Effectiveness of an Ophthalmic Hospital-Based Virtual Service during the COVID-19 Pandemic
Authors: Xiaohang Wu, Jingjing Chen, Dongyuan Yun, Meng Yuan, Zhenzhen Liu, Pisong Yan, Dawn A. Sim, Yi Zhu, Chuan Chen, Weiling Hu, Zijian Wu, Huaide Lin, Yandong Wang, Yanling Wu, Mingfei Chen, Caoxian Zhang, Yongxin Zheng, Xialin Liu, Xingwu Zhong, Hongxing Diao, Daniel Shu Wei Ting, Dinesh Visva Gunasekeran, Yongqiang Li, Jie Zhang, Yaobin Cai, Zhihao Lao, Yizhi Liu, Tien Yin Wong, Xiaofeng Lin, Haotian Lin
Journal: Ophthalmology (2020)

The coronavirus disease 2019 (COVID-19) pandemic has posed challenges for healthcare providers,1Wang C. Horby P.W. Hayden F.G. Gao G.F. A novel coronavirus outbreak of global health concern.Lancet. 2020; 395: 470-473Abstract Full Text Full Text PDF PubMed Scopus (5092) Google Scholar while also bringing about new opportunities for telehealth services worldwide. Although media publicity for telehealth and virtual consultations has been widespread,2Hollander J.E. Carr B.G. Virtually perfect? Telemedicine for Covid-19.N Engl J Med. 2020; 382: 1679-1681Crossref PubMed Scopus (2086) Google Scholar few peer-reviewed studies have been conducted to describe the characteristics and effectiveness of hospital-based telehealth virtual practice in response to the COVID-19 pandemic. In China, the Zhongshan Ophthalmic Center (ZOC) of Sun Yat-sen University established a virtual clinical service using several digital technologies3Ting D.S.W. Carin L. Dzau V. Wong T.Y. Digital technology and COVID-19.Nat Med. 2020; 26: 459-461Crossref PubMed Scopus (944) Google Scholar (5G telecommunication networks, big data analytics, artificial intelligence,4Gunasekeran D.V. Wong T.Y. Artificial intelligence in ophthalmology in 2020: a technology on the cusp for translation and implementation.Asia Pac J Ophthalmol (Phila). 2020; 9: 61-66Crossref PubMed Scopus (36) Google Scholar and blockchain technology5Radanović I. Likić R. Opportunities for use of blockchain technology in medicine.Appl Health Econ Health Policy. 2018; 16: 583-590Crossref PubMed Scopus (213) Google Scholar) to deliver online ophthalmic diagnosis and treatment services. This study analyzed the characteristics and effectiveness of a virtual service run by the tertiary ophthalmic center in China to construct a pragmatic paradigm for telehealth eye care services during and beyond the pandemic. With lockdown regulations for the COVID-19 epidemic being implemented, from February 1 to 7, 2020, ZOC on-site registration was open for emergencies only. Comprehensive and specialist clinics were reopened gradually beginning on February 15, 2020. The ZOC internet hospital was launched on February 1 to provide patients with diagnosis and treatment options. Three interlinked modules constituted the main body of the ZOC internet hospital: artificial intelligence prescreening by chatbot and image recognition,6Li W. Yang Y. Zhang K. et al.Dense anatomical annotation of slit-lamp images improves the performance of deep learning for the diagnosis of ophthalmic disorders.Nat Biomed Eng. 2020; 4: 767-777Crossref PubMed Scopus (46) Google Scholar virtual live consultation with ophthalmologists, and online pharmacy for prescription renewals and remote drug delivery (details in Fig S1A, available at www.aaojournal.org). We extracted clinical services records from virtual 2020, face-to-face 2020, and face-to-face 2019 encounters from February 1 through March 13 for analysis, including patient age, gender, address, date and hour for consultation, transcript records of online communications, diagnosis of on-site clinic visits, and so forth. We used the Shapiro-Wilk test to evaluate for normal distribution of each sample. The median and interquartile range (IQR) were used for the description of continuous variables that did not conform to a normal distribution. The Kruskal-Wallis test (among the 3 groups) and the Wilcoxon rank-sum test (between 2 groups) were used for comparisons. The frequency and proportion were used for descriptions of categorical variables, and the chi-square test was used for comparisons between groups. P values of less than 0.05 were considered statistically significant for all tests. This study followed the principles outlined in the Declaration of Helsinki. The study protocol was approved by the ethical board committee of the Zhongshan Ophthalmic Center, Sun Yat-sen University. The requirement for informed consent was waived because of the retrospective nature of the study. During the 6-week study period, a total of 38 038 visits online (virtual 2020) and offline (face-to-face 