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BLOG: Moving your eye examination to primary care
A large number of optometrists use the term “primary care" to describe their services or their type or mode of practice. There are, however, a number of key points that separate an eye exam from a primary care eye exam.
If you desire to truly use the wording, you need to look at the elements of your examination to be sure that you meet the standard. With more chart reviews and the transparency of health care reform, this issue is becoming critical to the integrity of your practice and to the profession of optometry.
A primary care eye examination begins with the history. The history must include a review of systems, family health history, medical reconciliation and a social history in addition to the traditional items of the case history. These items in particular will guide the examination above and beyond the reason for visit and the ophthalmic history.
For example, even for a patient who presents for a routine eye examination with no ophthalmic issues but may have hypertension or diabetes or parents with diabetes or who is taking high-risk medicines such as chloroquine or prednisone or who is a smoker requires an eye examination that looks specifically at the eye-related complications of these issues.
The physical examination must include the collection of vital signs. These include height, weight with the calculation of body mass index and blood pressure. These findings can be collected by your staff as part of the pre-testing, but the results should be reviewed and addressed.
Other primary care testing that is not required but is consistent with the mission would include glucose testing either with the traditional finger stick or with the noninvasive measurement of the autofluorescence of the crystalline lens with the ClearPath DS-120 (Freedom Meditech). This type of testing is not currently reimbursed as a separate service but should be part of the comprehensive eye examination if we expect our services to be considered as primary care encounters.
For those who use a federally qualified electronic health record (EHR), these issues are not new, as they are hardwired into the format and expected to be completed to meet the standards of stage 1 and stage 2 of meaningful use. There is an option for optometrists to decline the collection of vital signs as irrelevant data for an eye exam in the attestation for meaningful use. To do this, however, would relegate the profession back to an ancillary health service and demote our role in primary care.
The physical eye examination should be provided with a special emphasis on the eye findings related to systemic medical problems that were identified in the primary care history or vital sign findings.
For example, patients with measured high blood pressure or with a medical history of hypertension should have a close examination of the retinal blood vessels to look for subtle evidence of hypertensive retinopathy. Likewise, known diabetics or patients with parents who are diabetic or patients who are obese or with abnormal blood testing or autofluorescence should have a careful evaluation of the optic nerve, vascular arcades and temporal peripheral retina to look for signs of subtle vascular changes. These are just two common examples of chronic medical problems with ocular findings that require a more focused physical examination.
The last and perhaps most critical elements of a primary care eye examination happen at the end when the doctor discusses the overall impressions of the examination and designs a management plan. As I have noted in a prior blog, this element is really the doctoring of the eye exam. In addition to the traditional eye findings, primary care doctoring must address general health and medical issues with information and education related to family history risk factors, current medical problems and medications, abnormal vital signs and, of course, any ophthalmic signs of systemic medical problems. Social problems such as smoking, alcohol or drug abuse must be discussed. Diet and exercise may also be part of the patient education process. This may also be the time to discuss referrals or other medical professionals to address management beyond the scope of optometry or the comfort and knowledge level of the individual optometrist.
With the evolution of primary care teams and electronic collection and transfer of information, the last hurdle for a complete primary care encounter is the secure electronic transfer of the clinical data to other providers that are also caring for your patient. This includes, most commonly, ophthalmologists and primary care physicians but also may include physician assistants, nurse practitioners, nutritionists, diabetologists and others in the primary care space. EHR users have this neatly summarized in the clinical summary or consolidated-clinical document architecture (C-CDA) that can be generated with a mouse click. Transfer of data though the Direct Trust system using an ophthalmic platform such as OcuHub assures HIPAA-compliant data exchange.
The primary care eye examination is evolving in the rapidly accelerating climate of health care reform. Optometrists must begin to move in this direction by beginning to implement some of the elements discussed here. The implementation of a qualified EHR and working through the steps of meaningful use will serve as a guide to your evolution.
Having implemented many of these in my own practice, I can say that patients notice the difference. They now relate to me as a trusted medical professional interested in all my patients enjoying a lifetime of good vision that is supported by a healthy life.
If the majority of us can upgrade our eye exams to true primary care, our accepted role as part of the primary health care team will evolve, and the compensation will follow. Health care reform is providing the political opportunity, the tools and now the blueprint for a relevant and secure role in the American health care system.