instrumental strategies

Maximize the Value of Imaging

How delegation and networking increased the value of this HRT3.

ELLIOT M. KIRSTEIN, OD, FAAO

Many optometrists enjoy the increasing benefit of access to the newer technologies in ophthalmic imaging. The notion of "a picture is worth a thousand words" is far from new and clearly validates the rewards of moving away from the age-old standard of using colored pencils to document ocular pathology. From the perspective of diagnosis, the results are obvious; better images render better information which begat better diagnosis.

Our practice has used various imaging devises for the past 20 years. In 1990, we installed our first analogue slit lamp video attachments. While in the examination chair, patients could see images of their own eyes, including cornea, contact lenses and fundus. We quickly realized the benefits of excellent clinical documentation combined with the patient "wow factor" that imaging creates.

Keep the patient in the loop

In 2002, we purchased our HRT II. In doing so, we maintained our vigilance with regard to keeping the patient in the loop. It seemed intuitive that the instrument offered a wealth in patient and doctor education and "wow factor" that would be thrown to waste if the test were performed by a technician.

Just think about it: The technician runs the test, prints a report and attaches it to the patient record. The doctor scans the results and, hopefully, reviews the results with the patient. Scenario #2 has the doctor taking the test. The data is immediately shared with the patient their patients with far greater splendor that than any one page report could ever offer. Indeed, the actual imaging system offers far more useful data for the doctor and the patient than it provides on its printed report.

As the practice grew busier, Dr. Kirstein delegated the operation of the HRT3 to technicians, which remove the bottleneck from the office's patient flow.

A compliance tool

During the past five years, my partner and I have considered the HRT as a valuable tool to optimize compliance. Our practice manages approximately 1,200 patients who either have glaucoma or are suspects. We use the HRT3 to take images of about 150 patients each month, including those who are considered at risk due to any combination of high IOP, visual field defect or glaucomatous nerve appearance. They are imaged at baseline and followed once or twice per year depending on the severity of their risk factors.

As an asymptomatic chronic disease which bears the risk of severe morbidity, glaucoma management has much in common with management of diabetes and systemic hypertension. Physicians require all the help they can get to help their patients to develop the knowledge and understanding of their disease to combat their human nature to eat that piece of cake because "I deserve it", stop taking their blood pressure meds because "I feel pretty good" or ignore their glaucoma medications because their eyes" feel fine."

The HRT delivers the ability to graphically show a patient that their nerve is at risk or, even more compelling, that they have permanently lost optic nerve tissue because of disease progression. These graphics deliver a powerful message to the patient. I can easily recall countless times when patients could not be convinced to take their glaucoma medicine until we showed them the red spots on the HRT screen showing their irreversible progression or, with the newer HRT3 software, the toggle between their original and current nerve photos images.

While we have no research that documents that these techniques increase the rate of compliance with glaucoma therapies, it is my anecdotal impression that patients have a better understanding of their illness and better confidence in our ability to deliver the very best eye care. I believe these factors facilitate compliance. The time it takes to review the HRT images with each glaucoma patient or suspect is two to three minutes well-spent.

Out of the Dark Ages

Last January, we moved into our new office. It is much larger and much more organized. My partner and I made the commitment to move out of the dark ages and, finally, let our technicians run the HRT. In fact, we had no choice. The only other way to avoid patient flow bottlenecks would be to buy another machine.

By networking the HRT3 software to existing computers within the practice, Dr. Kirstein was able to create eight HRT viewing stations.

Fortunately, when we upgraded to HRT3, we learned that the new software was "networkable." This means that we could review and manage HRT3 data — in its entirety — from remote viewing stations. These viewing stations are simply our existing computers, located in the O.D.'s offices and examination rooms, that operate on the same network as the HRT. It's like having eight imaging systems for little more than the price of one!

One of the old concerns of having technicians take the test was that they might not draw the nerve margins accurately. This concern was obviated given our ability to manage all data from any viewing station. If we do not like the technicians drawing, we can easily adjust it. The result is that, with one HRT3, we can view and manage all data in each of the practice's examination room as well as our private offices.

A simple, cost-saving system

The cost of the additional viewing stations was modest. As the computers already operated on our existing network, the only cost was a $500 license fee per station. (If the work station is located outside of the network from which the HRT operates, the cost of the license fee is $1,000 per station.) We use a typical Ethernet system with Windows XP Professional on our viewing stations.

The networked imaging system also provided us with quantifiable practice management efficiencies. The average visit time per patient for a complete workup (including dilation, fields, imaging, tonometry, etc.) has been reduced from one hour to 35 to 40 minutes due to the eight HRT viewing stations.

Our practice bills $70 per eye for HRT3 imaging. Insurance reimbursement averages about 70% of the amount billed.

It all goes back to the patient

Economics aside, think about the "wow factor." The technician takes a test, and 10 minutes later the patient is in the exam room with their doc watching a movie — or a series of pictures — showing the progression of their disease. We may have to write an addendum to the adage of "a picture is worth a thousand words." How about "and a movie is worth 100,000." OM

Dr. Kirstein received is the director of Harper's Point Eye Associates, in Cincinnati, Ohio. He is a member of the AOA, ARVO and the National Board of Examiners in Optometry. He is a fellow of the American Academy of Optometry and a member of the Optometric Glaucoma Society. He is now in his thirty second year of optometric practice..