Volume 80, Issue 11 , Pages 657-661, November 2009
High-efficiency optometry
Article Outline
An Air Force optometry clinic doubles its capacity and provides uniquely personalized service by maximizing the role of paraoptometrics and the utilization of technology.
Figure 1
The Maxwell Air Force Base optometry clinic.
Dr. Hsu and his staff realized they would be forced to dramatically increase the clinic's efficiency. “You can be more efficient and you can save some time but you must take care of the patient,” Dr. Hsu said, setting down the ground rules for revamping the clinic's operations. He and Holena then set about developing a plan to restructure the clinic around “a highly systematic approach” to patient care. Like a growing number of practices around the nation, the Maxwell clinic implemented “staggered” scheduling, essentially cutting the time allotted for patient slots in half, allowing the optometrist to see one patient while the office staff tended to the next. To accomplish that, the system emphasized 2 key elements: maximum utilization of paraoptometrics and state-of-the-art technology.
The result, Holena modestly admits, has been better than anyone really expected. Clinic capacity has effectively doubled, complete 15-minute eye examination service (with no waiting) has become the norm, and—in a unique patient service move—each patient is now personally escorted through every step of the visit by a paraoptometric who acts as primary point of contact and host (see Figure 2). And the improvements at the clinic are drawing notice. The military's TRICARE health program recently praised the clinic in its national newsletter.
Figure 2
A patient provides insurance information at the Maxwell Air Force Base optometry clinic reception desk before being escorted through the practice in most cases by the same paraoptometric who greeted the patient at the front desk.
“Maximum utilization of paraoptometrics is fundamental” to the Maxwell AFB Optometry Clinic's approach, Holena emphasizes. Overall, AOA surveys find paraoptometrics are providing a wider range of services in optometric practices today. However, in many offices they may be limited to administrative functions, such as greeting patients, taking patient information, calling up patient records, and staffing the dispensary. In the Maxwell AFB clinic, paraoptometrics perform not only a full range of administrative tasks but as much objective testing and pretesting for patients as is permitted by law and appropriate standards of care, Holena said. Moreover, in most cases, instead of waiting for the optometrist to perform an initial examination on the patient and then ordering tests, the Maxwell paraoptometrics have authority to consider the patient's reason for the office visit, review the patient record, and then take the initiative to perform any tests that appear necessary before the optometrist sees the patient. In addition, “the paraoptometrics in our setting do not just gather data, they provide some initial interpretation of data, which is of course subject to final review and approval by the doctor,” Dr. Hsu notes.
“For instance, we do a lot of PRK (photorefractive keratectomy) or LASIK pretesting,” Dr. Hsu explained. “When a refractive surgery candidate comes into the clinic, the paraoptometric knows to do a corneal topography. They also know basically what a typical topography looks like and therefore can recognize irregularities such as a keratoconus. They will look at the topography and say: ‘this looks a little different.’ They will note the irregularity in the patient's record. I can then look at the record and be ready to assess the severity of the problem.”
“When a patient is referred by another practitioner for care of a red eye, the paraoptometric questions the patient in detail and notes in the record which eye is affected, if the eye hurts, or if there is a foreign body sensation. The paraoptometric also knows how to use the slit lamp. This is a very helpful technique. The detailed questioning and testing helps me to quickly determine whether it is the result of illness, injury, allergy, or some other condition and quickly tend to the patient's needs,” Dr. Hsu notes.
The Maxwell AFB clinic's approach requires highly competent and motivated paraoptometrics, Dr. Hsu and Holena agree. None of the Maxwell AFB paraoptometrics received any special clinical training when the new system was implemented. However, thanks to years of experience in the clinic, all generally know in advance what tests an optometrist is likely to order for a given type of patient and over time begin to understand the significance of the results, Dr. Hsu notes. The system really started to take shape when staff paraoptometrics began taking the initiative to make notes on test results in patient records, he says. “When a paraoptometric demonstrates the initiative to help interpret test results, the paraoptometric is demonstrating competency and experience. I then can feel it may be appropriate to teach the paraoptometric more and give that paraoptometric additional responsibility. There is a trust that has developed between the clinic paraoptometrics and myself over a period of time.” Holena is a 23-year Air Force veteran who has spent his entire military career as a paraoptometric and has worked part time in civilian optometric practices. Also in the clinic at the time of the transition to the new system were Tech. Sgt. Michael Rountree, an Air Force paraoptometric for 15 years; Senior Airman Dexter Raflores with 6 years of experience; and civilian Air Force employee James Matherly with 25 years. (In the Air Force, paraoptometry is predominately a male profession, Holena notes.) Together the clinic paraoptometrics have 60 years of experience in their field. “That really helps,” Holena notes.
