Implementing Telemedicine Visits in an Underserved Ophthalmology
Clinic in the COVID-19 Era
The coronavirus 2019 (COVID-19) pandemic has resulted in drastic changes in the
delivery of medical care in an effort to minimize transmission of SARS-CoV-2. In the
month following declaration of the pandemic, telehealth visits increased 300-fold
compared to the same time frame in 2019. However, as healthcare delivery continues to evolve and the role of
telehealth is further defined, consideration must be taken to ensure that health
disparities are not further widened during this period of transition. Telehealth has been envisioned as a method to minimize health disparities by
increasing access to care. However, level of digital literacy, access to broadband
internet and modern technology, and language barriers may limit the ability to
utilize telehealth. Many of these potential barriers already disproportionately impact vulnerable
populations. Adults with limited digital literacy are more likely to be older in
age, less educated, Black or Hispanic, foreign-born, and have limited English
proficiency. , Some studies have already demonstrated a decrease in the proportion of visits with
these vulnerable populations since the implementation of telemedicine services
during the pandemic. It is therefore critical to study these populations in the context of providing
telemedicine services. Our tertiary university-based ophthalmology department has an
underserved patient clinic designed to see referrals of low-income and uninsured
patients from community organizations. Due to COVID-19, all non-urgent patient
visits in our department were rescheduled or converted to telemedicine visits using
the guidelines established by the American Academy of Ophthalmology telemedicine
task force. The medically underserved patient clinic, similarly to our other scheduled
clinics, was forced to adapt and find alternative methods to provide appropriate
care during this period. The purpose of this study was to assess the incorporation
of synchronous ophthalmology telemedicine visits in our tertiary university-based
ophthalmology clinic for low-income and uninsured patients in the COVID-19 era. 

Study Participants The records of 18 patients who were due for an in-person visit in our tertiary
university-based ophthalmology clinic for low-income and uninsured patients were
retrospectively reviewed. This descriptive cross-sectional study followed the
tenets of the Declaration of Helsinki and was deemed exempt from Institutional
Review Board (IRB) review. Patients of all ages who were due for an in-person
visit between 01 March 2020 and 01 June 2020 in the medically underserved
patient ophthalmology clinic were included in this retrospective review. New and established patients were triaged via review of medical records by an
attending ophthalmologist. Patients with high risk of ocular morbidity
progression were approved to proceed with an in-person visit. Patients with
non-urgent visit indications were considered appropriate to be offered a
telemedicine telephone visit as an alternative to a postponed in-person office
visit. All patients were attempted to be contacted by telephone to arrange their
visits, using either the telephone number within the referral documentation or
the telephone number in the electronic medical record for new and established
patients, respectively. A minimum of 3 attempts was made to contact each
patient. If unable to be contacted by telephone, a voicemail message was left
when able. Study Parameters and Data Analysis The contents of the electronic medical record, including referral documentation
from community clinics, were reviewed to obtain the following data: demographics
(including age, gender, ethnicity, race, region of origin, and preferred
language), visit indications and ocular diagnoses, visit type (established or
new patient visit), and various telemedicine visit parameters. These variables
were studied due to prior associations with limited digital literacy, which may
affect ability of patients to utilize telehealth, as well as associations with
eye care underutilization. - , The telemedicine visit
parameters included ability to contact patient to offer telemedicine visit,
patient amenability to scheduling a telemedicine visit, whether interpreter
services were used during the visit, the language used to communicate during the
visit, and follow-up instructions. Continuous variables are summarized as mean ± standard deviation (SD) and range.
Categorical variables are summarized as frequencies and percentages. Descriptive
analyses were used to describe the study findings. Statistical analyses and
frequencies were calculated using the program RStudio version 1.2.5033 (RStudio
Inc., Boston, MA, USA). 

The records of 18 patients who were due for an in-person visit in our tertiary
university-based ophthalmology clinic for low-income and uninsured patients were
retrospectively reviewed. This descriptive cross-sectional study followed the
tenets of the Declaration of Helsinki and was deemed exempt from Institutional
Review Board (IRB) review. Patients of all ages who were due for an in-person
visit between 01 March 2020 and 01 June 2020 in the medically underserved
patient ophthalmology clinic were included in this retrospective review. New and established patients were triaged via review of medical records by an
attending ophthalmologist. Patients with high risk of ocular morbidity
progression were approved to proceed with an in-person visit. Patients with
non-urgent visit indications were considered appropriate to be offered a
telemedicine telephone visit as an alternative to a postponed in-person office
visit. All patients were attempted to be contacted by telephone to arrange their
visits, using either the telephone number within the referral documentation or
the telephone number in the electronic medical record for new and established
patients, respectively. A minimum of 3 attempts was made to contact each
patient. If unable to be contacted by telephone, a voicemail message was left
when able. 

