Going with the flow

Office space must reflect changing practice modalities. How and why will it change is a matter of the specializtion of each optometrist. But whatever the case, the form needs to follow the function. And that means ODs' offices need to change with the times.

Going with the flow header
When Gabriel Avila, O.D., in Abilene, Texas, built a new space for his practice in 2009, he first consulted with Chad Fleming, O.D., of AOAExcel™. As a result, the flow of his space changed from linear to circular, beginning and ending in a beautiful optical display area. Here are the inspiring before and after shots.
Photographs courtesy of Gabriel Avila, O.D.

By Heather Boerner, AOA Focus, July/August, 2014, pages 33-39

In the 30 years he's been an optometrist in Pittsburgh, Pennsylvania, Bob Bittel, O.D., has renovated his office six times. First, the typewriters and the paper appointment book disappeared. Then the space doubled, then tripled, to the point that the office is now three and a half times its original size. He's added room for digital cameras, visual field tests and ocular coherence tomography (OCT) machines.

And let's not forget the technicians. Moving from a staff that included only himself and a receptionist to employing 17 people means larger exam rooms, bigger break rooms and space for all those people to move. Lanes have expanded, computers and tablets have been introduced, and electronic records take the place of file cabinets.

And all along, Dr. Bittel says he's kept his eye on a single thing: the patient.

"The business of an optometry practice should be motivated by good patient care," he says. "That's the way we've done it. Decisions on your physical plant should always be based on wanting to provide the best possible care, whether that's pediatrics or gerontology or everything in between."

In order to do that, your space must reflect changing practice modalities. As the baby boomers age into conditions such as cataracts, glaucoma and age-related macular degeneration, and the Affordable Care Act expands access to eye care to children, office space must change, too. How and why it will change is a matter of the specialization of each optometrist. But whatever the case, the form needs to follow the function. And that means ODs' offices need to change with the times.

A growing medical model
When Dr. Bittel began treating patients in 1984, the typical course of an exam was very different than it is today. Back then, you'd dilate a patient's pupil, perform a refraction test, test visual acuity and prescribe glasses or contacts. Today, he works with patients with glaucoma or cataracts, or complications from diabetes or high blood pressure that affect the eye.

The law made these changes possible. The first laws allowing optometrists to prescribe medications for their patients went into effect in the 1970s, and it wasn't until 1998 when those laws reached every state in the country. That has meant Dr. Bittel, like his colleagues, is increasingly practicing a medical model of eye care that diagnoses and treats patients with complex health issues, changing the type and variety of equipment and services optometrists must offer. As the AOA comes out with evidence-based treatment guidelines (see the January/February issue of AOA Focus), that equipment and that treatment may continue to evolve.

How these changes affect practice is clear to Beth Kneib, O.D., director of the AOA Clinical Resources Group. It changes the length of exams for one thing. Primary care exams with new patients require more testing to diagnose, create a medical plan, and educate the patient. Medical appointments to check the status of long-standing patients on medicine for glaucoma or an optical check, for example, can be shorter.

And then there's the fact that practicing the medical model means triaging patients, and treating differently based on the condition.

"What is this patient coming in for?" she says doctors must ask themselves. "Are they coming in because they are having flashes or floaters? You'll work up that patient differently than you would if that patient were a contact lens follow-up patient."

While some of these appointments can be quicker than average—a 10-minute check to ensure that medication is having the intended effect—they can also be quite a bit longer, as an OD walks a patient through what diabetes might mean for his or her eyes and what treatments are available. For doctors pursuing the medical model, the type and variety of equipment necessary to treat those patients is proliferating, says Christopher Quinn, O.D., member of the AOA Board of Trustees, who practices at Omni Eye Services in New Jersey. Just in glaucoma, one of two areas that Dr. Quinn specializes in, the equipment needs have skyrocketed. This is good news for patients. Some of this equipment, like ultrasounds to measure corneal thickness, or the OCT, which allows optometrists to analyze the structure of the eye, can eliminate false positive diagnoses. It also can help doctors assess with greater precision when treatment needs to begin and how aggressive it should be.

But it also means space for all this equipment and creating a flow that supports care.

Changing care, by the numbers
At the same time, the need for optometry has been growing. By 2030, more than 72 million Americans are expected to be over age 65, according to the U.S. Census Bureau's 2012 estimates. With that comes a host of eye-related health issues, such as diabetes, high blood pressure, glaucoma and cataracts.

On the other end of the spectrum, the Affordable Care Act is expanding access to eye care for children under age 19, adding vision benefits to the list of 10 essential health benefits covered by insurance. That means millions more children will be coming into care, and optometrists will need to have the equipment and offices to treat them.

And then there's the electronic medical record. Depending on whether you store your medical records on servers on your premises or on the cloud, you'll need to accommodate—and ventilate well—rooms set up just for electronic equipment.

Lori J. Kindschy, CPOT at May Vision Center in Waunakee, Wisconsin, says the office today is very different from the office she worked in when she started 23 years ago. Pretests cannot be conducted as quickly because paraoptometric staff have more on their plates. "I really think the days of the doctor doing the pretest are gone," she says. "With lower reimbursement rates and a lot of these new insurance plans reimbursing at Medicare rates, I think [practices are] definitely going to see more patients in a day to keep the lights on."

