David Kading, OD, FAAO, FCLSA

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was introduced to the optometric community, many ODs did not understand the capabilities of the technology-nor how they would be utilizing it in their clinical practices.

Over the last decade, ODs have learned how to maximize the use of OCT in clinical practice.

There are four commonly utilized reasons for anterior segment OCT.
	
	

Previously by Dr. Brujic and Dr. Kading: 

Blog: Understand the science and art of managing chronic conditions


	Anterior segment OCT was initially developed to measure the anterior segment-not 

. Many proactive contact lens practitioners realized that they could see the contact lens resting on the cornea when using this technology. This became an exceptional imaging system when ODs realized they could utilize it for fitting more advanced lenses like scleral lenses.

Scleral lens fitting abides by a few rules: They need to be fit with the appropriate central corneal clearance, limbal clearance, and landing zone fitting the relationship.
	ODs can measure the central corneal clearance along with limbal clearance. (Figures 1 and 2) This enables them to communicate more accurately with specialty lens laboratories and determine exact measurements and microns of clearance.
	
	

In our experience, this creates a more efficient fitting process and ultimately requires less lens adjustments to optimize the fit for the patient.


	Keratoconus is a condition traditionally monitored with topography to measure corneal curvature. With this condition, the cornea is steeper at the cone. 

Anterior segment OCT technology monitors the condition by assessing the corneal thickness and at the thinnest region of the cornea, typically located in the region of the cone. This has become critically important for ODs because some vision plans require this measurement to determine the severity of the keratoconus.

Anterior segment OCT provides an additional metric to topographies to monitor disease progression over time. 
	
	


	One study looking at the epithelial thickness maps (ETM) of patients showed that individuals with dry eye had thickened ETM compared to those without dry eye.

In a second study, researchers demonstrated a thinning of the ETM in the superior region of the cornea compared age-related normals.

Although these studies may seem contradictory, they can be viewed as representing different phases of 

. Thought leaders in DED realized early on that ETM thickening may be secondary to early inflammation. With more chronic long-term DED, there may be an increased risk of chronic inflammation, causing a thinning of the ETM.

We have noted this in our clinical experience as well. Those patients with earlier DED tend to have thickened ETM, while those who have had chronic dry eye for decades tend to have thinner ETM superiorly (Figure 3). We have also seen more variability in ETM in the dry eye patient than normal individuals.
	
	

This has become one of the new metrics to follow in dry eye patients. It is our goal to stabilize the ETM so there is less variability in the thickness of the ETM in those individuals with dry eye and to help avoid long-term thinning that can occur in some DED patients.
	
	

Blog: Don't leave dry eye disease patients high and dry 


	ETM has provided new insight and understanding into certain visual characteristics of post-

An interesting relationship was found between ETM and visual outcomes for patients. We determined that those individuals who experience more visual disturbance tend to have increased ETM. The total pachymetry readings of post-refractive surgery patients was predictably thinner centrally where the myopic ablation occurred.

But there is a variance in the ETM that exists in these patients, and we found a strong correlation between thicker ETM and more visual complaints. In normal individuals, the expected ETM is 50 to 59 µm. In some post-refractive surgery patients, we have seen ETM as high as 73 µm of epithelial thickness (Figure 4).
	
	

Blog: Dive into the widening landscape of refractive surgery


	Other conditions for anterior segment OCT include epithelial basement membrane dystrophy (EBMD), Fuch’s endothelial dystrophy, and narrow-angle glaucoma.

Viewing the anterior segment with higher diagnostic technologies gives ODs a greater insight into understanding the physiology of the anterior segment and helps illuminate the unexplained visual outcomes that our patients may have.

With more time and research, ODs will continue to increase their understanding of anterior segment OCT as it becomes an increasingly important part of clinical practices.
	
	

1. Kanellopoulus AJ, Asimellis G. In vivo 3-dimensional corneal epithelial thickness mapping as an indicator of dry eye: preliminary clinical assessment. 

