ARE YOU Ready to Develop a Dry Eye Clinic?

Before you make the move, be sure your practice is up to the challenge.

By Patti Barkey, COE

If a patient presents in your office with a pressure of 34 but the reason for the visit is a cataract follow up, do you treat the pressure? It may seem like a silly question, but my point is that we should be addressing all of our patients’ needs.

Like glaucoma, dry eye is a chronic condition. Patients are often symptomatic, but many practices don’t go the extra mile to address the dry eye problem.

At Bowden Eye & Associates, we’ve always taken care of dry eye. If a patient walks through our doors for any reason and complains of dry eye symptoms, that patient will leave having received treatment for the initial reason for the visit and the dry eye. In short, we address all of our patients’ needs. For billing compliance, we are all required to address the patient’s reason for the visit.

New Treatment Options

Until recently, our options for treating dry eye were limited to lubricating drops, cyclosporine ophthalmic emulsion (Restasis, Allergan), punctal cautery, punctal plugs, compresses, lid scrubs and and intense pulsed light therapy (IPL).

But treatment options have expanded. Doctors are now able to offer groundbreaking therapies and testing, such as LipiView/LipiFlow (TearScience), osmolarity testing (TearLab), Inflammadry (RPS), Sjogren’s testing (Nicox), meibomian gland probing, allergy testing (Doctor’s Allergy), the Fire & Ice Mask (Rhein Medical) and neutraceuticals such as HydroEye (ScienceBased Health).

These therapeutic advances sparked our desire to increase patient awareness of dry eye and options for treatment, so 2 years ago, we established a more formal dry eye standard of care within our practice. The results have been outstanding in terms of increased patient satisfaction and increased referrals of friends and family, many of whom previously switched from physician to physician for years while seeking help for their dry eye issues. Our surgical outcomes are better than ever as we apply this dry eye standard of care before cataract surgery or refractive procedures. Our practice will see about $1.8 million (largely out-of-pocket) in dry eye income this year, and these patients will return for treatment of this chronic disease for life. Patient satisfaction with income rewards equals a win-win situation for all.

The Most Important Components

Visitors from other practices love witnessing our dry eye patient experience. They want to know how they can return to their practice and replicate it – how it’s laid out, what they need to buy, how it should be organized, and so on. I’m happy to show them our set up and answer any questions.

I often find they’re overlooking the three most important items they need in place before starting a dry eye clinic.

1. Strong physician involvement. Dry eye is a disease process. Creating a dry eye clinic isn’t the same as building an optical shop or adding aesthetic treatments. Dry eye care takes place in the medical part of the clinic, just like glaucoma or diabetes. As an administrator, I can’t decide to start clinical treatment without having physicians who understand how to take care of dry eye patients, and those physicians must develop and agree upon a standard of care, in other words, a plan for approaching treatment of the disease.

We have six physicians at our practice, all of whom are on board with the dry eye standard of care within our practice. Frank W. Bowden, III, MD, a cataract and refractive surgeon, champions the idea. He believes dry eye must be treated for patients to be comfortable with surgery and satisfied with their outcomes. Our practice even had two cases recently where our physicians found that dry eye, not cataracts, were responsible for fluctuating vision. We didn’t have the ability to diagnose and address dry eye at this level just a few years ago. We’ve reached this level because of the dedication of our physicians.

2. Administrator commitment. Some practices send their administrators to see our dry eye patient experience. Administrators alone can’t convince physicians how to treat disease — but administrator involvement is key. We develop policies and procedures, handle staff training, establish dry eye interactions with the providers and troubleshoot to ensure a successful transition.

Some administrators fear a dry eye focus may slow down their providers, but having a chance to see how it works can help alleviate this concern. Great administrators are always looking for ways to increase patient satisfaction and boost revenue.

3. Great infastructure. All practices should be working on patient satisfaction, customer service, and official office policies and procedures so that when new technology comes knocking, it’s easy to add. My staff works hard to make patient satisfaction a priority. It isn’t easy. Training and formal meetings in which we work on group communication and staff buy-in are key to our success.

Working to Meet Patients’ Needs

If the physicians, administrator and staff are all committed and involved, then the first step in treating dry eye is to think about how the practice meets patients’ needs. The culture in your practice has to include the core understanding that in addition to addressing the purpose for each patient’s visit, the physicians and staff should ensure that they meet all of the patient’s needs.

I often hear from our visitors, “We don’t know what to do with dry eye. Do we deal with dry eye when patients are here for a cataract evaluation, or do we bring them back for another visit?” My answer is always, “Why did the patient come in, and what were the patient’s complaints?”

Most practices can simply audit a month of records and find that in many instances, the patients came in with part of their chief complaint revolving around dry eye symptoms and complaints. Treating dry eye doesn’t require a huge marketing budget. The patients are walking through the doors daily.

Failure to address all complaints is one of the stumbling blocks I see for practices attempting to add dry eye to their clinics. The practice has to routinely treat both the originating purpose and any other complaints at every visit – in short, meet the patient’s needs.

After initial recommendations are made and treatments have been initiated, we see patients for dry eye follow-up. If we didn’t treat dry eye at the initial visit and told the patient to come back, we would, in a sense, be telling him that dry eye treatment isn’t important to the physician. And he wouldn’t think twice because many patients have visited eye doctors for years without anyone addressing their dry eye complaints.

