Upgrading Your Photography Department
Here are steps you can take to increase efficiency and revenue and improve patient care.
By Mark Erickson, CRA, COT, and Myra Cherchio, COMT

When it comes to maximizing practice resources and quality of care, making changes in your photography department may not be the first thing that comes to mind. But in reality, most practices could derive more value from clinical photography by doing two things: offering services that are comprehensive and up-to-date enough to truly meet the needs of both practice and patients, and improving technician expertise, space usage, instrument care, record keeping, and other factors that affect efficiency, costs and service quality.

In this article, we'd like to share a few ideas along these lines that have helped us increase our efficiency and revenue, and -- most importantly -- improve our patient care.

Offering the right services

When most ophthalmologists think about photography, fluorescein angiography comes to mind. However, whether you have a large multispecialty practice or you're a general ophthalmologist who practices multiple specialties, you and your patients stand to benefit by expanding your department to offer multiple photographic services, including angiography, fundus, slit-lamp and external photography. Slit-lamp and external capabilities are excellent tools for patient education, documentation and following the progression of eye disease. Also, photography is mandated by Medicare and HMOs in many cases.

Here are some of the advantages offered by the different photographic modalities:

ILLUSTRATION: PHILIP HOWE

Fundus photography/fluorescein angiography. If you currently outsource just 8 to 10 fundus photos or FAs each month, purchasing a fundus camera could be a well-justified expense. At current reimbursement rates, even a state-of-the-art fundus camera should pay for itself in just 1 year.

In fact, fundus cameras don't necessarily come with a hefty price tag. Prices range from $5,000 for a used system to $17,000 for an entry-level new system, so there's something for everyone. Certainly the improvement in patient care is well worth the investment. For example, serial stereo disc photos are a vital part of routine glaucoma care. And having instant access to fluorescein angiography results could save many patients' vision.

Slit-lamp photography. A photo slit lamp allows you to perform both examinations and photography. It's invaluable for documenting pathology, such as a recurrent corneal erosion or entropion. And many types of external and anterior segment pathology are eligible for reimbursement of photography.

Whether you're planning to purchase a slit-lamp microscope for clinical exams, or you already own one, upgrading to a photo slit lamp is a great move. The difference between a slit lamp and photo slit lamp is just a bit of hardware, including a beam splitter, diffuse illuminator, electronic flash and a camera back.

External photography. Although many practices don't use this type of photography regularly, external photography is usually a necessity for oculoplastics. Luckily, a good quality single-lens-reflex camera equipped with a 105-millimeter macro lens and medical ring flash can cost as little as $1,100.

Be sure to have equipment on hand to create copies of any patient photographic records requested by insurance companies. If you shoot 35-mm slides, an instant slide printer can mean big savings because you won't have to send slides to a lab for duplication.

Regardless of the system you're considering, when you decide to take the plunge, remember that you get what you pay for. A good quality camera known for durability and endurance is well worth the extra investment.

Streamlining for success

Streamlining doesn't have to mean cutting corners. Ideally, streamlining simply means investing wisely.

In our practice, we've tried to invest our resources where we'll get the best return: in a well-trained, knowledgeable staff and durable, high-quality equipment, instead of costly floor space. We've also worked hard to establish data-management systems that save our doctors time and keep patients from waiting.

Here are some strategies you can use that have improved our efficiency and patient care:

Hire a skilled photographer. Experienced, certified photographers are hard to come by, but they're well worth the investment. If you hire a photographer, he or she should:

• be comfortable and familiar with all three types of ophthalmic photography
• be eager to learn and enhance existing skills
• know how to work efficiently
• be the kind of person who will develop innovative ways to reduce the time and costs incurred in the photography department
• have experience and be capable of playing an integral role in the diagnosis and documentation of ocular pathology. (Note: Education is not a substitute for experience.)

Make the most of your existing equipment. If you already own a fundus camera, it's possible that you're not using it to its fullest potential. Most good fundus cameras have a setting that enables the photographer to capture the anterior segment. While this won't yield the same quality as a dedicated slit-lamp camera, it still provides very useable results.

So, if you don't have a slit-lamp camera, use your fundus camera to capture both anterior and posterior segment pathology. This will allow you to provide another valuable service.

Make the most of your space. Space is at a premium in our office, as it is at most practices. Even though we service a staff of 22 ophthalmologists, our entire office is just 250 square feet. Nevertheless, we've managed to arrange our equipment so that we're using every square inch. Some helpful advice:

More modern equipment may be more compact. Do you have an outdated fundus camera with an 85-pound power supply? If so, you're probably wasting precious space. Today's fundus cameras take up much less space than their predecessors from the '70s and '80s. Also, the camera tables are more ergonomic and comfortable for the patients, so upgrading to a more modern fundus camera could save you space and improve patient care at the same time.

