key: cord-0699284-bt62bib9
authors: Keilty, Matthew; Houston, Kevin E.; Collins, Caroline; Trehan, Ritika; Chen, Ya-Ting; Merabet, Lotfi; Watts, Amy; Pundlik, Shrinivas; Luo, Gang
title: Inpatient Virtual Vision Clinic Improves Access to Vision Rehabilitation Before and During the COVID-19 Pandemic.
date: 2020-12-19
journal: Arch Rehabil Res Clin Transl
DOI: 10.1016/j.arrct.2020.100100
sha: 97f82a53cf4c9f3bc5698d0e77875cd3df35ee7c
doc_id: 699284
cord_uid: bt62bib9

Objective To describe and evaluate a secure video call system combined with a suite of iPad vision testing apps to improve access to vision rehabilitation assessment for inpatients. Design Retrospective. Setting Two acute care inpatient rehabilitation hospitals (AR1 and AR2) and 1 long-term acute care hospital (LTAC). Participants Records of inpatients seen by the vision service Interventions Records from a one-year telemedicine pilot performed at AR1 and then expanded to AR2 and LTAC during COVID-19 were reviewed. In the virtual visits, an occupational therapist (OT) measured the patients’ vision with the iPad apps and forwarded results to the off-site Optometrist (OD) for review prior to a video visit. The OD provided diagnosis and education, press-on prisms, strategies and modifications, and follow-up recommendations. Providers completed the telehealth usability questionnaire (10-point scale). Main Outcome Measure(s) Vision exams per month at AR1 before and with telemedicine. Results With telemedicine at AR1, mean visits per month significantly increased from 10.7 ± 5 to 14.9 ± 5 (p=0.002). Prism was trialed in 40% of cases of which 83% were successful, similar to previously reported in-person success rates. COVID-19 caused only a marginal decrease in visits per month (p = 0.08) at AR1, whereas the site without an established program (AR2) had a 3-4 week gap in care while the program was initiated. Cases at the LTAC tended to be more complex and difficult to manage virtually. The telehealth usability questionnaire median category scores were 7 for Ease of Use, 8 for Interface Quality, 6 for Reliability, and 9 for Satisfaction and Future Use. Conclusion(s) The virtual vision clinic process improved inpatient access to eye and visual neuro-rehabilitation assessment before and during the COVID-19 quarantine and was well accepted by providers and patients.

Background 31 32 33 Vision problems are common in inpatient rehabilitation facility (IRF) stroke and brain injury units, 34

affecting 60-70% of patients. [1] [2] [3] [4] [5] Strabismus (misaligned eyes) occurs in approximately 1 in 5 stroke 35 survivors, causing functional impairment, reading difficulties, and mobility challenges in the elderly 36 with 2.2 times increased odds of falls with musculoskeletal injury 6 and substantially decreased quality 37 of life scores. 7 Homonymous visual field defects are also very common, occurring in 29% to 50% of 38 stroke survivors 8, 9 causing reduced detection and delayed responses for obstacles when walking 10-12 39 and driving, 13, 14 affecting independence 12 and quality of life 12, 15 and are likely to increase risk for fall, 40 readmissions, and be a barrier to community re-entry. 41 42 Neurological visual impairments might be addressed during the inpatient stay with vision 43 rehabilitation. Vision rehabilitation has been defined as the process of treatment and education that 44 helps individuals who are visually disabled attain maximum function, a sense of well-being, a 45 personally satisfying level of independence, and optimum quality of life. 16 Visual neuro-rehabilitation 46 is a subspecialty in this field 16 involving a multidisciplinary team which may include Doctors of 47 Optometry (ODs residency-trained in either in low vision, neuro-optometry, or both), occupational 48 therapists (OT) specializing in visual/perceptual deficits or low vision, or orthoptists. In the U.S., 49

Ophthalmologists (OMDs) only rarely specialize in vision rehabilitation; however, the American 50 Academy of Ophthalmology advocates for vision rehabilitation. 17 Neuro-ophthalmologists may staff 51

