How to make technology work for you

By Sumitra S. Khandelwal, MD

It’s not about having enough time, it’s about making enough time.” —Rachael Bermingham

If efficiency is the name of the game, it’s hard not to feel like you are always playing from behind the eight ball. I resolve every six months to figure out where and how I can best optimize my time during my work day. Patients appreciate it because they spend less time waiting, but, most importantly, this time savings allows me to spend more hours at home with family rather than catching up from the day’s activities.

Here are some of the ways I’ve found to use technology to increase my efficiency.

SO MANY TESTS, SO LITTLE TIME

At our practice at Baylor, we have a variety of diagnostic and imaging technologies. Like you, we have bought these technologies over the years — for refractive calculations, dry eye assessment and so on. The dream would be to use each of our tests on every patient so we could analyze the data, much like a case report. However, this was never practical due to the time required for the patient, technician and provider. Performing each test would have added about five minutes to the exam and 10 to 15 minutes if the patient needed to walk to a different room.

The real push to be more efficient came a few years back when I joined the group, followed by another associate the next year. We also had high technician turnover that second year. With two new physicians and a fleet of newer techs, it became more apparent than ever that efficiency in patient workup needed to improve.

In addition, Baylor rolled out Press Ganey reports and linked to departments revenue, much like we will see in the future in reimbursement. Our marks were high for all parts of patient care except for two factors: wait time and notification about wait time. We decided to move forward and reassess how to work up a patient using the excellent diagnostics and imaging at hand without losing time by escorting patients between rooms.

It’s an ever-changing process — to limit patient movement and increase efficiency, our practice rearranges the location of the equipment at least once a year, especially as new technology becomes available.

ALL ABOUT THE SOPS

Developing standard operating procedures (SOPs) for the various types of visits goes a long way toward preventing confusion among newer technicians. To me, a technology exists to either give a diagnostic answer or to assist me in moving through the technician portion of the exam. Certain visits, such as dry eye or cornea ulcers, need my input prior to any eye drops. However, other exams, like cataract or cornea evaluations, can move along faster if the technician sees the patient once and completes the workup (including dilation and pressure) prior to my seeing the patient. It is a balance — we want the technician to stop if he notices any red flags such as dry eye.

In these cases, technology can help. For example, we use Galilei topography (Ziemer), which has the placido maps plus the Scheimpflug images for cataract evaluations. From this, I get the topographic data as well as the quality of the rings from the placido maps. This can catch dry eye, anterior basement dystrophy and subtle irregularities to the tear film. I print out the placido map large on a sheet of paper so I can study the rings, but my technicians know to stop before dilating or checking pressure if the rings are abnormal. This allows me to discuss the cornea issues prior to continuing the exam and better counsel them about the poor cataract-surgery outcomes for those with dry eye.¹ This one device saves time and allows us to address these issues prior to the rest of the exam.²

Technology with multiple features is also essential — on a busy day, we would prefer to do one test on one machine that gives the same information as running three tests on three machines. One example is the IOLMaster 700 (Zeiss), which provides accurate formulas including ones that take postrefractive corneas into account. The device also captures long eyes and dense lenses, thus avoiding the need for a separate immersion scan.³ It also provides a small OCT image and a lens tilt snapshot. The macular OCT is small with a high specificity but only moderate sensitivity, so it does not replace the macular OCT for premium patients.⁴ However, it can be a great way to catch pathology in monofocal patients. Also, this device is easy to operate, even in dense lenses, and fast for technicians to use — one study shows half the capture time compared to other devices.⁵ So, it saves the additional trip to receive an immersion scan.

Another example is our Tomey topographer, which gives topography information, keratoconus grading and a placido image with the Klyce index that essentially grades the tear breakup time in one click.

TRULY PAPERLESS?

For my generation, EMR was established as early as medical school, so we don’t know any other way. Still, EMR is rarely considered a technology that makes life more efficient.

In our academic center, we use Epic software, and our practice tries to make it the most efficient for us. This includes smart phrases, exam templates and an assistant to help with prescribing. The EMR also helps by checking off items to ensure an appropriate billing. These include components to the exam, use of modifiers in the postop period, and so on. (For surgery, my technicians print out the patient’s surgical charts).

OR: MY MOST EFFICIENT DAY

OR days can be predictable days. If I have access to two rooms, I fly back and forth to each, and the day ends early enough to allow me to catch up on work. The one-room days, however, are much less efficient. While waiting for the room to turn over between cases, I could fill the time browsing the Internet or e-mail.

