Article Date: 11/1/2001

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Try this popular ophthalmology strategy to increase efficiency while providing top-quality care.
BY NEIL B. GAILMARD, O.D., M.B.A., F.A.A.O., Munster, Ind.

One delegated task that leads to the ultimate in efficiency and that's used widely in ophthalmology, but rarely in optometry, is scribing. Though some call those who perform this task "scribes," I prefer to call them chairside technicians because they do much more than just write notes in the record. We've employed them in our office since 1986.

I've always been a big advocate of delegation in optometric practice, but now it's more important than ever. Ophthalmologists tend to think big, and despite the many differences we have with them, we can learn a lot from them.


Quality time

I first got the idea to use chairside techs when I was visiting a local M.D. and saw him providing his patients with clinical care. I marveled at how quickly he moved from one patient to the next -- yet despite his efficient manner, his patients clearly admired and respected him. They never felt that he wasn't spending enough time with them -- the expert care was obvious.

Not so obvious was the important role his ophthalmic tech played. She quietly joined the doctor in the exam room, sitting in the corner at the edge of a built-in counter, recording the test results and the doctor's recommendations in the patient's record. Witnessing the immediate benefit of this way of practice, I decided to begin using a chairside tech in my own office.

Our new office environment

We've developed and refined a system in our practice that works as well (or better) than what I observed in the M.D.'s office (see "Realizing the Full Benefit of Technicians"). We trained existing staff members to fill the role of our chairside techs. They provide complete care from pre-testing to frame measurements, without leaving the patient's side during a visit.

We continuously survey our patients to monitor their quality of care, and the staff perceives that patients don't feel rushed. In fact, I believe this system is impressive to patients, resulting in strong word-of-mouth referrals.

Patients sense that they're being well cared for in a busy, yet high-service practice. There's plenty of time for the personal, friendly touch our staff enjoys providing. We never leave patients alone, and they don't experience a long wait.


Realizing the Full Benefit of Technicians


How our techs manage patient flow in my practice.

  • A patient checks in at the front desk for his appointment and completes our "Welcome to the Office "questionnaire.
  • The front desk staff pages for an available tech over our phone system. The receptionist announces "A1 please," which is our way of signaling that a workup needs to be started.
  • The technician calls the patient in from the reception area, introduces herself and takes him to a pretest room to perform autorefraction, auto-Ks, non-contact tonometry, visual field screening and lensometry of habitual prescription.
  • The tech also takes digital retinal photographs and corneal topography on every patient, and I call up these images later on the computer in the exam room.
  • The tech escorts the patient to an exam room, takes a case history including chief complaint, visual acuities, blood pressure measurement, stereopsis and color vision, then dials the habitual prescription or autorefraction findings into the phoropter. The technician then starts a playlist of narrated eyecare topics on the computer workstation for the patient to view while waiting for me.
  • The tech notifies me that the patient is ready by silently paging me (on vibrate mode) using office phones with my pager number programmed on speed dial.
  • I join the technician and the patient and perform the exam, review all findings and make my recommendations for the patient's care. (Our doctors have a 15-minute appointment slot for this portion of the visit.)
  • My tech records all exam data as dictated by me and takes general notes about the exam.
  • I then leave the tech to complete the patient's care, which may include frame selection and measurement, trial contact lens insertion, instillation of eye drops, further testing, referral appointments, etc. If we dilated the patient, the tech works him back into an exam room for a final check.
  • The tech writes up and explains all fees and escorts the patient to the business office for checkout.

This whole exam process is different than the usual procedure patients have experienced in the past, and I find that they're impressed with the thoroughness.

- Neil Gailmard, O.D., M.B.A., F.A.A.O.

Reaping the rewards

The following are just a few of the many benefits of using chairside technicians:

Making the change

If you're interested in using a chairside tech in your own office, I have some advice on how to implement this new approach.

Don't take on the role of a dictator and abruptly announce the change in office procedure. This approach may make staff members apprehensive, and they may not support an idea that they didn't help invent. I recommend holding a staff meeting to discuss a problem (in this case, the growing need for increased efficiency and more patients seen per day) and listen to staff input.

Inform staff of the chairside assisting concept -- refer to this article or the professions of ophthalmology, dentistry, etc. Pledge your support for training and your desire to hire additional staff to keep the practice stress-free. Reassure staff that you'll be patient as they learn new terms. Design special exam forms that guide techs to proper recording. Then, just do it.

Modify your system as you go along. High-level delegation such as scribing does best if you already delegate well in your practice. If you don't, you may need to move toward this goal in smaller steps.

For example, in the beginning, train staff after office hours or during down time. Once they feel that they're ready, use them as chairside techs only a few times a day, then kick it into high gear and have them in the exam room with you all the time.

Scribing also works best for doctors who are comfortable with fairly quick exam times -- if not, and it takes you half an hour or longer to perform an exam, you'll waste your staff's time (plus it can become extremely boring).

Chairside manner

Exam room etiquette may seem a little strange at first, but it'll quickly become comfortable. I'm often glad to have a third person in the exam room with me. The tech has had plenty of time to talk with the patient, so when I join the picture, I prefer that the tech stay in the background unless I request her help.

The tech records some data at her discretion, such as new information revealed in the case history. I'll recite my findings out loud, but I avoid making the patient feel left out by saying something such as, "These numbers are just part of the formula we use for your lens prescription . . . I'll go over this with you later."

If part of the eye exam is normal, then I tell the patient that everything looks fine, and then I speak directly to the tech and describe the media, nerve head, cup/disc ratio and other findings.

However, if part of the exam reveals problems, I may elect to remain silent so that I can discuss the diagnosis and treatment with the patient after I've gathered more information. I can reach over and record or draw something myself, and it seems perfectly normal to the patient.

Set your worries aside

Some doctors are concerned that using chairside technicians will cause a large increase in staff payroll, but my experience has been that the increased productivity more than compensates for the cost of additional salaries. You may need to hire additional technicians, but you can do this in small steps as you go. I believe that most optometric practices are understaffed anyway.

There need not be an instant staff shortage as you begin this new system. I tell our office manager that if the office is ever in great need of a tech for some task, she always knows where to find one. She can simply knock on the exam room door, peek in and ask the tech to step out. I'll understand the office needs her and carry on alone.

The next level of efficiency

Intelligent delegation can definitely take your practice to the next level of efficiency and productivity, but one thing is for sure -- if you begin using chairside techs, you'll see some major changes occur in your practice. You'll experience less confusion when it comes to managing patients, you'll be able to delegate more to your technicians and the office will run like a well-oiled machine. Try it out in your office and see for yourself.

Dr. Gailmard is in group practice at Gailmard Eye & Laser Center in Munster, Ind. He's also OM's chief optometric editor.



Optometric Management, Issue: November 2001