IRFs or act as external consultants, having a higher level of expertise in diagnosis and medical 52 management but with less emphasis on prism and rehabilitation strategies compared to ODs. OTs The visual neuro-rehabilitation process may include but is not limited to visual diagnosis, education, 58 compensatory training, restorative therapies, assistive technology and ophthalmic prism application. 59

Fresnel press-on prisms are frequently applied by ODs and OMDs for strabismus to restore binocular 60 vision and sometimes for homonymous field defects to expand the visual field and are a valuable part 61 of our preferred vision rehabilitation approach; therefore, the ability to fit prisms virtually was an 62 important consideration in this study. They are inexpensive, can be applied at the time of 63 examination with only a pair of scissors, and can be easily removed or changed as the patient recovers 64 so long as the patient can access an eye care specialist (OD or OMD) . Press-on prism success rates are 65 relatively high with reported ranges of 64% 18 to 80% 19 for strabismus and ~50% for hemianopia. 11 The 66

Peli prism design for hemianopia is supported by a double-blind multicenter RCT which found 67 significant improvements in self-reported mobility over a sham. 11 In addition to prisms, compensatory 68 methods may be taught by OTs or ODs such as positioning the head or reading material in such a way 69 as to reduce double vision in strabismus or by strategically positioning the eyes (eccentric viewing) or 70 frequently scanning toward the blind side in hemianopia. 20, 21 Oculomotor therapies which aim to 71 restore normal function by asking patients to repeatedly make eye movements in the direction of a 72 weakened extraocular muscle may be employed, although the evidence base in neurological visual 73 disorders is limited to small studies. Our vision rehabilitation protocols (supplement 1) contain 74 activities approved by a vision special interest group with representatives from each site (AR1, 2, and 75 LTAC) ( Table 1 ). The protocols have been in place for ~8 years and were not developed for the 76 purpose of this telemedicine program. Aside from prism fitting and initial education, little to no vision 77 rehabilitation training or therapy was provided via the video conferencing platform. The treating OT 78 J o u r n a l P r e -p r o o f provided this care in-person after the assessment, reinforcing the education pieces and rehabilitation 79 protocol activities prescribed. 80 81 Given the negative functional and psychological impacts caused by neurological visual impairments 82 and the availability of inexpensive and effective evidence-based interventions which can be modified 83 as the patient recovers, beginning the process of vision rehabilitation alongside inpatient 84 occupational, physical, and speech-language rehabilitation is logical. Ideally, an OT and OD would 85 deliver this care as a team; however, in the U.S., rehabilitation facilities have limited access to ODs 86 specializing in vision rehabilitation. The reason for this is not particularly well described, but in our 87 experience OD availability to come to an IRF is usually limited to 1-day per week or less, with access to 88 neuro-ophthalmologists being even more limited. While OTs with vision rehab training and 89 experience are routinely employed full-time by IRFs, it is our experience that most prefer to 90 collaborate with an OD or OMD to conduct the visual neuro-rehabilitation assessment in the interest 91 of providing the highest quality care and avoid scope of care issues. For example, application, 92 training, and fitting of assistive and prosthetic devices is part of the OT scope and may interpreted to 93 include prism and magnifiers for visual impairments; 22 however, OD vision rehab specialists have 94 direct training and experience that is useful to guide the specialized OT (see supplement table S2) . 95

Likewise, an OT will typically intervene for symptoms of a homonymous field cut during functional 96 mobility, ADL and IADL training by providing multimodal cuing to encourage/facilitate the patient to 97 scan and shift their gaze (clearly within the scope of the OT); however, they often avoid specific eye 98 exercises or dedicated scanning exercises aimed at improving saccadic eye movements (questionable 99 as within OT scope) 22 despite their known efficacy, 23, 24 with which an OD can assist. Therefore, a 100 multidisciplinary approach which involves a vision rehab OD and OT is preferable. 101 102 J o u r n a l P r e -p r o o f

