Strategies for improving efficiency in retina practices highlighted at FLORetina Conference

Transcript edited for clarity

David Hutton: Hi. I'm David Hutton of Ophthalmology Times. The FLORetina conference was recently held in Florence. At that event, Dr John Kitchens made a presentation titled "Efficiencies In and Out of the OR." Thanks for joining me. First, what inspired you to focus on efficiencies, both inside and outside the operating room in your practice, and what are some of the specific challenges you aim to address through these improvements?

John W. Kitchens, MD: Yeah, David, you know, this has been a talk that I've thought about for a long time. It really comes from a couple of different origins. First and foremost, I'm in a large retina-only practice in Lexington, Kentucky, and I'm fortunate to have 10 partners who are all very like minded and very efficiency focused. And so I find that all the time, I'm getting suggestions from one partner or something that our scribes will recommend that one of the doctors does differently that makes things more efficient. And so I feel like we have this cross-pollination in our group that's always looking for ways that we can be more efficient and do things better, more patient-centric, and, frankly, more efficiently. The second thing is, every time I've been to a conference or whatnot, I find that the things that interest me the most - and the things that I talk to my friends and colleagues about the most-are are the little pearls and tricks that you can use to make things work better. And I'm constantly finding things that are unique from other doctors that make them more efficient, or sharing things that we do that make other practices more efficient. And this actually crosses borders. And a great example of that is about 3 or 4 months ago, we had some doctors come in from Oslo, Norway, and they came and watched us work at some of our satellite clinics. Believe it or not, in Norway, they don't have satellite clinics. They were actually able to see how we ran a satellite. They thought it was very unique. And they're now taking this back, and they're going to implement it in their country. So, it's just really neat to be able to cross-pollinate ideas and best practices from each other in the US and internationally.

David Hutton: Could you elaborate on some of the strategies or tools you've implemented, and how have they impacted patient outcomes?

John W. Kitchens, MD: Yeah, so a variety of different things, both in the clinic and in the operating room. I think the biggest difference maker for us in the clinic is utilizing scribes. Now, a lot of practices use scribes, but our scribes function in a way that's almost like an assistant to the physician, in that they're all very, very well-trained. They've been doing this for years. They're not just inputting data, but they're actually looking at the scans, pulling up the scans, talking to the patients as they bring them back to the exam room, and getting a little bit of insight. And it's not uncommon for my scribes to come and say, "Oh, we have Mrs. Jenkins here. She went 10 weeks in her injection interval. She feels like she's worse. Her scans look a little bit worse. We might want to think about taking her back to 8 weeks." Then, I'm able to actually delve into that chart, look, confirm what they're saying, and then decide if that is the course of action you want to make, and it's a team approach. And they, once again, also do the documentation. They help with the billing and other things like that. But I find that they always have really great insight and recommendations and make my day and my flow go a lot easier. A few other things that don't necessarily involve the scribes ... love injection-only visits. These are visits where we don't bill a patient for an exam. We don't dilate the patient. They come in, and we know they're going to get a shot. We follow their OCT, and we determine their interval based off what we see with their OCT, visual acuity, subjective complaints. I love to dictate. I feel like it's a lost art. Dictating notes on patients is really important, and it personalizes that visit to the referring doctor and then also sending a copy to the patient … great way to document, really gets my thoughts on paper in my own voice.And then a few other things. We do a lot of laser indirect for our PRP. It's all different than what's done in Europe, where they do more slit-lamp-based laser. Laser indirect seems to be a little bit faster. We’re starting to use chlorhexidine for our cleaning agent for injections instead of betadine. That seems to eliminate some of the follow-up calls with ocular irritation, corneal epithelial defects, and whatnot. We're not seeing a significant increase in endophthalmitis since using chlorhexidine, so that's also reassuring.When we look at in the operating room, we're constantly looking at ways to do things better, and these are just little pearls, techniques such as, you know you're doing a membrane peeling, and you have some ILM or epiretinal membrane on your forceps, just being able to swipe that off inside the eye with your light pipe. Not having to externalize your instruments where you wipe them on an instrument wipe, where you could then introduce fibers into the eye. You're not coming in and out of the eye quite as much, utilizing when the BIOM or wide-angle viewing system happens to inadvertently touch the cornea. In the past, we've pulled that out of the eye. I have my OR technician clean the BIOM underside. In reality, if you have a clean, gloved finger, you can swipe that and squeegee that lens off and get 90% of your view restored very, very quickly by yourself, not having to have that person, you know, go and actually do a full cleaning procedure. So just a lot of little things that we do.The last one actually kind of a bridging of the OR and the clinic is how we manage our post-op patients. You know, one of my partners, Tom Stone, who's been in this practice that I'm in for more than 20 years now, he's always been a very progressive-thinking, thoughtful guy, and, you know, about 5 or 6 years ago, he said, "Why do we use steroid drops? We're not really dealing with the anterior segment. We're not really inducing a lot of cystoid macular edema. Why don't we just try antibiotic ointment twice a day for a week?" And so, 5 years ago, we cut out all of our steroid drops, all of our dilating drops for our retina surgical patients, with the exception of patients that have an IOL placed or something that could induce a CME situation. We saw no increased rates of cystoid macular edema, no increased rates of infection. Patients are on antibiotic ointment twice a day for one week after the surgery, then they stop the antibiotic ointment. And we've had great results with this. The patients get 1 tube of ointment, and that suffices for the entirety of that week. And then we don't get a lot of calls. The referring doctors don't get a lot of calls for drop refills and confusion around drops and whatnot. And it's been absolutely great, and we published those results at ARVO a few years back.

