Article Date: 4/1/2009

Breaking The "Bell"
practice management

Breaking The "Bell"

Putting management ideas into practice allowed us to transform our practice.

LOREN AZEVEDO, O.D., F.A.A.O. Arcata, Calif.

During the past two years, three of five optometrists left our practice, A to Z Eyecare, Arcata, Calif. We built the practice with Jim Barnes, O.D., who decided to retire after 44 years of excellent service. The other two doctors, a husband and wife, moved to be closer to family after the birth of their twins.

As one of the two doctors who remained, I had practiced for 25 years and hadn't anticipated major changes at that stage of my career. I understood that the lifespan of most private practices typically follows a bell curve: At first, growth is slow, then it accelerates and peaks when doctors are in their 40s or 50s. Finally, growth declines as the doctors taper back their schedules. Considering this, it was reasonable to expect that our practice would decline in both patients and revenue.

Today, I'm happy to report the contrary. Our practice has actually grown from $1.8 million in adjusted gross sales to $2.2 million, a 22% increase. How did we "break the bell"? Surprisingly, it wasn't that difficult. Using the following eight steps, we created a new paradigm for management in our practice.

1 We installed Electronic Medical Records (EMR).

We began the installation process during our transition from five to three doctors. It was challenging and sometimes painful. Nevertheless, the best advice we can give is — to borrow Nike's motto — "Just do it!"

Here's why: Efficiency nearly doubled and mistakes in ordering contact lenses and spectacles dropped nearly in half. Exam times went from 45 minutes to 20 minutes as quality improved. Efficiency drivers include:

► full utilization of all EMR functions, not just the popular bookkeeping and scheduling modules.

► Easy access to all records, including referring patients, family and friends. Our paper system wasn't efficient. For example, we recently removed an old file cabinet and found a lost patient record behind it. Our worst feeling was trying to explain a "lost record" to patients. Then, there is the mom in the exam chair who asks about her son's vision — and he presented 200 patient visits ago. Now, we can access records with one click.

► We add items to the "social history" section that our feeble minds cannot remember, such as a child winning a spelling bee or a 50th wedding anniversary. No longer do we start exams with a "foot-in-the-mouth" comment.

► We have instant access to vision and medical insurance. Last year, we significantly increased our fitting of "medically-necessary contact lenses" because EMR quickly alerted us to patients who were eligible for such coverage. We could tell these patients, "Because of your coverage, did you know that we can refit to a new lens technology for no out-of-pocket expense, vs. the normal charge of $650."

► We integrated our EMR with Vision Service Plan (VSP). About 70% of our practice is VSP. An electronic link to VSP's Web-based services speeds information and transactions.

► With template scheduling, the reception team no longer has to analyze which time slot is available for a particular patient and doctor. The system prepares appointments two months in advance.

► We pre-appoint patients automatically.

► Notes are all clear and concise, and handwriting issues are eliminated. All charts can be accessed from any monitor.

► We list family members on each chart. Now, when mom visits for her appointment, I can look in her record and with her, schedule the rest of the family for appointments.

2 We review charts one day in advance.

With EMR, staff members can create new exam records two days ahead, leaving the doctors to review and amend the charts one day ahead. The doctor can request retinal images, and specify wide angle or superior or zoom variations. Through e-mail prior to the office visit, we address such concerns as: "time to schedule a glaucoma workup," "Two redos last year; pay attention to seg height," "husband and wife scheduled together but recently divorced" and "time to schedule patient's children for their annual exam." The result is a nearly seamless and efficient day.

3 We include retinal imaging with pre-testing.

In response to an increased emphasis on the medical aspect of eye care in optometry, we've found that recent optometry school graduates dilate much more than senior doctors. A better option is retinal imaging, which is fast, easy, and creates better records than drawings. By directing the patient to gaze in various directions, you can get good peripheral images with normal pupils. Sure, we still dilate, but that number represents only about 10% of the patients we dilated prior to acquiring the imaging system.

We have found that many images can be reimbursed through the patient's insurance or managed vision care plan. Also, complimentary images work great to illustrate the doctor's recommendation. While these systems do not always provide the perfect images, they work much better than our drawings and memory.