When purchasing new equipment, check your options. We recently upgraded our digital imaging system. The new camera came with a picnic-sized table to display it in all of its splendor. Attractive? Yes. Practical? Definitely not. By purchasing the optional equipment "cart" that conveniently stacks the hardware vertically, we freed up 20 square feet of precious office space.

Get creative about instrument and furniture placement. For example:

• Reduce clutter by sharing stools and patient chairs between the fundus and slit-lamp stations, instead of having one for each camera.
• Save floor space by stacking power supplies, printers and other hardware on racks or shelves.
• Use pocket doors (the kind that slide into the wall instead of swinging on hinges) in small offices where floor space is at a premium.
• Position the photo station near the door to open up traffic patterns and make the room feel larger to the patient who's seated there.

Extend the life of your equipment. It's important to keep photography equipment in good shape and practice routine maintenance. Even though purchasing an annual service contract is a wise move, it can't replace the revenue and patient care lost during a few days working without a camera.

To minimize equipment downtime:

• Train your technician to maintain your equipment properly.
• Develop a maintenance routine, and stick to it. Perform scheduled calibrations and parts replacements. This will not only add years of life to expensive ophthalmic photography equipment, it will preserve image quality.
• Keep cameras and power supplies covered when not in use.
• Clean your equipment frequently. This simple step takes just minutes a day and it can make your photographic equipment last significantly longer.

Communicate clearly. Communication between doctor and photographer is a must. After all, your photographer's first priority is to understand what you need on film. If you develop an intuitive photography request form, you'll eliminate guesswork, questions and mistakes that cost time and money.

The form should indicate what type of photography you're requesting, what pathology is being captured and which area of the eye should be photographed. (Spotting a 1-mm choroidal nevus might be easy when performing ophthalmoscopy with a 20-diopter lens, but it's a different story with a 25° camera.) Include template diagrams on your photo request form so you can indicate the area you're interested in.

Save time by preparing patients. In busy, multispecialty clinics, preparing patients before they arrive at the photography department is a must. Patients should be well-informed and have the opportunity to ask questions and share concerns with the attending physician. Make sure your staff understands the process of explaining risk and obtaining informed consent, and knows when to dilate. Allergies should be flagged and easily identified. All of this will save your photographer time -- and make a better impression on the patient.

This should be a well-established routine for everyone involved.

Keep your records organized. If you shoot slides or prints, archive them securely in the patient's chart. We use a labeled tab system for our charts so all of our patients' photographs are at the doctors' fingertips.

Also, consider keeping a spreadsheet that summarizes the information about all of the patients you're seeing. Our spreadsheet includes patients' names and chart numbers, the date, the doctor, and the photography requested.

This spreadsheet has been invaluable in numerous ways. It helps us to:

• locate missing slides
• monitor patient flow in the department
• provide pertinent information to our business and accounting offices for billing and overhead purposes
• give our doctors detailed reports and spreadsheets in a snap
• match a patient to a slide that returns from the lab with a missing ID number.

The 30 seconds per patient spent on data entry may save you hours of searching for lost identifications, doing bookkeeping and monitoring patient flow.

Reduce your expenses. Ask your photographer to explore ways to decrease costs and increase efficiency. It's possible to decrease per-patient costs by a sizeable margin simply by examining your spending habits and use of materials.

Here are some strategies that have helped us save money:

• Have your photographer shop around for less expensive materials that produce the same quality results. Try running test rolls using various brands and prices of film to see which delivers the best image for the least cost.
• If you use film, have your photographer roll his own film canisters. This could cut your film expenses in half.
• Buy film and fluorescein kits in bulk.
• Instead of mailing your film to a processing lab, find a local lab that can give a volume discount or deliver to your facility. We recently changed labs for color processing simply because the new lab offered both processing and delivery for the same price the previous lab charged for processing alone. This change saves us nearly $2,000 per year!

Picture perfect

Purchasing new equipment is always a tough decision when the economy isn't thriving. Nevertheless, adding to the photographic services you currently offer could turn out to be a wise move, both in terms of patient care and in terms of your bottom line. If you haven't thought about it before, it's certainly worth considering.

Whether or not you decide to invest in new equipment, be sure to spend some time working with your photography staff to streamline your existing setup. Many of the changes suggested here not only won't cost your practice anything, but could save you considerable day-to-day expense -- just as they have at our practice.

Mark Erickson and Myra Cherchio work at St. Luke's Cataract & Laser Institute in Tarpon Springs, Fla. Mark is a certified ophthalmic technician and retinal angiographer who lectures on the subject of ophthalmic photography. His photographs and illustrations have appeared in numerous ophthalmology magazines. Myra Cherchio is director of clinical research and director of the ultrasound department at St. Luke's. She has co-authored numerous scientific papers and medical books, and produced several educational videos.