Last updated April 6, 2020
State of Emergency
As of March 22, 2020, all Canadian provinces had declared public health states of emergency in an attempt to curb the spread of COVID-19. The levels of restrictions vary somewhat from province to province, but optometrists should not offer routine and non-urgent care to their patients in-clinic. As of March 31, 2020, no province has mandated the complete closure of optometry clinics and some have identified optometry an essential service.
Caring for Urgent Cases
Unless specifically prohibited by relevant provincial authorities, CAO recommends that optometrists continue to care for urgent cases, but only after screening patients for signs of upper respiratory tract infection (URTI) or recent travel history outside of Canada. This is especially important in areas where there are COVID-19 cases, so that as many patients as possible can be diverted away from hospital emergency rooms. In cases when patient screening reveals symptoms of URTI, optometrists are advised to refer the patient to an ophthalmologist in their area or to a local hospital, but only after informing the ophthalmologist or hospital, so that they can take appropriate protective measures. CAO advises optometrists to look for URTI in general, rather than COVID-19 symptoms. When in doubt, assume that a URTI is COVID-19.
What Constitutes an Urgent Case?
Unless specifically indicated by relevant provincial and territorial health authorities, CAO strongly recommends that optometrists rely on their clinical judgement to determine what constitutes an urgent case. Broadly speaking, urgent cases could include, but might not be restricted to the following: sudden onset of flashers or floaters, foreign body in the eye, broken glasses with no replacement, or any other condition that might not, at the time, qualify as an emergency but if left untreated will require emergency care.
Urgent care cases in all provinces should be seen in-clinic, but only if all safety precautions are taken to minimize or eliminate the risk of disease transmission. This includes maintaining minimum distance between patients, and using all protective gear as recommended by Health Canada and/or local authorities. This includes surgical masks or N95 masks, slit lamp shield, eye protection (goggles or full-face shield) and disposable gloves. Note that safety precaution recommendations might vary from province to province. Optometrists are advised to consult with their provincial college. Optometrists who do not have access to adequate and appropriate personal protective equipment are advised to refer urgent care patients to an optometrist who does.
FORAC defines teleoptometry as “… the provision of vision and eye health services that are delivered within the scope of practice of optometry using electronic health information, medical and communication technologies, and where the provider and patient are separated by remote distance.”
During the current pandemic and as of March 31, 2020, none of the provincial or territorial health authorities, except for Prince Edward Island, has restricted teleoptometry for non-urgent vision care. At the same time, few colleges have published teleoptometry-specific guidelines. For those that have, the basic principles are similar. It is CAO’s view that in the absence of provincial guidelines, the principles of FORAC’s Policy on Teleoptometry apply:
“In order for Optometrists in Canada to engage in the practice of teleoptometry:
- Optometrists must be registered, practice within the scope of practice, and maintain appropriate professional liability insurance in the province or territory where patients are located;
- Optometrists must comply with all privacy regulations within their province or territory and the province or territory of the patient;
- Optometrists must establish an appropriate practitioner-patient relationship before any care or recommendation is provided to the patient;
- Optometrists must adhere to all ethical and legal requirements to obtain valid informed consent and to protect the privacy and confidentiality of patient information;
- Optometrists must ensure that their identity and location is known to the patient and the identity and location of the patient is confirmed at each consultation;
- Optometrists must provide the same level of care and observe the same responsibilities as provided in direct patient care;
- Optometrists must fulfil the same obligations for patient follow up in teleoptometry as in a direct patient care;
- Optometrists must maintain proper clinical records for all patients to whom care is delivered through the practice of teleoptometry;
- Optometrists must ensure that all digital health information that is collected is appropriately stored and protected;
- Optometrists must comply with relevant legislation and regulatory policies concerning conflict of interest, advertising and communication with the public, as well as the sale of goods and services, and expectations of ongoing competence, including as it applies to current and evolving technologies used in teleoptometry.”
It is strongly recommended that optometrists wishing to engage in teleoptometry consult with their college for the most up to date policies on teleoptometry. The following are examples of current teleoptometry policies and position papers:
CAO further recommends that:
1) any optometrists engaging in teleoptometry purchase cybersecurity insurance in addition to ensuring that their professional liability insurance covers teleoptometry and 2) that any and all communication between the optometrist and their patient are secure (e.g. encrypted emails and files exchanged over the internet).
Delivering Care through Teleoptometry
Practitioners offering teleoptometry services should make that clear in their communication with patients (Electronic mail, website, telephone and other means.)
Possible Modalities for Teleoptometry
There is a range of modalities whereby optometrists can provide care to their patients remotely. These range from telephone triage and consultation to the use of electronic platforms such as EyeCareLive, Livecare, Doxy.me, Zoom Health and others.
Whichever modality optometrists may chose for teleoptometry, optometrists are encouraged to consult the BMS-CAO site for most up to date important insurance information and considerations.
Billing, Public Coverage and Third Party Payers
With the exception of Prince Edward Island, teleoptometry is considered to be in alignment with the scope of practice of optometry provided that the provisions listed above, and those of the specific provincial colleges are met.
A number of provincial associations are currently in the process of negotiating or finalizing billing codes for teleoptometry with their provincial health authorities. As of April 2, 2020, only British Columbia has established such codes (on a temporary basis).
Information will be routinely updated as CAO receives new information about public reimbursement in any of the provinces.
Third Party Payers
As of April 1st 2020, one insurer (Medavie Blue Cross) had approved direct billing for teleoptometry. CAO is providing the Canadian Life and Health Insurance Association (CLHIA), with information to support private insurance coverage for teleoptometry, a decision that will be independently made by each member of CLHIA. This page will be regularly updated with new information on private coverage as it becomes available to CAO.
Maintaining detailed documentation of all teleoptometry consults is critical in the event that private insurers reimburse services retroactively.
Where the practice of teleoptometry is not specifically prohibited by the college, it is generally acceptable to bill the patient directly for the service in the absence of public or private insurance coverage. Generally speaking, fee ranges for teleoptometry services have not been established or confirmed. CAO recommends that optometrists consult with their respective provincial association for advice on this matter.
Ethics and Informed Consent
In addition to all the ethical and regulatory standards that govern the practice of optometry, optometrists providing care through teleoptometry must be particularly cognizant of the risks that teleoptometry presents and do everything in their capacity to mitigate those risks. This includes fully informing the patient of the risks that teleoptometry poses to the delivery of their care.
BMS and CAO have developed a template consent form that could be adapted by optometrists for use in teleoptometry. Those using commercial teleoptometry/telehealth platforms such as the ones previously identified could use consent forms supplied by the platform providers so long as they are in compliance with their provincial colleges’ standards.
Keep in mind that informed consent is intended to protect the patient, not the practitioner.