Announcement – Migrating my blog to #Tips4EyeDocs by @GrandRounds4ODs

My new website address is

The blog site has served me well. Alas, I want to expand the capabilities of my blog site and associate All Things About Optometry and Healthcare Technology with #Tips4EyeDocs, a much easier to pronounce, spell and remember tagline and user name that GrandRounds4ODs.  I will still keep both.

Please go to my new WordPress-driven blog site and refollow or resubscribe at All of the content from this blog has been exported to the new site.

Look for new capabilities and functions in the new site including pod casts, video feeds, etc. I hope to launch these new functions this year.

If you would like to donate to this endeavor, send any amount via PayPal Email Address of

Thanks and enjoy the new site as I slowly build its functionality.

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After Hours Availability – #Tips4EyeDocs

Not often do optometrists think about their after hours availability.  In fact, for some doctors, this concern is never a concern or problem.  It’s even required by many vision and medical care plans as a condition to being a panel provider. There is wide latitude on how after hours care is handled.  It ranges from a message to call the nearest hospital emergency department to the doctor’s own cell phone.

Whatever approach a doctor takes, it telegraphs clearly to the patient how emergencies are handled.  It also implies whether the doctor is ready, willing and interested in caring for the patient beyond glasses and contact lenses. Because medical eye and chronic care conditions are becoming more important in optometry, setting the tone for your practice that it goes beyond glasses and contact lens care is important.

The customary answering machine  that offers a call back number or a number to an emergency department is common. If a personal after hours number is used, this gives the practice a chance to personally manage the patient. Otherwise, giving the nearest emergency department number actually provides no direction; in other words, it is the patient’s responsibility to find the emergency department.

Any kind of call back number can be used.  It could be a single cellular phone that is passed around the office to the doctor who is “on call” or it could be the doctor’s personal cellular phone dedicated for emergency calls.  Because mobile phones are so prevalent, text messaging a doctor for an emergency is like having a private paging number just for you. Text messaging is known to have the highest callback rate in communications with estimates reaching 90% call back within a few minutes.  Patients rarely abuse this policy.

If patient management and retention are primary goals in a practice, it makes sense to intervene with the doctor rather than using the nearest emergency department. Doctors who are quick to ride the medical eye care train will find that offering a chance for a patient to directly talk with the doctor encourages practice loyalty and can make your after hours care a source of revenue and customer service.

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Spotlight on First Insight – Maximeyes – #Tips4EyeDocs

Tips4EyeDocs talked with Mr. Nitin Rai, founder of First Insight (, a software company that has risen to be a top tier player in the competitive eye care market.

Why did you start First Insight Corporation?

I started First Insight in 1994. It was a result of a visit with my optometrist, Dr. Craig Bowen that year, who had diagnosed me with Lattice Degeneration. He had used paper charts prior, but in this annual visit he had a Macintosh chair side with my record opened up on the Macintosh. It was a flashing lattice degeneration as an alert. I had just left my job as a Software Engineering Manager at another company to start my own company. I was looking for ideas for a product. Here it was right in front of me. I worked out an arrangement with Dr.  Bowen to acquire the software he had developed so far.  I hired college interns to do research and found that virtually no eyecare practitioner was using an Exam / EHR software, let alone on a Macintosh or Windows. Practices were not happy with the quality of service, support, and inflexibility of the products they were using. First Insight had a unique solution and the market was ready.

What are First Insight’s strengths? What do you do best?

