The optometric practice of tomorrow


The future of care is connected, in more ways than one.

By Heather Boerner, AOA Focus, November/December 2015, pages 34-40

It's the year 2040 and Mark Schaeffer, O.D., is heading to his office in Birmingham, Alabama. And while it's the same office he roamed around when he visited his optometrist father as a child, the way he practices is quite different.

The day begins when he checks in: A wearable device downloads the schedule for the day before he even arrives at the office. He's got eight appointments today. First, a 55-year-old patient whose smart contacts alerted the office of increasing intraocular pressure, necessitating a glaucoma consult. Next, an 81-year-old patient whose macular degeneration medicine, administered through his contacts, needs a refill. Dr. Schaeffer will check that the medicine is having the intended effect, which it should—it was selected for the patient based on his genetic code.

Then it's a well-child check of a 6-month-old patient. Dr. Schaeffer will take a tear sample so its DNA can form the basis of a lifelong preventive regimen, and treatment if it's necessary. The data will automatically be added to the medical record Dr. Schaeffer shares with the child's pediatrician.

After that, Dr. Schaeffer will see three patients for refraction. Two will probably buy low-cost frames generated by his optical department's 3-D printer. The third has the money for high-end, handcrafted frames. Then, it's a consult with the doctors on another patient's medical team, to discuss how to manage her diabetes. All of this is topped off by a review of his patients' biostatistics—a requirement of the accountable care consortium to which he belongs. The review isn't difficult, just a simple scan of the predictive analytics report that monitors real-time data from his patients' wearable devices, electronic health record (EHR) and other data, which is uploaded automatically to the cloud. If anything is askew, he'll click the button to request an appointment for the next day.

He waves at his receptionist at the front desk and heads to exam room one, where his first patient's data has already been uploaded to his heads-up display, including testing done before he arrived. As he closes the door, the EHR starts recording, invisibly transcribing the appointment directly into the medical record.

"Hello, Mr. Chen," he says as he walks into his office. "How are your eyes feeling with those contacts?"

Welcome to the future of practice. Although prognostication is tricky, AOA Focus asked doctors of optometry to weigh in on what current trends will change the way they care for patients in the future. What unfolded was a vision that unites some of today's most powerful movements in health care and technology.

It's a future marked by rapid change, according to Rob Foster, vice general manager of Topcon Eye Care Corporation. Foster was part of an all-new session called "OD Talks: A Look Into the Future" at the 2015 Optometry's Meeting®. These cutting-edge, Ted-style talks were presented by industry futurists, who provided a sneak peek at what the profession could look like in 10 to 15 years, and will be included as part of the next Optometry's Meeting in Boston, June 29-July 3, 2016.

"The supercomputer in the late 1980s and early 1990s that broke the human genome had 270 percent less computing power than does this little device right here," he said, gesturing to his iPhone 5s. "That level of change will probably accelerate—not stay the same—in the next 20 years or so."

Looking back to see the future
Indeed, technology is the most obvious way practice has changed in the past 25 years. But demographic shifts are just as powerful. The U.S. Census predicts that the bubble of the baby boomers will continue to push the average age upward. About 20 percent of the total U.S. population is expected to be 65 or older by 2040, according to the Social Security Administration, compared with 12 percent in 2005. With aging come diseases and conditions such as age-related macular degeneration, vision loss and cataracts.

At the same time, the children of today may have different vision needs than today's adults, says Andrew Morgenstern, O.D., chair of AOA's New Technology Committee and a consultant with Booz Allen Hamilton whose current assignment is with the Vision Center of Excellence at Walter Reed National Military Medical Center in Bethesda, Maryland. Close-up use of tablets and long-term exposure to blue light may result in adults with more myopia or vision problems at a younger age, he suggests.

According to the National Eye Care Workforce Study, a joint venture by the AOA and the Association of Schools and Colleges of Optometry completed in 2014 (Click here to read more from the September 2014 edition of AOA Focus), there is an adequate supply of optometrists to meet this increased demand for eye care. Couple that with what the American Association of Medical Colleges projects to be a shortfall of ophthalmologists in 25 years, and you have conditions ripe for optometrist-led primary eye care, says Dr. Morgenstern.

"We're going to have to step in and fill the gap," he says.

The connected practice
But it's not just a matter of providing more care, says Dr. Schaeffer, who graduated from Southern College of Optometry in 2011 and completed a residency at Bascom Palmer Eye Institute in 2012. It's about integrating chronic disease management into a patient's eye care, too.

"All care should be integrated into optometric care," Dr. Schaeffer says. "Optometry will be part of the system. If a patient has diabetes, you'll be in communication with their endocrinologist and primary care doctor."

Indeed, when we think of the future, we think connectivity. But collaborative care may not be the connectivity most optometrists—three-fourths of whom operate independently in private practice, according to the latest AOA survey—imagine.

Underscoring the importance of how all aspects of technology are affecting our lives as human beings, as well as doctors and patients, futurist and founder of Yahoo Tech, David Pogue, spoke at a private industry event at Optometry's Meeting® in 2015. Pogue commented that while many feel technology isolates us, it really does the opposite-it keeps us in touch, and everyone wins.

