“We have a lot we have to learn about how we are going to see patients in the new normal,” said Eric Donnenfeld, MD, as he introduced the ASCRS symposium presentation, “Turning the Lights Back On: Part 2,” sponsored by Alcon. The symposium presenters shared various perspectives on reopening practices. These experts also offered insights into this new normal with discussions of challenges, opportunities and solutions for ophthalmology practices.
 

COVID-19 lessons learned

David W. Parke II, MD, CEO of the AAO, shared COVID-19 lessons learned, including: 

  • Ophthalmologic care should resume slowly, carefully, regionally, and practice-by-practice. Reopening should be guided by science and the judgment of individual ophthalmologists.

  • We are not returning to “normal.” The SARS-CoV-2virus will be with us for years” Dr. Parke says.

  • Health care is not recession-proof.

  • Patients, staff and our communities now have different expectations. 

  • Doctors must make decisions about use of personal protective equipment (PPE), serologic testing, new scheduling templates and social distancing.

 
Dr. Parke said the entire environment of medicine will be affected, including education, insurance, private equity and corporatization, scope of practice, telemedicine, clinical trial design, physician payment, development of professional surge capacity and disaster planning. 

Success will depend on leveraging the societal goodwill and will require leadership and unified action as a common profession. “If we cannot act together, the reforms that emerge will be designed and implemented without effective ophthalmologic input. These reforms will define not just the next six months, but the decades to come,” he says.

In addressing such reforms, the ASCRS leadership and AAO leadership “are working more effectively together now than probably in the history of the two societies,” Dr. Parke says. 
 

Cultivating courage and confidence

Consultant and psychologist Craig Piso, PhD, president of Piso and Associates, LLC, discussed how to help people feel safe enough to re-engage in their previous roles as employees and patients. Ophthalmologists will need to achieve both a “personal leadership victory,” finding strength as an individual physician leader, and a “public victory,” where leadership instills courage and strength in others. 

Steps to achieving the personal leadership victory include:

  • Understanding that real courage is a “heart-felt commitment” that is “taking action even when your knees are shaking.”

  • Applying leadership best practices, such as “working from within your wheelhouse rather than being distracted by external circumstances.”

  • Mobilizing the Stockdale paradox. Vietnam veteran Admiral James Stockdale said of surviving his 8 harrowing years of confinement as a prisoner of war, “You must never confuse faith that you will prevail in the end — which you can never afford to lose — with the discipline to confront the most brutal facts of your current reality, whatever they might be.”

 
To achieve the public victory, Dr. Piso recommends:

  • Shifting from “I” to “we”

  • Leading with a collaborative action plan that includes participation by key stakeholders

  • Making an action plan that is well-vetted by business and labor law experts 

  • Earning and maintaining trust by demonstrating “both competence and good character” 

  • Empowering people with information that is fact-based, complete, timely, relevant and helpful  

  • Inspiring loyalty and “followership” by being decisive and supporting people as you push them beyond their comfort zone 

 
These leaders “walk their own talk” and lead by positive example, Dr. Piso says. “Initially, people might think you’re too good to be true, but they learn comfortably, that you are, in fact, the real deal.” 
 

What the government is doing

Jeff Kimbell, president of Jeffrey J. Kimbell and Associates, a health policy and lobbying consulting firm, discussed the government programs that can benefit ophthalmology.

“If you look at the regulations, a lot of the things we have pushed for a number of years have now been implemented, particularly in telehealth and hospitals without walls,” he says. “ASCs are now allowed to contract with local health care systems to provide hospital services, which is a big jump.” 

In discussing President Trump’s plan for reopening America, Mr. Kimbell says, “Ultimately, it will be up to municipalities and governors to determine when and how they’re going to open.”

While the White House Testing Blueprint involves the federal government (the FDA), state governments and the private sector, the issues at hand will likely be solved by “the private sector — drug companies, biologics companies, device companies and a combination of probably a number of them,” he says.

