Efficient to the Core

At the center of a practice's success with verteporfin therapy, you'll find a profitable, comfortable structure of scheduling and patient flow.

Efficient to the Core
At the center of a practice's success with verteporfin therapy, you'll find a profitable, comfortable structure of scheduling and patient flow.

No doubt, scheduling and patient flow are two of the first challenges that come to mind when you consider how to make your practice efficient. Above all, this system needs to be smooth and organized. You should move through your day of examinations and procedures in an orderly rhythm, and your patients should have the same sense as they go from reception to exam, testing, treatment and follow-up.

When you add verteporfin therapy to your practice, you must consider how you'll schedule procedures and move patients through the process. In the "ideal situation," patients should be in the treatment room 20 to 25 minutes, allowing practices to treat two or three patients per hour. But every system, depending on staffing setup and physician preferences, has its own pace. Many different systems are effective, no matter how large, small or unique the practice is.

"There isn't just one way to do PDT," Dr. Slakter says, "so reading about a single practice would be misleading. You might think, 'Well, that doesn't pertain to me.' I don't think anybody does things the same, but we can get ideas from a variety of different practice sizes, styles and patterns."

Read on to find out how the panel members have made verteporfin therapy a successful part of their practices and how you can succeed in yours.


Who Handles the Billing?


Part of creating efficiency is distributing work in the most effective way. And part of offering verteporfin therapy is obtaining the drug. Dr. Fineman's large practice has a billing department, but you could delegate these duties within a practice of any size.

"Each of our six offices handles its own billing," he explains. "So the billing department at my office handles collection for my patients' drugs."

Because each of the 20 doctors in Dr. Fineman's group schedule their patients' treatments at the hospital location, each doctor supplies the drug for therapy. This keeps the billing at the office level. And then Dr. Fineman's office pays a flat fee for the hospital's laser, nurse, kit and space.

"All the infrastructure is there," he says. "We just bring the drug and handle the billing separately."

Fortunately, since the FDA approved verteporfin for certain occult lesions, Dr. Fineman can shield his patients from the billing concerns.

"We used to tell patients about the price beforehand, and they usually brought a check or a credit card on the day of the treatment," he says. "Now most of the lesions I'm treating are covered by insurance, so there really isn't an issue. It's just billed to the insurance and handled by the billing department."

One-day scheduling

Some practices simplify workflow by scheduling all treatments for one day (or several, depending on the patient volume). It helps physicians and staff avoid switching between tasks, and it allows practices to have part-time staff members, such as R.N.s dedicated solely to verteporfin therapy. For small practices in particular, a weekly, rotating schedule of screening, testing and treatment may work well.

"Initially, we tried to incorporate verteporfin therapy into every day. This wreaked havoc on everyone, including the staff and the other patients in the waiting room," recalls Ms. Gumina. "I did the infusions in the office, and I also was doing work-ups, dilations, consent forms and more. I was being pulled in six different directions."

The system didn't last very long. "We soon decided we had to change our staffing and scheduling," Ms. Gumina explains. "We started with a new, dedicated 'PDT day' and hired a part-time R.N. to work only on that day."

In Ms. Gumina's solo-physician practice, she and the part-time R.N. spend about 3 hours one morning every 2 weeks with about 15 PDT patients. When they started this system, they combined these duties with caring for postoperative laser treatment patients, but found that focusing on verteporfin therapy alone worked better.

"It turned out to be a distraction from what we were doing," she says. "The doctor, nurses and technicians couldn't concentrate on either treatment. It's much more efficient doing just verteporfin therapy at a designated time."

The treatment time also highlighted some of the practice's problems with patient education.

"Initially, we didn't provide adequate education on the fluorescein day, so we'd be answering a million questions on treatment day, and that hindered patient flow," Ms. Gumina recounts. "We were doing treatments every 15 minutes, but the questions from patients and family members slowed us down. So we shifted to spending more time on education during the initial assessment and angiogram, and we're moving patients to a patient education room after the treatment, where the physician can answer any additional questions between patients."

The new system has been working well. "We like to spend the exam visit doing the angiogram, explaining it and completing our education about treatment," says Ms. Gumina. "This way, when patients come back for treatment, we're able to do the treatment very efficiently. Doing this, we've doubled the efficiency of our office."

Of course, a patient might travel a distance for a visit and the physician determines he needs treatment. This calls for an adjustment to the routine.

"We accommodate patients when necessary because we realize it can be difficult to arrange for a driver. The driver needs to take time off from work and so on," Ms. Gumina explains. "So when we're seeing an out-of-town patient who might need treatment, we advise him to bring along appropriate clothing and sunglasses in case he's a candidate for verteporfin therapy. With a little flexibility and planning for exceptions, we can very easily set up for a treatment without disrupting the schedule."

Overall, the one-day scheduling approach has been a successful fit for the practice. "Our goal was to become as efficient as possible, and we've found that as we increase efficiency, our patients become more positive," Ms. Gumina says. "We run on time. It makes the patients more compliant, committed and happy."