2020) were observed in this study, including 10 641 visits with the artificial intelligence chatbot, 9850 virtual live consultations by 127 doctors, and 17 547 on-site face-to-face clinic visits. Along with the gradual opening of the on-site outpatient and emergency services by the ZOC, the number of on-site patients showed a steep rise. Simultaneously, online service numbers steadily increased because of the increased awareness of the service, optimization of the patient-user experience, and the availability of online pharmacy service and delivery (Fig S1B). Thus, we were able to offer an end-to-end solution based on a fully virtual diagnosis and treatment. The median age of virtual 2020 patients was 32 years, significantly younger than that of the face-to-face 2019 (35 years) and face-to-face 2020 (45 years) groups. The proportions of youth (18–34 years [35.9%]) and middle-aged (35–54 years [26.8%]) patients increased in the virtual 2020 group after the COVID-19 outbreak compared with the face-to-face 2019 group. Women were more likely to use virtual live consultations (53.3% of 9850 visits) than face-to-face 2020 (47.7% of 17 547 visits) or face-to-face 2019 (51.1% of 98 225 visits) encounters. Retinopathy was one of the most common reasons for the encounter in the virtual 2020 (22.6% [1644/7273]), face-to-face 2020 (26.5% [1203/4532]), and face-to-face 2019 (20.1% [10 740/53 308]) groups. Nevertheless, more visits were for ocular surface diseases (24.2% [1761/7273]) and glaucoma (19.4% [1411/7273]) in patients who undertook a virtual live consultation. Trauma (26.3% [1194/4532]) accounted for the second-largest proportion of face-to-face 2020 encounters. Refraction problems (26.1% [13 895/53 308]) were the most common reason for face-to-face 2019 consultations. Compared with face-to-face 2019 encounters, which represented the normal state before the COVID-19 outbreak, face-to-face 2020 visits in the corresponding period involved patients more geographically concentrated around ZOC clinics from Guangdong Province (85.6% [14 050/16 405] of China) and Guangzhou City (72.9% [10 112/13 876] of Guangdong Province) because of the travel restrictions during the national lockdown. By contrast, virtual 2020 visits were significantly more dispersed, with a median geographical distance of 340 km (IQR, 64.0–677 km), significantly farther than face-to-face 2020 (2.66 km [IQR, 0.01–128 km]) and face-to-face 2019 (2.65 km [IQR, 0.00–219 km]; Table S1, available at www.aaojournal.org) encounters. We further analyzed the indications of virtual live consultations in 2020. Specific disease consultation was the most commonly cited reason for virtual live consultation and accounted for 67.0% of the total 9850 visits, followed by symptomatic conditions (56.0%), prescription renewal (54.6%), other consultations (2.2%; including drug use, procedures for attending clinics during the lockdown period, eye health consultation, etc.), and repeated consultation (1.6%). Among the symptoms addressed, ocular discomfort or appearance abnormalities constituted the overwhelming majority (87.2%). In terms of specific disease consultations, 38.7% and 26.9% of the total 6597 visits concerned follow-up and queries about surgery-related information, respectively. The top 3 most referred diseases were ocular surface diseases (26.7%), retinopathy (24.9%), and glaucoma (21.4%; Fig S2A, available at www.aaojournal.org). When stratified by age, specific disease consultation was the most common reason across all age groups, and the demand increased with age from 64.7% in children (<18 years; 1339/2069) to 70.7% in older adults (>55 years; 1131/1599). Youth (18–34 years) were the most eager to seek virtual consultation for symptoms (60.4% [2036/3539]) and other consultations (2.6% [92/3539]). Older adults (>55 years) were most likely to use virtual consultation for prescription renewal, with up to 10% more older adults requesting prescription renewal than the other age groups. Repeated consultation was the only category that children or their guardians (1.8% [37/2039]) were more likely to use (Fig S2B). The study has several limitations. First, during the 6-week study period, the ZOC online and on-site services were running separately and thus were analyzed as independent parts. We could not trace the flow of visits for a patient from online to on-site, or vice versa. Subsequently, the online and on-site healthcare interactions were integrated and incorporated in the ZOC internet hospital design. Second, the direct reproducibility of the virtual clinical services may be limited by