The limited access to inpatient eye and vision rehabilitation care can be further compromised during 103 special circumstances, such as the ongoing (at the time of this study) COVID-19 quarantine, during 104 which in-person optometry and vision rehab clinics were suspended. Telemedicine is one possible 105 solution to improve access to inpatient vision rehab assessment, and to continue to provide care 106 during the COVID-19 crisis. Barriers to widespread telemedicine use prior to the COVID-19 pandemic 107 were two fold. The first was provider liability concerns regarding inadvertent HIPAA violations that 108 may occur using one of the many remote communication technologies. In February of 2020, the 109 Office for Civil Rights at the Department of Human and Health Services, encouraged telemedicine 110 visits and decreed that in the nationwide state of emergency, providers would not be held 111 accountable for HIPAA noncompliance incidents when using telemedicine in good faith. 25 Secondly 112 prior to COVID-19, insurance coverage for telemedicine was almost nonexistent. During the COVID-19 113 pandemic, Medicare granted payments for telemedicine visits 26 and many private insurers followed. 114

In order to address access to care issues, it may be feasible for the IRF OT staff to administer an app 116 based visual test battery, operate the teleconferencing equipment, apply press on prisms under the 117 ODs remote guidance, and facilitate use while monitoring response. While IRF OTs are typically 118 trained to conduct a vision screening, we expected the OD would require additional history and 119 testing along with test reliability parameters in order to confidently diagnose and recommend 120 appropriate treatment and follow-up. This might be best accomplished with a vision testing app suite 121 with guided history, auto testing distance measurement, fixation monitoring, and adherence to eye 122 covering protocols. The app should provide effective instructions to the OT and patients and produce 123 a report that can be rapidly and securely transferred to the offsite OD and uploaded to the medical 124 record. At the time of this project there were several vision testing software apps available on the 125 app store which might have been combined to create a suite for IRF vision virtual visit exam. A clinical 126 telemedicine product called EyeCare Live (Santa Clara CA) was available offering video conferencing 127 and an integrated visual acuity testing app; however, no other visual testing functions were available 128 at that time. A tablet-based vision testing approach for stroke had been reported by Quinn et. al. 129 2018, referred to as the StrokeVision App, 27 but was not available as a clinical product. Prior to this 130 present study, as part of their regular in-person exams the IRF vision service ODs were using Visual 131 Acuity XL (Kybervision, Montreal Quebec), and occasionally Pocket Eye Exam (NOMAD, Charlottesville 132 VA) for iOS which included acuity, color vision testing, OKN strips, red desaturation stimulus, and flash 133 light stimulus for pupil testing. Unfortunately these apps had serious limitations making them, in our 134 opinion, poorly suited for virtual vision rehabilitation examinations. The former was difficult to learn 135 because of insufficient instructions for the novice user and did not monitor testing distance and 136 therefore could not verify accuracy of testing method. The latter had inaccurate acuity measurement, 137 test results were not recorded, instructions were not given, and there was no visual field testing app. 138

The doctors had also been using EyeTurn, an app for strabismus measurement which was developed 139 by Massachusetts Eye and Ear and EyeNexo LLC (Boston MA) with funding from the NIH. Our hospitals 140 were a site for the validation study, which found similar accuracy between the app and standard 141 clinical tools 28 and was fairly effective to deliver IRF strabismus consult using a store-and-forward 142 approach. 29 However, the EyeTurn app was narrow in focus: it just measured strabismus angle and 143 its limitations were that the consult did not provide ocular motility exam such that common 144 strabismus patterns (3 rd , 4 th , and 6 th nerve palsies) could not be identified, visual acuity was unknown 145 (asymmetric acuity would preclude successful treatment), history provided was inconsistent, and 146 visual field defects and other visual and ocular issues could not be addressed. 147

148 Given the limitations of the various existing mobile apps, a vision testing app suite specialized for 149 visual neuro-rehabilitation was developed through an engineer-clinician feedback loop, combined 150 with a video conferencing process, and piloted for 1 year as a clinical service at a 60-bed inpatient 151 acute rehabilitation hospital (Spaulding Cape Cod (AR1), East Sandwich MA), which was 152 retrospectively reviewed. 153

