Enhancing Clinical Flow in the Retina Practice

Foster an obsession with excellence.


Today’s retina practice continues to evolve with increasing complexity due in part to the availability of new technologies such as the electronic medical record (EMR) and routine non-invasive multimodal imaging. To provide outstanding service, it is important to both truly understand the intricacies of your practice and have a relentless pursuit toward quality medical care. The best medical practices recognize that excellence in care is a constantly moving target. The following article will provide current clinical management pearls that may optimize your practice.


Clinic volume is one of the most critical aspects that define resource utilization in any practice. Low-volume (25 patients/day), medium-volume (50 patients/day), and high-volume (75 patients/day) practices have different staffing, imaging, and clinical support requirements. Equally important is understanding the idiosyncrasies of patients in the practice: medical vs surgical and new vs follow-up. Other aspects to consider include specialty care such as ocular oncology, pediatric retina, or uveitis.


Paper medical records were easy and affordable, but today, the increasing number of compliance requirements may limit the value of the old paper chart. A number of ophthalmology-focused electronic health records (EHRs) are available on the market.1 The most advanced EHRs provide up-to-date government and insurance compliance with seamless optimization of billing. However, new patients to the practice may require significant data entry and charting by all members of the staff. It is important to configure the record to easily populate it according to the most common diagnoses encountered in the practice.

Another vital pearl is to try to populate the EHR as much as possible prior to a new-patient encounter, especially if neuroimaging, biopsy results, electroretinograms, prior medical records, and other hard-to-access data are needed for patient management. Newer, small-volume practices that have a high proportion of new patients may benefit the most from prepopulation of the EHR. Mature, large-volume practices that mostly consist of a follow-up population may have enough buffer to allow EHR data entry the day of the encounter without significant waste of time.

Another key aspect of the EHR is quality. A common pitfall is to assume that because an EHR is compliant with government and insurance standards that it is providing excellent quality to your patients. Try to individualize and tailor the EHR to each patient to meet the needs of each individual as much as possible. Patients, referring ophthalmologists, and primary care physicians value when you display and provide an exceptional personalized service.


High clinic volumes may also require the use of a scribe in order to free the physician from an unnecessary waste of time during patient encounters. Smaller practices will see less value in hiring and training a scribe. It is important to highlight that the process of training a scribe to fit the practice can be long and tedious due to the individual practice patterns and patient characteristics. The cost of training must also be considered at the time of hiring this important member of the team, because the initial months may warrant decreasing the clinic volume or increasing the clinic hours in order to accommodate on-the-job training without reducing the quality of service.

Another central aspect of the practice to consider is the actual layout of the physical space.2 Low-volume practices may be able to function appropriately with only 1 waiting room. However, larger practices may warrant a second waiting room to minimize the patients’ perception of wait time. Making the process enjoyable with TV displays and/or a children’s area may help ease the often painful experience of waiting. Offering coffee and snack stations may also help occupy the wait time.


Low-volume practices may benefit from multifunctional rooms because typically they also have less physical space and staff (Figure 1). This also allows the staff to play multiple roles, such as ophthalmic technician and photographer. A low-volume practice may consider making the ophthalmic technician’s rooms slightly larger to accommodate 1 or more imaging platforms. This allows the patient to undergo routine imaging without having to spend time walking between rooms and avoids the need for an additional clinic area for imaging.

Figure 1. Multifunctional room with A/B-scan, ultrasound biomicroscopy, and 819-nm diode laser.

As clinic volume increases, separating these tasks has increasing value for multiple reasons. First, having the patient move around the clinic between different stations decreases the perception of waiting. This strategy has been used by amusement parks for decades. Second, dedicated clinical rooms decrease the relatively higher overhead cost of the multifunctional rooms design, which requires imaging hardware and additional square footage. Third, developing specialized clinic staff allows the quality of each service to improve (eg, better imaging outcomes).