With fewer patients dilated, there is an improved use of exam rooms, which leads to increased efficiency, a higher revenue per patient (RPP), due to quality time with contact lens fittings and eye wear selection, better patient care — as discussed above — and a much happier patient. Also, we've found that the additional revenues generated by the imaging system alone more than cover the cost of monthly payments.

4 We acquired and use quality aberrometers and auto refractors.

We estimate that these instruments have shortened our refraction time from eight to four minutes, mainly due to accuracy of the astigmatism prescription readings with today's aberrometers. The reading is so good that our Jackson Cross testing time has dropped by 80%. If we cannot get a reading, it's usually due to a cataract and occasionally a small pupil. This alerts us to a potential medical diagnosis before the health exam starts.

5 We recommend high-resolution spectacle lenses.

High-resolution lenses have improved patient satisfaction. The first year we prescribed them, they contributed to a $100 increase in RPP. Now, a year later, our patients are purchasing their second pair because they are so pleased with their vision.

6 We delegate and create ophthalmic professionals.

The most efficient way to fit contact lenses is to delegate the entire process. We have six contact lens professionals who can fit multifocal gas permeable lenses and toric lenses. Yes, we doctors are there if needed. For tough fits, we call our contact lens supplier's consultants, using a speakerphone with the patient in the room. This quick and simple call impresses patients, greatly increases their learning curve and improves fitting success. This is very high level of delegation empowers staff members to new levels of performance.

We delegate everything except the refraction and final health exam. This allows the doctors to stay where they are most needed, as it allows the staff to continue with the exam. Aside from the exam process, we've discovered other areas for delegation. Our stellar optical manager makes the majority of our inventory decisions. Our optician, who has an art degree, works on both the displays and the artwork that we show in our office. Another optician spends one day a week handling marketing details for the practice.

Other staff members are in charge of tasks, such as accounting, LASIK coordination, patient communication and tracking the business statistics that help us to make so many decisions. My staff keeps me informed by copying me on pertinent e-mail discussions and through regular updates and presentations. Once a week, we close for a one-hour office meeting. This meeting has become critical in helping us to stay connected and well-coordinated.

Our two-doctor practice maintains about the same number of full-time employees that we did with five doctors. We have simply improved efficiency and redistributed key tasks.

Note: An expanded staff requires a sharp manager, so again, delegate: Hire a great office manager and let him or her take care of all human resource issues.

7 We perfect the doctor-to-staff hand-off.

This hand-off is the crucial moment when the doctor transfers his or her authority to the staff member in front of the patient in the exam room. The hand-off may include as many as three staff members (an optician, a contact lens technician and a benefits coordinator). This very specific interaction means that the doctor can make recommendations in front of both the patient and staff. This allows the staff to present options based on the doctor's specific recommendations.

Good hand-offs have been indispensable for increasing our RPP. In the past three years we have increased our RPP from the $300's to $450 to $500. In large part, this is due to the fact that patients now order glasses based on the doctor's recommendations of how we can best meet their needs.

8 Hire a new O.D.

A new graduate starts at our practice in June. California just passed a new glaucoma privileges bill, and our new doctor will be the first optometrist, within 200 miles of our practice, who is fully licensed to treat glaucoma and other medical conditions. He also plans to start a low vision specialty.

How will independent optometry grow if existing practices don't provide the opportunities? After you have an efficient system, invite students and doctors to visit and see whether they like your style. If so, I recommend hiring them even before you think it's affordable. I find our talented young doctors provide a fresh viewpoint, improve office morale, increase the knowledge base of our practice and allow us to utilize our facilities more efficiently.

We plan to add two more optometrists in the next five years. Four of our patients now attend optometry school. Hopefully, at least one will want to return "home." In addition, we are starting a preceptorship through Pacific University that will provide the opportunity for the next generation to learn optometry, from "A to Z." OM

Dr. Azevedo is a partner in A to Z Eyecare, a private practice in Arcata on the Northcoast of California. For more information, e-mail him at

Optometric Management, Issue: April 2009