Mr. Kimbell noted that the Congressional response to the pandemic went beyond the CARES Act to include the Coronavirus Preparedness and Response Supplemental Appropriations Act, the Families First Coronavirus Response Act and the Paycheck Protection Program (PPP) and Health Care Enhancement Act. 

“A lot of money has been poured in to try to stabilize the economy, as well as incent businesses to help develop the next technologies to help solve the crisis,” he says. 
 

Sharpening your business plan

Symposium co-moderator Bruce Maller, founder and CEO, BSM Consulting, introduced three phases in managing a business through a crisis. Phase 1, occurring during the first 6 weeks of the crisis, is survival mode. In phase 2, practices wake up to a new reality, and, in Phase 3, practices shine a light on the future.  

Phase 1 is characterized by: 

  • Engagement with the practice team 

  • Preserving cash from any source

  • Monitoring daily and weekly cash flow (a PPP expense tracker and a 13-week cash flow forecasting tool are available on the BSM Consulting website)

  • Shoring up the balance sheet 

  • Right-sizing the cost structure

 
Mr. Maller says practices are now in Phase 2, where they wake up to their new reality. While continuing to raise and preserve cash, “you now have to think in terms of your new normal, in terms of where’s your ‘breakeven’ — that inflection point when you’re doing a sufficient amount of business where you cover your fixed and variable costs,” he says.

Phase 2 also includes creating a 2020 operating forecast and constantly evaluating the cost structure to align with the practice’s new reality. (BSM Consulting is currently developing a customer-facing operating forecasting tool.)
“The objective in Phase 2 is finding your footing,” say Mr. Maller.

Mr. Maller closed his presentation by offering several factors for success as practices transition to the next phase:

  • Create a model for each line of business.
  • Import historical results into the forecasting tool.
  • Calculate monthly averages.
  • Build a revenue forecast by provider and line of business.
  • Review each line item of expense and what it represents (“forget historical norms and start from zero”).
  • Align the cost structure with the new reality in terms of revenue.
  • Find your practice breakeven.
  • Develop “what if” scenarios for the forecast.
  • Prepare to tweak cost structure and right size as you go.

 
“I’m following exactly this tact, and it’s allowing me to make better decisions,” says Mr. Maller.
 

Bringing back refractive cataract surgery

Vance Thompson, MD, of Vance Thompson Vision, Sioux Falls, SD, explained that even in a post-COVID environment, presbyopia patients still want to hear about solutions for implant technology because people do a lot of work at distance, intermediate and near.

Practice growth will require changes in the patient journey, understanding that the future is not going to be totally remote. “So explain what you can do remotely and explain what you can’t. We use a lot of sophisticated technology that can’t be done remotely,” he says.

Remote steps that are easier to accomplish include talking to patients, patient education, discussing referring doctor’s information and counseling. What’s more difficult is advanced testing and examining the patient. By mapping out the patient journey, practices can get a better understanding of the steps that can be accomplished in a telehealth visit. 

Moving forward, “safety can be a great opportunity to show your patient how much you care,” Dr. Thompson says. “Patients appreciate the social distancing and the fact that we have them wear a mask and we’re all wearing masks, and of course, all the other safety measures.” 

Along with the safety measures, “we still want a great experience,” says Dr. Thompson. “So the practice continues to use a form to identify which patient is sitting in which chair. While observing social distancing, staff still greet the patient with a smile and good eye contact and say the patient’s name without yelling it.”

It is a practice differentiator “to show patients how much you care,” Dr. Thompson says.

In bringing back cataract surgery, conversion to premium IOLs can increase both patient satisfaction and the financial health of the practice. The key is to answer the question, “what kind of cataract surgery would this patient want if they had my knowledge and experience?” Dr. Thompson says. “We want them to know a monofocal implant gives them presbyopia, and a multifocal implant gives them the near vision of someone in their 30s…Both can make patients happy, but patients deserve a choice.”

In the current environment, practices need to change to provide a great patient experience, which, Dr. Thompson says, is “the missing link between a practice in its current state and its ultimate potential.”
 

