Optometric Management Tip # 171   -   Wednesday, April 27, 2005
A Pretesting Protocol

I’ve written many times about the value of delegation in a practice. You simply can’t build a big, successful practice without it. While there are many ways to delegate the pretesting phase of an eye exam, I thought I would share the system I’ve used in my practice for many years in case it may spark an idea for how you can refine your delegation protocol. Virtually all optometrists delegate to some degree, but taking a step up from wherever you are on the delegation scale will certainly increase productivity in your practice. It doesn’t matter if you don’t have enough patients to keep you fully busy; be efficient first.

Job Descriptions

The optometric technicians in my practice are all cross-trained to be competent in clinical pretesting as well as optical dispensing. This cross-training is an advantage in giving the practice flexibility to send an employee to the area where he or she is needed most, and it prevents boredom burnout because the staff member performs a variety of duties. Of course, these techs are also competent in contact lens assisting and special diagnostic testing.

The routine in my practice is somewhat unique in that a single technician works with a patient from the beginning of the exam to the very end of the visit, and virtually never leaves the patient’s side. A nice bond is formed between tech and patient, and the patient is never left alone.

In addition to the optometric technician job title, we also employ opticians (who are only stationed in the optical and do not perform clinical work), as well as business office personnel/receptionists, optical lab technicians and an office manager. We have four optometrists in our single location office.

Pretest Room

A typical exam appointment would proceed as follows. A technician calls the patient in from the reception room, introduces herself and explains that she is assisting Dr. ________ today. The tech is trained to be friendly first and to explain the nature of each test as she goes along.

The first stop is a pretest room, which contains four instruments on a rota-table. We currently have two of these rooms, and we are seeing the need for a third. The technician is trained to move in and out of this room quickly, because it can be a bottleneck for other patients who are waiting to be called in, so chit-chat is kept at a minimum and case history is done later. The tests performed in the pretest room are:

• Contact lenses are removed, if worn.
• Autorefraction / autokeratometry.
• Gentle air puff tonometry.
• Auto visual field screening.
• Autolensometry of habitual Rx (while patient is doing field screening).

Diagnostic Imaging

The patient is escorted to a special testing room, and non-mydriatic digital retinal photography is performed. If the patient wears contact lenses or expresses an interest in them, corneal topography is also done.

Exam Room

The patient is taken to an exam room by the technician, where the technician conducts additional work before the doctor arrives. Each doctor works out of two or three exam rooms, so it’s efficient to perform more pretesting here while the doctor is seeing another patient.

• Contact lenses are reinserted now, if worn.
• A case history is conducted by the technician. New patients completed a basic entrance questionnaire earlier. The doctor will review the case history with the patient.
• Visual acuity is measured, far and near, with the habitual Rx.
• Stereopsis, color vision and blood pressure are taken. These devices are inexpensive enough to have a set in each exam room.
• The retinal and corneal images taken earlier are brought up on the flat screen computer monitor on the desk, for the doctor’s review with the patient later.
• The habitual lens Rx (or the autorefraction value, if no habitual) is dialed into the phoroptor.
• A patient education CD-ROM is played on the monitor while the patient waits for the doctor. The technician pages the doctor on his or her silent pager (via speed dial on office phones), communicating that the next patient is ready.
• If unknown RGP contacts are worn, the technician will read and record the base curve, power and diameter while waiting for the doctor.

Doctor’s Session

The technician remains in the exam room during the doctor’s portion of the exam. She has a workstation at the end of the refraction desk and remains quiet, recording new information while the doctor and patient talk. The tech completes all aspects of the paperwork, some of which can be done in advance during testing procedures, such as all entries on the superbill (including coding, fee entry and recall date), all copies of prescriptions to be written out, and insurance worksheets, if any. She scribes the exam data as dictated verbally by the doctor and she listens to the doctor/patient consultation so she can carry out the treatment plan agreed upon. Possible actions for the technician include:

• Frame selection and lens design.
• Instilling mydriatic drops (generally waiting until after frame selection).
• Trial contact lens insertion for doctor evaluation later.
• Orders written for spectacles and/or contact lenses.
• Additional testing, such as threshold visual fields, pachymetry or nerve fiber analysis.
• Reappointing for additional testing.
• Referral to local specialists for further evaluation; appointments scheduled.
• Returning to an exam room for dilated fundus exam.
• The technician reviews and totals the fees charged today and escorts the patient to the front desk for check out.

Best wishes for continued success,

Neil B. Gailmard, OD, MBA, FAAO
Chief Optometric Editor, Optometric Management