Article Date: 11/1/2006

prescription authority
MAXIMIZE Prescription Authority

Here's how to put your training into action.

MICHELLE BOYLES, Managing Editor

According to statistics from the 2004 AOA Scope of Practice Survey (the last year for which numbers are available), O.D.s diagnosed about 36% more patients with glaucoma in 2004 versus 2002, and 23% more with other anterior segment disorders. However, optometrists with appropriate prescribing authority in 2004 treated or co-managed 66% of the glaucoma patients they diagnosed and 85% of those diagnosed with anterior segment disorders. A recent survey by the National Board of Examiners in Optometry found that ocular disease treatment is an integral part of optometric practice and that prescribing topical medications, both legend and over-the-counter, is a primary treatment option. But only 13% of optometric examinations were disease-related.

As optometry moves to encompass the medical model and Baby Boomers age, you will find greater opportunities to manage patients who suffer from eye disease. Providing prescriptions will enhance patient care, boost your confidence and benefit your practice.

Therapeutics Most Prescribed By O.D.s by Category

Average number of prescriptions written in a six-month period.

Dry Eye 108
Antimicrobials 69
Allergy 68
Glaucoma 46
Anti-inflammatory/steroids 45
Vitamin 44
*Numbers from 2004 AOA Scope of Practice Survey.

Practice evolution

There are numerous reasons why it's important for optometry to increase prescriptions. On a professional level, it helps support expanded scope-of-practice. There are also some who posit that utilizing prescription authority is essential to optometry's evolution. "Any profession, or professional, who does not continue to expand and meet the challenges of new technologies will be driven to extinction," says Tom Annunziato, O.D., president of the Texas optometric Association. "Today's practices won't grow if they don't adopt the medical model," says optometrist Douglas DeVries of Sparks, Nev.

Writing prescriptions may also improve your standing with pharmaceutical representatives. Most of these companies track the number of prescriptions written for a given product, where the prescriptions are filled and who wrote the script. Some studies have shown a discrepancy in the number of prescriptions O.D.s report writing and the actual number of prescriptions attributed to them. But new regu- lations under HIPAA may change that. (See "Rx Tracking" on page 43.)

Over the counter products

It's important for patients to receive timely and accurate care. And writing a script for those conditions you know how to treat is important to your practice because it elevates you in the patient's eyes. Studies have shown that patients take a written prescription more seriously than a general recommendation. "The act of writing a prescription, whether for over-the-counter or prescription medications, is very powerful," says Carla Mack, O.D., Director of Clinics at the Ohio State University College of Optometry and author of OM's Coding column. "It's something physical ... that reinforces to the patient that you have the expertise and experience to care for that patient's needs," she says. So, don't just write prescriptions for medications that require them, write down the appropriate contact lens solution, dry eye treatment or nutritional supplement and hand it over to the patient.

Where Optometry is Restricted

Dots show in which states O.D.s can't prescribe certain medications.



















District of Columbia





















new Hampshire      
New Mexico       
New York      
Rhode Island       
* Information derived from the American Optometric Association's State Government Relations Center.

"Without specific direction, a patient is bombarded with too many options when it comes to all over-the-counter medications," says Dr. Annunziato. "Without a professional's guidance, the patient is susceptible to the best-marketed products on the shelves."

Most patients aren't familiar with the differences in OTC products. "I believe when you recommend an over-the- counter product, you should always prescribe," says Dr. DeVries, "If you just say, 'artificial tear' patients will buy whatever is cheapest and end up doing more damage than good."

Patients are also often forgetful. A written prescription will both remind them of the right product and reinforce the importance of the proper treatment.

Serving the Baby Boomers

The future will also bring more patients into your office with conditions that require medical management like surgery and age-related eye disease. Currently, most cataract patients are over the age of 60. In the next 15 years, 80 million Americans will reach the age of retirement. Age-related eye diseases are becoming more prevalent partly as the result of Americans' longer life span. "Think of the impact it would make if the doctor records on a prescription pad that he would like the patient to return in six months for re-evaluation of cataracts as compared to the office reception staff advising the patient call back in six months to schedule and appointment," Dr. Mack says.

Numerous ongoing studies will investigate other treatments for primary care patients. As these patients are likely to take systemic medications or supplements as well, it becomes imperative that optometrists understand the interaction between therapies and communicate them, so that patients avoid any dangerous interaction between drugs.

Treating glaucoma

The National Board of Examiners in Optometry's 2006 Practice of Optometry survey lists glaucoma medications at the top of those prescribed by O.D.s. In these cases, it often takes many attempts to find the right medication or combination to sufficiently lower a patient's IOP. Because glaucoma drops are expensive, many O.D.s give patients a sample to test efficacy and only write the script after they know the medication works for that patient. Dr. DeVries cautions against this, however. "Avoid going to the sample before writing the script," he says, "Then reappoint for follow-up to make sure the medication has adequately addressed the problem. The patient might need additional therapies."

Dr. Mack says, "We have the ability and legal authority to prescribe and care for many of these patient's acute and chronic needs. I believe we should prescribe for those conditions we feel comfortable with and have the legal authority to do so."

Contact lens care

"No one in this country is more qualified than an optometrist to counsel and direct a patient to the proper use of OTC contact lens solutions and rewetting drops," says Dr. Annunziato, "The Fusarium outbreak has taught us that lesson."

Newer silicone hydrogel lenses are not compatible with every care system and rewetting drop. Using the wrong product could damage not only a patient's eyes, but also the lenses themselves.