  • Highly Customizable System:  This was a feature inherent in MaximEyes right from the inception of the product since 1994. It allows us and the practice to tailor MaximEyes to their needs—from allowing them to customize their exam forms, modify the workflow, change colors, adding selected items, to being able to add new data fields.
  • Ease of use:  Simple navigation allows you to quickly go where you need to go to enter exam information, versus being forced through a series of mouse clicks and a fixed document centric workflow. We focus on form-based entry, which makes the system very easy to use.
  • Technology. Our new certified EHR platform is built in Microsoft .NET and SQL Server that allows the software to scale from a small office to a large multi-physician, multi-location office. The technology can run both in a local office cloud or offsite cloud server.
  • Certified EHR and ARRA Advisor: MaximEyes SQL EHR is certified as a Complete EHR by CCHIT®n ONC-ATCB. With that certification, its doctor users qualify and have received  incentive checks from the CMS (click here for latest press release).  MaximEyes SQL Certified EHR incorporates Stage 1 meaningful use requirements directly into a MaximEyes workflow to improve office efficiencies and reduce redundant data entry requirements.
  • Industry Leader: Since 1994, we have grown to support more than 1,400 practices—includes more than 4,000 optometrists and ophthalmologists nationwide (including Canada).
  • Strong Research & Development and Support Staff: We employ more than 120 employees; more than 45% are dedicated to research and software development and 45% to technical support and training. We believe that exceptional customer service is a sincere and important aspect of our business.
  • Hands-on Training and Online Support: First Insight strongly believes in providing hands-on, comprehensive onsite training for all our clients. Customer service is available Monday – Saturday.  Support technicians can easily connect to a client’s computer via the Internet much like having a personal support representative sitting right next to you. Alternative learning options such as personalized phone trainings, onsite trainings at First Insight office, CBTs, online guides, and webinars.
  • Onsite Users Conference: For the past four years, we have hosted a two-day Users Conference in Portland, Oregon where hundreds of our clients come together each year.
  • Seamless Industry Integrations: Propriety VSP Calculator, integration with many ophthalmic equipment and vision care vendors, and integration with hundreds of labs for online spectacle lens/frames orders via VisionWeb and
  • Proprietary Patient Health Record Portal, First Insight will soon launch, which will allow patients and doctors to interact easily and secure through the Internet by sharing confidential healthcare information in real-time (ARRA requirement). Patients can send non-urgent messages between patient and office staff or doctors, schedule an appointment, view patient clinical summaries and current medical/Rx information, view educational materials or other paperwork, and update medical history/welcome form. Additional features, such as viewing billing information and making online payments will be added with future releases.

What new directions or highlights or products can we expect from First Insight in the next 1-2 years?

  • Platform Agnostic/Multi-Platform Capabilities: The MaximEyes paperless office is built on the latest technology to deliver streamlined performance for today’s ophthalmic office demands. By adopting cutting edge IT concepts and operating within a virtualized environment, offices can run MaximEyes in a public/private network or move to the ‘Cloud’ and consolidate infrastructure and costs.
  • iPad® Enabled: Doctors will be able to use their iPad doctors to access their medical charts outside of the office to present real-time information, education, 3D graphics and videos to enhance the patient-doctor encounter.
  • DICOM Integration for Ophthalmic Measurement and Imaging Devices. MaximEyes SQL EHR will conform to standards for receipt and representation of data from all ophthalmic instruments and devices. Request, retrieve, display and communicate all imaging and measurement data generated by ophthalmic instruments in a standard format. Manage all ophthalmic imaging data and provide a tight integration with PACS.
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Spotlight on Deegan Lew OD FAAO – #Tips4EyeDocs


Tips4EyeDocs has the honor of spotlighting Deegan Lew, OD FAAO. Dr. Lew has a wide breadth of experience in eye care.  His undergraduate degree is in Animal Physiology from the University of California, San Diego and his Doctor of Optometry from the University of California, Berkeley School of Optometry.  Dr. Lew completed a post-graduate residency in Hospital Based Optometry at the AlbuquerqueVA Medical Center.

Prior to joining the Faculty at the University of Colorado, he performed peri-surgical care for LasikPlus Centers in Colorado, California, New Mexico, and Utah, and TLC Laser Eye Center of La Jolla, California.  He lectures to other optometrist, nationally,  in the areas of refractive surgery and diseases of the eye.  He owned a practice in Poway, California,  was voted as California’s Young Optometrist of the Year and was formerly a Faculty Member of the University of California, Berkeley School of Optometry.   Especially noteworthy also are his multiple licenses, some several years after graduation.

Dr. Lew enjoys biking and skiing in his time outside of the clinic.

What is differnt about practicing in your setting as opposed to private practice?

The most noticeable difference between the two is that I don’t worry
nearly as much about running a business as when I was in private
practice.  Although I’m concerned with patient volume, metrics goals,
and patient satisfaction, I have no responsibilities in watching over
labor costs and cost of goods, or managing staff members.  Being a
part of a hospital faculty has enabled me to concentrate on what I was
trained to do in optometry school and residency–being a good
optometrist.  On a daily basis, I have relatively complex cases which
require my full clinical attention.  For the well being of the
patient, I cannot afford to be distracted by practice management

How can an optometrist prepare themselves for such a position?

