FEATURE ›› CLINICAL EFFICIENCY

HIT THE GROUND RUNNING

See which tips for achieving efficiency in the clinic you can propose for your practice.
Part 1

BY DESIREE IFFT, CONTRIBUTING EDITOR

Running an efficient clinic is a monumental task. The number of variables at play on any given day, the ever-lengthening list of regulations and the frequent introduction of new treatments and technologies would be enough to make TV doctor Marcus Welby, MD, hang up his white coat for good. Retina practices arguably have it the worst. But don’t despair. Efficiency is attainable; it just requires diligence, an open mind and a willingness to adapt. When a clinic is functioning efficiently, patients are happier, doctors and staff are content and more productive, and revenue is maximized.

To get you thinking about efficiency as you begin your career, we asked established doctors to share their best strategies. We present their insights in their own words, minus the quotation marks that would only slow you down, getting in the way of — well, efficiency. Also in the interest of streamlining, we organized the tips by doctor, rather than by topic. Finally, these aren’t all of the tips the experts provided. We’ll have more tips from other retina specialists in the next issue.

SEENU HARIPRASAD, MD
VITREORETINAL SERVICE
UNIVERSITY OF CHICAGO
DEPARTMENT OF SURGERY

›› Not every patient needs a full work up. Therefore, before clinic starts each day, I alert the technicians which patients can be streamlined, such as post-op or procedure-only patients.

›› I schedule patients for whom I anticipate a long visit, such as uveitis patients, at the end of the morning or the end of the afternoon. Scheduling complicated patients in the thick of clinic time can set you behind for the entire half-day.

›› Have technicians prepare injection kits ahead of time. Our kits are Ziploc bags that contain everything needed to administer an intravitreal injection (e.g., lid speculum, sterile field, Betadine, needles, syringe). When these kits are on hand, I don’t have to wait for the technician to gather the items for each injection.

PAMELA ANN WEBER, MD
ISLAND RETINA
SUFFOLK COUNTY, NY

›› I’ve been practicing retina for 24 years and frequently receive compliments regarding the operation of our office. My overall strategy for running the office starts with leadership. As the physician, I set the tone. Every day has to be a good day. Every patient is important and is greeted with a smile and a personal, albeit brief, conversation. Here, I provide details of how we handle certain day-to-day tasks efficiently as well as some general efficiency-related advice.

›› EHR is crucial. Most practices are on board with this by now. Those that aren’t should begin moving forward with implementation. A good place to start would be the AAO meeting this fall in Chicago, where all of the EHR companies will be happy to talk about what they have to offer. Every practice needs to choose the package that best fits its needs. If they’re honest, most practices will tell you it takes approximately 1 year to completely adapt to EHR, but once that’s done, they can’t imagine life without it.

›› Every Sunday, I review the upcoming week. With EHR, I can do this from my laptop at home. I review the schedules and then we tweak them as needed on Monday. For example, if I spot an overbooking, I may open up additional time on another day. I keep Thursdays open as a day off, but work on that day if needed. Another example: If I see that we may be in for a complicated visit with a particular patient, I allot more time for that visit and don’t book another patient in the next slot.

›› Every morning, I review each patient’s EHR to make sure I have a sense of the issues we’re facing and an idea of the direction we’re going with treatment.

›› We frequently perform testing that doesn’t require dilation, such as OCT, while patients are dilating. This improves patient flow.

›› We apply povidone iodine for our injection patients, then wait 10 minutes before giving the injection. This allows for maximum sterilization of the eye, and it gives us a chance to see other patients in the interim.

›› We participate in many phase 2 and phase 3 drug-testing studies, allowing us to interact with other retina centers, which in turn keeps us current and aware of new ideas.

›› To save time, technicians enter each patient’s basic information into our stand-alone testing devices (such as OCT) ahead of time.

›› We have regular staff meetings, with lunch, to address problems arising in the practice.

›› I perform my surgeries in the ambulatory surgery center in my building, which is a great arrangement. I can see patients in the morning, be in the OR in the afternoon and jump back to my office to see additional patients in the late afternoon, if necessary.

›› Assemble a well-educated team of employees who like their jobs and enjoy coming to work. I always study each employee and determine where his or her talents and interests lie. We use that knowledge to place each of them in an area where they can excel. Not everyone can be a fluorescein angiographer, but if I see that talent, I develop it. Also, I make sure everyone is always learning and advancing their careers.

›› Bigger is not always better. I'm hands-on in my office.