The Maxwell AFB staff not only provides a complete range of paraoptometric services collectively but individually as well. To facilitate the clinic's high level of paraoptometric utilization, all of the Maxwell AFB paraoptometrics have been cross trained on each other's jobs so they can perform any paraoptometric-level function in the clinic. Initially, the cross training was intended to ensure that trained personnel were always available at each of the clinic's stations, even if one of the clinic's staff members was called away on other business “as frequently happens on military bases,” Holena said. Hence, patients are never held up waiting at the admission desk, testing areas, dispensary, or anywhere else in the clinic, even if the practice is short a staff person (see Figure 3).
Figure 3
The constant flow of patients through the clinic means patients very seldom wait for care in the reception area.
However, improved patient flow turned out to be just the first benefit of cross training. The second is a unique form of highly personal service that has come to be almost a hallmark of the clinic. Rather than send patients from one staff person to the next as they proceed through the practice, the Maxwell paraoptometrics greet patients at the front desk on a rotating basis and then accompany them through each phase of the office visit. At the Maxwell clinic, during the course of patient visit, a single paraoptometric takes the patient's information, calls up the patient's records, performs any required testing, assists with the patient's frame selection or contact lens order, schedules the patient's next clinic visit or arranges any necessary referrals, and reports the services to the military health system. Personally escorting each patient through the practice tends to speed patient flow, Holena said. However, more important, it provides a kind of personalized one-on-one attention that patients find reassuring and appreciate.
Facilitating the constant escorting of patients through the practice is the clinic's U-shaped configuration, with reception desk and testing areas along one side, examination rooms to the rear, and dispensary on the other. “The clinic has always been U-shaped; however, it was not until we recognized the need to ensure a systematic flow of patients that we realized we had the perfect facility,” Holena said. “There are constantly people coming in one door and out the other. We could almost put an “enter” sign on one door and “exit” on the other, the way things flow in the clinic now.”
“The first section of the U-shaped office consists of 3 rooms known as the pretesting hallway; the first door to the right is where devices such as the visual field and auto refractor are located (see Figure 4, Figure 5). After that, the patient travels to the door on the left for history and data entry to the network system. If needed, the patient will then proceed to the testing room for fundus photos and vital fluids check,” Dr. Hsu said.
Figure 4
Paraoptometric Master Sgt. Patrick Holena, C.P.O.A, takes a fundus photo for a patient in the clinic pretesting area.
Figure 5
Paraoptometric Senior Airman Dexter Raflores, C.P.O.A., provides autorefraction for a patient in the pretesting area.
Patients are then directed to one of the 4 examination rooms located in the “curve” of the “U-shaped” office. Dr. Hsu sees patients in 2 of the examination rooms on an alternating basis. “Instead of traveling from room to room or waiting in the waiting room for the doctor, the patient is directed to one of the 2 examination rooms, and I travel between my 2 rooms to save time. When I am finished with one of the patients, I am able to use the network computer to check who's in my next room waiting for me. I will be able to browse their previous eye examination data and the notes made by the technicians moments ago from the pretesting room. Even before stepping into the room to meet the patient, I already know why the patient is here and what the primary concerns are. That is another secret to an efficient clinic!” Dr. Hsu said (see Figure 6).
Figure 6
In the examination room, before meeting each patient, the optometrist (in this case, Capt. Michael Calhoun, O.D.) checks chief complaint and pretesting information using the clinic's computer network.
Maximum utilization of the latest eye care technology is another central element in the Maxwell AFB clinic's system, Holena says. “Instead of resisting new technology, we have embraced it,” he says. Holena requested funding for a complete overhaul of the practice equipment as part of his plan to increase practice efficiency. The expenditure has proven well worth it, he reports. A state-of-the-art paperless practice, the clinic utilizes digital instrumentation exclusively in all 4 of its examination rooms. The system is centered around the Marco Epic® 5100 Refraction System, which feeds data from ophthalmic instruments directly into electronic patient health records for viewing by the practitioners on monitors in the examination rooms—and in some cases into other instruments. “Digital lensometer readings are transferred directly to the refractometer so the patient can easily compare them to the prescription suggested by the just-completed refraction. The doctor can then say: ‘Which looks better this or this?'” Holena said. “This system greatly simplifies the examination process for the patients and helps to decrease chair time. It has been a godsend” (see Figure 7, Figure 8).
Figure 7
The optometrist checks pretesting data sent electronically to the clinic's digital refraction system.
Figure 8
Capt. Calhoun adjusts the clinic's digital lensometer for a patient.
The clinic system meshes well with the military's entirely electronic health records system, which speeds patient recordkeeping operations, Holena notes. All 4 of the clinic examination rooms are arranged identically with equipment at standardized locations in each, he adds. “That in itself increases efficiency,” he adds (see Figure 9).
Figure 9
All 3 of the clinic's examination rooms are arranged identically to enhance efficiency.
