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BLOG: Applying risk management to clinical practice
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Risk assessment and risk management are common tools in modern society. Although the concept can be traced back to the ancient Greeks from around 400 BC, the science of risk management is a product of the late 20th century, according to Aven.
Risk assessment has been extensively used in health care and became a part of the standard of care for diabetes in 2002 (American Diabetes Association).
The nature of diabetes and the moving target of the test results, as well as a management plan that is based on lifestyle changes, make it a disease often treated by managing risk factors. Other disease management programs have also adapted risk-based tools as a foundation for care.
Artificial intelligence (AI) programs that are poised to make a significant impact on health care often use risk assessment as the platform for medical decision-making (Dankwa-Mullan et al.). Unlike most humans, AI can constantly update the underlying database and precisely assess risk well past the decimal point.
Optometry has been slow to adopt a risk management approach to clinical care. We have had a small taste in the field of myopic progression and counseling young teens and their parents on the contact lens strategies for myopia control. We assess the risk based on the refractive error of the parents, lifestyle factors of excessive reading, screen time and little time in the outdoors and clinical finding of early myopic tendencies. We intervene with contact lenses, bifocal glasses, vison therapy or cycloplegic medicines. These are good examples, but just the tip of the iceberg.
We should use risk assessment tools for many ocular diseases. Those with genetic tendencies and prevention strategies, such as age-related macular degeneration, are particularly well suited for a management plan to reduce risk. Others, as in glaucoma, are best treated on the basis of multiple risk factors rather than the traditional control of IOP.
When considering the medical necessity of special testing and procedures, a risk assessment tool can help document the medical necessity for third-party payors. As a seasoned medical chart reviewer, I can tell you this is exactly where I look when attempting to justify payment for medical services.
The comprehensive eye examination is, in essence, a risk assessment and management exercise. Starting with the “reason for visit” and proceeding with the family history, social habits, review of systems and medical reconciliation, this critical aspect of care is the gathering of a collection of risk factors. The battery of vision function tests with refraction, vital signs and the physical examination of the structures of the eye may pinpoint a diagnosis but more often provides a list of risk factors that point to a disease or disorder.
At the end of the data gathering, the doctor assesses all of the risk factors in context and may determine one or more specific diagnoses but more often establishes a pattern of risk that points toward a particular diagnosis. Along with actual diagnosed problems, many risk situations need to be managed. As optometrists, these recommendations may include glasses, contact lenses or vision therapy, medicine or surgery but also lifestyle changes and prevention measures such as sun filters or better reading posture that can modify the risk formula. This is the true doctoring of the eye examination and the best measure of quality health care.
The evolution of optometry into primary care requires looking at risk factors for chronic medical problems such as diabetes, hypertension and dyslipidemia. For many of our younger patients, these chronic medical problems may not have yet manifested as diagnosable disease, but finding a moderate number of risk factors is a clinical problem that needs to be managed. Many of these are modifiable risk factors and, because they all lead to vision loss, it is our responsibility to address wellness and prevention strategies as part of our comprehensive management plan.
Health care reform has brought us a number of new quality measures that affect how we practice. Our inclusion as an essential element of the Affordable Care Act has increased our responsibilities to the overall health of our patients. Using our electronic health records to the level of meaningful use requires our medical care to be consistent with the physician community. Risk assessment tools are an important part of our mainstream medical evolution.
References:
American Diabetes Association. Standards of Care for Patients with Diabetes Mellitus. 2002; doi.org/10.2337/diacare.25.1.213.
Aven T. European Journal of Operational Research. 2016;doi.org/10.1016/j.ejor.2015.12.023.
Dankwa-Mullan I, et al. Population Health Management. 2019;doi.org/10.1089/pop.2018.0129.