The Online Vision Platform: Prescriptions From a Questionnaire
Dr. Iyer holds an active Michigan optometry license and DEA registration and has never practiced telehealth. A national "online vision" company offers her $8 per prescription to review, for Michigan customers, an autorefractor printout, a 12-question intake form, and a visual acuity number the customer types in herself. Dr. Iyer would click "approve," and the company would transmit the spectacle prescription to its own optical laboratory. The company also asks her to clear a queue of red-eye photo uploads by prescribing topical moxifloxacin to anyone whose photo shows a red eye, and to sign "fit for work" letters for customers who want to skip employer physicals. One intake she opens reports a family history of glaucoma, a self-reported IOP of 30 mmHg, and evening halos; the platform's rule engine has already marked the order "no prescription needed." Her contract states she has no access to prior records and no obligation to contact customers.
1. Is there a valid optometrist-patient relationship here, and may Dr. Iyer lawfully issue these spectacle prescriptions?
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Michigan licenses the practice of optometry, not a modality. Providing optometric services to a person located in Michigan requires a Michigan license, and the standard of care is identical whether the encounter happens in a lane or through a portal. Telehealth changes the logistics, not the obligation.
A valid relationship sufficient to prescribe requires enough information to reach a defensible diagnosis, a way to follow up, informed consent to the modality, and a record. What Dr. Iyer has is a self-reported acuity, an autorefractor printout, and a questionnaire. That is not an examination and it is not a refraction. Autorefraction is a starting datum that must be refined and verified; a spectacle prescription issued without any verification of the measurement against the patient's actual response is a guess with a signature on it.
Several independent problems compound:
- She is signing findings she did not obtain, which misrepresents the record.
- The company's own acuity figure is patient-entered, so its reliability is unknown.
- $8 per approval is a volume incentive paid on the outcome, which pressure-tests her independence and can look like an inducement.
- No prior records and no follow-up obligation mean she cannot detect the patient whose new myopia is actually a cataract or a corneal problem.
The lawful version of this work exists, but it requires a real examination, verified refraction, a documented relationship, an ability to reach the patient, and compensation that is not contingent on saying yes.
2. Analyze the red-eye photo queue and the "fit for work" letters.
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Red-eye photos. A photograph of a red eye does not support a diagnosis, and moxifloxacin for every red eye is not treatment, it is a lottery ticket. The differential for a red eye includes bacterial and viral conjunctivitis, herpes simplex keratitis, corneal abrasion or ulcer, anterior uveitis, acute angle closure, scleritis, and a retained foreign body. Several of those are worsened by a fluoroquinolone and delayed care, and one is a same-day emergency.
Prescribing on a photo also breaches the basic rule that a prescriber must have sufficient information to establish a diagnosis before treating. A licensee who prescribes in this queue is not practicing defensively; she is creating a population of patients with undiagnosed disease and a prescription that masks it. The correct design is triage to an in-person examination within a defined window, with explicit red flags routed to urgent or emergency care.
The work letters. A "fit for work" letter is a certification. Signing one for a customer she has never examined, to help that customer skip an employer physical, is falsification of a document in her professional capacity. That is a disciplinary ground independent of any standard-of-care question, and it is the easiest allegation in this fact pattern for a complainant to prove, because the letter exists and the examination does not.
Both requests share a feature worth naming in the answer: they ask the licensee to lend her credential to someone else's decision. That is exactly what the licensing statute is designed to prevent.
3. What should Dr. Iyer do with the halos and IOP 30 intake, and what should she do about the contract itself?
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The patient first. Evening halos with a reported pressure of 30 mmHg and a family history of glaucoma raises a real possibility of angle closure or uncontrolled glaucoma. The platform's rule engine marking the order "no prescription needed" is irrelevant to her duty; she is the licensee, and an algorithm is not a defense. The pressure is self-reported and may be wrong, which cuts both ways: if it is wrong the patient still needs an examination, and if it is right the patient needs one today.
Her steps: attempt direct contact with the patient using whatever channel the platform allows, document the attempt, direct the patient to same-day in-person care with an explicit statement of why, and if contact fails, document that and notify the platform in writing that a patient-safety event is open. Do not simply close the queue item.
The contract. The clause stating she has no access to prior records and no obligation to contact customers is the clause that makes the work undefendable. Before accepting any of it she should:
- Obtain a written commitment that she can reach patients and that red-flag cases are routed to in-person care.
- Confirm she is compensated in a way not tied to approval volume.
- Confirm the platform verifies licensure and location for each customer, and clarify what happens for customers located outside Michigan, because her Michigan license does not authorize practicing into another state.
- Verify how records are created, retained, and released, since she may be the record holder.
If the platform will not change those terms, the correct professional decision is to decline. The license is worth more than $8 per click, and the first bad outcome will be litigated with her name on the prescription.