Pretesting is widely utilized in eye care and its popularity is understandable because office efficiency is greatly increased. Delegating most of the data collection during a comprehensive eye exam allows the doctor to focus on higher-level tasks like ocular health assessment and patient consultation. While pretesting is performed to some degree in most practices, there is a huge range of techniques and procedures. In the interest of pursuing more of a good thing, if your pretesting process is limited to one area, let's consider expanding it to the exam room.

The floor plan

The approach I like best uses one or more pretest rooms, a separate retinal imaging room and at least two exam rooms per doctor. In this arrangement, the pretest room is used to preinstall 2.5% phenylephrine, take autorefraction and autokeratometry readings, measure intraocular pressure with a non-contact tonometer and screen the visual fields with a small autoperimeter. If the patient has eyeglasses not made by our office, lensometry is performed in this room during the field screening.

Since most patients will go through the pretest room, we make an effort to avoid a bottleneck by minimizing the activities performed there and moving into any available exam room as soon as possible. Multiple exam rooms allow a tech to work in one room while the doctor works in another. Ideally, there will always be a patient waiting for the doctor (but not too long of a wait!) and the doc simply moves between two (or three or four) exam rooms.

The tech in the exam room

Here are some pretesting activities to conduct in the exam room.

• Case history. The doctor will review and expand on the history, but having it recorded by a tech in advance greatly speeds up the exam. Case histories can become time consuming, so I prefer the tech to do it in the exam room. If some personal chit chat develops between tech and patient, all the better. We like the personal touch and we want to have time for that.
• Reinsert contact lenses. Contacts are removed for the automated pretest instruments, but I usually like to have them back on the eye when I see the patient. We have patients remove contact lenses in pretest and hand carry them into the exam room to reinsert there.
• Visual acuities at far and near. I prefer to have the acuity measured on the same eye chart that I will refract with because it avoids variations that exist with different display systems, room lighting and chart distances. I like to have very accurate acuity before and after the refraction and that is best achieved by using the same chart. I believe preliminary acuity should not be measured by the doctor; it's a huge drain on time.
• Color vision. I feel this test is part of a thorough eye exam and I like to have it tested at each full exam. Color vision books are inexpensive enough that they can be duplicated in all exam rooms. Doing this test in the exam room instead of the pretest area helps improve patient flow.
• Stereopsis. This is an excellent pretest because it's easy to perform by a technician at any skill level and it provides me with a good gauge of binocularity. Stereo books and polarized glasses are in every exam room.
• Blood pressure. I like to have blood pressure performed at every eye exam because it's an important screening for general health and it's often a major factor in eye health. We've used several automated cuffs, but we always go back to the standard sphygmomanometer and stethoscope. It's easy to measure with the patient seated in the exam chair and the technician on a stool to the side.
• The technician wipes the exam instruments with alcohol in front of the patient.
• We have the tech dial the starting lens Rx into the phoroptor to speed up the refraction process. We tried delegating refraction to techs, but we migrated back to having it performed by a doctor in most cases.
• The doctor is paged by the tech on a simple numeric pager in vibrate mode. Wait time for the doctor is minimized by placing the page a few minutes before the end of pretesting.
• Patient education video clips may be displayed on the exam room computer while the patient waits for the doctor. We make this optional in most cases.

Refining and increasing your pretesting routine pays big dividends in patient flow and efficiency.