Practice Management begins in the Exam Room

To effectively run an eye care practice, many active processes, run by a variety of people have to be coordinated and constantly honed.  It is important to avoid duplication and contradiction in the process.  From Scheduling to Check-in, from Pre-Testing to Exam Room; from Contact Lenses to Optical and to Check-out.  It all has to work together.
Not to mention all the work to be done after the patient leaves to order product and to get paid.  

Where do you start?
Most practices have a set of processes that “evolve” over time.  As times change and as our practices grow, we make changes to our processes.  Sometimes a new employee comes along who “does it a little differently.” Inevitably, these small changes lead to problems in other zones because it is all connected.  In reaction, adjustments are made or breakdowns occur.  

Decrease Variation (starting in the exam room)
There are a multitude of vision tests that can be done to help us with our diagnosis and treatment plan for any given patient.  Some of these tests are typically performed by doctors, others can be delegated to staff members. All variations in technique decrease your efficiency in the exam room method.  

Some examples of exam technique variation are: 

• Stereo testing on all patients under 17

• Applanation tonometry if over 50

• Pinhole if VA less than 20/60

• Color Vision on all boys - new patients - under 10(*)

All rules of variation are put in for good, logical reasons.  The problem is that we keep adding variations without fully considering the impact on the entire exam flow.  This leads to inconsistencies and discombobulation that spills into every aspect of the practice.

There is a good argument for not performing stereo on an 84 year old, one-eyed, exotrope, (**) but I would like for you to consider the benefits of keeping the test in the routine for the sake of decreased variation.  This is an excellent exercise that should be completed by the entire team periodically to continuously refine the exam process.  

Consider your scheduling methods.  How much time is spent trying to match a particular type of patient with the corresponding slot in the schedule?  Do you instruct your team to schedule “older patients” earlier in the day because they take longer? (“Besides, they like to get up early.”)  

Consider pre-testing technique.  We all recognize that kids, contact lens wearers, glaucoma suspects, presbyopes, cataract survivors and esophores all have different needs.  But many of our patients fit into multiple categories…..then what? Sometimes more time is spent trying to decide if you need to do topography, then just doing topography.  

Consider exam room technique.  The advent of EHR has made the idea of an exam room scribe become the norm.  By always doing the same tests, in the same order makes it easier and quicker for your in-room support.  Not to mention - more accurate. Develop a system so everyone knows what everyone else is going to do.  

This is just the beginning.  
You can see where the decreased variation helps the exam flow better.  You can also see how it bleeds into other areas of the practice. After the Patient Care zone is addressed to your satisfaction - move to the Front of the House.  

(*Three variations in one)
(**I recognize that you can’t be “one-eyed” (aka monocular) AND an “exotrope” - but sometimes you just have to write things that make your point. Just imagine her prosthetic is misaligned.)

Telehealth Update

I recently returned from the annual meeting of the American Telemedicine Association in New Orleans.  This is the 25th anniversary of this organization and they are on the move.

Telemedicine (or telehealth) is defined as the distribution of health-related services and information via telecommunication.  My first memory of practicing telehealth was when my son texted a photo of his friend’s eye from the middle school cafeteria which he described as "funky."

The mission of telehealth is to expand the reach of care to the people who need it.  The biggest market seems to be healthcare systems with small hospitals who need access to specialty care.  The focus of this group tends to be shifting from technological advancements to improving the patient-provider interaction and the quality of that experience.  

Every specialty I could think of was represented and eye care was a very small part of it.  It was standing room only at the Medicare session because the rules about payments for telehealth services are being defined and updated.  Interestingly, the speaker for this session remoted in.  

In eye care, the most “mature” telehealth program seems to revolve around the use of retinal photos to monitor for diabetic retinopathy.  Fueled by affordable retinal cameras and the drive for improved HEDIS scores, many companies exist to match diabetic patient photos with a reader of those images.  Look for robots that can read fundus camera images.

What I also came to realize is that diabetic retinopathy is very well defined and commonly understood by a wide range of professionals. Plus the growth of diabetes ensures a long line of patients needing on-going care.  

However, there is still a good deal of disagreement about how much of an eye exam can be provided by distance providers.  The technology continues to improve and patients’ desire for this type of interaction is becoming stronger. I am confident that there is a way to deliver high quality eye care that is safe and effective for our patients.  

Stay tuned - this is going to be exciting!

I will keep you posted, 
Mike

Accommodative Spasm Survey

My wife was recently approached by one of the trainers at our local health club, “Why didn’t you tell me that your husband was an eye doctor?”  

