Is It Time to Stop Refracting?

How new, high-tech systems allow O.D.s to delegate refractions and get better results, both clinically and financially, than ever before


Is It Time to Stop Refracting?

How new, high-tech systems allow O.D.s to delegate refractions and get better results, both clinically and financially, than ever before.

Scot Morris, O.D.
Conifer, Colo.

What's in a refraction? Well … everything. A refraction does more than determine the optical prescription for the patient. In fact, it is one of the most critical parts of the eye exam experience for the patient. And we are blowing it.

Yes, you read correctly—we are blowing it. In this article, I'll explain the reasons why and offer solutions to improve the refraction process in terms of accuracy, patient-friendliness and practice profitability.

A new push

If we look at our offices, we find that while everything else has changed (the three-mirror and direct ophthalmoscopes, Shoitz tonometer, Goldmann visual fields, etc.), refraction has remained about the same. So now, I want to really push and ask you to quit refracting. Why?

Due to changes in the health-care landscape, our profession will need to see more patients more efficiently in order to survive on increasingly smaller reimbursement schedules. So, while many may consider quitting refracting as heresy, as optometrists we cannot afford to continue seeing a patient from the history-taking stage through pre-testing, refraction and the remainder of the exam as we have done in the past. This “old” way is incredibly inefficient.

In addition to issues of time, we must face the reality that diagnostic refracting systems are more accurate than we are, give us more information in less time, and take the guess work out of many procedures. In fact, the accuracy and ease of use of the new systems allow us to delegate refraction tasks to capable staff members.

In short, we must quit refracting because such a move provides us with more time to do what we were trained to do: Interpret data and use it to treat our patients' visual and medical issues.

Notice I did not say collect data. Ophthalmologists figured this out a long time ago. Do they personally refract all their patients? Absolutely not. Is their remake rate higher than ours because they delegate the refraction responsibilities to their staffs? No. Do their patients stop visiting practices because the technicians handle the refraction? No. In fact, the reason ophthalmologists can see 40-to-50 patients a day is that they don't get caught up thinking they have to collect the data. What the M.D. does is analyze the data and prescribe the best solution for the specific person in the exam chair. Accordingly, you are more valuable when you educate and consult rather than collect data.

Your practice can save thousands of dollars, make tens of thousands of dollars and get you and your patients through the refraction process more efficiently when you delegate the refraction. (Every state has slightly different laws on this subject, so please check with your state to see whether you can let your staff collect the data—and by this I mean all the data. Believe it or not, with very minimal training, they can collect data as well as you can for many tests.)

It takes about 12-to-16 hours to learn how to refract in school. In an office setting, it may take your staff about three months of hands-on training to learn the traditional refraction system. And fortunately, technology has now made this process easier than it ever was before.

The secret to efficiency

Let me share the secret to a more efficient refraction. It's called a high-definition (hi-technology, computer driven, digital, etc.) refraction system. (See the “Diagnostic Instrument Buying Guide,” [Supplement Issue], for a listing of high-tech refraction systems.) In a small footprint package, the new refracting systems offer synchronized state-of-the-art aberrometry, autorefraction, topography, auto lensometry and full manifest refraction capabilities.

After four months of using a high-definition refraction system in our practice, here is what we found:

► Average doctor refraction time fell from six to zero minutes.
► Average pre-test time increased by two minutes.
► Average patient perception of the efficiency of their exam went up one full point (on a scale of one to four) as they noted, “the technology made everything easier.”

Even more importantly, I took four of the six minutes we gained from our high-definition refraction process to educate patients about the features, benefits and advantages of the eyewear I prescribe. As a result, our optical revenue increased by 28%. We attribute this increase in large part to the new system, which allows us to show patients the difference between their old prescription and their new “high-definition” customized prescription. In my experience, most patients are significantly more likely to purchase a new pair of spectacles when they can actually see the difference in their prescriptions.

By showing patients this difference (such as their current prescription vs. customized prescription computer glasses) we've also increased our second-pair sales. In fact, double pairs sales increased 8%, and prescription sunglasses sales doubled.