Simplifying PDT Documentation

In many practices, a single treatment with verteporfin requires several pages of documentation, which can add to the preparation time needed before treatment.

To get all the information you need and cut the administrative time, you could follow the lead of practices that use a single sheet of essential documentation for PDT treatment. Of course, it must meet federal and state requirements for laser treatment, but it's a given that documentation should include:

  • Patient ID, height/weight and BSA
  • Verteporfin dose and lot number, D5W amount and IV initials
  • GLD, spot size, wavelength, dose, intensity and duration
  • Spaces to list complications and follow-up instructions
  • A checkbox verifying that staff provided patient education

In addition, to make the sheets easy to access in a patient's chart, some practices color-code them.

Same-day treatment

On the opposite end of the spectrum from one-day scheduling is treatment that's scheduled the day of the patient's exam and fluorescein angiogram. The four physicians at Retina Consultants of Southwest Florida have some flexibility in how they arrange treatment, but most opt for this approach.

"About 85% of our PDT patients get treatment on the day of their exams and fluorescein angiograms, and the rest are scheduled," he says. "We set up four PDT appointment slots per day to be used for new patients or appointments."

The physicians and staff find that the system works quite well, with no disruption of other activities. This is probably because the staffing approach at Mr. Holmes's practice uses several existing staff members for verteporfin therapy.

With recent changes in Medicare coverage approval, Mr. Holmes has seen an increase in patient volume that may affect the practice's ability to maintain the same-day treatment model.

"Our numbers have picked up 25% to 50% since April 1, 2004," he says. "One of our physicians predicts that number will double, so I'm not sure if we can continue to do on-the-spot treatments, or if we'll need to start scheduling."

Dr. Fineman agrees that patient volume is a built-in weakness of the same-day approach.

"When you do on-the-spot treatment," he explains. "You'll add new patients to the pool, and they'll all return for their scheduled second or third treatments. By the end of a year, you may find yourself in a very serious situation as far as volume goes."

Serving individual preferences

In a practice with several physicians, there's room for different scheduling approaches.

"There are six retina physicians in my group, and I think everyone handles verteporfin therapy a little bit differently," Dr. Hughes says. He uses a dual approach. "In Boston, I do everything the same day. It's a lot easier, given the parking situation. In the Stoneham office, about 8 miles north of Boston, patients come from New Hampshire and northern Massachusetts. I schedule these patients for Mondays and Tuesdays, when we do up to 15 treatments over the 2 days in addition to our regular patients."

By offering verteporfin therapy, Dr. Hughes' practice has added many new patients. "A number of retina physicians don't want to do PDT, so we've had a significant increase in patient volume coming from these practices," he explains. "We're happy to see them."

Changes in both facilities and staffing have helped make this a flexible system that smoothly handles the increased patient volume. "We doubled the size of the office about a year ago, and it's made all the difference in the world," he says. "We now have two technician rooms, three exam rooms, a fluorescein room and a room for optical coherence tomography."

Dr. Hughes and his colleagues also hired a part-time nurse to handle PDT. He explains, "It's been somewhat more expensive having an additional nurse, but when we look at our volume with the additional space, it is cost-effective."

Although you don't need to make capital improvements, except for buying the laser, or add office or technical staff to incorporate verteporfin therapy, Dr. Hughes emphasizes that a well-planned scheduling system is critical.

"You and your staff need to be on the same page, because the scheduling at the front desk can destroy your day. Scheduling four consults in an hour, plus having an emergency retinal detachment at the same time is unnecessarily difficult," he says. "You can train your staff to schedule in a pace you want to work -- maybe one or two treatments an hour, plus two post-ops, one or two consults or some routine follow-ups. You can see more patients if you plan accordingly, whereas poor planning gets you behind, and it can be impossible to recover."

Ms. Stout works with five ophthalmologists, and they also have a flexible system. "One doctor has his patients come in for their angiograms, and then does all his treatments one afternoon per week," she explains. "He does make exceptions for patients who live far away. They have pictures and treatment on the same day."

The other physicians in the group have a different approach, "All the other physicians will have a definite treatment and a follow-up every hour throughout the day," she says. "So we'll have a treatment, a patient who's coming in for pictures, and maybe lasers or new patients in between."

The nurses assist with about three treatments per hour on dedicated days; the number they accomplish in an 8-hour day with the other system varies. Ms. Stout prefers the one-day arrangement. "It cuts down on the wait time, as well as the number of times we need to get a physician to leave an exam room and do treatments," she explains. "But the other physicians think the two visits are an inconvenience for their patients, so they prefer the same-day arrangement."

Another option for busy practices is similar to the one-day system. With this option, patients are scheduled for verteporfin therapy in advance. Using an extended follow-up schedule, the staff sets the first few treatment dates and follow-up appointments going 3 to 6 months into the future. Patients receive a printed appointment table so they can easily, graphically, see their total treatment schedule. The table can include important reminders for the appointments, such as "Wear protective clothing."


