Get Out From Under the "Treatment Burden"

Rethinking staffing, facilities and patient flow is crucial to providing the best care efficiently.

Get Out From Under the "Treatment Burden"

Rethinking staffing, facilities and patient flow is crucial to providing the best care efficiently.

Lawrence J. Singerman, MD, FACS, FICS (moderator): In today's retinal practice, we are fortunate to have several new, effective treatments to offer our patients. As a result, we are treating a greater number of patients — many of whom had no therapy options previously.

It is a privilege to be able to help this many patients now, but it also places some strains on them and on our practices. This is sometimes referred to as the "treatment burden." I am not comfortable with the term "burden" because we are spending our days productively in terms of saving vision. On the other hand, what does this mean for efficiency in our practices?


David M. Brown, MD, FACS: The increase in the frequency with which we see our macular degeneration and diabetes patients is the biggest challenge we are facing. My clinics are running from early morning to evening. All of us are trying to find the best ways to care for our patients while being efficient at the same time.

Dr. Singerman: Staff members play a critical role in improving efficiency and providing better care for patients. This is not an all-doctor scenario by any means. We see this in our practice because we have many well-trained staff members with excellent credentials. Most of these staff members have been in our practice for a long time, so they understand the workflow, which makes them particularly valuable.

Most of our employees were with us before the new treatments, such as photodynamic therapy (PDT) with verteporfin (Visudyne, Novartis Ophthalmics), pegaptanib sodium (Macugen, [OSI] Eyetech) and ranibizumab (Lucentis, Genentech), were approved. In fact, many of them participated in the clinical trials that led to the FDA approval of these treatments. The fact that they were equipped to handle the changes really helped make our transition to a higher patient volume much easier. Staff members are definitely an important part of the overall efficiency picture.

John T. Lehr, MD: Yes, staff members are critical, especially with the new treatment options. They are often the ones with whom patients feel most comfortable asking questions. In our practice, they are educated and interact very well with patients. They really make the transition to new therapies much easier. They absolutely are a key component to a successful practice.

Christine R. Gonzales, MD: I agree. Staff members are critical not only for increased efficiency in the office but also for optimizing the patient's experience. The front desk staff or the technicians are the first people patients encounter when they come into the practice. It is so important that they are courteous and treat patients with respect. In a retinal practice in particular, many patients have blinding conditions and are very anxious about what the physician is going to tell them.

The staff is not a cost or a liability but an asset. I try to teach my staff that I need to do the things that only I, as the physician, can do, and they have to do everything else.

David M. Brown, MD

Dr. Brown: Peter F. Drucker, the "father of modern management," converted my way of thinking about staff. The staff is not a cost or a liability but an asset. I try to teach my staff that I need to do the things that only I, as the physician, can do, and they have to do everything else. When they execute this concept, they facilitate our work as a team. It is the staff members, not me, who enable me to have a productive day.


Dr. Singerman: The layout of our facilities and how we allocate our space also impact our efficiency and our ability to handle the new challenges we face with patient volume and flow.

Our practice has nine offices. Each of them is based on the prototype of the main office, where patient flow has always been important to us. We are fortunate to have plenty of space. In our layout, the waiting room and the workup rooms come first. Photography and diagnostic equipment are next in the sequence. We have a secondary waiting area from which patients can move to the exam rooms or diagnostic equipment rooms. The exam rooms are beside the laser rooms, as is typical. We have a designated injection room and two backup injection rooms, although we typically need only one backup.

Dr. Brown: Most of us did not have the luxury of designing our clinics with injection rooms in mind, because injections became a factor so quickly and recently. That said, anything we can do to avoid shuffling a patient and his or her family a long distance back to a waiting room and then back to an exam lane helps the flow.

Dr. Gonzales: Technicians and the front desk staff can be instrumental in directing patients. In our practice, we have a long waiting room that three doctors share. Staff members direct patients to sit in the section of the waiting room closest to where they will need to go, which increases efficiency and decreases the burden on patients.

Dr. Lehr: Our retina clinic is set up in a horseshoe shape. The center station and the waiting room are in the same location. I am always near that station, so I can move from room to room efficiently. Also, that proximity makes for a friendly, welcoming atmosphere. When they see me walking from room to room and interacting with the staff, patients seem to feel more at ease. So our setup eases their treatment burden as well as ours.

