Embrace advances in retina

How allied staff contribute to the succesful integration of retinal imaging technology and intravitreal injections in practice.


Recently, retina care has taken big leaps forward with advances that span from diagnostic devices to therapeutic agents and surgical systems.

Arguably, two areas most impacted by these advances have been retinal digital imaging (fundus photography, optical coherence tomography [OCT], etc.) and intravitreal injections (anti-VEGF and steroids). Both have helped streamline the diagnosis and management of blinding retinal diseases, such as neovascular age-related macular degeneration (AMD) and diabetic macular edema (DME). (See page 14 for a discussion of surgery in the retina practice.)

While these advances are inherently efficient, they also require “certain steps by staff to fully achieve this efficiency, or successful integration, in practice,” notes Michael Nore, COA, assistant clinical manager at Tennessee Retina, a nine-location practice, headquartered in Nashville.

Here, doctors and allied health-care professionals discuss steps they have taken to drive efficiency and help with the implementation of these innovations.

Retinal digital imaging

To integrate retinal digital technology into their operations successfully, those interviewed have taken the following steps:

1. Work closely with the device manufacturer(s). At Tennessee Retina, before a device is acquired, photography managers request personal instruction from device manufacturer representatives on both the operation and benefits of the device, says Mr. Nore.

“This way, the photography managers have a head start on the use and role of the device prior to receipt,” he says. “This allow managers to immediately start training staff on the device as opposed to awaiting formal training from the device manufacturer along with other staff members.” Overall, this greatly speeds on-boarding of new imaging devices.

The practice’s photography managers also stay up to date regarding forthcoming releases of new/updated device models that are not yet commercially available, so the managers will already know how to use devices when they become available, he explains. This is accomplished through communication with device manufacturer representatives who can provide a hands-on experience as well as by attending major educational meetings, such as the American Academy of Ophthalmology and American Society of Retinal Specialists annual meetings.

Michelle Zunitch, COA, OSC, clinical manager at Retinal Consultants of Arizona, a 32-location practice headquartered in Phoenix, says that the practice has “superusers,” or masters of new equipment, who train with device manufacturer representatives before personally training fellow staff too because, as is the case at Tennessee Retina, doing so saves time and promotes efficiency.

2. Schedule off-hours training sessions. “Our staff participates in several ‘lunch and learns’ driven by senior staff who have years of experience in using diagnostic technology,” says Paul Walia, MD, of Georgia Retina, PC, a 13-location practice based in Atlanta. “Additionally, they all work on training before or after practice hours, and once every two weeks we have a ‘no doctor day,’ in which allied staff train on new equipment and catch up on administrative tasks.”

During training, Dr. Walia says staff practice using diagnostic devices on each other. The training helps staff learn optimum image acquisition and troubleshooting. It also allows the staff to ask each other questions and practice patient scripting.

At Georgia Retina, senior staff teach technicians basic image reading skills, which help identify the retinal slices the doctor would want uploaded to the patients EMR for assessment, explains Paul Lucas, administrator/chief financial officer. “This way, when operating the device in clinic with an actual patient, they are more likely to get it right the first time.”

Ms. Zunitch says training on retinal digital imaging devices at Retinal Consultants of Arizona includes structured observation by the practice’s “superusers,” who evaluate staff members’ skill level and competency before they can operate the device on patients.

“We always want to ensure accurate data, patient confidence, comfort, and safety,” she says.

3. Assess infrastructure workflow. Retinal digital imaging technology, by virtue of aiding doctors in identifying early disease, has increased patient volume exponentially, say those interviewed. “We were used to seeing 30 to 40 patients a day, but now we’re seeing 70 to 80 patients a day,” notes Eric Schneider, MD, of Tennessee Retina.

Allied staff continue to assess infrastructure workflow to ensure all continues to run smoothly, those interviewed say.

“Before a device is brought in, senior staff determine the best place to house it, looking specifically at patient flow and, of course, space,” Dr. Walia says. “We want to make sure there won’t be bottlenecks, unneeded traveling by patients, or staff getting in each other’s way.”

At Tennessee Retina, allied staff realized one of its locations would need an additional reception room and more exam rooms as a result of increased patient volume. To provide the same quality of patient care as the patient load increased, this practice moved to a new building that provided this space, says Mr. Nore.

Staff continue to look ahead at patient growth projections, he explains. “We want to make sure we can continue to see patients who want to see us for their care and that we can provide them with the same quality of care,” Mr. Nore says.

Intravitreal injections

Those interviewed offered these steps to successfully integrate intravitreal injections into today’s practice:

1. Create prior-authorization protocols. To ensure patients receive their injections when needed and that practices receive timely reimbursements, prior-authorization protocols are necessary.

