I was drawn to ophthalmology because of the visual nature of the specialty. The eyes are one of the few organs that we can directly examine and actually see the pathology in action. For decades, we have been able to obtain high-quality photographs and even evaluate blood flow with fluorescein angiography (FA). Fundus photography went through a digital transformation, and now we have ultra-widefield (UWF) imaging to capture up to 200° of the retina in a single image. OCT has been around for almost 20 years and has proven to be an indispensable component in the care of patients with retinal diseases. Quality and resolution have improved immensely over the years, and we have now added OCT angiography to the mix.

New imaging technologies continue to hit the market, from UWF imaging combined with image-guided OCT to home OCT devices. But this plethora of imaging technologies has a downside: It can prove challenging to balance workflow efficiency, leading to significant wait times for patients and long hours for ophthalmologists.

Over the past few years, I have been pondering the following question: How can we leverage imaging technologies and improved workflows to better and more efficiently run our clinics and improve our patients’ experiences? COVID-19 required us to think differently and try new things with the goal of enhancing efficiency and safety while maintaining the highest level of care. Let’s use those lessons here.

DEMAND IS HIGH AND CONSTANT

As a retina specialist, I am highly dependent on advanced imaging — not only to diagnose retinal diseases but also to help us make critical treatment decisions for our patients on chronic anti-VEGF medications. As a result, whether I see 30 patients in a day or 90, pretty much all of them need at least one type of imaging; many require multiple types. The amount of imaging that is needed in modern-day retina practices presents significant challenges in time.

Prior to COVID-19, a busy retina clinic commonly meant packed schedules, full waiting rooms with patients sitting in close proximity and clinic wait times in the range of 90+ minutes: check-in, workup with a technician, followed by imaging with SD-OCT/photos then waiting for the doctor. Patients may need additional imaging after initial evaluation, including FA/indocyanine green angiography or B-scan. Following examination, most patients require procedures, such as intravitreal injection or laser.

How do we handle all this efficiently? Below are some of the strategies employed in our retina clinic, many of which can be applied in other subspecialties.

CROSS TRAINING IS CRITICAL

For background, each of our clinics only has one physician at a time, and we usually utilize seven to eight staff to enhance our efficiency when the clinic volume is 70 to 90 patients. We reduce this number when patient volumes are lower. I have found that it is difficult to see 70+ patients in a timely manner with six or fewer staff. I utilize two work-up technicians, one to two photographers, two floor/procedure technicians and two scribes.

The cross-training of staff is critical. My scribes, photographers, floor technicians and even many work-up technicians can perform work-up, obtain imaging and set up procedures. This allows me to utilize “free” staff to assist in areas of clinic where there is a bottleneck. Often I have a floor technician act as third work-up when we have a rush of patients pending. Scribes will serve as third procedure room setup when we have a backlog of injections pending; if we are short-staffed, floor technicians often serve as the second photographer.

STANDARDIZE FOR EFFICIENCY

Our retina practice obtains a heavy volume of imaging, notably SD-OCT and UWF for most patients. An exception is injection-only visits, where the patient only receives SD-OCT prior to their procedure. So, it is important to standardize the imaging information/capture that each physician requires. For example, I prefer a single UWF image centered on the macula with good capture into the periphery. In patients with peripheral pathology (retinal tears, acute PVDs, lattice, etc.), I like my photographers to obtain peripheral sweeps as well. I prefer SD-OCT with comparisons, so that I can see a summary comparison image as well as scroll through the individual line scans in sync with the previous visit and the current visit.

Each physician will have certain preferences, so the staff need to be aware of subtle differences between physicians.

YOUR REVIEW ROUTINE

With the copious information obtained during each visit, it is imperative to have a thorough and efficient review station setup. Each physician will differ, but I utilize a laptop linked with an additional large monitor. This setup is not only at my review station, but also in each exam room and procedure room. On the laptop, I display the EMR information (vision, IOP, etc.). I utilize the larger monitor to display patient images (Figure).

As a creature of habit, I perform each review of patient information in the same order each time. I look at the UWF image first, followed by the SD-OCT comparison snapshot, as well as scroll through the individual SD-OCT line scans as needed. My staff makes sure to have the next chart open and all the images displayed when I finish with the previous patient. As I review the images at the workstation, I relay all the findings on the UWF image and the SD-OCT to my scribes, as well as diagnoses and treatment recommendations if I can already make those assessments; this allows my scribes to get a head start.

MAKING THE MOST OF PATIENT TIME

In the exam room, I prioritize my time spent with the patient explaining their findings and educating them on their disease and potential treatments. As a result, I like to employ image-guided examinations, most notably for follow-up patients, pairing my visualization on UWF images and SD-OCT with my direct examination.

In each exam room and procedure room, the same setup of laptop and large monitor display the EMR and images. I use the large monitor to display SD-OCT and UWF images so that patients can view them with me. I value the education this provides, and my patients appreciate seeing the pathology and correlating it with their symptoms. Often, I find patients already viewing their images as I walk in the room, and you would be surprised how many can recognize improvement or worsening.

EFFICIENCY KILLERS AND HOW I AVOID THEM

I have experienced several issues that can significantly slow down image capture and review in clinic. First, ancillary imaging, such as FA, can tie up the UWF device for longer periods. To avoid this obstacle, we will often change the order of work-up in these situations.

For example, following initial work-up we will obtain all other imaging first and then slot back in for photos once the camera is free again. I will also make notes on prior visits if patients need FAs, so as to not cluster new patients and patients that I know will need FAs.

If the physicians are heavy FA users, a second UWF device may be beneficial to improve flow and decrease significant bottlenecks. Because that may be cost prohibitive, we have also considered adding older non-UWF devices (in offices where we upgraded to UWF) to clinics or locations where we are very FA-heavy to give clinicians a second option.

Scheduling is another critical component of clinic efficiency and flow that directly affects imaging efficiency. Too many new patients clustered together can have a detrimental effect, as will inadequate distribution of injection-only patients mixed with rechecks. I work very closely with my clinic managers to set up templates that are specific to the number of patients seen at an office, the number of expected staff, the clinic setup and space and the breakdown of new patients, rechecks, injections, lasers, etc. Each clinic requires its own setup based on these factors, and continuous assessments and adjustments are needed.

NECESSITY IS THE MOTHER OF INVENTION

We will continue to feel the effects of COVID-19 for some time and will never forget the initial struggles as we had to lock down, prioritize emergencies and injection patients and create a safe, socially distanced environment for our patients. However, it also required us to innovate and adjust our clinic workflows to emphasize safety and efficiency.

Going back to my initial question, I look forward to continued evolutions in imaging, and I personally hope to continue to leverage imaging technologies, image-guided examinations and improved workflows in my clinic to provide the best care to my patients in the safest and most efficient manner possible. OM

About the Author

S.K. Steven Houston III, MD, is a vitreoretinal surgeon and partner at the Florida Retina Institute. He is also CEO and co-founder of HealTheia, a telemedicine software company developing eyecare-specific software and workflows.