We hypothesized that the process was well accepted by practitioners and patients evidenced by 1) 155 greater numbers of patient exams relative to pre-implementation; 2) increasing frequency of clinic 156 days from twice monthly to weekly; 3) consistent or increasing utilization over the pilot period; and 157 4) low complaints/adverse events. We also hypothesized that the telemedicine program allowed 158 continued access to vision rehab assessment during the COVID-19 quarantine when all in-person 159 optometry and vision rehab services were suspended (as were other consultant services). This was a retrospective study of a clinical telemedicine pilot program at an acute inpatient 168 rehabilitation facility (IRF), AR1. All activities described were performed as part of a clinical process, 169 which was later studied retrospectively via record review to determine if access to care was improved. 170

As such informed consent was waived. The clinical process is described along with the retrospective 171 research methods in sufficient detail to allow replication. 172

The study was conducted in accordance with the tenets of the Declaration of Helsinki. The protocol 174 was approved by the institutional review board at Partners Healthcare. 175

Prototyping of an iPad-based Visual Neuro-rehab Testing Suite: An existing suite of apps for general 177 eye clinic (EyeXM, EyeNexo Boston MA) was modified by engineers at EyeNexo with advice and 178 feedback from the clinicians (ODs and OTs), in order to provide a guided history specific to neurological 179 vision problems (referred to as EyeXM Rehab). It allowed visual acuity testing with single-letter and 180 tumbling E optotype 30 options which were indicated by the clinicians as being conducive to testing 181 patients with cognitive impairment and aphasia. They also requested 3 visual field tests, an 182 extraocular motility (EOM) test which provided instructional cues to the patient/OT, and the EyeTurn 183 app 28 for strabismus detection and measurement (Fig 1) . The history app standardized questioning to 184 include important details such as "is the double vision present when covering an eye, how are the 185 double images positioned, do you wear glasses, and do you require reminders to look to the left or 186 right". Visual field testing software included a finger counting fields test (image of a hand appeared on 187 the screen), a visual extinction test (with single and double simultaneous presentation of stimuli), and 188 a novel fixation free visual field test. The fixation free field test could predict hemianopia with 76.5% 189 sensitivity and 78% specificity in the neuro-rehab population when the reaction time difference 190 between right and left fields was > 0.5 sec (unpublished). A 1-cm round white stimulus was presented 191 on a black background which the patient was asked to touch, with each successive stimulus 192 presented to the opposite hemifield. The difference in reaction time between the right and left 193 fields provided a measure of the functional impact of homonymous field loss as well as some visual 194 field information for patients who could not perform typical gaze-fixed visual field testing. A distance 195 meter function which used the built in camera was part of the apps and guided the OT to set the 196 correct distance for the visual acuity test and auto-calculated eccentricity of visual field stimuli. Physical or MRI reports did not support this diagnosis by localizing the pathology to the right 204 hemisphere, diagnosis of left neglect was withheld and the OD would discuss with the attending 205 physician or refer for additional assessment with neuropsychology. After testing, a PDF report, high 206 resolution ocular image, and EOM video file were generated and emailed to the OD. tasks that might be related to vision or behaviors suggestive of field cut or hemineglect. Then they 214 entered the room and performed the app testing and then brought the iPad to the OD outside the 215 patient's room. The OD reviewed the findings, mentally constructed a diagnosis and treatment plan 216 based on the app data, and then entered the room to perform the typical in-person exam. This process 217 allowed the OD to evaluate how well he might be able to diagnose the patient virtually if only the app 218 data were available. Notes were taken on the functioning and workflow of the apps to produce a 219 clinician-engineer feedback loop allowing refinements to occur. Qualitative feedback was 220 OTs were asked to confirm the counts were complete during manuscript preparation. Additionally, 295 providers involved in the tele-consult process were anonymously surveyed using a Likert-type scale 296 with items from the telehealth usability questionnaire, a validated instrument for assessing the 297 implementation of new virtual visit care technologies. 31 Items that were not relevant to the present 298 study were dropped and wording was slightly modified for context. Components of qualitative 299 information from the OD and two OTs involved in the prototyping at AR1 are also reported (authors 300 MK, CC, KH). There was also a significant increase in the number of clinic days per month, from a mean of 2.1 ± 326 0.8 before telemedicine to 3.5 ± 0.7 with telemedicine (p < 0.001). Figure 3a shows a year by year 327 breakdown of the total patients served before and with the telemedicine program. As can be seen, 328 the number of patients served in 2019 was higher than previous years, and majority were involved 329 with telemedicine vision consults. Utilization of the vision rehab telemedicine service at AR1 over 330 the pilot period was consistent, never dropping below 10 patients in a month during the 2019 pilot 331 (Fig. 3b) . 332 333 Results 2: Adverse Event, Complaints, and Refusals at AR1: One patient scheduled for telemedicine 334 vision consult started the process, and then refused to continue citing fatigue and discomfort. 335