Prescribing Dietary Supplements

Many patients today have shown a renewed interest in the role of dietary supplements. The Dietary Supplement Health and Education Act (DSHEA) of 1994 defines a dietary supplement as a product taken by mouth that contains a dietary ingredient that may include vitamins, minerals, herbs or other botanicals, amino acids and substances such as enzyme, organ tissues, glandulars and metabolites. The DSHEA created a new regulatory framework for the safety and labeling of dietary supplements and place them in the general category of foods, not drugs, so they do not require the approval of the U.S. Food and Drug Administration (FDA). Under this law, manufacturers are responsible for determining that its supplements are safe and to substantiate any claims made about the product.

Most Americans, however, don't know this. They see a bottle on the shelves of the local drug store that sometimes looks identical to over-the-counter medications and mistakenly believe the two products have undergone the same scrutiny. Prescribing the appropriate supplement will help patients avoid confusion in the aisles and keep them safe from dangerous side effects.

The Federal Trade Commission lists some common misconceptions among consumers:

BELIEF: The term "natural" means safe.

Truth: Although many supplements can be used safely by most people, others, including some herbal products, can be dangerous. Even certain vitamins can be toxic at high doses.

BELIEF: Dietary supplements are safer than prescription drugs because they do not require a professional's supervision.

Truth: Studies have shown that some herbal products interact with drugs and can have a wide range of effects. For example, St. John's Wort can lower the effects of certain HIV drugs and may interfere drugs used to treat depression.

Get involved

O.D.s who graduated from optometry school years ago may not feel comfortable prescribing newer medications. Dr. DeVries suggests starting with lower-morbidity disease entities such as allergy and chronic dry eye. "This is a great way to start to build a therapeutic subspecialty," he says. "Have an understanding of what acute or chronic disease processes you will feel most comfortable and have an interest in treating," Dr. Mack adds.

Dr. DeVries and Dr. Mack agree that continuing education seminars can help. "Continuing education will help bring you up-to-speed," says Dr. DeVries. "Go to major meetings such as the American Academy of Optometry and the American Optometric Association annual meetings and learn and communicate with your peers," says Dr. Mack, "Understand the current pharmaceuticals, their costs and side effects."

Dr. DeVries also suggests attending a specialty-oriented meeting. "Instead of an hour here or two hours there, you spend all day learning how to treat specific entity." Dr. Mack concurs, "Not a day goes by that we aren't receiving e-mails about these day or weekend courses that incorporate practice management as well," she says.

Educating staff and patients

You'll need to re-educate your staff and patients also. "Your staff has to buy into it," says Dr. DeVries.

"Relying on qualified ophthalmic technicians is crucial to a medical practice," says Dr. Annunziato. "Optometrists ... must learn to be data interpreters, rather than data gatherers."

He explains that 30 years ago, O.D.s could see 12 to 15 patients a day and make a reasonable living. Today, he says you need to see anywhere from 25 to 50 patients a day to maintain a standard practice. "A single practitioner gathering all his own data will not be able to meet this crushing demand," he says.

"Staff need to know that the doctor is going to be treating a wider range of patients," Dr. DeVries says. He suggests having a pharmaceutical representative host a "lunch and learn" with the staff.

Rx Tracking

Prescription tracking is the process through which pharmaceutical companies determine how many patients with a given condition you see and what medications you tend to prescribe for them. The data is gathered through a pharmacy-reporting program and used to plan marketing efforts. A 2003 study at the University of Missouri-St. Louis College of Optometry showed a significant difference in between the numbers of O.D.-written prescriptions reported by pharmaceutical companies and the number self-reported by O.D.s. In some cases, optometrists were under-credited by more than 90 prescriptions a month.

This could all change with the implementation of National Provider Identifier (NPI) numbers, a ten-digit number that will be used as a uniform means of health care provider identification. Under HIPAA, all public and private health insurance plans will have to recognize NPIs on electronically filed claims and many other transactions. HIPAA will not require the use of NPIs for prescriptions, but Medicare will require them for electronic prescriptions beginning in May 2007. And the DEA is strongly urging that NPIs be adopted as the generally-accepted means of prescriber identification for pharmaceutical prescriptions. It's uncertain when prescription-tracking services will begin using NPIs, but it may not be far off. You can apply for an NPI online, through the National Plan and Provider Enumeration System at

Annunziato T, Coble T. Appropriate use of pharmaceutical samples in the optometric practice. Optometry. 2006 Aug;77(8):405-12.

"Office staff often have lengthy conversation with your patients," says Dr. Mack, "They must internally promote all the services that you provide."

Marketing tools, such as on-hold messages, waiting room placards, etc., can alert patients to your new sub-specialty. "The timing of your message is critical," says Dr. Mack. "For example, right before allergy season, send a postcard, newsletter or e-newsletter out letting your patients know about the signs and symptoms of allergies and that you can treat them with the newest medications."

Best for the practice

Increasing your prescription authority will bring patients back to your office for continuing care and improve your reputation. "Your revenue will increase because the number of times a patient chooses to see you over time will increase as you monitor and treat their acute and chronic ocular diseases. The overall patient experience improves when they seek your care and you can provide that care and resolve the problem," says Dr. Mack.

Dr. DeVries sums it up, "My feeling is that we need to make our practice as healthy as we make our patients." Prescribing appropriately is a good start.    



Optometric Management, Issue: November 2006