 2014 Jan;157(1):63-68.
	2. Cui X, Hong J, Wang F, Deng SX, Yang Y, Zhu X, Wu D, Zhao Y, Xu J. Assessment of corneal epithelial thickness in dry eye patients. 

Articles

Blog: 4 uses for OCT in OD practices

In today’s eyecare world, optometrists are bombarded by numbers. It seems that everyone wants to show us a number or have us look at numbers.

My vendor reps have reports for how I am doing, my office team wants to have us look at sales, and my accountant and I look at our cost-of-goods margin. All of these numbers are important, but the reality is that most eyecare practitioners get overwhelmed with numbers and elect to not look at any numbers. It seems at times that putting our head in the sand can be very comforting.

How can ODs gather the information they need to understand the health of their practices?
	
	


	By using a metric software, performance dashboard, or EHR system’s reports generator, ODs can easily monitor numbers and see how their practices are performing.

If you utilize your EHR reports, you may need to spend time pulling the data into a spreadsheet in order to get the comparisons to years past, but with a little work, you can highlight the areas in which you are doing well and areas in which you need to address.

Alternatively, you can utilize a reporting system/performance dashboard that pulls the information directly from your EHR and interprets the data into an easy-to-access, easy-to-read format. Usually, the software systems will clump similar data into certain fields to allow you to assess what is and is not working. Some systems also provide a SWOT (strengths, weakness, opportunities, threats) analysis or check engine system that highlights areas performing well or underperforming.

Be aware that creating good, consistent billing habits is vital to eliminate viewing bad data. Some systems help to eliminate “garbage in/garbage out.” Whatever process you use in gathering insightful data for your practice, it is important to make a decision and commit to the process of uncovering business metrics.
	
	

Use technology advancements to modernize your practice


	All practices operate under three levels of metrics:
	• Global metrics. These include gross production, revenue per encounter, or revenue per refraction.
	• Contribution metrics. This is a dialed-down category which measures the impact of a global metric. Contribution metrics consist of daily disposable percentage and contact lens capture rate, for example. These two metrics are contributory toward the more global metric of revenue per contact lens fitting.
	• Absolute metrics. These metrics are independent of other metrics. They consist of measurements such as frame count and refraction count.

Having an understanding of how metrics build upon each other is critical to knowing where and how parts of the practice and their performance numbers relate to each other.

The key performance indicators (KPIs) that ODs choose to track should relate to a specific strategic business goal and reflect how successful the business is in achieving that goal.

In this article, we will discuss four of our favorite KPIs to monitor when it comes to tracking the performance in our practices:
	
	• Revenue per encounter
	• Revenue per contact lens fitting
	• Revenue per eyewear pair
	• Percentage write-offs

These four metrics offer a good pulse point of how well a practice is performing. Additionally, they are well defined and quantifiable. While other key metrics are important for the financial gains of a practice (gross margin, overhead, and staffing costs), let’s focus on areas that relate to patient care and overall billing services by the office team.
	
	

Keep an eye on meaningful metrics in the new year


	The first metric we will dive into is revenue per encounter (RPE) (also known as revenue per patient).

Many practices keep track of their revenue per refraction (RPR). If a practice conducts refractions and eye exams as much of its business, then RPR is a better number to track.

However, if a practice offers any medical eye care, then RPE may be a better metric to measure.

At Dr. Kading’s clinic, nearly half of all patient encounters are medical. We would be extrapolating a significant amount of data to put a value on a refraction (revenue at the end of the month divided by the number of refractions completed).

Instead, we place this value on the visit, regardless of whether it is a contact lens check, glaucoma encounter, or specialty contact lens fit. We think that, on average, it more closely resembles the amount of money Dr. Kading’s practice will make per patient encounter.

Everyone wants to improve their RPE, but it’s hard to simply track it and expect to see results. RPE should be viewed as a global metric because many smaller metrics can greatly contribute to the result.

Knowing the why of metrics is important to make a plan to improve RPE or to continue doing what is successful. Each practice may have key components which help to increase its RPE.
	