My advice for students in training is to find their passion in
optometry.  Although there are no formal specialties in the
profession, find out what part of optometry excites you.  Once you
find that one thing, focus on being the best that you can in that
area.  For me, I found that ocular disease was my passion in my third
year of optometry school.  If there is an opportunity to attain
residency training, do it.  There is no better place to do
concentrated training in your specialty than in residency.  Other than
training, a residency offers an opportunity to build bridges with
affiliate hospitals, university faculty, and the ophthalmic industry.

My advice to current practitioners is to study, join specialty
societies, and network with  your local physicians.  A largely
overlooked resource are industry sales representatives.

If you could give 3 tips to any optometrist about managing pathology, what would you say?

The first tip to managing pathology is to understand the “why” of apathological presentation, rather than “what.”  In optometry school,we are well-trained to identify many eye diseases–that is the “what,”as in, “what is it?”  However, eye disease, sometimes does not presentin a “text book” fashion.  There are variants and co-morbidities that affect the way a disease is seen.  The “why,” means “why does the disease present this way?”  Understanding the “why” helps us analytically diagnose at treat with more accuracy and effectiveness.

The second tip is to understand the drug formularies of your patients’
insurances.  The medications you prescribe are only as effective as
your patients’ willingness to take them.  I know it is common practice
to prescribe that latest medications, but often new medications are
non-formulary or Tier 3.  Some patients will delay or decline the
purchase of a medication because of it’s costliness.

Lastly, read, read, and read again.  The understanding of disease and
treatment paradigms constantly change.  Keeping current with clinical
studies benefits the patient as well as the doctor.


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Case study – Confirmed Orbital Floor Fracture by X Ray – What would you do?

This is a case of blunt force trauma while being assaulted. The patient presented to the emergency department with the following: Sight in both eyes with normal gross fields; normal pupillary function, normal IOP for age, diplopia in upgaze but not in primary, intact abduction and adduction; and after this photo taken, an intact retina 360 degrees each eye.

What would you recommend to the Emergency Department physician?

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Multifocal Contact Lenses – Setting Expectations – Part 5 #Tips4EyeDocs

From the first part to the fourth installment of my series on multifocal contact lens, I rediscovered the fun of fitting these lenses. I had scorned these lenses and failed to appreciate, pure happiness and satisfaction that patients experience from wearing them. Presbyopic patients have expectations and concerns about contact lenses in general and specifically lenses for their age group.  These concerns must be answered and doing it well will maintain patient confidence for the patient themselves, such as cognitive dissonance, or “buyer’s remorse” and for the doctor.

From the first word to the last word that you say to the patient, the doctor should be familiar with their patient’s interest and past experiences about contact lenses. It can uncover unmet needs and wants as well as biases or prejudices. Tailoring the presentation to those interests or potential needs will keep the interest level of the patient and supports the notion that you are listening to the patient.  Explore what the light level at the work place is as this will have a significant impact on the usability of the lenses.

As an example, a 51 year old male presented for a contact lens evaluation and fitting. He is naive to contact lenses or prescription corrective lenses and had been using over the counter reading glasses for near vision. He is a blacksmith and has had multiple readers being damaged in less than a week of wear at work. His use of safety goggles over the readers were unwieldy and prevented him from doing his job well.

The uncorrected vision was OD 20/20- and OS 20/40, which not deter him from driving without correction. His refraction was OD Plano -0.50 axis 090 and OS -0.50 -0.50 axis 090 VA’s 20/20-1 each eye His reading vision at the preferred working distance of 18 inches was 0.60 M with +2. 00 reading addition. His palpebral fissures were large and although proptosis was suspected, the Hertel measurement were equal in each eye at 18 mm. Both upper and lower lids were loose. The remaining internal and external examination were unremarkable or unspectacular.

In this case, the patient had a high degree of motivation, but his expectations might also be equally high. He wanted contacts. However, managing those expectations begins from the outset of the first visit and continues throughout the patient experience within your office. I successfully fit the patient with a pair of multifocal soft contact lenses and after demonstrating satisfactory handling of the lenses, a one week “real life” trial was suggested where he would use the contacts for work. The expectations doesn’t stop there. Cognitive dissonance, the buyer’s regret, must be managed and that comes from everyone in the office from the receptionist to the business manager to deter from discouraging the patient in any way.