the licensing requirements from different countries and regions. Nevertheless, we have offered lessons and collaborate with other ophthalmology services providers during and after the COVID-19 pandemic. Our results indicate that online medical services could be fully used for telehealth advantages, including time savings, bridging geographical barriers, and additional functionalities such as remote assessment, in a complementary manner to on-site face-to-face clinical services. Interestingly, we observed from the spectrum of diseases that ocular surface diseases were most cited in the virtual live consultations in 2020, which differs significantly from the most common reasons for the face-to-face 2020 (retinopathy) and face-to-face 2019 (refraction) consultations. This finding may reflect that COVID-19 may have ocular surface symptoms, although we did not record COVID-19-positive patients in our service. Alternatively, ocular surface disorders could be related to physical or psychological factors (break from regular life, overuse of digital screens, stress, anxiety during the pandemic).7Kitazawa M. Sakamoto C. Yoshimura M. et al.The relationship of dry eye disease with depression and anxiety: a naturalistic observational study.Transl Vis Sci Technol. 2018; 7: 35Crossref PubMed Scopus (46) Google Scholar Even as countries and systems adapt to the new normal after the COVID-19 pandemic, many of the virtual systems that were established to meet short-term needs eventually will evolve into long-term trends and solutions. The virtual clinical practice described herein was beneficial especially for patients with ocular surface symptoms or for those in need of follow-up medications. Furthermore, virtual evaluation could provide effective forward triage to specific on-site specialists as a useful complement. The virtual service also offered an alternative for patients with less time or those whose geographic locations made our services less accessible. The guidance and lessons from this study are a reference for other ophthalmology services in different countries during and after the COVID-19 pandemic. The authors thank the Guangdong Medical Association Ophthalmology Branch, Hubei Medical Association Ophthalmology Branch, and the Chinese Association of Artificial Intelligence for the leadership and administrative supports. The authors also thank each of the 127 voluntary ophthalmologists from the Zhongshan Ophthalmic Center and collaborating hospitals for providing virtual live consultations—Zhongshan Ophthalmic Center: Feng Wen, Xiaoming Lin, Yimin Zhong, Shaochong Zhang, Chenjin Jin, Jian Ge, Xialin Liu, Xing Liu, Yan Luo, Dongmei Cui, Xinguo Deng, Haotian Lin, Weirong Chen, Lin Lv, Tao Li, Kaili Wu, Siming Ai, Shengsong Huang, Keming Yu, Mingkai Lin, Qingjiong Zhang, Yang Gao, Xingyi Li, Sainan Xiao, Hui Xiao, Jing Yang, Xinbo Gao, Xuan Qiu, Zidong Chen, Jing Wu, Xueying Zhongliu, Xintong Jiang, Heping Wu, Xiujuan Zhao, Hui Chen, Saiqun Li, Dina Hu'an, Liangping Liu, Yingting Zhu, Rongxin Chen, Zhonghao Wang, Lingyi Liang, Jianjun Gu, Ying Kang, Junshu Wu, Danping Huang, Mingxing Wu, Lixia Luo, Quan Liu, Xianchai, Lin, Chengguo Zuo, Wei Chi, Jin Ma, Rong Lu, Xiangming Guo, Shida Chen, Fan Li, Binghua Kong, Zhengjie Xu, Xuhua Tan, Xiaoxiao Zhang, Chuangxin Huang, Qiwei Wang, Wei Xiao, Shanshan Wang, Jingjing Chen, Yao Yang, Ping Lian, Huijing Ye, Chunxiao Wang, Chang He, Lan Mi, Bing Xiao, Songshan Li, Xiling Yu, Zhenzhen Liu, Yunlan Ling, Jingchang Chen, Danying Zheng, Xiao Yang, Sheng Zhou, Zhaohui Yuan, Yangfan Yang, Ying Lin, Wenru Su, Bingqian Liu, Fang Duan, Siping Zhu, Xiaohu Ding, Lei Lei, Xiaohang Wu, Xiaoqing Chen, Wu Xiang, Linxing Chen, Shaohua Fang, Shiyi Li, Wenyan Peng, Wan Chen, Yiming Ye, Li Huang, Limei Sun, Xiaoning Liu, Feng Zhao, Xiongze Zhang, Lixia Lin, Ting Zhang, Yuying Ji, and Yin Hu; Zhongshan Ophthalmic Center, Nanchang Ophthalmic Hospital: Yingjie Li, Yu Jin, and Miao Liu; The First Hospital of Nanchang City: Yan Mei; Hainan Eye Hospital, Zhongshan Ophthalmic Center: Lingyun Wu; Yueyang Traditional Chinese Medicine Hospital: Li Zhou; Wuhan Eye and Optometry Hospital: Keneng Yan; The Central Hospital of Wuhan: Jun Jia; Zhongnan Hospital of Wuhan University: Ming Yan, Aihua Yu, Jing Zhang, and Qi Xiong; Renmin Hospital of Wuhan University: Bin Peng and Jing Yuan; Aier Eye Hospital of Wuhan University: Binxian Yan; Tai'an City Central Hospital: Shengxia Wang; Yichang Central People's Hospital: Xuemei Wang and Hao Wu; and The Central Hospital of E-zhou: Zheng Zhang. 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