Our Keys to Success

Establishing a practice standard for dry eye care and an efficient patient flow protocol are crucial.

Frank W. Bowden, III, MD, FACS and Patti Barkey, COE, CEO/Administrator Bowden Eye & Associates

Frank W. Bowden, III, MD, FACS
Bowden Eye & Associates

As was the case for many ophthalmology practices, FDA approval of the LipiFlow (TearScience) thermal pulsation treatment about two and a half years ago gave Bowden Eye & Associates an opportunity to renew our perspective on dry eye care. We’d been treating ocular surface disease, but we believed this therapy would change what we could do to help patients. We rallied our resources to develop the practice into a comprehensive center for dry eye. Today, we’re branded as the place to go for symptoms associated with meibomian gland disease, dry eye and ocular allergies. This has carried our practice to a new level of patient satisfaction and we’ve added an entirely new revenue stream. Finally, we enjoy taking care of these patients, many of whom have suffered for years.

Any practice can attain this first-rate level of dry eye care using the resources it already has. There’s no need to spend money on marketing. The patients are already sitting in the waiting room. The key is to make sure we’re listening when they tell us about the problems they want us to resolve. When the glaucoma patient says he’s had itchy eyes since the last visit, we need to address his itchy eyes in addition to checking his IOP. In the beginning, the patients fueling the dry eye segment of the practice present as glaucoma patients, cataract patients, and so on, but as the dry eye segment of the practice grows, the phones begin to ring with calls for dry eye consults.

In addition to listening to our patients, we believe that setting our practice’s standard of care for dry eye and establishing the associated patient flow protocol are the key ingredients in our recipe for success (Figure 1).

Figure 1. Creating a dry eye treatment center is a multi-faceted endeavor, but a goal any practice can accomplish.

Set the Standard of Care

The standard of care guides the diagnostic and therapeutic options available to the dry eye patient. It helps everyone get involved in the process because each person has a role and a responsibility. It’s extremely important to have all of the staff understand and embrace the standard of care, which means knowing the benefits of each diagnostic device, treatment or disease management product. For example, technicians have to understand each of the tests. They have to know the standard of care so they know when to perform the tear osmolarity test (TearLab), InflammaDry (Rapid Pathogen Screening, Inc.) and/or Sjögren’s testing (Nicox). In order to do this, they must be trained to recognize the symptoms and clinical findings that define dry eye. And they have to understand the products so they can teach the patients how to use them. Moreover, it’s extremely important to have all of the doctors agree and adhere to the standard of care. It’s not easy to get multiple providers to do that every day, so we remind them often and we have a monthly meeting to talk about how to enhance the patient experience.

Components of Our Standard of Care

The following are the diagnostic, management and treatment tools we use for dry eye.

Equipment

• Tear makeup — osmolarity testing (TearLab)

• Lipid/tear film evaluation — LipiView (TearScience)

• Lid closure/blink evaluation — LipiView (TearScience)

• Gland structure/imaging — LipiView II (TearScience) and slit lamp transillumination

• Gland function/score — Korb Meibomian Gland Evaluator (TearScience)

• Expressible gland count, lower lids — slit lamp exam

Testing

• Inflammation — InflammaDry (RPS)

• Sjögren’s — Nicox

• Allergy testing — Doctor’s Allergy Formula

• Vital stains — lissamine, fluorescein, rose bengal

These testing companies are helpful partners. They come to the practice to educate doctors and staff on implementing the testing processes.

Patient questionnaire and record documentation

• SPEED (Standard Patient Evaluation of Eye Dryness) — (originally developed by TearScience)

• Flowsheets — developed within our EMR to monitor the dry eye metrics

Disease Management Products

In addition to the medications and treatments administered by our doctors, we also offer patients several products they can purchase to help them manage their symptoms. We’ve found that it’s important to have these available so patients don’t go to the pharmacy and become overwhelmed by everything on the shelves. We’ve also learned that it’s crucial to have someone on the team who is responsible for inventory of the products, which include Retaine (OCuSOFT) artificial tears, tranquileyes goggles, HydroEye (ScienceBased Health) supplements, Cliradex cleanser (BioTissue) and OCuSOFT lid scrubs. The products always need to be on hand at all practice locations.

Treatments

• Systemic Doxycycline, Oracea or Minocycline

• Topical anti-inflammatories — steroids, Restasis (Allergan), AzaSite (Akorn)

• LipiFlow thermal pulsation (TearScience)

• Meibomian gland probing and expression

• BlephEx tool (Rysurg)

• Prokera Slim cryopreserved amniotic membrane (Bio-Tissue)

• Punctal occlusion

• Autologous serum tears

• Tarsorrhaphy

Patient Flow Protocol

Establishing and continually improving a dry eye patient flow protocol allows us to efficiently accomplish patient education and diagnostic testing prior to patients seeing the doctor. We start with the SPEED questionnaire, which we’ve adapted and are also using to help identify candidates for allergy and Sjögren’s testing. Every patient who comes into the practice completes the questionnaire, and every patient workup includes the Meibomian Gland Evaluator (MGE). We record the gland evaluation under slit lamp. For us, it’s as routine as looking at the patient’s lens.

SPEED and the MGE results guide technicians to the right diagnostic testing according to our standard of care, and the diagnostics guide the need for treatment and products. So patients first spend time with a technician, then they meet with one of our dry eye counselors before seeing the doctor and returning to a counselor. The counselors are critically important to our protocol. They start the education process for the patients who have a high SPEED score. After those patients see the doctor, the counselor schedules further testing or procedures according to what the doctor ordered. Once patients are educated about the testing and treatment recommendations, they can decide how to proceed. Most don’t mind paying out of pocket when it’s required, and we support them by having CareCredit financing available. The counselors also “close,” just as they would for premium IOLs or refractive surgery, getting the patient on the book for the product and services. Our technician-counselor-doctor-counselor flow is crucial to maintain a smooth flow without taking up too much physician time. It also allows consistent messaging to patients, which instills confidence.

Reap the Rewards

Once we began taking care of patients with the mindset of a dry eye treatment center, the benefits to our practice became apparent. On average, the revenue that comes in each week from dry eye testing and treatments, some covered by insurance and others paid out of pocket by patients, may range from $20,000 to $40,000 per week, not including the office visits and our use of Prokera Slim (Biotissue) amniotic membrane. Most importantly, our patients are happier and more satisfied than ever. ■