Find out why one OD thinks ocular telehealth is here to stay

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Ernie Bowling, OD, MS, FAAO, FNAP: Good morning. I am Dr. Ernie Bowling, editor emeritus of Optometry Times® magazine, and today I am joined by my dear friend, Dr. Chad Overman. Dr. Overman has worn many hats in his 25-year optometric career. He started out as an optometric physician for the first 12 years in Nebraska and later in Wyoming. And then an opportunity arose for him to broaden his horizons, his scope of influence, and he took a role at Walmart corporate to help shape the future of optometry. And at that time, I mean 3,200 locations, 4,000 ODs, and a $2 billion business, and he did a great job with that.

I remember talking about Chad before I ever knew him, about what a great job he was doing with this job with Walmart. But Chad took those 9 years of wonderful experience with Walmart and expanded his scope of influence yet again to become a leading consultant in our industry for the past 4 and a half years. He has an extensive experience with multiple modalities of practice, from corporate to private practice and working closely with many of the optometry schools and industry partners.

Dr. Chad has gained a tremendous reputation, someone who has seen almost all there is in our profession, and has found a way to keep the well-being of our profession at the forefront of all of it. And we all owe you a tremendous debt of gratitude for that, Chad. So, thank you for that.

Chad Overman, OD: Thanks for having me, Ernie, you’re too kind.

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Bowling: Nah, I have also had a chance to work with Chad on our journal a little while back and really got to know him well then and love to pick his brain about a lot of matters in optometry. We are going to jump into some of those this morning. I am going to give Chad a few minutes here to talk about his background. Tell us a little bit about yourself and about what you do and that kind of thing, and then we will talk about a few issues.

Overman: Thanks, I appreciate it. You covered my Walmart days—a lot of people know me from that. I did some exciting things, and you touched on, really what my overall plan in life has been. You know, I can make a difference in each stop that I take. And I want to make a bigger difference each time. So, I started out with one practice, moved to multiple practices. Then as you said, I went to corporate. I learned an incredible amount of experiences there. I always joke I don’t have an MBA, but I have got a Walmart MBA. You sit in on enough of those meetings, you tend to learn a few things. And then after doing that, I thought I could do even more.

So, I have joined the consulting world. As you said, it has been about 4 and a half, coming up on 5, years, since I left Walmart, and a whole new world opened up. It was really cool. I spent a lot of time with dry eye. I wanted to learn more than what I had done previously. So, I spent a lot of time with dry eye. Then I switched to retina, did a lot with MacuLogix and their AdaptDx on macular degeneration. That was incredible. It is a great device. I guess as I look back at that, Ernie, technology has been very much an influence in my life. And my overall goal, it sounds a little corny, but you know me, I sound corny once in a while.

Bowling: Never.

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Telehealth

Overman: I want to leave optometry better than I found it. And that has always been a passion of mine. Children are a huge passion of mine. Diabetics are a huge passion of mine. I try and make my passions drive what I do but keeping the optometrist at the key role. You know, a lot of, right now, technology is very much at the forefront with COVID-19. And what are we doing with that? It has really, to me, taken telehealth, tele-optometry, whatever, however you want to define it. It has pushed it so fast.

I have been working on telehealth for the last couple of years. And again, that is the technology part of things that that driven me. But I have just seen so much interest obviously over the last couple of months, that a lot of people are willing to have those conversations. But I keep going back to “Optometry has to win.” Optometrists have to be on the front line of this. If we put our heads in the sand and aren’t at the table to make decisions, we are going to get run over because ophthalmology will take it. And I don’t want optometry and optometrists to lose. So that has been a focus of mine quite a bit. So, it is one of those things, Ernie, if you stay with your passions, it is not like you are working.

Bowling: No.

Overman: And I absolutely love that. And so, it is fun to talk to our colleagues. It is fun to educate, you know, much like yourself. That is why I have loved to work with you in the past, and really, it is cool to be able to talk to you this way when we are in two completely different states.

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Bowling: It is exactly what I tell a lot of my friends that I kid all time that we are twin sons from different mothers with their haircuts and everything. So, passion is the key. I have always felt that way. I have always told my kids if you find something you are passionate about, you will never work a day in your life. Having spent 10 years in the coal mines before I started doing this, I haven’t worked a day since I’ve been out of the mines. I absolutely love what I do.

So, it is a very rewarding, great career. And a lot of new technology. Like you said, I know you are at the forefront of that. And I really want to take some time. Let’s talk about—I know that you are doing a lot of consulting with some companies, one of the biggest ones, I think right now is the 2020 Now. So, let’s let you kind of jump on that and talk about that a little bit. And how you see that going and what you see your role and our role, optometry and telehealth, going forward.