I’d like to think that her answer was, “I just don’t like to brag too much about that.”

The young woman went on to explain that she had just been to a local optometrist and didn’t know what to do.  She continued by saying that she had been having trouble driving and thought she needed glasses to help with that.  In addition to working at the gym, she is a full-time college student and admits to being on her phone “all the time.”

She said, “He told me that my problem was not distance vision, but that I used my phone too much and he gave me glasses to wear when looking at my phone or working on my computer.  But the glasses MAKE MY VISION WORSE.”

She went on to ask my wife - in the gym, “What should I do?”

Discussion:
While this story is third hand, I have heard it enough over the years to discern what I think is going on.  The trainer is experiencing accommodative spasms (aka computer vision syndrome, digital eye strain, etc.) Basically, the examining optometrist diagnosed that she does so much near work that her eyes can’t always focus in the distance very well.  

She would have “liked” some glasses that correct her distance vision when driving during these spasms, but the optometrist felt it best to relieve this near strain as a long term solution.  My guess is that the glasses have some low plus power.

This dilemma has several components: clinical, marketing and professional relations.  

Please complete this short (three question) survey to let me know the best way to handle this situation.

Thanks for helping,

Mike

p.s. To see the results of the survey, CLICK HERE.

A Lifetime of Watching Movies and the lessons from it........

I grew up in a small Southern town that had one movie theater.  Almost every Friday, a new movie came out.  As a teenager, our theater was upgrade to a “Cinema,” which meant we had 4 screens, all playing different movies.
 
Then came HBO and VCR’s.  My dad loved that one monthly fee allowed him to collect hundreds of movie titles on VHS tape, with no commercials!  It was a little work, but well worth it to have easy access to all the movies HBO ever showed.  (Those tapes were the main part of my inheritance.)
 
We all know about the well-chronicled rise and fall of Blockbuster video/DVD rental business.  We know how Netflix came along began mailing DVD’s, then streaming movies directly into the home. 
 
Your age dramatically influenced your relationship with Blockbuster Videos.  For me, it was a weekend ritual.  I remember many Friday nights roaming around the store looking for something to grab me.  Two for the kids, two for the whole family and a scary one for daddy after everyone went to bed. 
 
We lived through the transition from VHS to DVD and tried to see the added benefits of BlueRay.  It was during this time of Blockbuster domination, that many of us were investing in home theater systems.  Big screens, big sounds and for some – big, fancy chairs! 

Netflix introduced me to downloading movies and to the frustration of “buffering.”  I always took it personally when my family blamed me for the random pauses in a movie while it buffered.  As much as we hated pauses, grainy pictures and other troubles; we stopped our visits to Blockbuster. 
 
This trend continued so much that now my kids rarely even look at a tv, but instead watch their phones and laptops constantly.   As I am sure you can imagine, this bothers me.  They seem to be satisfied watching their choice of movie on whatever screen they are holding.

Saved by The Incredibles! 

Pixar’s movie, The Incredibles came out in 2004 and was a big hit in our house.  My kids were in elementary school, we saw it in the theater and of course, bought the DVD.  My son was even Dash for Halloween, twice.   
 
By the time that The Incredibles 2 came out in 2018, both of my kids are in college and wanted to relive the glory days by going to see it on the big screen.  To gear up for the event, we dug through our library, and found the DVD.  We realized the DVD player still worked and decided we would watch it.  Amazingly, the sound system was still connected to the DVD player so we went old school and LOVED it! 
 
Great picture, crisp sound and the room even shook!  I was blown away at how good it was.  How did we give up on this? 

It is another example of "easy beating good."

 In our practices, we sometimes convince ourselves that our patients are willing to deal with a little inconvenience since the quality of our care is so good.  It is important that we are careful with this line of thinking. 

In my experience, most practices have a problem with wait times.  What’s worse is that most practices don’t think it’s a problem or they say it out of their control.  My advice is to find a way to measure how long patients are in your practice and keep working to improve it. 

Keep watching this blog for more conversations about making visits to your practice "easier" for your patients.  
 
I was not invited to go to the Cinema to see The Incredibles 2, but the kids said it was good.  I couldn’t get much out of them about the details, but there was something about JackJack that you didn’t make sense unless you had seen the DVD – which they had!
 
(Did you know Netflix still will mail you a DVD?)

Look forward to seeing you soon, 
Mike Rothschild, Leadership OD

p.s. This is an interesting article about a Michigan mom arguing for a return to the "good old days."