Efficient patient flow

The integrated system combines most of your visual system diagnostic equipment into a four-foot by eight-foot space in your pretest area. That is about the same space utilized by a topographer, autorefractor and lensometer. We've found that our set up takes much of the data collection—and thus, chair time—out of the exam lane. This, in turn, allows us to see more patients while our exam rooms are not filled with patients waiting for diagnostic refractive testing.

The new system also changed our exam flow so that we can spend more time as vision consultants and less time collecting data. With limited time available, you must become efficient and use technology to collect and analyze more data so that you can form more detailed treatment plans for both ocular health and visual health issues. If you fall into the ever-increasing group of doctors who say they don't have time to see more patients, then embrace technology, and allow it to create more time for you.

Beyond the ordinary

Another “alternative” benefit of our refraction system is that it has allowed us to increase the accuracy of our patient records by automatically transferring data into our EHR system.

Perhaps an even greater benefit of the system is that we now write our prescriptions in 0.125D intervals. In the rare instances when patients go elsewhere to fill their prescriptions, we wait for the call later that day from the “other optical” saying that they can't produce glasses in 0.125D intervals. In most cases, the patient returns to get their customized glasses from us.

We have noticed a significant decrease in our remake rate, which ultimately is perceived by the patient as us providing better quality products and better service. Also, we have noticed that many more patients express their happiness with their new “high-tech” exam, and they now “need” to refer a friend or family member to us. This differentiation builds our practice.

And, a more subtle observation is that everyone in the office seems to be having more fun. (I hate it when that happens.)

Survive … and flourish

The survival of each optometric practice will depend on how well the practice is run and how efficiently and effectively the patients' experiences within that practice are managed. In my opinion, changing the way we refract is not just a means of profitability, but a means to survival.

The average patient spends 45 minutes from check-in through being “released” into the optical to shop for frames. Would you be happy spending 45 minutes in your physician's office? Our patients are no different. They not only judge you on your presumed quality of care, but they also judge you on how efficiently you get them through their exam. After all, time is money—their money.

Now, this high-definition refraction system costs about $60,000. Take a breath from the sticker shock. Remember that I cut my exam time from 22 minutes (we were pretty efficient before the new system) to 18 minutes, which allows me to see two additional patients each day. It gave me an extra exam room because the high-tech refraction is a stand-alone system that is located in our pretest area. This allows us to create workflow efficiency by adding another slot to my day. When you consider that I added three slots per day, and my average revenue per patient amounts to $278, my revenue increases by $208,500 per year ($278 x 3 = $834 [per day] x 5 = $4,170 [per week] x 50). This number does not include the cost of the lease (a little more than $1,000 per month).

Also, these numbers do not include the 28% increase in revenue from the optical, which through the first four months equaled just under $29,000 (annualized $87,000). Now, that one-time $60,000 price tag is looking pretty good, right?

Even more important are our patients' perceptions that they received a high-tech exam and that I spent more time with them. Yes, I actually spent an average of four minutes less with them, but the quality of the visit changed: Instead of hiding behind the phoropter, I now spend the time in face-to-face discussions with patients. In turn, these visits have led to more patient-based referrals, which frankly “steal” a lot of my competitions' patients.

By the numbers

So let's review the numbers one more time. My $60,000 investment annualized through three years is $20,000. Granted, the system will last probably 10 years, but let's think tax law, and pay this off through three years. Optical increase in revenue annualized through a year in my practice is $87,000. The increase in efficiency translated into more exam time (without increasing my office hours), which added three patients per day. The value of these three slots annualized equals $150,000 per year. And patient perception and word-of-mouth referrals—priceless.

We have seen so much profit from our high-tech refraction system in the first quarter, that we are going to buy another one (and have it paid for) before the end of the year. We are having more fun with refraction now than ever before. There is something I never thought I would say. OM

Dr. Morris opened his private practice, Eye Consultants of Colorado (, in 2004. He's operating partner of Morris Education and Consulting Associates ( and Ocular Technology Solutions, Inc. ( E-mail him at Or send comments to