What dentists got right

Overman: Sure. Like I said, I really, about 2 years ago, started down. I knew telehealth was coming. I actually, I can back track. You know, 6 years ago, I tried to do some telehealth type of things when I was at Walmart, in that particular role, and we piloted it but it never really got off the ground. But it is very similar to like what IBS is doing now. That was my goal and my thought process: how do we give quality, accessible, and affordable eye exams? And my goal the last couple of years has been how do I get people off their couch to have an eye exam, a yearly eye exam, you know. Dentists got it made they have figured it out, you know.

Related: The time is now for optometry and telehealth

Bowling: They have, yeah.

Overman: They have educated patients. I don’t think as optometrists, we have done our due diligence to get to that level. And that is what you know, we know. I don't think any optometrist is going to argue with you that we would like people to have a yearly eye exam. Well, they are sitting on that couch at home not doing enough. They are not motivated. They are not educated on why they need to have an eye exam. So that is where I started a couple of years ago looking into telehealth. And how do we educate people? How do we get to them? Now, 2 years ago, if you recall people, it was a really dirty subject to talk about online because it was all about online refraction.

Bowling: Yes.

Overman: Now, Ernie, you and I have talked about this. I am against online refraction. That is not what we are talking about. So, I always have to, you know, start with that. That is not what I am all about. I want full comprehensive eye exams. And I want the quality. So, you mentioned 2020. I did my due diligence, I looked into different companies, and I chose them because if you get a chance to see what they are doing, they are doing things right, in my opinion.

They are actually, their goal is to provide a better in-person eye exam through their technology than you or I could do if we were right in front of the patient. It is a lofty goal. We can do an awful lot. So, I joined them. And a lot of my initial was the clinical perspective of what equipment do we need? What tests do we need to do? How can we do those? Again, I always shoot for, in my mind, a better, more technological exam.

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You know, a lot of our colleagues don’t have the ability to do fundus photos. There are a lot of things that technology can actually do better. I am working with some companies that do pupil testing. Well, they can do better pupil testing than the human eye can do. So, if I continue to add that type of technology to the exam, I feel I will get a better exam. We can actually make it faster, also. So, if we can improve the quality, we can make it accessible. And then keep the cost down, I think everybody wins. So, that has been my focus. They have got an incredible platform that, you know, it is in a brick and mortar. So, I am not getting to the patient that is sitting on their couch. That is not what I am doing with this particular platform. We need to drive them into a location. But there are so many locations that don’t have a doctor.

Bowling: Yes.

Increasing access

Overman: I know from my Walmart days, trying to find a doctor for some locations is just impossible. And so, when you are talking a lot of rural locations, I think there is not access.

Bowling: When I practiced, I had patients coming in from an hour and a half away because I was the closest one. So, we really need to improve access.

Overman: I don’t have all the data right at my fingertips, but I know we are in a drought as far as the need in a lot of locations. So, I live in Iowa right now, Ernie, and there is a county that does not have an optometrist. So, what do those people do? So, I am going into a lot of locations, say I can go into that county, I can find the county seat or somewhere and I can put in a full lane and do a full comprehensive eye exam and have the doctor sitting somewhere else. They are going to be licensed in that state, but they don’t have to be sitting in the state.

A lot of regulations have changed, even in the last 6 months, I have been talking to a lot of optometric boards, and there is a lot of regulation or deregulation in this area. And I argue for that because if we overregulate the space, I think we are leaving it open to ophthalmology. And that is where optometry is going to lose.

So again, I don’t want online refractions. I want to drive patients to have eye exams. And the more they can have eye exams, the better. The only thing that this platform doesn’t do is dilation. So, we need optometrists, and I want to drive people from these locations to you as an optometrist. So, if there’s an issue, it is amazing the amount of pathology that we are seeing, right? Because we are taking fundus photos, widefield fundus photos on everyone running it through an artificial intelligence (AI) program.

And, it is incredible the information that we get. And so, we are able to then send this to the referring optometrist, who we are referring to, as an optometrist and give you that quick of a head start on what am I looking at? So, we are improving the quality of care for patients.

We are getting them in the system because we know there are so many people that don't have an eye exam for whatever reason. And if I can get access to locations where they are not currently, I can drive more eye exams. I can find those early diabetics, early glaucoma, macular degeneration, and take your pick. But we got to get them in.

Let’s just use Walmart as an example. If Walmart didn’t have a doctor, they couldn’t find a doctor for a location. And there’s many of them that haven’t had doctors for years. But there are patients there. And a lot of those patients aren’t going elsewhere. So, if we can drive them into the healthcare system by having a comprehensive eye exam there, and then maybe you are a private practitioner, you know, down the road that wasn’t seeing that person, but now you get to see them because they have a health issue. Then, you get to impress upon them the need for in-person care because you are going to follow up with that person and take care of them. So, not only do we get more people in, we get them in more often. I think we are going to help all of optometry as we drive this. So, it is very exciting.

