While providing optometric care in my rural Tennessee practice, I have found that issues with accessibility can create additional challenges for patients. Factors such as travel time to the clinic, dependance on others for transportation, and availability of diagnostic and treatment equipment for specialty care can all affect patients’ ocular health.

This article will discuss tools and methods that can help make an eye care practice more accessible to patients based on their physical and geographic needs, how to select devices for a practice based on return on investment and patient needs, and how to train staff to use these tools.

The right tool for the job

Improving accessibility to eye care involves not only offering a wide variety of services in the practice, but also includes traveling to nursing homes, hospitals, schools, and, on rare occasions, a patient’s home. Technology, such as handheld devices, can help provide services outside the walls of the office.

Handheld/portable devices and headsets that offer tests, such as visual field, allow optometrists to provide better care in the office setting for patients with limited mobility; properly positioning a patient is not nearly as critical with these portable devices as it would be with a larger device such as a slit lamp. This typically makes the patient more relaxed and comfortable, making the test itself easier.

It is easy to take these devices outside the office, and when used in the office can help free up space by being brought to the patient instead of moving them elsewhere in the clinic. I’ll discuss several of these devices in more detail below, and why I added them to my practice. (See “Additional diagnostic devices” on p. 31 for other handheld/portable tools, and “Patient-operated diagnostic devices” on P. 32 for tools patients can use at home.)

• Electroretinogram: The handheld electroretinogram (ERG) was simple to implement with technicians, and the printout of the results is very user-friendly and easy to share with patients, providing numbers they can understand. Just as patients understand numbers such as A1C, having a number associated with diabetic retinopathy helps my practice monitor progression with patients, and gives the patient a simple way to follow their health; when they see that number go up or down on subsequent visits, they have more context for their eye health and become more invested in their own care.
• Tonometer: The portability of handheld tonometers has been very useful in the hospital, nursing homes, and for screenings outside the office. While Goldmann applanation tonometry remains the “gold standard” for measuring eye pressure, handheld tonometers have been found to be very accurate and reliable in children and those patients in which positioning in a slit lamp can be difficult, such as wheelchair-bound patients. Using handheld tonometer technology is very accurate and efficient, as ophthalmic technicians can check IOP quickly and without any anesthetics. It typically puts patients more at ease, as you don’t need to put a drop of anesthetic in their eyes as you would for Goldmann. It is useful to take two measurements, especially for glaucoma patients, and compare the handheld results with the results from Goldmann tonometry.
• Visual field testing: Visual field testing is challenging due to a heavy reliance on patient participation. Many factors can affect the outcome of tests: trial lens alignment, patient positioning, patient alertness, and length of the test time. I have found that investing in a headset visual field testing device helps solve many of these problems. It doesn’t use trial lenses, it’s usually more comfortable for patients to wear, and some models have a computerized voice that gives helpful reminders during the test, such as keeping focused on the target. (Note: In addition to visual fields, patient headsets may offer one or more of the following tests: color vision, contour stereo, contrast sensitivity, extraocular motility, foveal threshold, pupillometry, suprathreshold, and visual acuity.)

Also worth mentioning, though it’s not a medical device per se, is how useful a cell phone can be when visiting patients outside your practice. I typically take video, using my phone’s default recording app, of a patient’s muscle or pupil movements to consult later to help with diagnosing conditions.

Calculating ROI

When my practice decides to add new technology, we first research it to determine if it would be beneficial for our patient base. Then, we calculate a return on investment – while providing quality patient care is obviously the most important factor, we do need to make sure we can cover the cost of the device.

For example, when adding the handheld ERG to my practice I first took note of its cost (the device typically costs between $18,00 and $22,000, and for each use I would need a new set of electrodes, at a cost of about $20). Then, I researched the patients who would benefit from the test, such as my diabetic patients, glaucoma patients, and macular degeneration patients. I then took note of the payment associated with the test – in this case, the average reimbursement was $100. After calculating those costs and the payment, I concluded that I would be able to recoup the cost of the device in about six months, which made it an easy choice to add it to my practice and help improve my patients’ care.

Providing for rural areas

Another way in which we consider adding new technology is how it would impact our rural area. At my practice, for example, we have added technology, such as OCT angiography (OCT-A) and the handheld ERG, in part so that we could properly evaluate patients without them needing to drive several hours to see a specialist.

If you’re considering adding more services to benefit your area, think about what kind of conditions you’re seeing and how often. For example, my practice frequently cares for nursing home patients, so we wanted to expand into technology that could be used for conditions we were seeing among that patient population.

As another example, we recently expanded into non-surgical treatments for dry eye, such as intense pulsed light (IPL) and low-level light therapy (LLLT), to our practice, as there was no other medical practitioner offering such services in our area. This saved our patients the added time and money it would have cost to travel several hours to the nearest dry eye specialist, for care that would have required three to four visits.

For me, what’s most important about offering these services is giving our patients the chance to prevent further vision loss. For example, I recognized the OCT-A scanner was a good investment when I was able to use it on a patient to detect choroidal neovascularization — without this device, it’s unlikely he would have received the referral he needed to help protect his vision.

Preparing staff

Behind all successful practices is a well-trained staff. When we add new technology, we thoroughly educate the whole staff on how the new device can detect, manage, and monitor progression.

Each piece of technology in our practice has a “how to” in the office’s protocol manual. Our protocol manual is a step-by-step approach so each team member can perform the test effectively and efficiently. This protocol manual also has a script to explain to the patient the “why and what” behind a test that is being performed. For every instrument we have, we want to explain to the patient in layman’s terms what it does and how it benefits them, as that usually puts them more at ease.

For example, our entry on the handheld ERG has the following script: “Ms. Jones, this is going to measure your retina function much like an EKG does of the heart.” Likewise, for the handheld tonometer, our script is: “We want to check what the pressure of your eye is, as it can indicate the presence of diseases such as glaucoma.”

Lastly, the protocol manual lists the proper billing and coding protocol for each technology.

Investing in accessibility

Providing patients with more accessibility to care by investing in the latest technological advancements can wow patients and give them the best clinical care available. These investments can not only bring care to patients with mobility challenges, but can provide improved care for patients whose medical choices may be limited by geography.

It is our responsibility to invest in our patients, because they have invested in us by choosing our services. OM

DR. BYNUM owns Northwest Tennessee Eye Clinic, P.C., with locations in Martin and Greenfield, Tenn. She has a background in contact lenses, ocular disease, and pathology, as well as refractive surgical care and comanagement of cataract and glaucoma procedures. She is a Vision Source Administrator and a speaker for CooperVision.