Another was unable to do most tests and specifically could not tolerate the flash used in the 336 computerized Hirschberg strabismus test (EyeTurn app), and so was recorded as a mild adverse 337 event. Qualitative reports suggested there were at least several other cases where patients could not 338 participate in the exam due to impaired cognition, aphasia or low arousal. Some patients had 339 difficulty tolerating the flash during imaging, particularly when repeat testing was needed. There 340 were no formal or incidental complaints by family members, caregivers, medical staff or other 341

therapists. No cases of misdiagnosis were identified in the record reviews or by professional 342 communication. A typical time for the entire process in the later stages of the pilot was about 35 343 minutes, which is very similar to in-person consultation. 344 345

The vision clinic telemedicine program was implemented at the 180-bed LTAC in June of 2019. Ten 347 evaluations were performed over that period through May 2020 (11 months). The population had a 348 mean age of 53 ± 19, was 70% female, and had medical diagnoses of brain tumor (2), stroke (4), and 349 1 each aneurysm, TBI, hypoxic brain injury, and other. Visual diagnoses included strabismus (5), 350 hemianopia (5), hemi-neglect (2), floaters (1), and blurred vision (1) (note that 5 patients had 351 multiple visual diagnoses). One patient with strabismus, hemianopia, and hemineglect was found to 352 be blind in one eye related to the HPI. The condition was later found by in-person dilated fundus 353 exam to be Terson's syndrome related to her subarachnoid hemorrhage, treatable by vitrectomy. 354

During the COVID-19 crisis, 2 LTAC patients were seen for vision rehab issues unrelated to 355 one of whom had previously been intubated for SARS-CoV-2 but not at the time of exam. An order 356 was written for one patient on the COVID vent unit for red eye symptoms but could not be seen due 357 to infection control policies which prevented bringing the iPad into the room. 358 359

In response to COVID-19, the comprehensive vision clinic telemedicine service was quickly 361 implemented at an urban 150-bed acute rehab facility (AR2) with 18 patients being evaluated virtually 362 during that 2.5-month period. The cumulative patients served by telemedicine grew exponentially over 363 that time, Fig. 4 . The population had a mean age of 61 ± 20, was 50% female, and had medical 364 diagnoses of stroke (6), TBI (2), brain tumor (2), respiratory distress (3), and other (5) . Three had been 365 COVID+ in the months prior and had recovered by the time they were examined, with visual diagnoses 366 of blurred vision/dizziness, interstitial keratitis (IK), and homonymous hemianopia. The IK case was 367 sent out to a cornea specialist who indicated it was likely related to the prior COVID-19 infection. The 368 AR2 population also changed somewhat during the COVID crisis. The hospital accepted more COVID-19 369 patients who needed post-acute care rehabilitation, and the interdisciplinary team worked together to 370 manage the complications of COVID-19, including acute cerebrovascular disease, deconditioning, and 371 critical illness associated weakness. 32, 33 To accommodate the potential increase in patient load, each 372 floor typically designated for a specific patient population (e.g. traumatic brain injury, stroke, spinal 373 cord injury, or amputation) started to provide beds for those with a different admission diagnoses. 374 375