David Hutton: How do these processes influence the overall patient experience and clinic workflow, and what kind of feedback are you getting from the patients?

John W. Kitchens, MD: Yeah, so I think anything that decreases the complexity for our patients is a benefit without compromising care. For instance, the antibiotic ointment — it's very easy to just recommend antibiotic ointment twice a day for a week, without having to talk about a taper. The patient doesn't have to deal with a copay, or as many copays, for getting drops and figuring out how to use them, so we get great responses on that. Occasionally, we'll hear from our referring doctors and from patients who might have had care elsewhere. They say, “Gosh, what do you do that's better so that we don't have to take those drops for a whole month?” I do think it's appreciated, and I think it shows that there's always this continual endeavor to not just accept the status quo, but actually look to be innovative.When we improve our clinic efficiency, I think it helps across the board for our clinics. You know, when you get upwards of 60 to 70 patients in a day, it's really hard to maintain that personalized feel and touch for patients, where you actually get a chance to talk to them about other things in their life — things you might have learned over the course of their treatment about their families and how things are going — and have time to answer all of their questions. So anything you can do to improve that efficiency helps. Patients don't wait as long. If a patient doesn't wait as long, they don't expect you to be in the room as long. They're more willing to say, “Hey, it’s a quick visit, but we're getting in and out really quick, so we appreciate that.” And then mostly, it just frees up time for those longer conversations that we do have to have with some patients.

David Hutton: And what role do technology and team dynamics play in achieving these efficiencies?

John W. Kitchens, MD: Yeah, so I'll tell you that we couldn't do it without the technology that we have. You know, more and more, retina is moving from a specialty that was focused on really the ability to examine the retina to the ability to strategize around best practices and the best ways to take care of patients, as well as ways to best educate patients. Now that we have OCT technology that we get on almost every patient, we're able to see the retina as well as the greatest retina specialists of the past. We're actually able to get a digital cross-section of the retina at every visit and look at the retina the way Don Gass used to be able to see it with a contact lens on the eye.With ultra-wide field imaging, we can now see 90% of the retina. So when a patient comes in with diabetic retinopathy or flashes and floaters, we can do an ultra-wide field image, capture 90% of the back of the eye, and make sure everything looks good. Then we can focus in, in a more targeted way, on areas that might concern us or perform a depressed examination in the patient with flashes and floaters. Furthermore, you have documentation right then and there of how that patient looks, so you can compare their condition going forward.So, technology is a huge piece. The second piece you mentioned is cooperation and teamwork amongst all of us. It's not just the doctors who are recommending some of these improvements in efficiency and discovering these methods; our scribes play a really active role in that as well. Even our workup team members will come and say, "Hey, I think we should do this differently," or "Hey, let's see these patients at the first part of the schedule and these other patients later." So it truly is a team environment, where everybody's experience, thoughts, and ideas matter, and we take all of those into consideration when making changes and adopting new practices.

David Hutton: And lastly, are there any specific innovations or team strategies that you consider game changers?

John W. Kitchens, MD: Yeah, boy, I'll tell you. I think the scribes being more involved ...100% are game changers. The injection-only visits are a huge game changer. When you don’t have to dilate every patient at every visit, it’s a game changer not just for the clinical flow. Effectively, what we’re looking at is what’s going on in the macula for most of these patients with AMD, DME, and RVO. By just getting an OCT, vision, and pressure, and then bringing them in for their treatment, you’re not only expediting the whole process, but you’re also avoiding the discomfort of dilation for the patient. Plus, you’re not charging their insurance for a full examination, and that saves the system money.So, I think those are a couple of big ideas. First, having scribes to help with everything, including interpreting some of the testing, talking to patients, and relaying information to patients. And second, the injection-only visits. I think those are the two biggest things. And we’re not alone in doing these things—there are a lot of great practices implementing them.Lastly, I will also say, the more you involve and educate the people around you, the more they feel invested in the practice and see themselves as valuable team members. We truly appreciate all they bring to the table—the fact that they allow me to see the number of patients we see but do it with such ease. It lets me spend my entire time in the room talking face-to-face with a patient. I don’t have my back to the patient, and I’m not typing on a computer the entire time. I utilize the electronic health records as a resource to know where the patient has been and how they’re doing. But my time in that room with the patient is spent talking directly to them.