Improving Patient Flow


These factors -- all correctable -- can encumber patient flow in practices that offer verteporfin therapy:

  • Inconvenient laser location. The laser should be placed in a central location, convenient to all staff and physicans.
  • Limited space.
  • Inefficient treatment notification. In some practices, the infusion staff must leave the patient to find the physician to start the laser. One option is to use two-way radios so the staff and the physician can relay treatment times and clinical information.
  • Premixing the drug. The manufacturer recommends obtaining venous access before mixing the drug to avoid wasting a vial.

Centralizing treatment for multiple practices

Dr. Fineman's practice has eight retina specialists, part of the 20 in private practice who are affiliated with Philadelphia's Wills Eye Hospital. They do exams and fluorescein angiography at their offices and pay a fee to send patients to the hospital's central location for verteporfin therapy.

"We're allotted a certain number of slots on the PDT schedule. There's one nurse, so we don't stagger them. We do one every half-hour," Dr. Fineman explains. "I fax the patient's information to the hospital, and someone from my office will hand-carry the angiogram there."

Despite being located in a separate facility, Dr. Fineman stays involved in the treatment. "I'm close enough that I can see my patients," he says. "The nurse who's doing the infusion will call me on my cell phone, or sometimes we use walkie-talkies. She'll alert me 10 minutes before the treatment and then again at 5 minutes, so I can gauge when I need to wrap up with a patient I'm seeing. I find that most patients don't mind this when I alert them in advance that I might be called away."

The system has been a success for Dr. Fineman and the other retina specialists involved. "Altogether, the doctors do about a dozen treatments a day. And because the facility nurses are shared by several groups, we lower our overhead."

A robust, adaptable addition

The panelists noted the same strong thread running through this discussion: They all had different approaches, all of which are successful in their practices.

"From a solo practice to a large practice with multiple offices, we've discussed five different approaches that all work," Dr. Slakter says. "This wide variety of approaches tells me verteporfin therapy is workable in almost any scenario.

"I don't understand it when I hear people say they can't make PDT work in their practices," he says. "All I can think is, 'They didn't get creative.'"

Adds Dr. Hughes, "Everyone does it a little bit differently. Hopefully, you get some good ideas from other practices and figure out a system that works for you."

Dr. Slakter agrees, promising, "I'll share these ideas in my office so we can get even better at offering verteporfin therapy."


The Hidden Benefits of Drug Accountability. What can it tell you about your practice?

What does "drug accountability" mean in your practice? If your staff defines it as a way to increase safety and efficiency through inventory management, you're getting most of the benefits. But by gathering and documenting the right data from your drug inventory, you also can track treatments, growth and productivity in your practice.

To be accountable for your practice's drug inventory -- and get all the benefits -- you and your staff need to manage these factors:

  • Supplies. For verteporfin therapy, this means being prepared for postoperative needs with an adequate supply of hats, gloves, sleeves and sunglasses.
  • Ordering. The staff should anticipate needs for scheduled and unscheduled treatments. It also pays to track confirmation numbers.
  • Drug inventory storage. Like many other drugs, verteporfin should be kept in a locked cabinet with limited access. Of course, the cabinet should also have the proper environmental conditions.
  • Documentation. You should outline precisely what information your staff should record about all drugs. Among other things, this should include lot numbers, which are necessary for medical affairs issues and tracking adverse events.
  • Expiration dates. Not only should your staff document these dates, but they should also have a schedule for rotating supplies so they're used before expiration, and for disposing of expired items.
  • Tracking vials. Your staff should number verteporfin vials. Next, by tracking the specific vial used for each treatment, you'll know where your inventory is going and how much of the drug a patient needs (one or two vials). It also will help you track vials that you send to other locations. A treatment and inventory log will help you track vials, lot numbers, patients and infusionists. It gives practices an at-a-glance look at this information, without looking at patients' charts or billing records to summarize drug use and productivity. In addition, the log can show growth by tracking initial versus follow-up treatments.



What would you change about how verteporfin therapy is handled in your practice?

Patty Gumina, R.N.
"I think we'd add a third pump in the office. Rather than infusing just two patients in exam rooms, we could also keep one pump directly in front of the laser."

Mitchell S. Fineman, M.D.
"If there were an issue, we'd change it. We've worked most of the issues out, and I'm satisfied with the way we're running right now."

Charity Stout, R.N.
"At this point, I don't think I'd change a thing. Verteporfin therapy is handled differently by all five physicians in the Knoxville area. The systems vary, and they all work well."

Mark Hughes, M.D.
"I don't want to collect the payment for a drug, so the billing process is one thing I'd change."

Jamieson R. Holmes

"I'd also change the billing process. I'm looking forward to 2006 when, hopefully, we'll be able to get verteporfin on a case-by-case basis from a central warehouse and not worry about collecting for it or receiving reimbursement. I'd go one step further and say I'd like to see the Medicare guidelines for verteporfin expanded to give doctors more discretion."