	

How to calculate the value of your practice

Several contribution metrics drive RPE:
	
	• Revenue per contact lens fitting
	• Revenue from eyewear sales
	• Frame capture rate
	• Revenue per medical patient

Focusing on increasing contribution metrics will inherently improve overall practice performance as well as improve RPE.

If an OD sees about 2,000 patient encounters during a year and generates $300 per RPE, the OD will bring in around $600,000.

However, if this OD works diligently to increase his RPE to $325, he will generate an additional $50,000.

In Dr. Kading’s office, some ODs generate $495 RPE, and others bring in $375. Some are related to the specialty that a person may have (such as high-revenue specialty contact lenses vs. pediatrics). Knowing these numbers for each doctor enables doctors to maximize how well they make recommendations for products or to detect if patients are following through on medical encounters or prescribed products.
	
	

Blog: Why medical coding is a big deal for ODs


	In many offices, contact lens revenue accounts for 30 percent of total gross production. This is a substantial percentage for most offices.

The revenue per contact lens fitting (RCLF) metric consists of the total revenue from the contact lens examination (such as the contact lens fitting fee) plus the revenue from the sale of the contact lenses.

In Dr. Kading’s grandfather’s day, he did not charge for contact lens fitting because 100 percent of his patients purchased their contact lenses from him. However, with the increase in contact lens fitting complexity and the rise of online retailers, ODs had to abandon that method of practice and generate revenue from contact lens fitting.

If you have noticed that your RCLF has decreased over the year, evaluate why. Many practitioners see RCLF as a number that needs to increase every year. Although this would be ideal, if contact lens material capture rate remains the same and fitting fees stay the same, then RCLF will remain the same. 

In order to increase RCLF, ODs must make more money from contact lens fittings or sell more materials per contact lens fitting.

Dr. Kading performs a lot of specialty lens fittings and myopia management. These fittings yield more revenue from the fitting and materials fees than a spherical soft fitting and a yearly supply of materials. He uses RCLF to gauge whether he is seeing more or fewer fittings from month to month. RCLF also tells him if he and his staff are succeeding in presenting and selling patients a supply of their contact lenses-or if patients are purchasing their lenses elsewhere.

If contact lenses are a huge part of your practice, it will serve you well to keep an eye on RCLF on a monthly basis.
	
	


	Many optometry practices rely on the optical to provide a substantial amount of revenue.

ODs and their optical staff face the problem every day of patients wanting only what their vision care plans provide. In effect, failing to prescribe and dispense what is best for the patient can allow the vision care plan to dictate the patient’s visual needs.

Dr. Kading and his staff believe that glasses with glare (meaning without anti-reflective [AR] coating) are not a safe option for patients. His optical sells only lenses with AR; making AR percentage 100 percent.

Some offices have strong beliefs around the type of frame or lens materials that patients receive. One way to gauge whether patients are buying into what ODs recommend is to follow revenue per eyewear pair (REP).

REP informs how well the doctor is prescribing and how well the optical staff is able to follow through on those recommendations.

When REP drops, it usually means that the patient handoff from exam room to the optical has failed. REP advises how effectively the practice sells premium lenses.

If the optical is a major revenue stream, strongly watch those numbers.


	This metric is also known as adjustment percentage.

Gross production (or sales) is the best way to measure a practice’s sales and growth. Gross production is the total amount billed to insurances or direct to the patient. Gross production is a lead factor; lead factors help to guide or influence the data to achieve desired results.

Change the overall health of a practice over time by tracking and improving gross production. Improving contribution metrics that are driving factors for gross production will produce substantial practice growth.

Examples of metrics that contribute to gross production are:
	• Number of exams
	• Number of encounters
	• Sales of contact lenses
	• Sales of glasses 

Increasing gross production provides the opportunity to also improve net production. 

Most practices value their worth based on the total amount of net production (money in the bank).

In order to set a net production goal, it is important to know the write-off percentage and what is affecting it.