The real test whether this would be a successful fit came in the second and third follow up visits where he expressed complete satisfaction of the contacts while at work but not at driving a car. He felt they were worse than no correction.  I adjusted the power of the dominant eye by increasing the minus, but kept the add power the same.  He immediately saw an improvement in distance vision. He became satisfied after the third visit.

The take home message in multifocal soft contact lens fitting for the presbyopic patient  is understand as much about the patient as you can.  If there is a spark of interest, I think the doctor is in the unique position to capitalize on that interest.  Denying a patient of that interest because of time constraints, doctor apathy or doctor knowledge is doing a disservice to the patient.  Become familiar with multifocal lenses in their performance capabilities and their fitting characteristics and you can improve your own success with these lenses.

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Case Study- 7 months post operative LASIK procedure – Tips4EyeDocs

This 60year old woman is status post LASIK, OU,  7 months. Everything went well until this.

She presents with mild light sensitivity, but not photophobic. The fellow eye is as red with and looks like this.CF 7ft is the vision PHNI. Pupils are reactive. No cells/flare in the AC. Cornea folds (~15% to 20% CCT increase) and obivous demarcation of the flap border where none was evident. Afebrile, normal pulse, normal oxygenation,. Cutlure negative(!)  (97F)

What would you do?

new URL

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Diagnostic Contact lens fitting in the young patient – #Tips4EyeDocs

Diagnostic contact lens fitting of the child patient from ten (10) through seventeen (17) years of age is probably one of the most rewarding in a clinician’s daily practice life. I have tried a few things over the years and I hope that these might help you.

Rarely do children have large palpebral aperture size nor are their lids loose. On the contrary, their apertures are small and the lids tight; these two make insertion of a diagnostic contact lens difficult at times.

When you do see a small aperture size, consider a 14.0 lens or smaller as a first fit trial lens. Because of the small apertures, success in inserting the lens the first time is essential to retain confidence in the process.  I have found that parents and patient alike will continue the lens fitting process if the doctor or the assistant can insert the lens on the first try.

Often the child will prefer not to wear glasses at all, even to the point of removing the glasses when they are out of sight of parents, family members or teachers.  Although this should be a strong motivation to try contact lenses, the fear factor is concomitantly high and the process of diagnostic contact lenses can quickly extinguish the drive for contacts. Of course, if the child wears eye makeup, the child may overcome this fear.

A good starting point is a lens of 14.0 mm in diameter. A larger lens, even 0.2mm larger, may be too large.  Although not ideal for an adult, a spherical lens that approximates the spherical equivalent may provide sufficient and satisfactory vision for a child. Such vision may be adequate and sufficient for average school activities. As facility with lens handling improves, then a larger toric lens may be contemplated.

For rigid lenses, the diagnostic fitting should be as comfortable as possible and I do apply a single drop of surface anesthesia to minimize lens sensation at the outset. There are quite a few of my peers who might find this unacceptable, but I have found that this dramatically improves rigid lens acceptance.  In addition, the lack of excessive tearing makes the lens movement that much better to assess and refract over.  Depending upon the goal of the rigid lens fit, I will start with an 8.6 diameter lens. Frequently this covers the cornea sufficiently while still providing satisfactory comfort, fit, movement and lens flexure.

Children who are short in stature may find difficulty in positioning themselves within a biomicroscope. The even when the chair is raised at its highest point, the child’s eyes might not be high enough.   In those cases, a bundled rubber block that is wrapped in plastic may give the additional one inch that elevates the eyes high enough for slit lamp use. Of course, a handheld slit lamp would be much preferred.

Dispensing the lens at the end of that first visit is key to continue the momentum and enthusiasm for lenses. If the patient cannot demonstrate facility with lens removal and insert, then a follow up will be needed.  I don’t usually see patients coming back more than twice for training in lens handling.

In summary, children make good contact lens patients. Frequently, just asking the patient what they know about contact lenses can spark an interest that is underlying but not mentioned. In general, parents support their children in wearing contact lenses. The doctor and staff can easily support that interest by introducing the topic and providing an immediate forum for beliefs and concerns that parent and child may have.  Don’t miss an opportunity by not talking about it.

