Integrated Eye Care in the United States

Optometry is undergoing major changes due to increased patient demands and advancements in eye care technologies. In conjunction with these changes, more skilled professionals will be needed to address patient needs. There is a great degree of heterogeneity among optometrists today, especially within Europe, where private and public institutions offer a variety of optometric certificates, degrees, and diplomas. Some countries do not have practicing optometrists and others have huge disparities in the scope of optometric practice. European countries also vary greatly in the integration of optometry into the health care arena.¹

In no other country do optometry and ophthalmology work as closely as in the United States. One reason for this is that there is a well-established curriculum in this country leading to a doctoral degree in optometry. This article serves as an opportunity to explain why and how this model has developed in the United States and what key benefits the integrated eye care model includes.

HISTORY OF INTEGRATED EYE CARE

Traditionally, ophthalmologists have been the sole providers of medical specialty eye care in the United States, and optometrists have concentrated on nonsurgical vision correction and detection. There has been a significant change in the scope of optometric practice in the past 30 years, including an incremental increase in optometric treatment of eye disease. These changes have allowed the two professions, ophthalmology and optometry, to evolve into the integrated eye care model that we currently use at Dell Laser Consultants in Austin, Texas (Cunningham), and Virginia Eye Consultants in Norfolk, Virginia (Whitley).

Increasing patient demand for surgery and decreasing reimbursement have forced many ophthalmologists to juggle a larger surgical load with limited clinic time. Because of the amount of knowledge required to treat every part of the eye and because of the dramatic advancements of surgical techniques and required skill levels, many ophthalmologists today pursue a fellowshiptrained subspecialty; others decide to enter the workforce. Nonetheless, surgeons are continually looking for ways to maintain an excellent clinical experience and develop patient care skills to implement within their respective subspecialties. When ophthalmologists enter practice, their goals are to provide the best patient care experience possible in the most efficient manner.

An integrated eye care practice can work in many forms, and it is up to the ophthalmologists and their colleagues to determine which situation works best to meet the practice’s needs. Within a vertically integrated practice, ophthalmologists can concentrate on surgical needs and advanced disease management, allowing optometrists to address the primary care issues, prescribe glasses and contact lenses, and treat a variety of disease states as their comfort and licensure allows. In situations that fall outside the scope of optometric care, patients are referred to the ophthalmologist for further care. In this modality, each party complements the other and improves efficiency within the practice. Other aspects of the vertically integrated model include certified ophthalmic technicians and opticians who are responsible for technical aspects and for prescribing and selling optical wear.

Another form of integrated eye care is a comanagement setting. Patients are referred to ophthalmologists for surgical care, and optometrists are in charge of perioperative care. In this system, mutual respect and trust in each provider’s abilities is essential to providing patients with the best care possible.

PATIENT CARE

Patients today are more knowledgeable and demand more chair time for complex procedures. As the number of surgeries per ophthalmologist increases, there is comparatively more chair time associated with preoperative patient education and postoperative follow-up care. Additionally, higher patient expectations and more technical procedures increase the amount of patient time needed before and after surgery. For example, the most timeconsuming elements of care for a patient who selects an advanced-technology IOL are proper patient screening; setting reasonable expectations before the surgery; tempering patient anxiety during the healing phase; and treating and managing postoperative issues such as residual refractive error, ocular surface disease, posterior opacification, and cystoid macular edema if the case arises.

Over the past 30 years, optometric education has placed more emphasis on treatment and management of ocular disease. In the United States, all 50 states allow optometrists to treat and manage ocular disease; however, some states restrict the use of specific medications and the treatment of certain ocular diseases. Optometry continues to primarily address nonsurgical vision correction, but, as the profession evolves, patients’ experience and comfort level with allowing optometrists to treat limited clinical disease is increasing. Optometrists can choose to limit their practice to ocular disease treatment or perioperative ocular care, and today there are accredited residency programs for optometrists with a special interest in these areas.

Because US schools have provided better optometry education and many states allow independent optometric management of ocular disease and postsurgical care, ophthalmologists have started to partner with optometrists to enhance patient care and increase their efficiency levels. Working with an optometrist who specializes in perioperative care provides the ophthalmologist with more time to proficiently screen patients for possible surgical complications.

In integrated eye care models, the optometrist is often the gatekeeper in charge of screening patients for preexisting diseases or comorbidities that may affect surgical outcomes. The result is more efficient treatment and stabilization of patients. When a patient sees the surgeon for a preoperative exam, there are no delays or surprises. This process allows us to follow a regimented and reliable preoperative exam and surgical scheduling processes for the patient and the surgeon. Additionally, the surgeon’s clinic time is minimized, allowing more operating time to be scheduled.

TABLE 1. ADVANTAGES OF INTEGRATED EYE CARE DELIVERY

• Utilizes the strengths of each practitioner.
• Improves efficiency in patient care.
• Includes a built-in checks-and-balances system.
• Provides better understanding of patient needs.
• Matches the procedure to the patient.
• Increases profitability.
• Increases surgical volume.

COOPERATIVE PATIENT MANAGEMENT AND TELEMEDICINE

An efficient optometry/ophthalmology (OD/MD) management relationship in the postoperative period is crucial for the integrated eye care model to flourish. Here the ophthalmologist relies on the optometrist to evaluate every patient for complications, communicate any complications with the surgeon, and manage the complications when necessary. This part of the OD/MD relationship requires trust between the two parties and begins with the optometrist accompanying the surgeon in the operating room to gain a better understanding of surgeon-specific tendencies and techniques that can affect the postoperative course.