Clinical Trials Present a Unique Set of Challenges
Dr. Singerman: All of us are involved in clinical trials at our practices. Clinical trials are necessary for the advancement of medicine. In addition, they give patients an opportunity to benefit from cuttingedge treatments. Some of these patients — for example, those who do not have insurance — would not be able to get cutting-edge care any other way.
However, without a doubt, practices that participate in clinical trials add to their daily "treatment burden." Data collection and administrative requirements make managing clinical trial patients very time-consuming. Tell us what you have learned about incorporating clinical trials into your offices so that the trials can improve, rather than detract from, your patient care.
Dr. Gonzales: Clinical trials are a nice opportunity for patients to receive new treatments before they are widely available.
On the other hand, it is important to recognize that these patients are sacrificing a great deal of time to participate in a trial. There often are extra office visits. Therefore, we do everything we can to expedite their visits. We treat these patients like VIPs. We see them as soon as they arrive. This lets them know that their time is appreciated. It also has a positive effect on patient retention in a trial.
One of the things that has been instrumental in our practice is the use of educated, high-level coordinators with some science background. They free up physician time in many ways, by educating patients about the trial and answering many of their questions.
Dr. Singerman: I could not agree more about coordinators being key. In my experience, it is also crucial to ensure that all associates and all of the people in the clinic buy into the concept that clinical trials are important. The whole staff must understand that trials are a priority.
In addition, we have a special workup room just for clinical trial patients.
Dr. Lehr: When we are participating in a clinical trial, we try to set aside a half-day, often Friday morning, so that trial patients don't have to wait. No other patients are scheduled for several hours. As the trial patients are going through their treatments or follow-ups, everyone is focused solely on them.
Dr. Brown: Because clinical trial patients are making a sacrifice and helping future generations, we try to make them a priority. At the same time, what about the other patients — the person with the retinal detachment or potential endophthalmitis, or the person who came from miles away for our medical opinion? Research coordinators are the key. In particular, it is important that they facilitate cooperation among the clinical staff members. Otherwise, everyone is competing for the physician's time. Getting everyone to work together on patient flow really helps.
For example, during most mornings, I see postoperative patients first and then new patients. Thus, the majority of my fluorescein angiograms are performed between 9:30 and 10:30. Therefore, we try to do the necessary angiograms for clinical trial patients earlier in the schedule, prior to my needing angiograms for the new consults. That helps prevent a backup and keeps clinical trial patients' visits as short as possible.

The front desk staff or technicians are often the first people patients encounter when they come into the practice. It is so important that they are courteous and treat patients with respect.

Christine R. Gonzales, MD

Dr. Brown: Many offices have a main waiting room and a sub-waiting room. Does anyone on the panel think two sub-waiting rooms are needed now?

Dr. Singerman: It depends on the overall physical layout. My first big office was long and narrow. The greatest designer in the world could not have made that work. In contrast, we recently built a "mini main office." We had raw land and a raw building that we were able to make any shape we wanted. In that situation, you can make the flow perfect.

We have plenty of space in our main office, too. When we began doing injections, I moved some of the administrative and research functions out of the main clinical area. People who did not have to be in the mainstream of clinical care moved to space on a lower floor. The clinical area was then expanded.

Having enough space is crucial for dealing with today's treatment challenges. Practices located in areas such as Manhattan, where space is at a premium and very costly, are really at a disadvantage. It is very expensive to have the amount of space it takes to optimize patient flow. Our rent is not small, but it is certainly cost-effective for us to have more than enough space to handle the volume. As I have said, we are lucky in that regard.


Dr. Brown: It is essential to involve everyone on the team — the doctor, the workup technicians, the optical coherence tomography (OCT) technicians — in determining how to maximize patient flow. Flow changes are based on evolving treatment patterns.

For example, most of my patients now undergo their OCT imaging before I see them. My technicians know to get the OCT before I see any follow-up patients with a diagnosis of "A, B, C, D, or E" — that is; AMD, BRVO, CRVO, CME, DME or Epiretinal membrane. Otherwise, the patients wait to see me, I examine them, I request the OCT, they have to wait for the exam and then come back to see me again. If I have to see them twice in the same visit, it is like seeing two patients in terms of workflow. Some of these OCT examinations are not billed, but the efficiency of the workflow more than compensates for these "extra" OCT exams.

We constantly evolve and try to maintain a team approach to facilitating flow.

Dr. Lehr: Do you print your OCTs and have them in the charts?

Dr. Brown: We use the EyeRoute system from Anka Systems Inc., which allows us to view all of the OCTs in some rooms. However, we do not have enough bandwidth to do this in the clinic, so the technicians tell me where I need to be.

When they need to, they direct me to the OCT room so I can run through several patients' scans, make notes in the charts and then go see those patients. I do not think I can properly manage macular degeneration patients unless I look at all of the scans.

Dr. Singerman: A light system for directing the physicians can be helpful, especially in a large practice. In most of our offices, I can come out of a room and just look for the blinking light, which staff members have activated in the proper sequence, and that tells me where I should go next.

Dr. Gonzales: Another aspect of flow and efficiency is the insurance authorization process. Office staff should be proactive in obtaining authorizations for tests such as OCTs and angiograms. They should know which types of tests the doctors are likely to order for certain patients. That way, the patients can have all the appropriate tests done and not have to return for multiple visits.

In fact, we now obtain preauthorization to administer ranibizumab for our returning macular degeneration patients.

Having enough space is crucial for dealing with today's treatment challenges. Practices … where space is at a premium and very costly are really at a disadvantage. It is very expensive to have the amount of space it takes to optimize patient flow.

Lawrence J. Singerman, MD

Dr. Singerman: My patients have their OCTs done before they see me, just as Dr. Brown explained. While we certainly have not eliminated fluorescein angiograms, it is clear that we will be using OCT even more in the future. Several spectral domain units are now available. They allow us to see things we have not been able to see before, which means they will help us even more with our management of macular degeneration patients. Integrating new imaging modalities into our practices as efficiently as possible will be an ongoing process. RP