After leaving the examination room, each patient is escorted down the clinic's final hallway where the accompanying paraoptometric helps the patient select frames in the dispensary (see Figure 10) or order contact lenses, arranges for the next scheduled visit or a referral to another practitioner (patients requiring ophthalmologic care are referred off the base to civilian practitioners), and reports the services to the military health system. (Like private sector health plans, the military health system requires meticulous coding and billing.) Again, the clinic's paperless technology tends, along with the military's electronic health records system, to speed to the process and help prevent errors, Holena notes. So does the extensive training and experience of the staff. Effective October 1, the Air Force requires all of its paraoptometrics to be certified through either The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or the AOA Commission on Paraoptometric Certification (CPC). Holena received his C.P.O.T. certification last year. The clinic's 3 other paraoptometrics were scheduled to take AOA CPC certification exams in August.
Figure 10
After his examination, a patient tries on frames in the clinic dispensary.
In finding a way to see as many patients with 1 practitioner as with 2, the clinic effectively became efficient enough to support a second full-time optometrist with no additional needs for staff or equipment, when one became available. When Air Force employee Paul Webb, O.D., became available to join the clinic early this year, “we already had the capacity to support a second optometrist,” Holena notes (see Figure 11).
Figure 11
Implementing the new, highly efficient system at the Maxwell Air Force Base Optometry Clinic this past spring were, from left: Senior Airman Dexter Raflores, C.P.O.A.; James Matherly, C.P.O.; Tech. Sgt. Michael Rountree, C.P.O.A.; Master Sgt. Patrick Holena, C.P.O.A.; Maj. Weilun Hsu, O.D.; and Paul Webb, O.D.
The clinic's increased efficiency is even proving to benefit patients outside the Air Force base, Dr. Hsu notes. After Dr. Webb joined the clinic, Dr. Hsu found he could continue to take time outside the clinic to participate in Air Force humanitarian missions. Over the last 4 years, Dr. Hsu has taken part in a total of 6 2-week Air Force health care missions to Bolivia; Grenada; the Dominican Republic; Gabon in Africa; Kodiak Island, Alaska; and Bethel, Alaska. The 25-person missions providing a wide range of health care services (including a complete range of optometric care services thanks to good portable equipment) have become important in promoting new U.S. relations abroad, Dr. Hsu notes.
Late this year, in line with U.S. Department of Defense policies mandating periodic transfers, Capt. Michael Calhoun, O.D., took over from Dr. Hsu as the clinic's chief optometrist. Holena, using a common military term, expressed confidence Dr. Hsu will able to use the “lessons learned” at the Maxwell AFB clinic to improve care at other clinics. In fact, Dr. Hsu and Holena agree, the clinic may hold valuable lessons for optometric practices both civilian and military.
The Maxwell AFB optometric clinic today exemplifies several major trends in optometric care practice, Dr. Hsu and Holena say. Many practices today are taking steps to become more highly organized and efficient, often by placing greater emphasis on staff and staff training (see Box 1). With electronic health records (EHRs) already used systemwide in the military and a national system of electronic health records scheduled to be in place across the United States by 2014, utilization of EHRs and digital instruments is bound to increase, Dr. Hsu and Holena agree.
From the reception room to the pretesting area and from the dispensary to the billing desk, paraoptometrics today are increasingly called on to show considerable expertise. The AOA Paraoptometric Section offers a wide range of staff training materials. Education materials are available covering online training for new staff, general knowledge for current staff, and certification examination study materials.
The AOA Paraoptometric Section recently added 2 new Education Modules to its Paraoptometric Training Learning Library. Optimizing Office Efficiency in the Optical Dispensary and Fitting Soft Toric Contact Lenses. Other Education Modules in the library include:
Sponsors such as HOYA, SpecialEyes, Luxottica, and Bausch & Lomb have made these education modules available through education grants. For more information on the modules and other education materials, contact PS@aoa.org or call (800) 365-2219, ext. 4108.
Implementation of the Maxwell AFB clinic's system could be advantageous for civilian practices seeking to increase productivity in an increasingly demanding managed care environment, Dr. Hsu believes. In some cases, state law may place restrictions on the utilization of paraoptometrics that may not be applicable in a military setting. However, many aspects of the clinics' system could still prove valuable in practices that are hoping to expand and take on new associates. Moreover, the Maxwell AFB clinic's system could help practices compete for today's increasingly convenience- and service-oriented patients. “Patients are almost always ‘in-and-out’ of the practice in 15 minutes,” Holena reiterated. “And that includes patient time in the waiting area, because, generally there isn't any. Patients are almost always seen immediately on entering the practice. You very seldom see anyone waiting in our reception area.”
However, although it holds benefits for patients and practice, implementation of high-efficiency optometric practice places demands on both practitioners and staff, Dr. Hsu and Holena agree. Both practitioners and staff must be ready to learn to use new technology. Staff members in particular must be able to show initiative and undergo training. However, with time, practitioners, staff—and above all patients—will notice the difference, Dr. Hsu and Holena agree.
Opinions expressed are not necessarily those of the American Optometric Association.
PII: S1529-1839(09)00487-4
doi:10.1016/j.optm.2009.09.006
Volume 80, Issue 11 , Pages 657-661, November 2009