COVID’s effect

Overman: Now, fast forward to COVID times. You know, what that has driven is: How do I still see my patients when I can’t go into the office? And that’s what has driven to seeing them on the couch. 20/20Now is also working on a way to do that. That is not really their focus because there are quite a few others that do that also. But we need to be able to do that, too. So that is telehealth on a whole other level that we didn’t know we needed, until this pandemic. But our patients need to be seen, we need in-home care.

So, I think we are just touching the surface on ocular telehealth, and it is very exciting. I talk to our colleagues, pretty much on a daily basis. There is somebody that reaches out to me that wants more information. And I like that, you know, they are trying to get educated, they know there is something going on out there. I would rather be the one to educate them. So, I feel they are getting the true education. So, any of your listeners, of course, here they can figure out how to get me. My name is all over the place. I am happy to talk to them.

Bowling: I know you are. I was thinking about while you were saying about using the corporate in the dark stores. I also know that they are thinking about using it in some of their really big operations as well, so that they can expand the hours because a doctor can’t work 10 to 12 hours a day.

So, they are looking to have a telehealth lane in adjunct to a full-time doctor so that they can provide care for patients in high volume stores, too. So that is a, you know, there are so many avenues for this technology to go. You know, increased hours more locations, can you talk a little bit more about the hub-and-spoke model of that. I know we I did an article, several months back, but talk a little bit about the hub-and-spoke model of telehealth.

Overman: Yeah, so we are getting doctors wanting to do all kinds of different things. I talked to doctors; I do a lot of consulting for their private practice. And I go in, I look at it, and a lot of these doctors think that it is a good thing to have a 6-week backlog of patient. It is not a good thing.

Bowling: No, no.

Overman: Up to a couple of weeks. You know, I can see that, but I have got doctors that actually brag about having 6 weeks. Now, it may work in some locations, but overall, people don’t want to wait that long. They think they will wait a little while, but this is a “we want it now” society.

Bowling: Right.

Hub-and-spoke model

Overman: So, they are going to leave you eventually and go to a competitor. if they can’t get in. Now, especially if it is something a little more emergent, not that you would consider emergent, but they consider emergent. Now, we can’t see you for 6 weeks. So, the hub-and-spoke model has come up. We have doctors that are super busy in 1 location. So, they will do a couple of different things.

They will open up another lane and let tele-optometry run it. So, there are multiple ways you can do this. You can have 2020/Now doctors do the readings. You can have your doctors do the readings because some practices have 5 doctors and maybe one is a junior that isn’t busy or something like that. So, I am not telling doctors I want you to work more, but you can increase the access of your own practice. By nights, weekends.

By golly, doctors want to go on vacation and should, but the practice still needs to keep running. So, you can plug in tele-optometry for all of those times and actually increase your practice, the times that you are doing it. So, that is 1 way.

The other that has been very popular is the hub-and-spoke that you mentioned. So, a doctor will have their main location. But there are so many places that are maybe a half an hour away, 40 minutes away, something like that, that the doctor is going out and opening up a clinic in those locations. So that is increasing access. Huge. You don’t know where those patients are going.

You know, are you getting them? Is someone else, you know, an hour the other direction getting them? So, it increases your footprint. So, you can go out, you can be the middle spoke of that, and draw patients into your private practice. What works even better is by doing that you are going to identify all of the medical issues. And then if your main practice is close enough, if it is a half an hour or so, you refer to yourself.

So, you are increasing, so the quality goes up, you are increasing the care. The accessibility goes up. You know everybody is winning in this scenario, and that gets really exciting for me. There are upfront costs to do that. But the business model, you can go in and punch in the numbers and see what you have to do. But we are seeing major success, both financially for the doctors and again, obviously the patients win. too. So, you know, just about any scenario that a doctor has been able to come up with, we have found a way; “we” meaning 20/20Now. Hey, I will take credit, but they are doing the work. But they find a way—they are extremely flexible and find a way to make it happen for the doctor. As long as you have internet capabilities. I mean, obviously, we are all digital here. So, we need the internet. But anymore, that is not much of an issue. And there are ways around that, too.

It has really been exciting, Ernie. You take some of these doctors that have had 1 practice but are just bursting at the seams. I have seen them expand out, open multiple practices, be extremely successful. And again, you are not the one having to do all the work, all the time.

