By Jessica Kim Cohen
When a patient goes to Children’s Hospital of Orange County for an annual well-child visit, there’s the standard exam: a nurse measures the child’s vital signs, weight and height, before the patient checks in with the doctor. But for the youngest children, there’s another step—and it involves a smartphone.
CHOC early last year integrated an app called GoCheck Kids as part of routine care in well-child visits for patients ages 1 to 3 who visit providers in its primary-care network. The app screens for vision disorders in young children, many of whom are too young to describe their own vision, to help the provider decide whether a referral to an eye specialist is needed.
If the app detects a risk factor, an off-site team at GoCheck—the company that developed GoCheck Kids—reviews the photos to confirm the finding.
Existing methods to screen young children for conditions that lead to amblyopia, better known as lazy eye, weren’t cutting it, according to Dr. Charles Golden, a pediatrician and executive medical director of the primary-care network at CHOC. “There was a presumption that we were missing subtle cases,” he said.
Vision problems are one of the most prevalent disabling conditions among children, according to the Centers for Disease Control and Prevention, although some—such as amblyopia—can be treated if healthcare professionals intervene early.
The U.S. Preventive Services Task Force in 2017 said there’s insufficient evidence to recommend vision screening for children younger than age 3, but pediatrics industry groups like the American Academy of Pediatrics have said that instrument-based screening—such as photoscreening, the technique used by GoCheck Kids—should be used for children ages 1 to 3.
If a child with amblyopia doesn’t receive treatment, it can lead to long-term vision issues.
“Once the brain is fully mature, you cannot go back in time and reverse that amblyopia,” said Dr. Geoffrey Bradford, the AAP’s section chair for ophthalmology and a pediatric ophthalmologist at West Virginia University Medicine.
But vision screening for young children is particularly challenging, he said.
For children who are too young to read, or even speak, a Snellen chart—the standard eye exam with letters of various sizes—won’t work. So screening for vision problems would likely involve something called the cover-uncover test, in which a clinician would ask a child to watch an object in front of them, and assess their eye movements as they cover and uncover each eye.
“It requires a great deal of skill,” Golden said of the test. “There are subtleties of abnormalities that may be missed.”
GoCheck Kids is part of a growing market of these photoscreening tools, including those from companies like iScreen Vision, Plusoptix and Rebion. That market growth has been fueled, in part, by the AAP in 2016 releasing a policy statement that photoscreening can be used at annual well-child visits through age 5, or until a child can be reliably assessed using an eye chart.
Well-child visits are the opportune time to do vision screening, Bradford said, though he acknowledged photoscreening can be expensive for providers. “It’s a big capital investment for a pediatrician to purchase one of these,” he said.
For a standard plan, GoCheck charges healthcare organizations an estimated $149 per month per phone. As part of that, the company provides customers with an iPhone outfitted with a specialized case that concentrates the camera’s flash. Fees might vary if a customer wants other services like on-site training or volume-based discounts.
On top of the cost for the service, not all health plans cover photoscreening. CHOC has applied for some grants for the program, but it’s overall a cost for the health system, as at least half of its patients aren’t covered for the exam, according to Golden.
“We’re doing the service for all children that need a well-visit check,” Golden said. “We code for it, submit the claim form—if we get reimbursed, great. If we don’t, we just chalk that up as, unfortunately, a loss.”
There’s also a cost impact for not screening pediatric patients, Golden said. If a patient with a vision disorder isn’t treated, they could need more costly interventions later on, such as glasses, ongoing ophthalmology visits and even surgeries.