In total across all sites and years, 237 telemedicine vision consults had been performed, 99 of which 377 were reviewed in detail, including all 38 cases from 2020 and a 25% random sampling from 2019 (see 378 methods). The most common visual diagnoses seen virtually were Strabismus (39% of cases seen 379 (39/99)), Hemianopia (37%), and Neglect (26%), Fig. 5a . Note that some patients had multiple 380 diagnoses so totals do not sum to 100%. Prism was tried by the OT with OD virtual oversight in 40% 381 of cases (40/99) and was accepted, at least initially in a short trial, in 83% (33/40). Further 382 breakdown found that prism was tried in 49% (19/39) of strabismus cases, 46% (17/37) of 383 hemianopia, and 8% (2/26) of neglect (when they also had hemianopia or strabismus). Acceptance 384 rates were 94%, 74%, and 100% respectively. Data on long term acceptance were not available. 385

Critical visual diagnoses included total or near-total blindness in 3% of cases and low vision in 6%. In-386 person exam data from AR1 are provided in Fig. 5a for comparison showing a substantially higher 387 proportion of strabismus, neglect, hemianopia, low vision, and blindness in the virtual visits. Four 388 cases seen by telemedicine vision consult at 2 sites (2 ea.) had to be sent out for urgent evaluation, 389 and are described in Fig. 5b . Likely all of these cases would have needed to be sent out even with in-390 person care as they were visually threatening and required ophthalmologist intervention. 391 392 Results 6: Perceived Value and Telemedicine Usability Questionnaire 393 17 OTs, 2 ODs, and 1 MD (physiatry resident physician) were involved in use of the vision clinic 394 telemedicine consult software and 14 responded to the questionnaire (70%). The data is presented 395 for all respondents and for just the ODs, who may have had different ratings as they were required to 396 make clinical judgments based on the technology. Visual inspection of the data (Fig 6a vs. b) showed 397 similar responses to other respondents, a median OD overall satisfaction of 6.5. Ratings for the 398 "same as in-person" question were 5 and 4 for the 2 providers. The overall median (IQR) category 399 scores were 7 for Ease of Use (7 to 7), 8 (8 to 8.75) for Interface Quality, 6 (5 to 6) for Reliability, and 9 400 This study investigated the use of a new telemedicine service consisting of a suite of custom iPad vision 406 testing apps and a video conferencing system which intended to improve access to inpatient visual 407 rehabilitation care before and during the COVID-19 pandemic. At the time of this report, 237 virtual visits 408 had been provided across 3 different inpatient sites including 2 acute IRFs and 1 LTAC. 409

The main finding was a significant increase in the number of patients who received vision rehabilitation 411 consultation during the 1 year pilot. The increase is best explained as being a direct result of the new 412 telemedicine service. The frequency of vision clinics during this period increased from twice monthly to 413 weekly, which given the average length of stay of ~2 weeks, allowed access to more patients who needed 414 care. Prior to the telemedicine service, patients who were admitted on or immediately after a vision 415 clinic day were discharged before they could be seen; an issue which was successfully addressed with 416 telemedicine. The virtual vision clinic service was consistently utilized during the 1 year pilot period with 417 no fewer than 10 consults per month and as many as 26 (Fig 3b) , reflecting both the need for the service 418 & indirectly supporting its efficacy. Overall patients seemed pleased with the process and only one 419 refused care via telemedicine consultation after starting the exam process. The whole process took 30 to 420 45 minutes per patient at the more experienced AR1 site, and 1-hour at the other sites. Hospitals 421 implementing a similar process may want to schedule an hour initially until staff are more experienced. It 422 was also helpful for OTs new to the process to have the OD on the video call during the app testing to 423 guide the process; however, once proficient it may be feasible to have the OD join only after the testing is 424 complete. In our clinics OTs were always involved in the vision testing contributing their specialized 425 training and experience to the process to ensure exam data was as accurate and reliable as possible. This 426 is the preferred approach as opposed to training a technician or OT aide to perform the testing. 427 428 Data from the validated telehealth usability questionnaire was obtained anonymously and should 429 therefore represent a valid opinion of the process. Findings were encouraging with a median Overall 430