Instead, I make the most of that time with efficient applications. For example, I use the Stickies application to create various colored sticky notes on my desktop. Each color is based on how much time I need to complete the task. One is a “quickie” list — important but quick action items that do not involve much brainpower: registering for meetings, paperwork for research, booking flights or scheduling my kids’ doctor appointments. When I have extended periods of time to sit down to work, having these quick items checked off my list goes a long way toward making that time more efficient.

WAVING THE WHITE FLAG

As efficient as we try to be at work, some items may still remain outstanding. The goal is to avoid taking clinical work home, but that is not realistic when balancing clinic, surgery, research and teaching. My husband and I have decided that we have to devote some evenings to work after our children are asleep. We order take-out, open up a bottle of wine and work at our laptops. This is the reality of trying to do it all, but at least we do it guilt free. OM

REFERENCES

1. Chuang J, Shih KC, Chan TC, et al. Preoperative optimization of ocular surface disease before cataract surgery. J Cataract Refract Surg. 2017;43:1596-1607.
2. Epitropoulos AT, Matossian C, Berdy GJ, Malhotra RP, Potvin R. Effect of tear osmolarity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41:1672-1677.
3. Arriola-Villalobos P, Almendral-Gómez J, Garzón N, et al. Agreement and clinical comparison between a new swept-source optical coherence tomography-based optical biometer and an optical low-coherence reflectometry biometer. Eye (Lond). 2017;31:437-442.
4. Hirnschall N, Leisser C, Radda S, Maedel S, Findl O. Macular disease detection with a swept-source optical coherence tomography-based biometry device in patients scheduled for cataract surgery. J Cataract Refract Surg. 2016;42:530-536.
5. Srivannaboon S, Chirapapaisan C, Chonpimai P, Loket S. Clinical comparison of a new swept-source optical coherence tomography-based optical biometer and a time-domain optical coherence tomography-based optical tomography-based optical biometer. J Cataract Refract Surg. 2015;41:2224-2232

About the Author

Sumitra S. Khandelwal, MD, is assistant professor at the Cullen Eye Institute, Baylor College of Medicine and medical director for the Lions Eye Bank of Texas. Also, she serves as staff ophthalmologist at the Michael DeBakey Veterans Affairs Hospital.

How a unified voice helps conversions

By Cathleen McCabe, MD

Underestimating the value of employing a well-educated counseling staff will inevitably impact your bottom line.* These staff members are a vital resource for your patients to turn to for answers when they are considering surgical options. They are also an integral tool to help you meet cataract, refractive and LASIK surgical goals. Employing a friendly, well-educated and easily accessible counseling team is a relatively simple way to give patients an extra point of contact and reassurance before surgery. To meet practice goals, it is vital to have educated staff who are trained to assist patients in their decision making.

An office’s counseling staff should be an extension of the surgeon: knowledgeable about the whole procedure and able to make the patient feel comfortable. To that end, counselors require the same education regarding premium IOLs and refractive surgery that the technical staff receive. A counselor must be able to discuss the benefits and drawbacks of each type of lens or procedure with the same confidence that a technician possesses. I cannot stress enough how important education is in preparing a surgical counselor for success. A hesitant or confused counselor can decrease the confidence the patient has in choosing the appropriate or recommended premium lens package.

FOR THE PRACTICE

Physicians and medical staff constantly run up against time restraints: working up, examining and checking out each patient in a timely manner does not leave much time to allay a patient’s concerns and fears. It also does not always give clinical staff the opportunity to answer every question a patient may have.

Within high-volume cataract surgery practices, it can be difficult for a patient to speak with the same technician or staff member over the course of multiple days or calls. Different staff members may present different or conflicting information. Having a dedicated counseling team can help to remedy this situation.

When I began my practice 17 years ago, I started with one counselor. My practice now employs six full-time counselors to complement our three cataract surgeons. We assign one counselor to a patient and allow the patient to call the counselor’s direct line to allow for a more timely and personalized response. This way, surgical patients always receive consistent feedback and never have to be frustrated by the need to explain their unique circumstances multiple times to multiple people. It can be very frustrating for a surgical patient to receive inconsistent information, and that frustration can be magnified by the potential financial commitment and the anxiety or fear of the proposed surgery.