Calculate write-off percentage: 1-(net production/gross production)

Compliance with entering all write-offs into the practice management system in a timely manner is important to maintaining accurate numbers. Write-offs occur when medical insurance or vision care plans don’t pay the complete billed fee.
	
	

Most practices do not know the amount they are writing off the day of service. Explanation of benefits (EOBs) statements from insurance companies are mailed about six to eight weeks after the date of service and the claim is submitted.

Some insurance companies pay throughout the month, while VSP pays two times a month.

Varied payment schedules can cause large write-off amounts that show a negative net production amount at the beginning of the month, making daily tracking difficult. In most cases, net production will even out by the end of the month.

For example, a practice could receive a large VSP insurance payment on a particular day for $10K and write off $15K in one day. On the second of the month, if gross production sales were $10K, then net production would be negative $5K. (Calculate gross production minus all adjustments)

Monitoring write-off percentage month to month and comparing it year over year can provide insight and serve as a check point to ensure all write-offs have been entered each month.
	
	

Blog: How to calculate your compensation as a practice owner


	We could write a book (and maybe we will!) on metrics. The game of optometry is fun, but you have to know the score and how you can affect the score. Ultimately, our goals are to bring about better patient care. Most of the time, more sales means better patient care because patients are following your recommendations.

For ODs not following their metrics, we encourage you to look into a metric measuring system and track the numbers. They will give you the vital signs of your practice’s success.
	 

 disclosed speaking, research, or consulting relationships with Alcon Laboratories, Allergan, Bausch + Lomb, BioTissue, CooperVision, EyeVance, EyeEco, Facebook, Johnson & Johnson Vision, Novartis, Oculus, Optovue, RPS, Shire, SolutionReach, Sun Pharma, TearScience, Valeant Pharmaceuticals, Valley Contax, VSP, Weave, ZeaVision, and Zeiss. 
	

has over 20 years experience in the optical industry focusing on measuring KPIs. 
	

Know what practice metrics to measure


	
	Optometry is a remarkably empowering profession. ODs care for patients’ visual welfare through appropriate refractive correction and optimizing ocular health.  Within the last 15 years, the technologies available to both diagnose and treat ocular conditions has drastically changed.

Looking back at our brief history as optometrists has been enlightening. Refractive care of patients is usually managed as a long-term chronic condition, but its symptoms are treated effectively by power changes that can be noticed immediately by the patient.

This makes refractive conditions somewhat straight forward as changes in treatment (the prescription in lenses), provides patients immediate improvement in symptoms.

Previously by Dr. Brujic and Dr. Kading: Blog: Keep an eye on meaningful metrics in the new year

An example is a myope whose myopia has progressed, and we are now increasing the power in his glasses. This provides immediate benefits to the patient.

If the patient is solely an eyeglass wearer, we can demonstrate the patient’s new prescription immediately with the help of loose lenses held over his glasses. 

wearer, ODs have an opportunity to demonstrate the immediate benefits of the new prescription by placing the patient’s updated prescription on his eyes.

This clinical interaction produces a positive patient response for the patient by providing a change in treatment (prescription change) after managing a chronic condition.

With the chronic condition of myopia, the acute symptom is a change in vision. A positive patient response is delivered by an appropriate refractive correction-through glasses and/or contact lens prescription.


	Chronic ocular disease brings a different set of opportunities and challenges with it. 

, for example, allows ODs to help patients avoid the potentially blinding effects of a condition that-for most patients-is relatively asymptomatic until the condition is advanced. 

Glaucoma can be diagnosed and treated by ODs in most states in the United States. Many ODs are directly involved in caring for these patients by making decisions on whether intraocular pressures (IOPs) are appropriately controlled in light of exam and diagnostic test findings. But, there are differences in managing a patient with this condition versus a patient experiencing a change in refractive error.

Related: Chronic ocular diseases and patient psyche


	Despite both being chronic conditions and requiring long-term patient care, these individuals are managed with different expectations. 