Satisfaction score of 8/10 (Fig. 6, question 18) . The lowest scores were in the reliability category 431 suggesting the users did not think the service was the same as in-person care and that it was difficult to 432 recover in the software after making an error. This is likely due to the iPad app suite having been 433 originally designed for waiting room patient self-administration and so was specifically written to prevent 434 the patient from going back to repeat a test. This known issue could have been addressed but required a 435 major re-writing of the code which was not feasible at the time. Fortunately this did not prevent the 436 process from being successful and can be interpreted as more of an inconvenience. If re-testing was 437 needed or a test was accidentally skipped, the software allowed the user to start a new session and select 438 just the necessary tests requiring only a couple minutes of additional time. Improving the "similarity 439 ranking" between virtual and in-person care would likely require development of methods for posterior 440 pole exam, pupil measurement, intraocular pressure measurement, enhanced ocular surface evaluation, 441 and improved video call interface. 442 443 There were no complaints or misdiagnoses reported or found by record review. The record review further 444 indicated high short-term acceptance rates of prismatic interventions prescribed over telemedicine. The 445

ODs reported being comfortable enough with the exam data to make key diagnoses related to the 446 specific problem focused consult request and implement vision rehabilitation. The ODs had access to 447 neuro-ophthalmology consult when needed within the healthcare network, although it required transfer 448 to an outside facility. In any case the ODs worked within their training and scope of practice to make 449 diagnoses to the level possible in the telemedicine format, planning for in-person evaluation when 450 possible. In many cases the OD and Physiatry continuum of care plans included an evaluation with neuro-451 ophthalmology after discharge. While not available at the time of this study, it may be possible to receive 452 problem focused neuro-ophthalmology e-consult using the same app exam data. 453 454 Inpatient visual neuro-rehabilitation may be among the best early use cases for telemedicine in eye care. 455

The majority of vision conditions encountered in the IRF, shown in Fig With an inability to test pupil function, visual startle or optokinetic response, the value of the current 481 suite of apps was limited. Still, there were 10 patients over the 11 months reviewed who were able to 482 participate in the virtual exam. The app suite was also used by specialist OTs in advance of the onsite 483 vision clinic in order to reduce the time the OD had to spend with each patient allowing more patients to 484 be seen in a clinic day. Such a process may be valuable for similar hospitals. For all the sites, it was 485 important to have an onsite OT directing the vision clinic who was familiar with the process and could 486 help select appropriate candidates. 487 488 Results showed that the COVID-19 shutdown, which resulted in suspension of inpatient consultant 490 services across the rehab network, only caused a marginal decrease in the number of patients receiving 491 vision consultation at the established AR1 site. Implementing the program at AR2 during the COVID-19 492 crisis where none existed previously was much more challenging with a gap in care of about a month (last 493 in-person clinic on 3/13/20 and first virtual visit on 4/8/20). It took an additional month for staff to 494 become comfortable with the process and being utilizing it at a rate more consistent with the in-person 495 service (5-10 patients per week). Staff also attempted to use the virtual vision clinic process for two 496 patients with eye problems and a current or recent history of SARS-CoV-2, and for a medically fragile 497 patient at high risk for mortality. None of these 3 cases could be managed by telemedicine and required 498 transfer to an ophthalmic facility. In-person optometry evaluation capable of hand held slit lamp, 499 tonometry, and dilated fundus exam may have prevented the need for transfer in 2 of these cases. 500

Nevertheless, the physiatry physician (author YC) reported high value of the telemedicine consult to help 501 triage and provide valuable clinical guidance to physicians and patients. Telemedicine visits have 502 increased considerably for all medical disciplines during the COVID pandemic as both providers and 503 patients become more comfortable with the technology and enjoy the convenience of virtual visits. 504