Work smarter, not harder

Overman: The work smarter, not harder part certainly comes up to me here. And it has been exciting to be a part of. And, you know, my future role of 20/20Now is to continue that. How do I use new instrumentation to drive a better exam? Make it faster? Of course, I spend a lot of time on 2020's behalf talking to colleagues. Some of them, I can't believe the number that actually want to be the reading doctors, right now.

You know, the quality of life, if you want to be at home for a couple of days and not go into the office but see patients from home. I certainly get that, as well. So, that is exciting. It is opening up a lot of options for optometry. And I think we are able to educate the patients more. I don’t know how much longer I will be on this earth, but I would love to be able to see a large percentage of people have yearly eye exams. And, again, I am going to keep that as my focus. And as long as I do that, and I keep optometrists at the forefront, I think we are all going to win.

Bowling: What barrier do you see, Chad, to this? You know, Obviously, you are very much in tune to this. You are very excited about it, your passion shows, but what barriers do you see professionally, to optometric telehealth?

Overman: Well, I am fairly blunt, for the most part, Ernie, and I think it is our own selves getting out of the way. And it is education for optometrists. I have had dozens of optometrists to the office in New York to do demos personally for them, and I tell them going in, I said, “Rip it apart. I want you to tell me all the things that you dislike about it, so that I can fix that and make it better.” Right? So that is my goal. They don’t come out with very much to say negatively, once they see it, and I was having breakfast. Well, actually, you were at that breakfast, when I think about it. We were sitting there with a few of our colleagues, maybe 3 others, I think it was at Vision Expo. And we were talking about it, and it made me laugh. Because optometrists all think we do the best refraction. We are better than anybody else out there because it is my craft. I have honed it, I do a really good job.

Bowling: Well, I had each one of those other doctors go through a demo and watch the certified ophthalmic technician that 2020 has do the refraction. I said, “What do you think?” And from every person, I got a “Yeah, they are probably at least as good as I am.”

Overman: We don’t want to admit, maybe someone is better than us, but “at least as good as me” tells me that they did not have a problem with that refraction. And, as I have watched a lot of these technicians do the refractions, they are way more thorough on balancing and everything than a lot of optometrists are. So, I think we need to educate optometrists because too many are still stuck in that online refraction discussion. That is not what we are talking about.

Fragmentation

Overman: Maybe technology will get good enough at some point that it can do that. Which means, if it can do that in 4 or 5 years, we have that amount of time to educate our patients why they need an optometrist. Why they need us more than they need that? Because some will go do that. It is just, it is going to be driven by consumers, and it will happen. But we need to educate, in the meantime, those patients why they need us. And we need to do it as a collective group.

We are very fragmented right now,on this topic in optometry. I love everything that the American Optometric Assocation (AOA) does. They do great. There are lots of state legislatures, associations that are doing incredible things. But when I go to an optometric board meeting or optometric association meeting, I get a little bit of everything on that board as far as what they have been educated on. And so, we need all of us to actually reach out and educate ourselves. And then those boards we sit on, those associations we sit on, we need to have an open mind. Is everything perfect? No. Can it be better? Yes. And that is what we need: to be all pulling in the same direction so that we are making the technology better for our patients, better for optometry.

And I do not see that happening right now. It is getting better. But I think we can move that forward even faster. There are all kinds of different groups that are looking at telemedicine, and most of them are not looking at regulating more. They are looking at how do we make this better. But hey, we still want to take care of our patients. So that is where, I love to be the one to educate people. You know me, I will give you my opinion. No, no problem whatsoever.

Bowling: And no caution, straight up always like that.

Overman: Well, yeah, I mean, I will give you the truth. And you may not always like the truth or what I am telling you. But it is true because I have done a lot of research. And we talked about, I have my hands in an awful lot of different parts of optometry. I do that to stay educated myself, and to make educated opinion, not just some guy sitting here in Iowa, coming up with something.

There is a reason, and I will walk you through my reasoning. And if you don’t agree, that is fine. We can agree to disagree. But I am also very willing to listen to other people’s opinions and take those into account because I don’t have all the answers. There are an awful lot of smart people out there much smarter than I am. I want to hear those opinions as well, because they may have an opinion that changes my opinion at some point. But to go back to your question, I think it is optometry that is the largest barrier to optometry using telehealth.

Bowling: Fair enough. And with that, we will cease. I appreciate your time. I think I said your passion for this subject comes across. Everybody, if you don’t have a way to reach out, don’t know how to get ahold of Chad, get ahold of me and I’ll put you in touch with Chad. Because I got him on speed dial. So, I appreciate your time. I appreciate all you do for our profession, Chad. I really do. And thank you on behalf of optometry, thank you for being my friend. I appreciate that more than you know.

Overman: Thank you, I appreciate all that you do, as well. And we will talk again soon. So, have a great day.

Bowling: All right. You take care.

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