Multifunctional rooms may also play a role while designing the office space with regard to intravitreal injections. Intravitreal injections may be performed in the physician evaluation room or may be performed in a separate room. Low-volume practices with limited space may benefit from performing intravitreal injections in the evaluation room. However, high-volume practices will decrease the bottleneck effects of intravitreal injections by using 1 or more rooms exclusively for intravitreal injections. This also allows for dedicated nurses to monitor and educate the patient before, during, and after intravitreal injections. Similarly, a dedicated room to perform retinal and choroidal laser procedures may become necessary as the clinic volume increases.


Ocular oncology practices have a high demand for multimodal imaging (ultrasonography, fundus photography, angiography, and tomography). Low-volume practices may use multifunctional rooms that allow the ophthalmic technician to perform noncontact imaging and the physician to perform ultrasonography. However, high-volume ocular oncology practices demand a dedicated room for an ultrasonographer.

Practices that focus on pediatric retinal disease need to invest in training the staff in regards to pediatric ophthalmic examination. The most important aspect for ophthalmic technicians includes the evaluation of visual acuity. Special intraocular pressure instrumentation also may be needed. High-volume practices need to have an extremely well-trained team that understands the subtleties associated to providing excellent pediatric care. These practices may also want to modify the waiting room for children of different ages.

Practices with a strong focus in uveitic care should consider the time spent performing fluorescein and indocyanine green angiography. Low-volume practices may perform angiographies with only 1 platform. However, high-volume practices may need to invest in a second or third platform to accommodate the time spent on imaging.


The ideal evaluation room allows the clinician to portray all data captured in individual monitors to minimize opening and closing different windows. This allows displaying all the data seamlessly without having to waste time. At the same time this allows the patient to understand the clinical scenario with ease. As a physician, you may know what your management will be even before the patient walks into the room; however, a well-educated patient who understands the medical disorder will be invested in compliance and optimal clinical outcomes.


A number of factors can affect patient flow, such as emergencies, patients arriving late or early, and equipment and staffing availability, to name a few. Ideally, a perfect synchrony between patient and physician availability would minimize wasted time. The best way to incorporate the clinical team into the elimination of inefficiencies is to allow for staff input. This permits the team to recognize the impediments associated to reaching synchrony and generate solutions. The clinic should undergo performance assessments regularly. This may become particularly important if staff availability changes or new technology is introduced into the practice.


In many practices, patient check-in and checkout can be a significant bottleneck, especially if the front desk has to work on preauthorizations for intravitreal injections and lasers. Therefore, in high-volume clinics, a dedicated staff member for this may be an asset. In low-volume practices with a population skewed toward new encounters, this may be less of a factor, especially if prepopulation of the chart and preapproval of any potential procedure has been done by the staff.


The most important routine imaging performed in any retina practice is spectral-domain optical coherence tomography (SDOCT). Assess if a bottleneck is present for utilization of this resource. Low-volume practices that develop a wait for the availability of the SDOCT may consider hiring a dedicated ophthalmic photographer to fully maximize the SDOCT resource prior to acquiring an additional platform. High-volume practices will undoubtedly need 2 SDOCT platforms and 1 or more dedicated fundus photographers. New SDOCT angiography may decrease the volume of contrast-based angiography performed in the practice, but it may also create new problems, such as increasing computer hardware demand, decreasing the turnover time at the imaging area if performed routinely, or increasing the time the staff is not available to perform other tasks. Imaging requirements of the practice may also change depending on specialty care.


Focus the practice on the process the patient has to encounter during a visit. Identify areas that you value and improve them one at a time. This approach decreases the chances that you may run into an inadvertent bottleneck or new unsought problem. Changing many variables at the same time may make it difficult to assess the results. Monitor patient satisfaction directly with surveys or indirectly via web-based analysis in order to continually concentrate on the patient interest.


Providing excellence in medical care requires a patient-centered systematic approach that prioritizes efficiency. Understanding the details in your practice and anticipating the problems as the practice evolves is an ongoing but important challenge in maintaining outstanding care. The best medical practices constantly assess the changing inefficiencies and address them in a team-oriented approach without losing track of their passion for medicine and patient care. RP


  1. EHR systems. American Academy of Ophthalmology. Available at .
  2. Han D, Suneja A. Make Your Clinics Flow With Synchrony: A Practical and Innovative Guide for Physicians, Managers, and Staff. Phoenix, AZ: Quality Press; 2016.