›› More is not always better. All practices are forced to increase volume as revenue drops, but don’t sacrifice the overall happiness of your office.

›› Be flexible. As medicine changes, we need to change with it.

NANCY M. HOLEKAMP, MD
PEPOSE VISION INSTITUTE
ST. LOUIS, MO.

›› The doctor must show up to work on time.

›› The schedule must contain a reasonable number of patients to be seen in a day. Double- and triple-booking patients leads to inefficiencies and unhappy patients.

›› Front-office personnel should review each day’s schedule in advance, recognize who may be getting injections, and obtain pre-certification for treatment before the patient walks in the door.

›› All technicians should be cross-trained so all are able to work up patients, perform OCT and angiography, assist with procedures and help patients check out.

CHARLES WYKOFF, MD, PHD, FACS
RETINA CONSULTANTS OF HOUSTON

›› Diagnostic imaging is a large part of the retina practice. Rather than review results once before meeting with each patient and then again with the patient, ideally I review them for the first time with the patient. When possible, I go over the scans with my patient and his or her family on a computer monitor. In addition to being efficient, this approach gives patients a deeper understanding of their condition and my management strategy.

›› Rather than rely solely on EHR and faxes, I interact personally with my referring doctors quite frequently. I don’t hesitate to call them about mutual patients, especially those with sick eyes who require multifaceted care and multiple procedures. This minimizes information slipping through the cracks and maximizes care efficiency.

›› When not handled properly, the EHR interface can be a barrier to efficiency in the clinic. Delegation is the key to overcoming this barrier. I typically have a scribe in the exam room with me, who enters the relevant information into the electronic record during the visit.

›› Delegation also enhances efficiency when it comes to the most frequently conveyed patient education information. We have thoroughly educated our staff on exactly what to say about common topics, including how to use an Amsler grid, recommendations for AREDS vitamins and the warning signs of retinal detachment. Once the doctor leaves the room, the staff member spends time reviewing and further explaining the information to the patient.

›› The more staff members a practice has, the more challenging it becomes to coordinate what each person should be doing throughout the day and ensuring they’re doing it. We make it a point to stay on top of how the whole system is working and to clearly articulate each staff member’s duties.

›› A good team dynamic is also crucial to an efficient clinic. I try to bring together people who get along and respect each other. If I sense a problem emerging, it’s well worth trying to address it. Because we have several retina specialists in our practice, we’ve been able to shift staff members from one doctor to another until we achieve the right mix of people.

To be productive, team members need to know that what they do is important and makes a difference. I try to find ways to show them directly how much they are appreciated by myself and by my patients.

SOPHIE BAKRI, MD
MAYO CLINIC
ROCHESTER, MINN.

›› Stay focused on the day’s patients while you’re in the clinic. Make every effort to minimize distractions and avoid getting caught up in anything not related to patient care.

›› Pre-order any necessary imaging so your treatment decision can be made as soon as you see the patient.

›› Make sure the EHR would read well to referring physicians. If it does, you can send a copy of the records directly to them without duplicating the information in a letter.

JORDAN M. GRAFF, MD
BARNET DULANEY PERKINS EYE CENTER
PHOENIX, ARIZ.

›› Intravitreal injections, and the associated patient prepping, are among the greatest challenges to efficiency in the modern retina clinic. To numb our patients’ eyes, we use 4% subconjunctival lidocaine, which takes effect quickly so the injection can be given within 2 to 3 minutes. A tiny, focal bleb of the lidocaine is all that is needed, and the surgeon never has to leave the room once the decision is made to inject. Other options require too much time for adequate onset of analgesia, resulting in an uncomfortable (and thus unhappy) patient, or require the surgeon to be otherwise occupied for a prolonged time before returning to the room to administer the injection.

›› With electronic health records and the intense scrutiny of documentation retina practices face today, efficiency must be balanced with cautious, meticulous documentation. Allowing one to suffer at the expense of the other is intolerable. Our practice has found that having adequate IT support is crucial. We’re a very large enterprise, so we have an in-house IT team. We rely on the team to adjust and refine our EHR templates, reduce clicks and typing for EHR users and create and continually refine economy of motion throughout the documentation process.

As surgeons, we’re accustomed to applying these types of principles in the operating room, where we pay attention to and minimize redundant movements. However, refining our actions similarly in the clinic requires specific feedback from doctors and nimble, skilled IT support, whether that support is in-house or contracted in some other manner. NRP