The increasing number of drugs available for intravitreal injections offers hope for patients and new options for retinal specialists. At the same time, those added choices can complicate scheduling and efficiency for retinal practices, burdening already packed patient days.

In this article, we’ll provide tips and techniques for efficiency, including managing new patients, handling urgent patients and staff training. Whether you work in private practice or an academic setting, these methods can help accelerate your efficiency with retina patient visits.

INTERSPERSING INJECTIONS

At Orange County (Calif.) Retina, Esther Lee Kim, MD, vitreoretinal surgeon, travels to four of the private practice’s five offices each week, which includes a half-day of OR operating at an ASC and working in clinic during the other four and a half days.

In contrast, Jaclyn L. Kovach, MD, FASRS, professor of clinical ophthalmology and medical retina fellowship director at Bascom Palmer Eye Institute, Naples, Fla., works out of one exam room all week. She handles medical retina visits from patients with macular degeneration, retinal vascular diseases and retinal dystrophies and does not have OR days.

Despite their different practice settings, both physicians have a similar approach to injections, interspersing them throughout their day as opposed to scheduling them separately in the clinic. Dr. Kim prefers this approach, she notes, because it balances out exam-only visits as the injections are generally straightforward.

Dr. Kovach estimates that a larger percentage of her clinic days are now filled with injection patients. Mainly, those injections are anti-VEGF injections, as well as anti-complement injections for geographic atrophy (GA) patients. Like Dr. Kim, Dr. Kovach intersperses injection patients throughout her day. 

COMPLEXITY AND NUANCE

Dr. Kovach estimates that there has been more innovation in the retina space in the past year or two than during the past 15 years. After seeing TV commercials or doing their own research, her patients will occasionally ask for a specific drug, such as one of the new anti-VEGF agents or GA drug. If Dr. Kovach believes a patient would benefit from the drug, she will present the new treatment option to the patient and briefly discuss the potential benefits, risks and alternatives and send the patient home with literature about the drug for review with the family. Then she schedules a follow-up appointment in a few weeks to initiate the new therapy if desired.

She has found this to be the best way to balance clinic efficiency and patient education. 
Dr. Kovach uses the same approach when she initiates the drug therapy.

Most injections for Dr. Kim are anti-VEGF drugs interspersed with some steroid injections and GA therapies. She may do a handful of other types of injections when indicated as well, including intravitreal methotrexate.

With more drug options, “I think the decision making for injections is becoming more complex and nuanced,” says Dr. Kim. In the past, for a patient with wet AMD, fewer drugs were available for treatment. Today, “what you reach for next is a more nuanced thought process.”

On the anti-VEGF side, “there is more of an emphasis on extending the patient and being more aggressive about that,” she says. “At every juncture, I try to scrutinize and ask myself, can this patient be extended? Am I doing the best that I can for this patient? Should I be switching the drugs so that they may get further durability? It’s not so much a straightforward thought process anymore.”

With these treatment decisions along with those regarding whether a patient needs to start GA treatment and the timing involved, these conversations take up a lot of chair time, says Dr. Kim. “I think now that the toolbox for intravitreal injections is getting larger and larger, that makes the decision making a bit more complex for retina specialists.”

NEW PATIENTS

New patients add their own challenges as they require additional time for paperwork and a clinical workup. To accommodate these patients, Dr. Kim’s practice schedules them earlier in the clinic day.

Dr. Kovach never schedules a new patient as the first or last patient of the day. She begins seeing patients at 7 a.m., starting with follow-up or injection patients, and then schedules new patients around 9 a.m. or 10 a.m. With new patients, Dr. Kovach notes, you don’t know how much imaging they will need or what procedures they will require. You don’t want to have patients who need procedures and extensive imaging towards the end of the day, she explains, because that will delay the end of clinic.

