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 By Neil B. Gailmard, OD, MBA, FAAO, Editor November 7, 2007 - Tip #302 
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A Novel System for Patient Flow

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Additional Information

I never really thought the patient flow and staffing model I use in my practice was all that novel, but after analyzing many other practices, it seems so. I have used this model for over 20 years and it's worked well, so I'll describe it here. The unique aspect of the system is that one technician begins to work with a patient and stays with that patient throughout the entire visit. The patient is never left alone or handed off to another person. A strong relationship develops between the technician and patient and we are able to deliver outstanding service, while maximizing office efficiency.

The exam sequence

Typically, after a patient checks in at the front desk, a receptionist will page for an optometric technician over the office intercom. This page is only heard in areas of the office that are not open to patients, but available technicians will hear it and respond. The tech calls the patient in and introduces herself (or himself) and explains that she will perform some tests before seeing Dr. ________. If the appointment is for a comprehensive eye exam, the tech begins an extensive pretest work-up, which includes retinal photography and corneal topography for contact lens wearers. The technician and patient move into one of the exam rooms for additional pretesting. Technicians act as scribes with every patient encounter, so the pretester becomes the scribe when the doctor arrives.

Doctors don't page technicians; technicians page doctors

As the technician nears the end of pretesting, she uses any office telephone to page the doctor who is scheduled to do the eye exam. All doctors wear small numeric pagers, set to vibrate mode, and each pager phone number is programmed into speed dial on the telephone system. So the tech pushes one speed dial key, waits for the pager service to answer and just hangs up. No message is needed since we just use the pager as a signal device.

Because the doctor is silently notified that the next patient is ready, he or she can decide how to best respond in order minimize patient wait times. There are really many ways the doctor can be flexible and by doing so, stay on schedule. If the previous exam is nearly over, then just complete it and move on to the waiting patient. Otherwise, since a scribe is assisting on this exam also, it may be a good time to have the tech instill mydriatic drops, or apply diagnostic contact lenses, or do some special testing, or whatever may be helpful. The doctor can come back to this patient if needed.

The examination

The doctor joins the technician and greets the patient. With all the pretest data and images on display, the exam moves along fairly easily. During the exam and refraction, the doctor states the findings and lens values aloud and the technician records the data. She also makes notes of any additional information elicited from the patient and records any advice the doctor gives. The doctor focuses on the patient's history and complaints and on recommendations for treatment. The technician listens to the doctor/patient consultation at the end of the exam because she is going to carry out whatever steps are needed. As time permits during the visit, the technician completes the record with the diagnosis and plan, enters all fees, checks off the proper codes, and applies any insurance plans. Written copies of lens prescriptions for the patient are completed by the technician and recall dates are indicated. The doctor says goodbye and leaves the technician and patient.

The technician continues to work with the patient with whatever care is needed. If the visit is over, the tech walks the patient to the front desk. If contact lenses are to be fitted, the tech retrieves the lenses ordered by the doctor and inserts them. If more testing is needed, the tech either does it or reappoints for it. Any questions that remain about insurance or other matters are answered by the technician.

The best handoff is no handoff

In many cases, the next step after the exam is that the patient wishes to order eyeglasses. In that case, the same technician that did the pretesting walks the patient to the optical area and does the frame selection. The tech becomes an optician at this point, educating the patient about lens design options, checking the frame fit, and taking all measurements. The eyeglass order is written, fees are written up and vision plans are applied, if any. Because the technician heard the doctor's recommendations for lenses at chairside, no further communication is needed and we have maximum continuity. At the completion of the eyeglass order, the technician escorts the patient to the front desk and says goodbye. A receptionist enters all fees for the visit into the office management system, makes payment arrangements and prints the final receipt statement.

Appointment scheduling

We have a very simple appointment system. Every exam is given a 15 minute slot no matter what kind of visit it is and I don't try to control what kind of visits are accepted on various days or times. In this way, we can fill any slot easily. We schedule doctors, not technicians, and I don't worry about the lag time required to do a pretest. All staff members and doctors work hard to be on time for appointments and to start the day on time and quit on time.


All clinical technicians are trained in optical dispensing, but we have two full time opticians who only work in optical and do not do any pretesting work. We have additional staff for the business office and for the optical laboratory. This patient flow system may seem sophisticated, but it's really quite doable.

How many technicians?

When comparing numbers of employees from one practice to another, it's important to be aware that every office is different and how the office functions effects staffing numbers. Having said that, I've found that I'm optimally staffed with three technicians per working doctor. If we have two doctors working, six techs would be ideal. There are times when I don't have the luxury of the three to one ratio (due to call-offs, vacations, etc.), but that is my goal.

Best wishes for continued success,

Read Past Tips Neil B. Gailmard, OD, MBA, FAAO
Editor, Optometric Management Tip of the Week

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