Putting Concept Into Practice

Now that we have a well-established dry eye clinic, many of our patients call specifically for a dry eye evaluation. Often, they’ve come because they’re frustrated by our competitors or because their own doctor sent them to us for treatment. At the end of the visit, these patients always say, “How did my doctor not see this? How did he not recognize this problem and offer me treatment?” It’s hard for us to answer. Dry eye diagnosis seems simple, but the standard of care and treatment plans are actually quite complex, so many practices have avoided dealing with dry eye, thus effectively ignoring their patients’ complaints.

As an administrator for four practice locations, an ASC and 78 staff members, I can tell you that making any type of change in your organization takes time and commitment. Technicians need to explore patient complaints and symptoms and physicians need to make sure every patient leaves with solutions for each problem presented.

Dr. Bowden and I set the standards and expectations in our practice, and we train the staff to address dry eye and all of our patients’ needs. But we still need to continually review how we’re doing things and if they’re working as planned. For example, we found that when patients came in for cataract consults and we told them we needed to address their dry eye first, they thought they couldn’t have cataract surgery. Obviously, we needed to do a better job of explaining that the doctor needs to get the ocular surface under control first, and then perform surgery. Even if a patient is asymptomatic or isn’t bothered by the symptoms but testing shows signs of dry eye, we like to treat the ocular surface before proceeding with cataract or refractive surgery. Today’s patients are looking for the “wow factor” following cataract and refractive surgery, and they don’t want to hear that they have fluctuating vision after surgery because of dry eye. They need to understand how dry eye affects vision up front and ideally, have dry eye treated before any procedure.

Establishing a Standard of Care

Some practices may avoid treating dry eye because of habits formed in the years before good diagnostic technologies and treatments existed. Creating a standard of care is the essential next step in developing a successful dry eye clinic.

If a patient has dry, scratchy, burning or itchy eyes, what diagnostic steps will you take? Will you check for meibomian gland disease? What is the first course of treatment? Will you start everyone on the same drop or will the first treatment steps vary? How will physicians decide which drop to use? Will drops be the only treatment, or will physicians recommend other steps?

When it comes to diagnosing dry eye, there are several options. Physicians can check tear osmolarity, analyze the tear layer, express the meibomian glands to evaluate their function and the type of expression, and determine whether there’s an inflammatory component to the disease. Physicians need to lay out a systematic approach to using all of these tools as part of the standard of care.

Our standard of care also includes allergy testing so we can rule out certain environmental factors. Our physicians order testing, which includes a panel of 60 regional allergens. Allergy testing is utilized for patients who complain of itching, watery eyes and redness. Patients often don’t know that they’re allergic to grass, pets or feather pillows, but that information is essential to providing relief for the ocular symptoms.

We also implemented a review of the meibomian glands as part of a normal slit lamp evaluation. The providers record the number of functioning glands and the appearance of the meibum.

Once the physicians agree on a standard of care, administrators educate the staff about what dry eye is, its signs and symptoms, and the diagnostic tools and treatment options we offer. In our practice, staff members can speak to a variety of treatment options.

Moving Patients Through the Clinic

If your physicians and administrator are committed and involved, and the whole staff is thinking in terms of meeting all patients’ needs, and the physicians have a standard of care in place for dry eye, then the hardest part is done.

The final piece of the puzzle is comparatively simple: as you follow the standard of care every day, you need to do so in a way that moves patients through the practice efficiently.

Administrators often ask me if a dry eye clinic will slow down the practice. Things may slow down at first, but the practice will be rewarded with better outcomes, more satisfied patients and increased revenue. When we first started the dry eye clinic, physicians handled all of the patient education about dry eye and its treatments, and things did slow down. Our solution? Dry eye counselors.

The process begins when patients complete the SPEED dry eye questionnaire (TearScience) to identify their signs and symptoms. A technician reviews the document and scores the answers. If the score is 1 or higher, the patient needs to see the dry eye counselor prior to seeing the physician. The counselor educates the patient about what dry eye is, how the disease works and what products are available for treatment. This way, when the doctor is ready to recommend a treatment, it’s not all new to the patient.

If a patient balks about seeing the counselor, we explain that we treat dry eye like any other disease. We need to tell patients what’s happening to their eyes and what to expect. Once our patients receive treatment for dry eye, they’re often excited to see the counselor for follow up to discuss progress and see their improved test scores.

Getting Ahead of the Curve

It’s my belief that every practice should treat dry eye. In 5 or 6 years, I think it will be the norm. Patients with dry eye come through our doors every day, and many of them are miserable. Our practices have the power to make them feel better, to meet their needs, and to exceed their expectations. What’s more, you may notice that I haven’t mentioned any physical changes required for a dry eye clinic. That’s because there aren’t any. We made no changes to our physical environment when we started our dry eye clinic. The testing equipment can be kept in any testing room. A treatment might require countertop space here or there. Our dry eye counselor is also a refractive and surgical counselor and uses that office for dry eye patients. You already have all the space you need for a dry eye clinic, and the patients are already in your practice. So what are you waiting for? ■

Patti Barkey, COE, is Chief Executive Officer and an Administrator at Bowden Eye & Associates, Eye Surgery Center of North Florida, LLC, in Jacksonville.