URGENT PATIENTS

For urgent cases, such as a patient with a retinal tear or endophthalmitis, Dr. Kovach leaves open a few slots during her day to accommodate them. Because they are essentially similar to a new patient, she will work them into the middle of her day, instead of one of the first or last few patients.
Dr. Kim prefers to see them towards the end of clinic so that they don’t delay existing appointments. But, realistically, those patients get scheduled throughout the day. “We just try to accommodate those patients as much as possible,” says Dr. Kim.

As a physician in private practice, Dr. Kim strives to see urgent patients soon after being notified about the case. This helps maintain good relationships with referring physicians. That differs from academic practices, she notes, which can be thought of as essentially large multispecialty practices with colleagues who refer to each other. That academic practice, she explains, isn’t going to shop the patient around to another retina practice, for instance, which might occur in private practice.

OFFICE SET UP: SAVE STEPS

Dr. Kovach’s office set up lends itself to increased efficiency. She works in an area she calls a “pod,” which is a hallway with various rooms, including her exam room, two other rooms where she does injections and an imaging room. A pod coordinator ensures patients are in the appropriate area. “I’m walking as little as possible, and the patient is walking as little as possible to maximize efficiency,” says Dr. Kovach.

Once the visit wraps up, Dr. Kovach escorts the patient out of the room, doing a “talk and walk.” As the staff brings in the next patient, she’s closing out one chart, opening another chart and looking at the next patient’s images. The goal is to make the most of every moment, because “every few minutes that you save for each patient adds up to hours saved by the end of the day,” Dr. Kovach says.

A FLEXIBLE, MULTIFUNCTIONAL STAFF

At times, flexibility is needed to keep the clinic flowing, Dr. Kovach notes. For instance, if all her techs are busy and patients are waiting to be worked up by a tech, the patient might be sent first to imaging for an OCT and then see the technician for dilation before seeing Dr. Kovach.

“Ideally, the staff should be cross-trained in multiple tasks and there should be flexibility in clinical operations if you want to keep the clinic flowing properly,” Dr. Kovach says. “You want to have a multifunctional staff.” Although it takes time to cross-train staff, the effort is definitely worthwhile, according to Dr. Kovach.

Dr. Kim agrees. “I think that in terms of clinic efficiency, one thing that’s helpful is that a lot of our staff are cross-trained. Oftentimes, we have techs who can cover the front office and the back office so they can help each other,” she says.

Having cross-trained staff helps with the day-to-day clinic flow, notes Dr. Kim, in that staff members can be moved around, for instance from imaging to injection preparation. Instead of having a single surgical coordinator, she explains, a large pool of technicians can schedule surgeries. While there can be a downside to this method in that there is no one central point of contact, it avoids being reliant on one or two people to do one job, according to Dr. Kim.

“I find that having techs cross-trained to do a variety of tasks is very helpful,” she says.
There can be unforeseen circumstances, as evidenced by the COVID-19 pandemic, so having redundancies in the system allows clinics to keep running smoothly even if relatively key staff members are out, Dr. Kim notes.

It’s rare to have one staff member capable of doing everything, such as front desk, photography/imaging, back office, booking surgeries and so forth, notes Dr. Kim. Her practice starts by hiring staff for either the front or the back office. After working with the staff for a couple months, they get a sense of their strengths. The practice then slowly expands their training to other areas, starting with shadowing staff members in those areas over a couple of weeks. The staff can expand their skill sets, and the practice has a more well-rounded staff.
One obstacle involves making sure the training is consistent across the board, so that each technique is carried out consistently and effectively from one staff member to another. Each person may develop his or her own “style,” but the overall technique should carry the same quality and effectiveness regardless of who administers it, notes Dr. Kim.

‘DRIVING FORCE’

Ultimately, the responsibility for efficiency lies with the physician, stresses Dr. Kovach. The physician has to “adopt a mindset where you’re going to value your patient’s time as much as you value your own time.” For instance, older patients will find it uncomfortable to wait for hours in a waiting room, she notes.

“Efficiency is something you really have to commit to, and it has to be a driving force throughout your day,” says Dr. Kovach. “You also have to realize that no one’s really going to care as much about keeping your clinic running efficiently as you are.”  OM