to stay this way or not, before the pandemic, there was some push to move to telemedicine from a number of fronts, the societal demand for convenience, financial pressures from payers, it's much cheaper to provide online care than it is face-to-face care, and financial incentives by the platforms that provide for telemedicine utilization. Those incentives are not going to go away. I think the demand for convenience is now backed up by fear of going somewhere and being exposed to the virus. That demand is going to be there.
But what's going to change, and what has changed already, in fact, is people aren't very happy with the experience of telemedicine when there's a real problem. Now, 80% of the patients that see a doctor don't have an urgent need to be there. It's either monitoring some preexisting condition, checking on something that's not terribly threatening. For that 80%, telemedicine is still going to be a viable option. But where telemedicine fails, and it's going to fail worse as we go forward in using it, is the 20% of people who have a serious condition and either are, say, symptomatic, subclinical, or the diagnosis is more difficult than the textbook would indicate. That 20% telemedicine won't ever be able to deal with.
Dr. Freeman: Got it. It seems like the pandemic has been an accelerant to doing this whole telehealth/telemedicine thing. I looked at a report that showed 65% of optometry practices are going to offer some form of this communication. Do you think that, based on what you just said, that eye care is an area that we're going to see this kind of communication grow? Or is it going to shrink? What's going to happen?
Dr. Petito: I think overall in medicine you can say it's going to grow. It's not going to stay at the levels that it is now. The regulations were really just thrown out the window in terms of HIPAA, in terms of record keeping, in terms of the technologies that are acceptable to use under these circumstances. Now, we can count a phone call as a telemedicine visit. That was specifically disallowed prior to the pandemic. I think the regulations are going to be more lax than they were prior to the pandemic, going forward, but they're not going to be at this level after this emergency is over with. The number is going to go down because of that.
Dr. Freeman: Yeah. I guess some of it, as you pointed out, is time-saving and some of it allows for flexibility, and obviously, economics. How do you see, speaking specifically for eye care professionals, how do you see this impacting on office flow, as an example? Or do you see it impacting on office flow?
Dr. Petito: Well, it certainly does. Eye care is one of those areas of healthcare that isn't particularly well suited to telemedicine. The type of data we collect is psychometric, which means you need to understand the person's approach to answering the questions, performing the tests. The environment that they perform the tests in should be standardized. We forget about that when we just go through our daily lives and everything is standardized.
Once you start doing visual fields on laptops and smartphones, the visual field database doesn't apply anymore. All of the metrics we use to interpret these tests aren't valid anymore. It opens up the refractive care versus healthcare question in eye care, but the fact of the matter is our remote data collection opportunities are limited in eye care.
The things that we can use effectively in eye care are for monitoring conditions that are diagnosed, surveillance of a person's longterm stability for conditions, say macular degeneration or glaucoma, although you need measurements periodically anyway. But to see if the medication is okay for a red eye, is it getting better, yes. All of that is valuable. But you have to schedule that time with the provider, so that time is not available for gathering that data that I have to do in person or interpreting that data and explaining to the patient sitting here in person.
It changes the workflow. It should probably be scheduled so it doesn't mess up every other aspect of practice. That's not how it's sold to the patient; for the patient, it's 24/7. You can call me at three in the morning and then someone will be there. Well, I'm not going to be there at three in the morning. I don't know about you. There's a disconnect between the marketing of telehealth and telemedicine in terms of its benefit to patients and the reality of actually delivering high-quality care out of an office.
Dr. Freeman: Yeah. Let me ask you this question then, because we've all experienced this. If you're working with a patient, how do you, if you do this, how do you control for connectedness? In the middle of telling a patient something or you're monitoring something, the system freezes or it drops. I mean, is there kind of a way that you can control for that in some fashion? Or do you just let things go as they go?
Dr. Petito: Well, I mean, if you're going to have telemedicine or telehealth as a major part of your practice modality, you need to really upgrade the technology because T1 lines or fiber optics is still the way to be connected if you want reliability, if you want speed. If you're going to be passing back and forth, say, MRI images between you and a consultant, and that would be also telemedicine. I'm consulting with you on a case that has an MRI available, I've got the MRI disc in my computer, and I'm sending you images. If I try to do that over wifi or over an old connection or a connection that's got too many other people on it in my office complex, that's not going to be a satisfactory approach.
If you're going to do it as part of the going forward, you're not just doing it because the pandemic kind of set it up that way, but you're going to really be a telemedicine provider going forward, there's some infrastructure and security improvements you need to make.
Dr. Freeman: Got it.
Dr. Petito: Because this is HIPAA-protected information that goes back and forth.
Dr. Freeman: Right.
Dr. Petito: Your regular networks, unless you can encrypt the information appropriately, that's a HIPAA violation all day long.
Dr. Freeman: Right. Listen, I think that you've given me a lot to think about, and I think you've given the people who are going to listen to this a lot to think about. I appreciate you taking your time for today's presentation. Thank you very much for sharing your information with us.
Dr. Petito: Thank you. My pleasure.