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In practice: Integrating instrumentation, EHR

November 5, 2012

LFEC staff demonstrates their use of the integrated instrumentation.

By Dominick M. Maino, O.D., and Geoffrey W. Goodfellow, O.D.

AOA member Stephanie Lyons, O.D., and her husband and office manager, John, knew immediately when they created their own private practice it had to offer both warm and compassionate care, as well as the latest integrated technology.

Even though Dr. Lyons is a fairly recent graduate of the Illinois College of Optometry and her husband’s undergraduate degree in business was yet to be put to substantial use, there was no question that creating an exciting, patient-friendly, and high-tech office was their overriding goal.

In a previous column we discussed their use of iPads in the delivery of eye care (see EyeTech: Chicago practice puts the eye in iPad. AOA News. June 16, 2012) and hinted that future articles would take a look at how Lyons Family Eye Care integrates technology within their office.

I (Dr. Maino) write this column as a patient who has been through the examination process at Lyons Family Eye Care (LFEC) and as someone who has utilized this instrumentation within LFEC as a primary care optometrist. If you recall from the previous column, as a patient the very first thing I did was to fill out the new patient intake form on the iPad, which was then sent to the doctor’s computer via Dropbox so that all the information would be readily available. Next, I moved on to the pretesting area, where several integrated instruments and I became well-acquainted.

Shown is the integrated control system for the digital refractor.

The pretesting area was not large, but was adequate for all the instrumentation used. Both the optometric technician and I were comfortable within this high-tech environment. I was asked to look into several of these marvels while various tests were automatically performed. The instrumentation in the pretesting area included the Nidek Tonoref II, (an auto-refractor/ keratometer/ tonometer), Nidek LM-600 (an auto-lensometer), Zeiss Humphrey Matrix (visual fields) and the Nidek RT-5100 (a computerized phoropter that was in the doctor’s examination room). Although many ophthalmic instruments are “connected” these days, these will be the only ones discussed in this column.

The Nidek Tonoref II is a three-in-one instrument with combined autorefractor, autokeratometer (auto K’s), and non-contact tonometer. It takes but a few minutes to have all tests completed. The Nidek LM-600 not only determines the lens power of a patient’s glasses, but also lets you determine the amount of ultraviolet protection the lenses provide.

Stephanie Lyons, O.D., employs an integrated computerized refractor in her practice.

LFEC has used this latter capability as a “free summertime special service” where all (patients and non-patients) were invited in to have their sunglasses assessed for protection from the sun. This public service generated a fair amount of “buzz” on the LFEC Facebook page and from the general public.

As we finished in the pretest area, one of the last things done was the Humphrey Matrix Perimeter with frequency doubling technology. This offers a quick and easy-to-understand visual field screening (as well as more complex visual field assessments). LFEC staff note that even children seem to be able to understand and complete this test. All of the data (refractions, auto K’s, fields, etc.) are then saved to a credit card-sized card, which is given to the examining doctor.

As a patient I appreciated the well-organized approach to pretesting. As a primary eye care optometrist, I welcomed the ease of use of the instrumentation and integration of all the data collected onto one card. This card is then inserted into a small device that sits on the doctor’s desk and is linked to the computerized, “smart” refractor (Nidek RT-5100). When I was the patient, several aspects of using the digital refractor made my participation in the examination sequence easier.

I particularly liked the way cylinder and cylinder axis were determined.

Instead of asking patients to look at “1” and “2” and then struggling to determine which one they liked better (which many of our patients find challenging and frustrating), the refractor shows both images side by side. This allows the patient to easily compare the two choices. This methodology decreases the patient frustration associated with this often daunting task.

As the examining optometrist, I found this technology a bit more challenging. After conducting refractions with a standard phoropter for many years and having my motor memory automatically, almost without even thinking about it, complete the task; the challenge was to once again think through the whole process. I was seated at my examination desk, turning a dial and pushing a few buttons on the digital device linked to the refractor in response to the patient’s answers to my questions. This small change (from standing chair-side with the standard phoropter to sitting at my desk) required establishing a new sense of motor memory and eventually automaticity.

Chris Sarakaitis, the Marco representative who helped LFEC choose and integrate all of this technology, also assisted me in learning how to utilize the instrumentation. He noted, “We work closely with our doctors, like Dr. Lyons, and their respective EHR companies to make sure we have a seamless integration between technologies. Integration between equipment and an EHR system is quickly becoming a must-have capability. Digital refractors are the most frequently used integrated technology by optometrists. Marco is committed to partnering with our doctors so that they can reach their goals. We believe our success is based on their success.”

With his help, I found that the Nidek RT-5100 refractor was fairly easy to learn how to use. It is set up to be flexible to readily meet your needs and can be programmed to the examination sequence of your liking. Near vision refraction for presbyopes is easily accomplished and conducting an evaluation of vergences, heterophorias, negative relative accommodation (NRA)/ positive relative accommodation (PRA), and just about any other near point test typically done using a standard phoropter is at your fingertips as well. Once your refractive analysis is complete, you hit “print” twice and all the data collected to date is transferred to your electronic health record (EHR). (I will discuss the EHR used by LFEC in a future column.)

Does using this level of technology in your office really make a difference? Dr. Lyons noted, “Patients have absolutely loved our high tech environment. Many of the patient referrals we receive are a direct result of the technology we use. When our patients arrive at LFEC, they check in using an iPad. Their first impression is that this comprehensive eye examination will be very different from anything they have experienced before. When we explain how their pretesting results automatically feed into our phoropter and EHR, they know that their level of eye care just went into the next century.

From the practice management side, John Lyons, LFEC business manager, remarked, “It is extremely rare for a patient to leave without mentioning how impressed they are by the whole experience. This technology, along with the compassionate care we give our patients, has made a significant contribution to the fiscal well-being of the practice.”

If you want to integrate multiply pretesting instrumentation, the steps taken by Dr. Lyons at LFEC can easily be duplicated within your office environment. It will require a bit of planning and research, but once accomplished this will make evaluating patients not only easier but also more efficient. To learn more about Lyons Family Eye Care, go to their website at www.Lyons FamilyEyeCare.com or visit their Facebook page.

Dominick M. Maino, O.D. is a professor of pediatrics and binocluar vision at the Illinois College of Optometry (ICO) and a Distinguished Practitioner of the National Academies of Practice. He can be contacted at dmaino@ico.edu. Geoffrey G. Goodfellow, O.D., is an associate professor of optometry at ICO, ICO’s assistant dean for Curriculum and Assessment and the president of the Illinois Optometric Association. He can be contacted at ggoodfel@ico.edu.

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