Managing change, managing flow
To do that well, optometrists must manage patient flow carefully. When Kindschy's boss, David K. May, O.D., decided to build a new office to accommodate his growing practice five years ago, he invited Kindschy and the other technicians to design it. He brought in architectural plans and set them down in front of the staff. Out came the Wite-Out®, down came the walls. When the team was done with it, Kindschy says, "If you track a patient from the time they walked into the office to the time they go out, it doesn't look like a bowl of spaghetti."

Indeed, most optometrists who spoke to AOA Focus for this story say the name of the game in space planning is controlling patient flow. This means, in the midst of growing patient loads, doctors must schedule medical patients for longer appointments while making time and room for quicker optical patients. But it also means arranging space so that patients aren't "bumping into each other" as they move through the exam lanes.

When Gabriel Avila, O.D., who has a private practice in Abilene, Texas, moved offices in 2009, he was in a situation many relatively young ODs face. When he started his practice in 2004, he moved into a strip mall that was economical and already built out. But its design was old school—a long hallway down the middle, with rooms on either side.

"Patients were always bumping into each other," he says. "It was more congestion than flow."

The solution was to move from a linear design—where everyone is going in and out of the same hallway in all directions—to a circular flow, moving from check-in to pretesting to medical history to exams to the waiting area, which doubles as an optical showroom. It's a typical design for larger practices, he says, but he might not have thought of it without the help of Chad Fleming, O.D., a consultant he found through AOAExcelTM, a wholly owned subsidiary of the AOA that provides endorsed business and career services.

Adding on for special tests
But the proliferation of diagnostic equipment can stymie flow, as well. OCTs, digital fundus cameras and osmolarity devices, for instance, test for specific eye problems and, while advanced, some tests can take up to 20 minutes. Meanwhile, the advancement of automated perimetry, lensometers or refracting systems allows ODs to create exam lanes complete with automated equipment, which allows ODs to delegate some simple exams to CPOTs, freeing the OD to diagnose and treat.

All of this equipment needs to be present, but how it's organized allows doctors, technicians and patients to move smoothly through the office.

In Kindschy's office, for instance, one testing room holds all the equipment. Soon, an OPD aberrometer will arrive—and will need to be crammed in a room that's already full, and warm from the sheer number of electronic devices in it.

"It will go in the pretest room with everything else," she says. "We'll have to move everything around a little bit."

In Dr. Avila's five-year-old space, he's already getting ready for renovations. Adding 2,000 square feet, Avila says part of that space will be a special room just for advanced medical testing, which will include an OCT to do laser retina scans and a visual evoked potential (VEP) testing device.

"This will get [these more medically complex patients] out of the flow," he says. "Plus, if all diagnostic and testing equipment is in one room, even if it's large, you're running into Health Insurance Portability and Accountability Act issues by talking to patients about what you're doing, what problems you're testing for. So even though much of the new equipment is faster, some is not. That's why we're creating a special space for it."

Tearing down walls
Jeff Gamble, O.D., jokes that he feels like a modern-day Ronald Reagan, circa, "Mr. Gorbachev, tear down this wall."

"If you came in here right now, you'd wonder what the heck was going on," says Dr. Gamble, who is part of Columbia Eye Consultants Optometry, a large, multidisciplinary practice in Columbia, Missouri. "When our practice started 40 years ago, we had a partner who was not interested in having optical as part of the practice. He built a wall to separate the main office from the main optical department. We literally blew that wall up last week and we're incorporating optical into our waiting room."

Dr. Gamble is not alone. Practice changes aren't the only motivation for office redesigns. The emergence of online optical sales are forcing optometrists to compete on aesthetics as well as medical excellence.

For Dr. Gamble, that's meant blowing up the division between optical and clinical care, and building a new, beautiful waiting room that allows patients to browse spectacle selections. But Dr. Gamble is going one step further: During an examination, Gamble can now page an optician, who will come back to the exam room, talk to the patient about what kinds of eyeglasses will be best for their particular vision needs, and offer to walk through their inventory right then.

"What we found was that patients told us they weren't sure what to do next," he says. "It's really increased our capture rate, doing the handoff."

Adding in for children
For Dr. Bittel in Pittsburgh, it's getting close to time for another remodel. This time, he's going to look to add three things: a larger break room for his growing staff, an expanded sunglasses section to respond to demand, and a children's play area.

Indeed, the ACA's mandate to include eye care in essential benefits coverage for children went into effect in January, a little more than 100 days ago, so the ODs who spoke to AOA Focus say they haven't seen an influx of children—yet. But they are preparing for it. While some ODs specialize in pediatric optometry, multidisciplinary practices like Dr. Bittel's must do some careful planning to accommodate the elderly and young alike.

"To have a large practice that deals with pediatric cases, you need different equipment and special places where you can keep the children interested and active," he says. "A lot of big pediatric practices have play areas. We're considering something like that. That will also require us to configure our current space. We may need more space for that."