At Colorado Retina Associates, a seven-location practice headquartered in Englewood, CO, the process is analogous to passing a baton during a sprint relay, says Kylie Wakasugi, a scribe at the practice. Through a secure email system, the practice’s main call center first emails patient information, including diagnosis, to the physician and the primary scribe. The scribe then matches the referring diagnosis to an ICD-10 code and emails the patient finance department with this information, which then contacts the insurance company for authorization and to verify coverage. That way, if an injection is needed, authorization will already be in place — otherwise, the physician and scribe will know that authorization is needed, meaning a same day injection may not be possible.

Once confirmed, the finance department emails the primary scribe with the prior authorization so that “everything is ready to go” when the patient presents for the appointment, says Ms. Wakasugi.

At Georgia Retina, one staff member works solely on prior authorizations. “Through a series of either online portals, phone calls or faxes, the process starts and then ends with a final communication to each practice location, via our EMR system, that prior authorization is in place,” Mr. Lucas says.

In addition, Georgia Retina is implementing a semi-automated software system to assist this process. “Essentially, it would eliminate some of the repetitive entry process and make for quicker communication when insurance approval is granted,” Mr. Lucas says.

Along with a staff member who works solely on prior authorizations, Tennessee Retina has two employees who work exclusively on co-pay assistance, says Dr. Schneider.

“Part of our prior-authorization process is educating patients about their co-pays ahead of time and letting them know that patient assistance programs are available,” he says. “And we have counselors who work with patients on applying for these programs in advance of a patient’s needed injection.”

Pravin Dugel, MD, of Retinal Consultants of Arizona, says once a well thought out prior-authorization process is created, its repetition creates additional efficiencies.

“Our billing department staff is now able to anticipate the needed prior authorization, based on established relationships with the various health insurance companies,” he says.

Part of Georgia Retina’s prior-authorization protocol is to have the practice’s scribes do a final check to ensure approval, that the patient isn’t too early for the injection and that the injectable is the correct medication, all before the doctor enters the room, Dr. Walia says.

2. Develop inventory management procedures. At Retinal Consultants of Arizona, Ms. Zunitch orders the injectables for all 32 practice locations for the coming week and makes sure those orders get the practices through to the next order with a “bit of a cushion.” Working with a vendor has facilitated the process, as she says she’s able to purchase everything online very easily.

Individual staff members are responsible for ordering specific injections at Georgia Retina, Dr. Walia says. “The roles are split up where one person oversees the ordering of Eylea (Regeneron), one person oversees the ordering of Lucentis (Genentech), one person handles Ozurdex (Allergan), and so on.”

At each location, Colorado Retina Associates’ lead techs maintain a drug log. “The lead tech places the patient’s name on the drug log, along with the specific drug, lot number, expiration date, and the injection date,” Ms. Wakasugi says.

Georgia Retina staff use a refrigerator inventory management system, which delivers each drug pre-tagged, lot tracked, and serialized to the practice to be placed in the cabinet that uses radio frequency identification (RFID), says Mr. Lucas. The cabinet is essentially a smart refrigerator that automatically reads each drug’s RFID tag and tracks and scans drugs as they are added and removed. The system provides alerts regarding expired inventory and temperature changes. Additionally, the system affords detailed reports on injectable usage, and all these data can be accessed online.

3. Train on injection preparation. “We have something called ‘Scribe University,’ during which staff learn injection preparation,” says Brian Joondeph, MD, of Colorado Retina Associates. Training involves watching videos and informal classroom training with a scribe trainer, observation in clinic, then gradual performance of all steps of injection preparation under supervision of a trainer. Final certification takes place once the trainee demonstrates comfort and competence with the procedure.

4. Schedule intravitreal injection visits for mornings. “Intravitreal injection visits are among the shorter visits, so we’ll front-end load those in the morning,” Mr. Lucas says. “The scribes prepare five exam rooms for injections, so that when the doctor walks in the door he can hit the ground running.”

An evolving process

The successful integration of retinal digital imaging and intravitreal injections in practice is an evolving process, which Dr. Dugel says is based on balancing efficiency with safety, outcomes, and patient satisfaction. For example, Dr. Dugel no longer drapes patients or uses a speculum because, over time, “those are the steps that haven’t really shown to be of a great benefit to patients but require a lot of time, a lot of effort, and, sometimes, cause patient discomfort.”

Doctors at Colorado Retina Associates now use a lidocaine-soaked cotton pledget under the eyelid over the injection site as a pre-injection numbing agent, Ms. Wakasugi adds, because the process takes 5 to 7 minutes to numb vs. two rounds at 5 minutes with lidocaine gel. The pledget also causes much less patient discomfort post-injection, she says. OP