Also, having counseling staff who feel comfortable discussing the financial obligations of the patient relieves the clinical staff of that responsibility. Many clinicians and surgeons feel uncomfortable discussing the cost of premium options with patients, and a strong counseling team can remove the onus from the clinical staff. This frees up the clinical staff to spend more time educating patients on the details regarding their options. The counseling team also can offer financing options to patients who may not otherwise be able to afford an upgraded package. Having knowledgeable staff who understand and believe in the technology is key to the patient’s understanding of the benefit of premium lens options.

Patients often feel more comfortable asking questions of a nonmedical staff member and will frequently trust what the counselor says over what they heard from the medical staff. It is the trust the patient places with the counselor that is key to meeting the practice’s goals as a whole. We measure the success of this philosophy by tracking a gradual and consistent rise in adoption of premium lens options.

For those reasons, our practice schedules regular meetings that include the counseling staff, biometry team, scribes and surgeons. These ensure that all patients hear an accurate and consistent message through their whole surgical journey. We have found it extremely productive to have all the key employees in the same room, hearing the same information at the same time. They help to make sure that each employee knows his role and understands how to best facilitate the process as a whole.

A portion of this education also includes an understanding of some of the limitations and drawbacks that the premium lenses can entail. A thorough understanding of the technology allows the counseling staff to avoid overselling premium IOLs and disappointment after surgery. Counselors must understand astigmatism, its effect on vision, how it correlates with the patient and lifestyle choice. The counselor’s role is to educate and reinforce what the surgeon says.

Just as the medical staff uses words and terms that a patient can understand, the surgical counseling staff should use those same words and phrases to reduce patient confusion. It is helpful to have the surgical counselors shadow the physician in clinic to become familiar with how the physician presents this information and answers frequently asked questions.

We also secret-shop the competition to know what options they offer. This has given us valuable insight into our competitors as well as a unique view when treating patients who might be looking for a second opinion.

It is clear that not just anyone is fit for this key role. We have learned that an effective counselor is detailed oriented and has a commitment to continued education.

A counselor needs to be friendly and approachable. When patients see the clinical staff, they are often nervous so they do not always absorb every detail while in the exam room. A personable and knowledgeable counselor can make all the difference to these patients. Creating a counseling team made up of knowledgeable, positive and compassionate educators can be a daunting challenge, but the reward is well worth it. Our practice lets our counselors know that their contribution to the company is vital — that what they say and how they say it has an important effect on the patients and their treatment. OM

*According to Guest Editor Dee Stephenson, MD, surgical counseling, over the years, has helped with increasing conversions from 30% to 79%.

About the Author

Cathleen McCabe, MD, is the medical director of The Eye Associates. A graduate of Bascom Palmer Eye Institute at the University of Miami’s School of Medicine, Dr. McCabe serves as the cochair for the cataract section of the Practicing Ophthalmologist Curriculum for the American Academy of Ophthalmology.

The case for adding a femtosecond laser

By Audrey Talley Rostov, MD

As surgeons, we are constantly seeking newer, more effective and less invasive techniques and technologies to help our patients achieve better outcomes. For me, femtosecond laser-assisted cataract surgery, or FLACS, is one such technology. A recent study by Al-Mohtaseb et al. has demonstrated decreased endothelial cell loss with FLACS.¹ In addition, Tauber et al. noted a decreased risk of complications with FLACS,² and a recent ESCRS review found noninferiority of FLACS compared with modern day non-FLACS phaco techniques.¹

NOT JUST FOR CATARACT SURGERY

Femtosecond laser technology is a familiar platform for various applications in ophthalmic surgery. When femtosecond laser technology was introduced for creating LASIK flaps, the process became more reliable, safer and consistent. Gone were the fears of forgetting to place the safety plate in the microkeratome and inadvertently entering the anterior chamber. Free flaps were a distant memory. Flaps could be created thinner and more predictable in terms of size and thickness. I don’t think that anyone today would choose to create a LASIK flap with a microkeratome rather than a femtosecond laser.

Femtosecond laser technology is also a great addition to cornea surgery. It allows the surgeon to more accurately match the graft/host interface with resultant faster visual rehabilitation for cornea transplant patients. I am working with this technology to create a better deep anterior lamellar keratoplasty (DALK) procedure and perform femtosecond-assisted cornea surgery on over 90% of my full thickness and DALK cornea transplants. (The work is not ready for publication.)