When managing a glaucoma patient, ODs may think they are successful with treatment because they have attained their set IOP goal.

Yet, the patient doesn’t see any better because of the treatment. The patient doesn’t feel any better because of the treatment. 

Interestingly, a significant portion of patients may experience symptoms created by the medications ODs utilize to treat the condition. 

This is what can often make compliance with glaucoma treatment a challenge. Unlike correcting refractive error, glaucoma treatment does not necessarily improve symptoms with successful treatment. 

Related: Why documenting target IOP helps ODs


	An OD’s role in treating the glaucoma patient is similar to the primary care physicians’ or endocrinologists’ role in treating a diabetic patient. 

Those healthcare providers utilize objective metrics-such as hemoglobin A1c levels-in order to determine success or failure with treatment. 

Although elevated glucose levels can have other effects on a person’s physiology, it will be the success or failure of maintaining appropriate glucose levels that will determine the long-term ramifications to other end organs-including the eye.

This is a similar strategy that ODs employ with glaucoma patients. Although ODs know the pathophysiology of glaucoma can be complex, the one modifiable risk factor is modifying the IOP.

Related: How to improve glaucoma referrals


	Technological advancements have made tremendous improvements in how ODs diagnose and manage a number of conditions in their practices. 

Our understanding, diagnosis, and management of ocular surface disease has expanded because of the passion behind the companies developing the tools available to manage this condition. 

 by a patient’s complaint of ocular dryness. We often treated the condition with artificial tears. 

For those practitioners who have embraced dry eye management, we understand that artificial tears have a place for temporarily ameliorating the symptoms a patient experiences.

But we now have technologies to improve how the ocular surface functions. ODs now understand that it is the delicate balance of appropriately produced tears, along with a functional blink, that will lead to the most successful outcomes.

With that said, managing a chronic condition such as dry eye disease requires a new set of clinical rules. ODs need to be cognizant of inflammation on the ocular surface, tear volume, health of the lids and meibomian glands, and with exogenous factors that may affect the way tears are formed on the eyes. 

Related: Modern-day techniques for diagnosing dry eye disease


	Because there is no known cure for dry eye disease-only effective ways to manage the condition-more patient visits are required to help rehabilitate the ocular surface. 

Improvement in both signs and symptoms is the goal; it usually requires a strategic approach that is multifaceted in nature. This is different than providing an updated glasses or contact lens prescription when managing a patient’s refractive error-the patient is able to immediately benefit from the new prescription.

Multiple clinic visits throughout the year instead of a single visit are often required when managing chronic ocular disease.

It is critical for an OD to give clear guidance to the patient on a treatment plan and appropriate expectations, including potential side effects from the treatment. 

Related: Dry eye protocol for any practice


	The way ODs manage refractive conditions today is much different than how we did in the past. Myopia progressing in the pediatric patient used to simply be corrected optically. Now, through myopia management, ODs are actively managing this condition through slowing the progression of myopia.

As diagnostics and treatments continue to evolve, ODs’ involvement in managing chronic ocular conditions will continue to increase. A greater portion of our clinical time is already devoted to managing many of these chronic conditions, and it will likely continue to only increase as optometry’s role in medically managing patients grows.

Understanding the scientific rationale for the diagnostics and treatments utilized to manage these conditions is critical. But understanding the difference in management strategy with chronic conditions provides us with the art of managing these conditions and our patients at more appropriate levels. 

A successful understanding of the science and art of appropriately caring for chronic ocular conditions will offer us the best opportunity to best manage these patients that need our care the most.

: The views expressed here belong to the authors. They do not necessarily represent the views of Optometry Times or UBM Medica.

Over the last four years, we have spoken to thousands of optometry students and younger practitioners.

The purpose of our company, Optometric Insights, is to hit the accelerator on what our new optometric colleagues desire. Our countless hours have revealed incredible insights into what both new and established optometrists look for in success.

For most of ODs, whether we are new or established in our careers, our definition of success and view of the future is not clearly defined.

