A Snapshot of the Digital Age
See how digital retinal photography systems can benefit both your patients and your practice.
BY R. WHITMAN LORD, O.D., Statesboro, Ga.

Many of you are probably used to using slit lamp camera systems to take retinal images, but most O.D.s prefer retinal cameras because they provide a wider field of view than a slit lamp and because the camera's easier for a technician to use. Thanks to continuous advances in technology, we now have a better method for obtaining full fundus images -- digital retinal photography.

In this article, I'll talk about the technology, how to use it, what benefits it offers, as well as how to set up your fee structures. There's no doubt that digital retinal photography can enhance your practice's bottom line and increase patient compliance with treatment.

DIGITAL IMAGERY BY JOHN BRUSZEWSKI

Technology to treasure

Advanced camera technology, computer software and hardware work together to provide digital color images of the retina with extremely high resolution and clarity. Because the digital retinal photography component is tied to a computer system, you can store fundus images on your hard drive or you can make copies.

While you and your patients can view images on any workstation, a high-quality printer and glossy photo paper creates beautiful large prints should you need them.

For example, you can use the printout as a natural extension of a patient's electronic medical record to document a change or a finding in his eye health.

We use a non-mydriatic camera with a digital attachment connected to a desktop computer to capture the image. While a slit lamp digital camera system can provide retinal photos through the use of pre-corneal lenses, the wide angle of view is superior with the retinal camera.

Also, we can quickly and easily train our technicians to take the photos before the exam without dilation. Having the photos viewable when you begin the exam is a big time saver.

Most digital retinal photography units now use invisible light illumination and a low flash (95% less than conventional retinal photography) for vastly improved patient comfort. The system that we use takes a 30-degree image without causing pupil constriction, which aids in patient flow.

After acquiring the image, we can send it directly to the PC for forward transmission to exam rooms, review it with patients, or print out a hard copy.

Covering the cost

While the cost of this instrumentation is fairly high ($6,000 to $37,500) when compared to the cost of a slit lamp ($3,550 to $13,940), it's a wonderful investment. With sufficient patient volume, it's one of those instruments that ends up costing nothing.

You can pay for the basic retinal camera through an increase in your exam fee or by billing for retinal photography with a medical diagnosis. We'll cover more on this later. Because I was already taking routine retinal photos with an instant Polaroid camera attachment, switching to digital was paid completely by the savings I realized in Polaroid film!

Setting fee structures

As with any procedure, it's important to know how to best charge your patients for retinal photography. The following are three basic methods of charging for digital retinal photography.

1 Include it as part of your routine eye exam and raise the basic exam fee. This is my approach and it results in maximum equipment utilization and public relations value. Many O.D.s probably prefer to either make retinal photos elective to the patient or make them based on a retinal diagnosis and charge extra.

There are valid reasons for these two positions, however, I would rather not have to get permission from the patient or be in the position of routinely having to sell this important procedure to the patient. If your practice relies heavily on managed care, a raise in the exam fee may be ineffective because you can only accept what the plan pays.

2 Offer retinal photography as an optional additional test to all patients and charge an additional nominal fee. This is effective in heavily managed care practices -- because the additional test isn't covered and thus becomes a private purchase.

You may not, however, charge your vision plan patients extra unless you do the same for your private pay patients. You can inform patients of this optional test as they check in by handing them a handout that explains the test and the fee and asks them to indicate if they'd like you to perform the test and sign the form. This offers patients a graceful way to decline the test without embarrassment.

Most practices that offer retinal photography in this fashion find that most patients want the test. The disadvantage is that not everyone will elect to have photos taken.

3 Perform retinal photography when indicated by medical diagnosis of a retinal problem such as macular degeneration. Medical insurance will pay for retinal photography if you're on the panel. The typical procedure code is 92250 and the current Medicare approved fee is roughly $62.

The problem with this approach is that a fairly small percentage of optometric patients will have a diagnosis that supports medical billing and you can't charge two different fees for a procedure based on insurance coverage or private pay.

How we use it

Our office has routinely taken retinal photographs for more than a decade. We switched to digital retinal photography a little over 1 year ago. I don't charge an additional fee for this service. My office provides this test as part of the overall comprehensive exam fee to all patients 18 years of age and older. This keeps with my ongoing effort to try to always exceed patient expectations.

We have a special room for retinal photography, which also serves as a pre-test room. This arrangement helps our patient flow and speeds things up. Pre-test technicians take the picture and give a standard generic explanation to the patient in the pre-test room.

I networked the camera system to my exam rooms and the computer in the retinal photography room forwards the images to the exam rooms for my initial reference. I typically look at the retinal image first. It's a starting point for the exam because it's already on the screen. It's a great conversation piece and if the patient asks, I can provide more of an explanation after performing an internal exam.

We also use the fundus photo to expand patient education. Computer software also allows manipulation of the photo on any computer screen -- such as zoom in on any retinal area; electronic assistance in calculating the cup-to-disc ratio; add notations and drawings; lighten the brightness and contrast of the image; sharpen details; invert the image colors to enhance retinal layers; intensify the image; or view it in grayscale. We get many referrals and favorable comments on this diagnostic test.

Digital retinal photography is strictly a task for my technicians, who are also in charge of case histories, tonometry, autorefraction, testing color vision and visual acuity. We save the pictures to a file each day and can easily retrieve them on a future date. As the next step in our evolution of electronic record keeping, we will simply store the photos in the patient's file.

Marketing benefits

The following is a list of some of the marketing benefits to using digital retinal photography in your practice:

• patient education
• recall compliance and retention of patients
• enhance practice image (It's not just an eyeglass exam)
• increase referrals -- doing something different and impressive, it's a competitive advantage
• can print extra copies of photos to give to a patient.
  In addition to marketing, digital retinal photography also provides these clinical benefits:
• easier detection of abnormalities
• documentation of abnormalities and anatomical structures
• comparison of lesions and anatomical changes over time
• an aid in referrals to retinal specialists and others
• an aid in reporting to doctors who refer to you
• protection in the event of malpractice charges.

Other benefits

Here's a quick grocery list of some of the general benefits of performing retinal photography:

• increased referrals from the "wow" factor
• a gain competitive advantage over other offices.
• improved compliance with recall because of better understanding.
• the clinical value of a permanent electronic record
• time-saving factor because of no dilation and reduced fundus exam time
• digital photography uses a much reduced flash intensity than other cameras
• allows going from right eye to the left eye with no delay and no discomfort for the patient.
• digital photography provides better clarity than Polaroid -- but instant viewing, unlike 35 mm slides.

More benefits for your buck

I enjoy the comfort of having photo documentation for future reference. Increased referrals and patient awareness is my compensation, although it's hard to forget about the excellent public relations and educational value that this instrumentation holds. Consider the transition from slit lamp retinal documentation to digital documentation. You won't regret it.

Dr. Lord is the sole owner of a four-location optometric/optical practice. He's president of the Georgia State Board of Optometry and is the author of numerous articles that have appeared in national optometric journals.