MY FLACS EXPERIENCE

We introduced FLACS to our practice three years ago. While I can create an excellent capsulorhexis and perform consistent cataract surgery, with FLACS my surgery is even better, with perfectly centered anterior capsulotomies of consistent size, shape and centration. This assists in better estimated lens position (ELP) and centration, especially with premium IOLs. FLACS essentially provides a “pre-chop” for the cataract, thereby reducing the phaco power required⁴ and decreasing endothelial cell loss, which is especially advantageous in patients with previous transplants or early Fuchs dystrophy.⁵

Patients who have pseudoexfoliation or other zonular compromise, such as trauma or Marfan’s syndrome, also benefit from performing a femtosecond laser assisted capsulotomy, owing to decreased stress on the zonules and the ability to center the anterior capsulotomy on the bag. Patients with white, intumescent cataracts can also benefit from decreased risk of the Argentinian flag sign with FLACS capsulotomy.

I have performed FLACS on patients with previous RK, PK, intrastromal corneal ring segments, existing phakic IOLs, including ICL and Verisyse (Johnson+Johnson Vision) and in posterior polar cataracts with good results.

Also, reducing astigmatism with femtosecond-assisted corneal relaxing incisions (CRI) with or without a toric IOL provides much better accuracy compared with manual CRIs or limbal relaxing incisions (LRIs).⁵ The ability to place toric marks for axis marking and the integration of iris registration on some laser platforms further improves the ability to more accurately position toric IOLs and manage astigmatism. In post-PK patients with astigmatism, the ability to place CRIs within the previous graft and combine with a toric IOL can yield superlative refractive outcomes.

The only step in which I do not use the laser is in the creation of cataract incisions. This is because I perform 100% bimanual cataract surgery and I always need to enlarge the 1.3-mm incision for IOL placement. In addition, the hand placement for bimanual surgery with two small incisions can be more variable and sensitive to even a small amount of cyclotorsion or shift in patient positioning.

PATIENT SELECTION AND BILLING

When I first began performing FLACS procedures, I noted that some patients who would benefit the most, such as those with advanced brunescent, intumescent and traumatic cataracts, were also the patients who could afford the procedure the least. We made the decision in our practice to offer FLACS to everyone and have an all-femtosecond laser platform for cataract surgery. This includes using the laser for the capsulotomy and phacofragmentation, but not for astigmatism management. We do not charge additional fees for FLACS, which is achievable because 70% to 80% of our patients choose to pay for our vision correction packages.

CONCLUSION

Just as the femtosecond laser has supplanted the microkeratome for LASIK procedures, the femtosecond laser could become the new standard for creating a safer, more consistent cataract surgery allowing for decreased endothelial cell loss, ease in performing complex surgeries and, ultimately, better outcomes for our patients. OM

REFERENCES

1. Al-Mohtaseb Z, He X, Yesilirmak N, Donaldson KE. Comparison of corneal endothelial Cell Loss Between two femtosecond laser platforms and standard phacoemulsification. J refractive Surgery 2017. Oct;1:33(10):708-712.
2. Scott WJ, Tauber S, Gessler JA, et al. Comparison of vitreous loss rates between manual phacoemulsification and femtosecond laser-assisted cataract surgery JCRS presented at the annual meeting of the ASCRS Symposium on Cataract, IOL and Refractive Surgery San Diego, CA USA April 2015.
3. Lundström M, Dickman M, Henry Y, Manning S, Rosen P, et al. Femtosecond laser-assisted cataract surgeries reported to the European Registry of Quality Outcomes for Cataract and Refractive Surgery: Baseline characteristics, surgical procedure, and outcomes. J Cataract Refract Surg. 2017 Dec;43(12):1549-1556
4. Yesilirmak N, Diakonis VF, Sise A, Waren DP, et al. Differences in energy expenditure for conventional and femtosecond-assisted cataract surgery using 2 different phacoemulsification systems. J Cataract Refract Surg. 2017 Jan;43(1):16-21
5. Kymionis GD, Yoo SH, Ide T, Culbertson WW. Femtosecond assisted astigmatic keratotomy for post keratoplasty irregular astigmatism. J Cataract Refract Surg. 2009 Jan;35(1):11-13.

About the Author

Audrey Talley Rostov, MD, is a partner at Northwest Eye Surgeons and director of cornea, cataract and refractive surgery and global medical director at SightLife.

Dr. Talley Rostov was the first surgeon to perform and teach femtosecond laser keratoplasty in New Delhi, India. Since 2009, she has served on the medical advisory board of SightLife, a global health organization whose mission is to eliminate corneal blindness worldwide.

Disclosures: Dr. Talley Rostov is a consultant to Allergan, Avedro, Bausch + Lomb, Omeros and Shire and is a speaker for Allergan, Bausch + Lomb and Shire.