The contents of the electronic medical record, including referral documentation
from community clinics, were reviewed to obtain the following data: demographics
(including age, gender, ethnicity, race, region of origin, and preferred
language), visit indications and ocular diagnoses, visit type (established or
new patient visit), and various telemedicine visit parameters. These variables
were studied due to prior associations with limited digital literacy, which may
affect ability of patients to utilize telehealth, as well as associations with
eye care underutilization. - , The telemedicine visit
parameters included ability to contact patient to offer telemedicine visit,
patient amenability to scheduling a telemedicine visit, whether interpreter
services were used during the visit, the language used to communicate during the
visit, and follow-up instructions. Continuous variables are summarized as mean ± standard deviation (SD) and range.
Categorical variables are summarized as frequencies and percentages. Descriptive
analyses were used to describe the study findings. Statistical analyses and
frequencies were calculated using the program RStudio version 1.2.5033 (RStudio
Inc., Boston, MA, USA). 

Between 01 March 2020 and 01 June 2020, a total of 18 patients were due for an
in-person visit in the medically underserved patient clinic at our tertiary
university-based ophthalmology department. All patients were attempted to be
contacted by telephone to arrange the recommended visit type based on clinical
triage by an attending ophthalmologist. depicts the triage and communication
process of the study patients. One patient was triaged as high risk for ocular
morbidity progression associated with advanced glaucoma and scheduled for an urgent
in-person visit during the study period. The remaining 17 patients (94.4%, n = 18) had non-urgent visit indications considered
appropriate for a telemedicine visit as an alternative to a postponed in-person
office visit. Six of these patients (35.3%, n = 17) were successfully contacted and
offered a telemedicine visit. All successfully contacted patients were amenable to a
telemedicine visit with an attending ophthalmologist, and all patients who accepted
a telemedicine visit completed the visit as scheduled. Eleven patients (64.7%,
n = 17) were not able to be successfully contacted during the telephone triage and
scheduling process. Of the patients who were not able to be successfully contacted,
8 patients (72.7%, n = 11) received voicemail messages but did not return the calls,
2 patients (18.2%, n = 11) had full voicemail messaging systems, and 1 patient
(9.1%, n = 11) did not have a voicemail messaging system set up. Due to the
inability to contact these patients, they were not able to be scheduled for a
postponed in-person office visit either. The demographics and clinical characteristics of the patients with non-urgent visit
indications considered appropriate for evaluation by telemedicine (n = 17) are
presented in .
The mean ± SD (range) age of the patients was 50.3 ± 13.7 (31-82) years. Eight
patients (47.1%, n = 17) were female, while 9 patients (52.9%, n = 17) were male.
The vast majority of participants originated from Africa (41.2%, n = 17) or Latin
America (47.1%, n = 17), comprising a total of 88.2% of the patients. Eight patients
(47.1%, n = 17) self-identified as Hispanic or Latino. The mean ± SD (range) age of the patients who were successfully contacted to offer a
telemedicine visit was 53.5 ± 15.2 (31-72) years. The patients in this group were
predominantly male (66.7%, n = 6), not Hispanic/Latino (66.7%, n = 6), Black (50.0%,
n = 6), from regions other than the United States (100.0%, n = 6; predominantly from
Africa in 50.0%, n = 6), with a preferred language other than English (83.3%, n = 6;
preferred language of Spanish in 33.3%, n = 6), and established patients (66.7%,
n = 6). The mean ± SD (range) age of the patients who were not able to be successfully
contacted to offer a telemedicine visit was 48.5 ± 13.2 (34-82) years. The patients
in this group were predominantly female (54.5%, n = 11), Hispanic/Latino (54.5%,
n = 11), Black (45.5%, n = 11), from regions other than the United States (90.9%,
n = 11; predominantly from Latin America in 54.5%, n = 11), with a preferred
language other than English (81.8%, n = 11; predominantly preferred language of
Spanish in 54.5%, n = 11), and established patients (63.6%, n = 11). Comparing these 2 groups demonstrates that patients who were successfully contacted
were on average older in age and more likely to be male, not Hispanic/Latino, and
from Africa. In contrast, patients who were not able to be successfully contacted
were on average younger in age and more likely to be female, Hispanic/Latino, from
Latin America, with a preferred language of Spanish. Established patients were
predominant in both groups. Diabetic eye disease and glaucoma suspect were the most
common visit indications among both groups. The telemedicine visit parameters of the patients who successfully completed visits
are presented in . Medical interpreter services were offered based on the preferred language
indicated in the clinical medical record. 50.0% of visits (n = 6) were completed in
English without interpreter services. There were no technologic or connectivity
issues that prevented completion of any visit. Five patients (83.3%, n = 6) were
recommended to follow up within 2 to 4 months with comprehensive ophthalmology. One
patient (16.7%, n = 6) was recommended to follow up with subspecialists (retina and
glaucoma providers) within 2 months. 