Initially, the surgeon and optometrist conduct postoperative exams together so that they can establish a protocol acceptable to both parties. The optometrist must develop an understanding of the surgeon’s preferences, and the surgeon must develop trust in the optometrist to manage complications. As the OD/MD relationship and comfort levels grow, the optometrist will begin to progressively manage more complex postoperative complications under the supervision of the surgeon. Although the surgeon may not directly see the patient after surgery, the surgeon must be made aware of any complication and remain accessible to the optometrist for consultation on complex cases. It is also important to point out that both the surgeon and the optometrist practice under independent licenses but work together to address any issues that may arise. As in any relationship, communication and trust are the keys to providing optimal patient care.

Another opportunity for the integrated model is telemedicine. Our practices rely heavily on telemedicine for instant consultation in complex cases. When a complex case, whether pre- or postoperative, requires consultation with a surgeon who is offsite, digital images can be sent directly to that surgeon’s phone or computer. The data can include photos, digital scans, pertinent exam findings, and patient history. This takes 3 to 5 minutes to compile and transmit, and a response is typically received several minutes later. The responses range from simple text recommendations to involved phone calls and even the rare urgent clinic visit by the surgeon.

TABLE 2. POTENTIAL ISSUES FACED IN THE INTEGRATED EYE CARE SYSTEM

• Lack of communication.
• It may be hard for the patient to understand the role each practitioner plays.
• Complexity of the OD/MD relationship.
• Some laws affect the ability to provide patient care.

ADVANTAGES OF INTEGRATED CARE

There are great benefits to the integrated eye care model (Table 1). First, an automatic checks-and-balances system is in place. For instance, more than one doctor reviews the preoperative patient charts, and the surgeon and optometrist collaborate on complex postoperative cases. Second, mistakes are minimized and practice efficiency is maintained within an integrated eye care practice. The team approach begins with the optometrist independently reviewing the preoperative measurements and surgical plan. The surgeon checks the data and surgical plan prior to surgery.

Our referral practices include both ophthalmologists and optometrists who work together to provide integrated patient care while comanaging patients with referring providers. Each center has a director of optometric services whose function it is to serve as the liaison between the practice and the referral community, which includes optometrists, ophthalmologists, emergency and urgent care centers, and numerous other providers. The majority of our referrals come from the optometric community’s system of coordinating care.

Optometrists provide roughly 66% of the primary eye care in the United States2 and are able to handle the majority of patient vision and eye care needs. When it comes to secondary and tertiary care, optometrists have developed working relationships with ophthalmologists or specialists to whom they can refer their patients to receive the best care possible, and referrals from optometrists often constitute a significant portion of patient visits in ophthalmology practices.

Additionally, optometrists can call the referring ophthalmic practice and speak to one of the ophthalmologists when a referral or consult is needed. If the ophthalmologist in not available, the staff optometrist can guide the referral when indicated. This serves as a winwin for the integrated eye care practice as well as the optometric community by having a go-to person available in the surgeon’s absence. Additionally, the optometrist in an integrated practice understands the needs and concerns of primary eye care providers and secondary and tertiary care services, providing a valued benefit for referring optometrists.

The most common reason for referrals to ophthalmology are for cataract surgery. In cases of cataract referral, optometrists are responsible for providing the perioperative care for cataract surgery if the patient elects to comanage with his or her optometrist. The US Centers for Medicare and Medicaid Services (CMS) recognizes cataract comanagement as long as it is in the patient’s best interest and he or she desires this management strategy. Cataract referrals are made to the surgeon, where thorough surgical evaluation and testing are completed to prepare the patient for the procedure. The perioperative optometrist serves as a valuable resource for answering questions about surgical requirements and complications, postoperative management, and patient concerns from the referring doctors.

CONCLUSION

In the United States, we have started to overcome the traditional barriers associated with integrated eye care, but more work must be done before this system of patient comanagement is the gold standard of care (Table 2). Both professions are essential parts of successful integrated eye care models, and we (the authors) have witnessed the benefits that this system can provide. We challenge our European colleagues, where local professional standards allow, to promote integrated care as another way to improve patient results.

Derek N. Cunningham, OD, FAAO, is the Director of Optometry at Dell Laser Consultants, Austin, Texas. Dr. Cunningham states that he is a consultant to Abbott Medical Optics Inc.; Allergan, Inc.; Bausch + Lomb; Ista Pharmaceuticals; and Inspire Pharmaceuticals, Inc. He may be reached at e-mail: dcunningham@dellvision.com.

Walter O. Whitley, OD, MBA, FAAO, is Director of Optometric Services at Virginia Eye Consultants, Norfolk, Virginia. Dr. Whitley states that he is a consultant to Alcon Laboratories, Inc.; Allergan, Inc.; Bausch + Lomb; and Inspire Pharmaceuticals, Inc. He may be reached at e-mail: wwhitley@vec2020.com.

1. Sebate IA.Overseas Optometric Education:My Own Experience.http://www.medical-colleges.net/optometric.htm on 4/15/11.Accessed May 9,2011.
2. Caring for the Eyes of America 2007. American Optometric Association.http://www.aoa.org/x9791.xml.Accessed May 9,2011.

TAKE-HOME MESSAGE

• In an integrated eye care model, the optometrist is often the gatekeeper in charge of screening patients for preexisting diseases or comorbidities that may affect surgical outcomes.
• The surgeon and the optometrist practice under independent licenses but work together closely.