That is where optometry is heading, says Joe Ellis, O.D., chair of the AOAExcel® Board, who practices in Kentucky. Between the full implementation of the Affordable Care Act, ever-decreasing reimbursement rates, continued regulation and more population-health-based payments and less fee-for-service, optometrists will have the chance to work closely to ensure eye health is a key part of overall health. And they'll do it by joining networks and accountable care organizations (ACOs) that are paid based on the overall health of their patients. (Learn more about integrated care on page 26 of the May 2015 edition of AOA Focus.)

"We can't just practice in our four walls," says Dr. Ellis. "It has to be me working with the care coordinator of the ACO, working with him or her to coordinate the care of the patient."

The truth in the tears
And that care is likely to be lightyears ahead of what's available to patients today. If you ask Dr. Schaeffer, that treatment will start with tears.

"Your DNA is in your tears," he says. "In 25 years, we'll be able to take a tear sample and tell, based on your DNA, anything and everything about your eye. We can prescribe medicines for macular degeneration, diabetes, myopia, all on your genetic makeup."

What Dr. Schaeffer is talking about is what the National Institutes of Health has dubbed "precision medicine." For patients, DNA will provide an early warning system, alerting them to genetic susceptibilities. For providers, it will trigger intensive screening and perhaps as-yet-unavailable preventive regimens.

Those regimens could include nanobots that seek out and destroy cancer cells or genetic-based biologics for macular degeneration. Our genes might be the key to our health, and optometrists will need to know how to interpret them.

David Friess, O.D., has spent his career working with clinical research and development groups at Alcon and other organizations, helping them organize and run clinical trials and develop diagnostic and analysis tools. He sees a future where smart contact lenses monitor eye health—Google is already developing a contact that can measure blood glucose levels through tears.

Or, imagine a contact lens that monitors intraocular pressure in a patient who is supposed to be using eye drops. In the future, doctors won't have to rely on patient reports to track adherence.

"If there were this intelligent contact lens, the doctor could say, 'Aha, let's take a look at the data and see how many times you took your drops,'" he says.

And there's more: Dr. Friess says contact lenses loaded up with timed-release medicine that doctors prescribe and monitor via the cloud are already in development.

"The use of drug-eluting materials for contact lenses is a major, major industry trend that will take place in the next five, 10, 15 years," says Friess. "Think of an elderly patient who no longer has to drive to the pharmacy to get his or her medicine.

The patient can just go to the doctor and get prescribed something he or she doesn't have to remember to take. It will be incredibly helpful." (Click here to read more about contact lenses of the future from the July/August 2014 edition of AOA Focus.)

Big promise for big data
Also helpful, especially for optometrists: EHRs that fulfill their potential.

Dr. Morgenstern likens today's EHRs to the first automobiles: The Model T was an incredible machine. It was also the most rudimentary any car would ever be, in terms of technology, safety and comfort. Likewise, he says, are EHRs and data usability.

He imagines medical records that are so advanced they disappear from view. Rather than sitting with a computer between himself and his patient, he imagines EHRs that seamlessly connect equipment, wearable contacts, watches and fabrics, and other doctors' offices. They are always up to date. He even sees technology replacing scribes. Instead, optometrists will simply speak aloud, and the EHR will record and log the data in the record. (Learn about AOA MORE, optometry's clinical registry that will integrate data from EHRs and facilitate secondary uses of that data by doctors and the profession, in the September 2015 edition of AOA Focus.)

Once the data is connected, doctors will need a way to parse the gigabytes of data that are going to flow into their EHR systems.

"[Right now,] your office can be filled with a dozen diagnostics," he says. "But if they're not speaking to each other or speaking to you, you get overloaded as the doctor, and get overloaded by data."

That's where predictive analytics come in. Predictive analytics is just that—an algorithm created for medical data, based on prospective and longitudinal research that connects certain data points with likelihood of disease progression. It will make big use of big data.

But that's not all. Topcon's Foster told Optometry's Meeting attendees that doctors will have a "borderless office."

That's because high-tech apps—whether on cell phones or some future permutation that we can't now imagine—will allow doctors to log in to those devices and gain access to patient information.

At Optometry's Meeting, Foster asked how many doctors in the audience were under 40.

"I have a single suggestion for you," he told the younger generation. "Take flying lessons, because you're going to be in that cockpit."

Quality care: No invention competes
All of this is to say that technology and practice will support optometrists' biggest value: the one-on-one relationship with the patient.

"If we can get all 40,000 optometrists on the same page, and make a case not only to ourselves but also to the public as a whole, we can explain that, 'You should get your red eye checked with your optometrist, and not your primary care physician. We will take great care of you for the same price, plus we offer more specialized care without making it more difficult for you,' " says Dr. Schaeffer. "That changes the way everyone thinks about the eye doctor. And it gets all of us excited, because it means we can take care of our patients better."