Medicare is considering making the telemedicine expansion that occurred for COVID -19 a permanent 505 change which would encourage more clinical outcome research comparing telemedicine to in person 506 visits. 34 With reimbursements secured, technology improvements and increasingly user friendly and 507 secure apps will be developed to improve upon this platform that is presently in its infancy. As the 508 mobile technologies rapidly evolve, most mobile devices will come with much boosted artificial 509 intelligence computation power, fast wireless connection (e.g. 5G), higher frame rate cameras with 510 higher light sensitivity, and displays with higher resolution. We anticipate that these advances will 511 further support virtual eye care, allowing more comprehensive ocular health assessment of the cornea 512 and retina. 513 514 Strengths, Limitations, and Future Directions 515

The current study employed methodologies to improve scientific rigor including masking of the author 516 performing the primary statistical analysis, use of an anonymous and validated questionnaire, and the 517 gold standard simple random sampling to select charts for review. A limitation is the possibility that the 518 increase in vision consults was due to some other factor unrelated to the availability of telemedicine 519 consults, but this is unlikely, and the effect size is fairly large. The lack of an effect of COVID on consult 520 rate (i.e. there was not a significant reduction in vision rehab consults) may represent the efficacy of the 521 telemedicine program; however, it may also have failed to reach significance due to being under powered 522

with a relatively small sample size. Fortunately there were not more months of the shutdown by which 523 to evaluate this. This finding should therefore be interpreted with caution in the sense that if other IRFs 524 plan to implement a similar program (e.g. in anticipation of another quarantine in winter of 2020-2021), 525 they may still see a significant drop in vision consults provided. Still, results suggest that access to vision 526 care should be improved with a similar telemedicine program with low risk for misdiagnoses or other 527 adverse events both during a crisis and as a long-term solution. Future similar studies are needed at 528 other IRFs to evaluate if the approach is successful with different providers in slightly different 529 environments. In order to more definitively confirm safety of the approach, a study involving a direct 530 comparison between in-person and virtual vision clinic would be helpful. The value of additional exam 531 data provided by the suite of apps compared to an entirely video conference based exam might also be 532 studied for suspected benefits of using the apps. In our experience, the resolution on the video call was 533 not sufficient to adequately assess the patient and having high resolution photos and videos as part of 534 the evaluation was essential. 535 536 Conclusions 537 538 539 Access to vision rehabilitation care was improved using a telemedicine system consisting of a suite of 540 vision testing apps to compliment the OT vision screening combined with a video conference system, 541 evidenced by an increase in the mean number of patients seen per month and increase clinical sessions 542 from twice monthly to weekly. The access was maintained even during the COVID-19 quarantine period. 543

Quality of care did not appear to suffer with this approach with no complaints or serious adverse events 544 and a prism fitting success rates similar to in-person. 545 J o u r n a l P r e -p r o o f (3/2020-6/2020) . Boxes represent the 25 th to 75 th interquartile range, central line is the median, and the whiskers are the ranges. Vision rehab clinic frequency improved from monthly to weekly and significantly increased the number of patients receiving services. Despite suspension of the in-person inpatient vision rehab service during the COVID-19 quarantine access to care was not significantly impacted, although it was trending toward lower numbers seen, p=0.08 (Bonferroni corrected). [one column width] : a) Incidence of common and critical visual diagnoses in cases seen by tele-consult (white bars) compared to in-person visits. A greater proportion of Hemianopia, Neglect, and Strabismus in telemedicine may reflect the suitability of the tele-consult platform to address these issues. b) Four cases seen by tele-consult had to be sent out for urgent evaluation, which may have been in part due to an inability of the technology to evaluate pathology of the ocular posterior segment. [1.5 column width] Figure 6 : Tele-health usability questionnaire results. Of the 20 providers involved in the tele-consult process, 14 completed the anonymous questionnaire (70%). The box plot data represent the group median and 25 th -75 th interquartile range (IQR) for each question. The whiskers represent the range of data with outliers denoted as dots. Question 3 had 10 responses, 6 of which had a ranking of "8", explaining the lack of an IQR box. [one column width]

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A pilot inpatient tele-consult program for vision rehabilitation (abstract)

COVID-19 pandemic. What should PRM specialists do? A clinician's perspective

Neurologic complications of COVID-19

Medicare considering making telehealth expansion permanent, Verma says HFMA

J o u r n a l P r e -p r o o f