Implementing telemedicine in practice

Ranya Habash, MD, medical director, technology innovation and assistant professor of clinical ophthalmology, Bascom Palmer Eye Institute, shared insights on implementing tele-ophthalmology both during and after the pandemic. In addition to CMS rule changes to telehealth rules and proper coding and billing, Dr. Habash discussed best practices for telehealth implementation learned at Bascom Palmer. These include:

  • Engage the office staff. “This has been the number-one factor that’s helped us spur our telehealth volume,” Dr. Habash says. 

  • Allow for triaging and advertising of telehealth via the office phone line.

  • Proactively review existing schedules and identify patients for telehealth who is a high risk. 

  • Add telemedicine consent to patient forms. 

  • Choose a video platform (such as Zoom, Doximity, etc.)

  • Develop templates for telemedicine encounters

  • Follow standard exam procedure, including technician and scribe workflows, that you follow in the office.

  • Market telehealth.

 
“Above all, the one thing we’ve learned is the same thing you learn the first day of medical school: Keep it simple stupid,” says Dr. Habash. “This is very easy to overcomplicate.”

Examples of virtual visits that work well at Bascom Palmer include:

  • Acute/ER triage

  • New, follow-up, post-op visits 

  • Doctor-to-doctor consults

  • Virtual counseling 

  • Second opinion consults

  • “Hybrid tele-visits,” a “game-changing” visit where the patient comes in for a very targeted, expedited exam, such as the retina patient who needs an OCT scan. The patient leaves immediately after the testing and is called later with the results. 

  • Drive-through IOP checks where the technician does a quick IOP check through the patient’s car window 

  • Resident/ER tele-staffing where the resident is in-house and the physician views remotely using tools such as a video slit lamp adapter and a video platform. 

  • Remote exams: a sophisticated drone slit lamp, designed at Bascom Palmer, where there is not doctor or staff present but the doctor can log in remotely to control the slit lamp 

  • Remote home monitoring, which are tools for patients to use at home to check themselves. “You get an alert when there is a statistically significant difference in something like the Amsler grid,” says Dr. Habash.

 
“This is a Darwinian moment for all of us, our time when we have to adapt to survive, so it’s very important to think creatively and out of the box and have practical solutions,” says Dr. Habash. “In fact, it’s a great opportunity to spur medicine forward, so we should all embrace that.”
 

The international experience

Francesco Carones, MD, medical director and CEO, Carones Vision, Milan, Italy, presented four strategies to grow the practice back in the current environment.

The first is global safety, as the fear of contagion stresses both staff and patients. By implementing safety measures and communicating them, staff and patients are given confidence that the practice “is doing the right thing in the safest way,” says Dr. Carones. This helps build stronger relationships.

Carones Vision developed a protocol for blood antibodies testing “to prevent patients who are infected and not showing symptoms from coming into the practice,” he says.

The protocol was implemented in three phases, testing all people working in the practice, all surgical patients and, finally, all patients on a voluntary basis.   

With the second strategy, patient outreach, the practice completely changed how it communicated, using means that are: active rather than passive, personal rather than mass and voice rather than email. During surgical appointments, the doctors, rather than staff, communicate the safety message. To educate, the practice used its website social media and webinars on COVID-19 and surgical topics.

Product leadership, the third strategy, recognizes that the biggest challenges are reducing the patient’s time at the practice, reducing the number of patient visits and reaching patients remotely. “There must be a strong commitment to a service-oriented virtual practice,” says Dr. Carones. The practice also started to promote the doctor performing exams, either in the patient’s home or place of work, so that the patient does not have to visit the office.

With regards to internal efficiency, the fourth strategy, Carones Vision reorganized its workflow. Appointments were changed to prioritize surgical/laser procedures. Regarding patient flow, the practice provided a separate entrance and exit, social distancing in waiting areas, PPE, waiting in parking lots, no access prior to scheduled times and no accompanying persons.

