Dry Eye

Create a Protocol to Build a Dry Eye Practice

By Scott Huffer, OD, FAAO

June 29, 2016


Develop a protocol for staff to follow in pre-testing patients for dry eye that leads up to your evaluation. Capture a fast-growing opportunity to help your patients.


ASSESS YOUR NUMBERS AND GROWTH POTENTIAL. See how many dry eye patients are currently in your practice, and how many you suspect may have dry eye.

CURRENT SYSTEM. How long is your current system taking, and are as many patients as need it receiving dry eye testing?

MAKE IMPROVEMENTS. Use EHR to set up a template for staff to fill in information about dry eye symptoms, and then to automatically advance to testing when warranted.

Our aging population means a greater number of people with dry eye, including many of the patients we see at our five-OD practice. We have made a conscious effort to recognize the growing needs in dry eye treatment–and we’ve set in place protocols that guide the patientthrough their entire treatment.

Educate staff to recognize signs of dry eye, and make a multi-pronged effort to educate patients on dry eye–something that largely is unrecognized, along with the OD’s capacity to treat it and improve lives.

To ensure my patients receive the best care for their eyes, and that we make the most of this practice-building opportunity, we created a dry eye protocol for staff to follow when working with patients. ?

The need to better provide for dry eye patients came out of a meeting I attended with other ODs from our area. We have listened to many patients complaining of dry eye symptoms, and our largest competitor in the region markets dry eye care extensively. Our patients and our competition made the need obvious. We did not say we want to be the go-to office for managing dry eye, but I think we would love it if that were to happen. We have a large group ophthalmology practice in our area offering educational seminars to the public on dry eye. I believe these patients can be managed just as well medically by our office, if not better.

The cost to the patient with our TearLab instrument, for tear film osmolarity testing, is billed directly to insurance. We have had very limited negative feedback from patients, and we will note if a patient would rather not have the testing done without further discussion or insurance prior authorization.The patients who have been upset were unhappy because they received a bill after the testing was applied to a deductible, or not covered. Most patients are happy to have the testing done, and like having a number to quantify the condition.My patients frequently ask me their number at follow-up visits. It has elevated our care of dry eye patients.

We have done a little over 1,000 TearLab tests year-to-date. It’s likely that we will hit the 2,100-2,200 range of TearLab tests done by the end of 2016. We have five providers, and the test can be repeated at reasonable intervals to determine treatment efficacy. Most of the insurances we accept now are having us bill bilaterally and reimbursing around $38 dollars. There is a cost of approximately $20 dollars to us in instrument cartridges. A separate cartridge is used for each eye and then disposed.

Gauge ROI of New Protocol

Our new dry eye protocol has increased our testing by 50-60 percent. That means $20,000-$25,000 annually in just testing revenue. The real value of the test is better understanding that dry eye complaints don’t always correlate with disease severity. In being able to objectively measure tear film osmolarity, I can better identify dry eye patients needing further treatment. I have found with that I am also inserting more punctal plugs, writing more Restasis prescriptions and selling more fish oil supplementation.

Conservatively, I would say we doubled revenue from overall dry eye-related services and products after introducing our new protocol.

The page on Dr. Huffer’s practice web site devoted to educating patients about dry eye. Dr. Huffer says to educate staff and patients about dry eye, and create a set protocol for staff to follow to ensure all patients get screened as potential dry eye patients.

Assess Current System of Interacting with Potential Dry Eye Patients

Before creating our current protocol, our staff were told to perform the test on those with dry eye, or those suspected of having dry eye. The technicians didn’t seem comfortable making that judgement, and they were not performing the test.

It was then being done only when requested by the doctor mid-exam. This is inefficient and slowed the doctors down too much, making it hard for us to remain on schedule. Ideally the patient should only enter an exam room once.

Our old system took too long and put us behind schedule. The only way for the testing to be useful would be to have the results ready when entering the exam room. This required outlining the criteria for when the test is indicated.

The problem was timing with the old way. The doctor would re-read history and determine need for TearLab testing, then have the testing done, and then get back to the exam. This interrupted flow too much for our office.

To maximize efficiency the doctor should only enter and exit an exam room once with a patient. To take them back to another room, complete testing, and return later to the exam room, and finish up, took too long. The doctors were deciding to not complete testing to remain on schedule. With the indications for TearLab testing outlined for technicians, they have the testing done before the doctors enter the room. Doing the testing before, or after, the doctor sees the patient does not change the workload of the technician. It is more work than not doing testing, but we feel it is important to provide good care. The testing can save doctor time in identifying a proper diagnosis.

Make Improvements Where Needed

Our technicians now ?enter the patients’ information into the EHR and review the information. They were already asking patients if they use any eye drops and reviewing medications. If the criteria ?for dry eye, which we established for support staff and created a checklist for in our EHR, are met, then dry eye testing via our TearLab system is performed. There is no extra work for staff, as they are now just taking the added “step” of thinking about the information they are typing into the computer, instead of just mindlessly passing it onto the doctors.

The TearLab test takes 1-2 minutes to perform. The cartridges used by the instrument are per eye and disposable. They cost around $10-11 each.

Get Input from Staff & Continue to Educate

Our staff continually pushed for the simplification of the protocol, which certainly helped implementation. I think in going through the creation of the protocol the staff learned a lot about dry eye disease, and it helped them understand how the new system would allow us to provide better care.

We frequently remind our technicians of the importance of following the protocol. As with most office processes, staff needs gentle reminders every now and then.

Optimize EHR to Enhance Protocol

We utilize RevolutionEHR, and have created a special area for recording TearLab testing results in our exam template. It is nice that we are able to customize our templates with this vendor’s software so easily.

Scott Huffer, OD, is a partner with with Drs. Helfman, Lasky & Associates in Nashua, N.H. To contact: eyedocscott@gmail.com

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