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Surveys 101 – Spotlight on Willard Hom, MBA


Surveys abound in optometric practice. They are used frequently for customer satisfaction and market research. The Tips4EyeDocs Spotlight is on Willard Hom, MBA who will unravel the art and science of surveys. Mr. Hom is a published author in academic journals and was a member of the American Statistical Association. His love for this science grew from his 30+ years of public service which culminated as the Director, Research and Planning at the Chancellor’s Office for the California Community Colleges. He continues to work in research as a consultant with WestEd, an educational think tank.

Q1 – Why do we do we use patient satisfaction surveys

The provider usually wants to know how it is doing with its patients beyond the usual health assessments and diagnoses. Such surveys help the provider to retain patients as customers (a business decision) and to help patients to follow a healthy regimen. If the survey informs the provider about how it can obtain from patients timely office visits, compliance with doctor’s orders, and family support (or other supports), for example, then patients may have a high probability of attaining healthy outcomes. A real, but less meritorious, reason for surveys is to indicate to the public, especially to patients, that the provider follows good business practices and that it cares. Unless the concern is genuine, this last motive has less value from the public health viewpoint.

Q2 – What can doctors help in doing surveys

The doctors should participate in the planning and analysis of the surveys but delegate the task to an expert third party. The doctors should also read the results and try to use them. The delegation of planning, execution, and analysis of the survey to an independent and expert third party helps assure to others (and the doctor) that the survey data and analysis are valid and unbiased. Doctors can help in the survey project by respecting confidentiality and by understanding the issue of different perceptions that patients may have about offices and personnel. Most importantly, doctors can help surveys succeed by establishing the objective of the survey and its desired consequences early in the survey planning process.  It’s worth repeating that doctors will support the validity of the survey data by refraining from (a) influencing patients that doctors know will be surveyed and (b) using the survey process itself to market a service or product.

Q3 – How can it be applied/executed

Surveys currently use multiple contact modes to obtain the most valid survey responses. This “mixed mode” strategy allows the survey administrator the ability to exploit the strengths of the different survey modes (such as in-person, mail, internet, and phone) and mitigate the weaknesses of the modes. There may be a best mix of modes for each study situation so it isn’t helpful to prescribe one mode over the others. When the provider authorizes and funds the survey project at an adequate level, the provider will receive data and analysis that should address the pre-defined decisions or questions.

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What and Why of EMRs, a tutorial: Part 1 – Tips4EyeDocs

In the brief history of electronic medical records (EMRs), the major objective has been two fold. The traditional paper medical records had become unwieldy, difficult to transfer to another provider or to share with another provider. Legibility became a major issue and digital medical data further complicated information sharing.

Patients and the federal government wanted a better approach. This approach must match a patients who had multiple providers under simultaneous or serial care. It must be current, deliverable and portable to follow a patient. And it had to be legible.

Electronic record keeping had begun begrudgingly as large hospitals ramped up billing systems as the practice of health care became  driven by third party payers who wanted an easier way to handle and track claims submissions.  Thus practice management and front office software had a lead of many years of use before the onset of electronic record keeping of medical charts, now called electronic medical/health records (“EMR”).

With the decreasing cost of compute power, the increasing simplicity of programming code and the wide spread expectation that EMR would become a standard way of recording a medical visit, the EMR was born.  But its birth or path to maturity has been more rocky than that of its brethren, the practice management program.

First, the direct tie to improved productivity and revenue were not apparent. Newer metrics for return on investment (ROI) were needed.  Reduced medical errors, the collection of data for medical research and informatio portability became a better know metric than better revenue.

Second, while a hospital had particular control of provider use of EMR within its walls, such control did not extend outside its walls. Office-based providers were under no such pressure to conform to a particular way of recording medical data nor were they pressured to convert to EMR.

Lastly, hospitals and monolithic health centers had a far wider range and depth of revenue sources to finance the acquisition of softeware programs. Such is not the case with an office-based provider who must bear the complete cost by themselves.

EMR software needed an additional impetus to speed its adoption. From successive presidential administrations of either political party, widespread adoption of EMRs for everyday medical practice had become increasingly important with the hopes that medical care costs could eventually be monitored and better managed.  The road has not and will not be easy but is one that our medical care system must eventually adopt if it is to wring out as much excess cost and plumb as much efficiency as it can.

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