The field of ophthalmology has utilized telehealth in the screening and monitoring of
eye diseases such as diabetic retinopathy and retinopathy of prematurity for years.
However, this has historically involved “store-and-forward” or asynchronous methods
of reviewing remote retinal imaging. , Further advances in the
implementation of ophthalmology telemedicine services prior to the COVID-19 pandemic
were hindered in large part due to physician perspectives regarding the ability to
provide appropriate patient care remotely. , More recently and due largely
to the pandemic, synchronous ophthalmology telemedicine services have been reported
in the literature in rural regions as well as academic settings. , To the best of our knowledge, this is the first report of a tertiary university-based
ophthalmology clinic for low-income and uninsured patients to incorporate
telemedicine visits as an alternative to in-person visits during the COVID-19
pandemic. We found it important to specifically study this population in order to
identify barriers to providing appropriate care during the COVID-19 pandemic and
beyond as telemedicine services become more routinely incorporated into medical
care. High-risk populations for eye care underutilization include racial and ethnic
minorities, specifically Black and Hispanic individuals; individuals of low
socioeconomic status; and the uninsured. Additional barriers to eye care include low
education level, language other than English, and immigration status. Concerningly, many of these same patient characteristics have also been
associated with limited digital literacy, which could compound their effects on
health disparities as telemedicine services are implemented. , Our study found low-income and uninsured patients to be amenable to ophthalmology
telemedicine visits when offered. The primary barrier to providing telemedicine
visits in this sample was the ability to successfully contact patients to offer and
schedule these visits. The majority of patients (64.7%, n = 17) with visits
considered appropriate for conversion to telemedicine were not able to be
successfully contacted to offer this option. These patients who were not able to be
successfully contacted were on average younger in age and more likely to be female,
Hispanic/Latino, from Latin America, with a preferred language of Spanish.
Interestingly, there was no trend in visit type (established versus new visit)
between the groups. Prior to the COVID-19 pandemic, visits in our medically underserved patient clinic
have always been scheduled by telephone. New patient referrals are called with their
initial appointment information. Established patient visits are also scheduled in
this manner, with follow-up telephone calls made to arrange their next visits,
rather than being scheduled at the time of their prior in-person visit. This has
historically been the case due to the logistics of scheduling this bimonthly evening
clinic. However, as we have found that the primary barrier to scheduling visits in
this population is the ability to contact patients by telephone, future efforts will
involve scheduling visits (regardless of visit type—telemedicine or in-person) when
the patient is present whenever possible. This study has several limitations, including those inherent to a retrospective study
design. Due to the small sample size, we only assessed the data in the context of
general trends and recognize that this limits our ability to draw conclusions. In
addition, all patients included in this report were from 1 urban university-based
ophthalmology department. Thus, the findings of this study may not be generalizable
to the medically underserved patient population in other settings. Future research using larger sample sizes and independent sub-groups is necessary to
better elucidate the value of telemedicine in ophthalmology clinics for low-income
and uninsured patients. Additionally, follow-up communication with patients who have
completed telemedicine visits as well as with providers who provide these visits
could provide useful information regarding the patient and provider experiences with
these visits. 

This study found that synchronous ophthalmology telemedicine visits were able to be
incorporated in a tertiary university-based ophthalmology clinic for low-income and
uninsured patients as an alternative to postponed in-person visits in the COVID-19
era. Importantly, all successfully contacted patients accepted, scheduled, and
completed a telemedicine visit. The primary barrier to providing telemedicine visits
in this population was the ability to successfully contact patients to offer and
schedule these visits. Further research must be conducted on vulnerable populations
as telehealth services are implemented to minimize disparities in access to care and
health outcomes. 