We pursue patient care on a daily basis with the intention of providing good service to those who walk through our doors. Thoughts of the future rarely go beyond the next day’s patients, the next vacation, our next equipment purchase-and how we are going to pay for it.

Related: Find the right platform to monitor your practice's performance

The reality is we cannot get to success faster if we do not know what success is. In our optometric world, just like the real world, success can mean many different things.

For some clinicians, it relates to the success of their business in numbers, revenue, or patients seen. Others consider it to be freedom, which urges them to work toward a four-day work week, or more vacation time.

Others may see it as becoming debt-free and a practice owner. Others have less entrepreneurial urges and desire a steady salary as an associate with stability so they can focus on other things between 6 p.m. and 8 a.m. 

Regardless of the view of success, we urge all practitioners we interact with to come up with their own definition. After defining success, we have something to dream about.


Our next step is to put a dream on a timeline. With a timeline, a dream is goal. When we put a date, year, or age when something will be accomplished, we have a desired outcome with parameters. 

We urge people to draw a linear line with today on one end and the goal listed with the date when it should be accomplished on the other end.


Take Frank as an example. We met Frank when he was a third-year optometry student. He shared with us that he wanted to practice in his hometown when he graduated and be a practice owner or partner within 10 years of graduating.

We asked Frank to map out a timeline that included his time left in school and his residency year and requested he list the obstacles that would keep him from reaching these objectives in 10 years, then narrow down the obstacles that would keep him from achieving them success in three and five years. 

By the time the exercise was over, Frank had changed his goal to five years.
Two years post-residency, Frank is on track to becoming partner in a three-doctor practice. He has negotiated a lower salary that covers his living expenses, and student debt., with the remaining amount going toward his share of the practice.

Because he knew what he wanted and when he wanted it, Frank was able to knowingly negotiate with his soon-to-be partners in order to create a win-win situation. 


Dr. Johnson (DJ) has been practicing successfully in a commercial setting. He said that he always envisioned himself being in private practice so he could practice medical eyecare and primary care, all without leaving his commercial setting and patients. 

We asked DJ how he envisioned the perfect situation: He said that he wanted to be treating glaucoma, macular degeneration, and dry eye within his setting rather than sending those patients elsewhere for monitoring and treatment.

A lack of equipment and space and lack of knowledge about how to charge patients for these services was keeping him from achieving his goals.

We told him to create a timeline. After doing so, he said that in five years he would have an ocular coherence tomography (OCT), visual fields (VF), and the dry eye tools that he needed. We asked him why it would take five years. He said that it would take time to learn the things he needed, be able to pay for the technology, and figure out where things would fit in the office. 

We connected DJ to several companies that had instruments with multifunctions and small footprints. We urged him to look at his office in terms of efficiency and what he used.

Read more from Dr. Kading and Dr. Brujic.

He discovered that he had a room for contact lens training and contact lens trials. He was seeing patients without a technician about every 30 minutes and had two exam rooms. 

After receiving education on coding and billing and talking with several commercial colleagues who had done similar work, we urged DJ to take three evenings and clear out his office. 

He made room for equipment obtained low-interest financing with six-month delayed payments, and was up and running seeing his first full glaucoma work-up within six months of telling us it was going to take five years. 

By altering his schedule, and hiring a technician, DJ is able to keep all the medical patients who he was previously sending out without losing any of his current exam patients. 


Failure, for most of us, will never mean losing our houses, or going bankrupt. But it may mean that you do not achieve the things that you desire and want. 

In optometry, most of the things that we desire will make both our lives and our patients’ lives better. Sit down, figure out what you are putting off, map out the success, and then determine what obstacles you can overcome to achieve your goals in half the time that you originally set.

Author | David Kading, OD, FAAO, FCLSA

Articles

Blog: 4 uses for OCT in OD practices

Know what practice metrics to measure

Blog: Understand the science and art of managing chronic conditions

How to accelerate success through goal planning