The practice reorganized surgical procedures with the goal of the patient visiting the practice “maybe once only and just for the surgery,” says Dr. Carones. Here, steps included assigning agenda slot allocations, dedicated waiting areas, same-day sequential bilateral surgery where appropriate, limiting post-op control visits and offering video consults. 
 

Re-framing clinical flow

Elizabeth Yeu, MD, assistant professor, Eastern Virginia Medical School and in practice at Virginia Eye Consultants (VEC), offered pearls for taking care of both patients and staff.

  1. Prepare patients for their visit. Dr. Yeu noted that of VEC elective surgeries that were on hold but cleared as of May 1, two of three patients want to further delay the surgery. “For those who are willing to make those appointments, the practice is contacting patients and communicating what to expect during the appointment,” said Dr. Yeu.

  2. Reduce face-to-face time in the office. This can be accomplished by remote visits and where possible, automating the process, such as through zero-contact check-ins, or a change in workflows. For example, patient appointments, such as cataract evaluations, are split between diagnostics and in-person evaluation with the doctor. The practice also changed the frequency of follow-up exams, alternating between telehealth and in-person appointments, especially for those patients whose conditions are stable. For a trial period, the practice is scheduling virtual day-1 postop appointments for patients who feel well after undergoing routine cataract procedures. 

  3. Observe the 6-feet social distancing rule. VEC distanced equipment and chairs in the waiting room, established separate check-in and check-out locations, and instructed family and caregivers to wait in the car. “A lot of traffic jams can occur at check-in and check-out, so for our check-in process, we have tents set up with the automatic check-in free-standing stations,” Dr. Yeu says. 

  4. Prevent the spread of COVID-19. To prevent any infection, “number-one is, of course, wearing face masks at all times,” says Dr. Yeu. Other steps include:

    • Instructing patients to arrive no more than 10 minutes ahead of scheduled appointment times 

    • Upon arrival, having all clinic members and patients answer a COVID-19 questionnaire and have a temperature check

    • Considering PCR testing of surgical patients preoperatively

    • Having ASC patients use a mouth rinse with 0.2% povidone iodine

    • Considering bilateral, immediately sequential cataract surgery

  1. Take care of the work family and promote goodwill. It may be difficult for certain clinic members to return to work, as they may have issues, such as child care, to address. So it’s important to communicate to them and provide PPE for clinicians and staff. “For that goodwill component of our office, we made over 1,000 cloth face masks for employees,” Dr. Yeu says. “These small measures of goodwill do carry a lot of weight.” 

 

Refining and Right-sizing your model

Mr. Maller focused on staff in his second presentation that addressed refining and right-sizing the operating model. 
Mr. Maller recommends incorporating an operations checklist that focuses on every aspect of re-entry. (A sample “Ophthalmic Practice Checklist” is available here.) This will help practices get used to the concept of reinventing, which “requires adapting a new mindset, recognizing things in this new world are going to be hard to predict and at times, hard to execute.” 

In addition, practices must be flexible and re-align their cost structures to their new reality, which requires refining the pratice’s operating model. He recommended implementing a re-opening plan and aligning cost structures with expected revenues that depend on patient volume. He also recommended assessing “scheduling and patient flow, both clinic as well as surgery center,” Mr. Maller says.

The BSM Consulting checklist includes sections on patient safety, financial considerations, facility management, patient scheduling and check-in, employee recall, extended telehealth services and ongoing marketing. In using such a checklist, Mr. Maller identified key success factors:

  • Use the tool as a living document that is adapted, updated and customized for your practice.

  • Be thoughtful and realistic in setting goals and timelines.

  • Allow staff to “own” tasks and share goals.

  • Keep the checklist on a shared drive for team access.

  • Use the tool during meetings to organize priorities and next steps.

 

From adversity to opportunity

Mr. Maller concluded the symposium by telling attendees, “If we effectively engage our teams and one another, there are really no challenges too big. Throughout my career, the one characteristic that has always impressed me is the ability of ophthalmologists to take on adversity and convert it to opportunity, and I have no doubt that you will do the same in the context of the current crisis.” OM