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Feature by Howard Larkin A picture is worth 1,000 words – and maybe 1,000 sales Managing your Practice J ust about every LASIK and multifocal intraocular lens candidate who sees Jorge L Alió, MD, PhD, at Instituto Oftalmológico de Alicante (VISSUM) in Spain also sees an interactive video about her or his eye condition, and the benefits and risks of various treatment options. The multimedia presentations that Dr Alió uses are produced by Eyemaginations, of Towson, Maryland, US (www.eyemaginations.com).The presentations include animations of procedures, simulations of how the condition might affect vision if left untreated, information on aftercare, and simulations of what the patient's vision might be like after treatment, including minor complications like halos and glare. Similar vision simulators and products also are available from Eyeland Design Network, a German firm (www.eyeland-design.com). “Without this it is very difficult to transmit this information,” Dr Alió says.“But after this presentation, patients really understand what will happen and how it will affect them.” Clinical benefits are the main reason Dr Alió uses the videos, which are generally presented by a nurse after he examines the patient.“There is always a qualified healthcare professional present to answer questions.” If necessary, the patient is referred back to Dr Alió for additional counselling.“But that rarely happens because the presentations are very good.” The animations show patients how their vision could deteriorate if they ignore their condition, and demonstrate clearly how to take care of their eyes, such as applying eye drops or doing eyelid scrubs.As a result, patients tend to adhere better to treatment plans.And because the simulations show patients what they might see in terms of halos or other postoperative side-effects, they tend to be more patient in waiting for such side-effects to subside. “If you don't tell them that this is a possible complication in advance, they will be angry or dissatisfied if it happens, but if you show them, they will accept it,” Dr Alió says. “This is one of the main causes of patient dissatisfaction with multifocal IOLs.” The interactive videos also improve the practice's business performance, Dr Alió notes. For one, the videos make him more efficient. He estimates that handing off patients to a nurse with animation software saves him about 10 minutes per patient compared with having to explain it himself using hand-drawn illustrations.The patient also ends up with a much clearer understanding of the operation, he adds. Enhanced understanding also makes the practice more profitable. Once patients grasp the benefits of extra-cost options such as multifocal IOLs or femstosecond laser flap 48 cutters, they are much more willing to pay extra for them.“Before they watch, some patients don't understand how the flap can be made without a knife,” Dr Alió says.“After they watch, they understand how the IntraLase works and how the mechanical microkeratome works.With this information they are much more comfortable making a decision.” Raising conversion rates Dr Alió can't say precisely how much multimedia patient education has increased his sales of premium products and services. “But it is for sure evident,” he says. Indeed, Dr Alió is so impressed with the benefits of the product, which he currently uses only at his Alicante location, that he plans to introduce them into VISSUM's 52 surgery centres throughout Spain. Paolo Vinciguerra, MD, also finds Eyemaginations animations a helpful tool to promote premium IOLs at the Humanitas Institute Rozzano in Milan, Italy. If anything, the tool is too effective.“Sometimes the expectation grows too much because the animation is so nice.” (See sidebar on risk management.) That squares with Eyemaginations' claims that its animation products, which include presentations for all types of eye conditions, eye care, and procedures in eight languages, help increase sales of all kinds of products and services, says Eyemaginations president Jeff Peres.“It works across the board with every procedure – high-end glasses, punctal plugs for dry eyes, contact lenses.” By showing patients what they can expect, prospects for premium products are converted into sales, multiplying the effectiveness of expensive outreach efforts such as patient information seminars that many refractive surgeons offer.Though the company hasn't commissioned any formal studies of sales impact, many clients report conversion rates doubling or tripling with the software, Mr Peres says.That can mean hundreds of thousands of extra Euros in revenue per year.“Eyemaginations not only helped our conversions to premium lenses and custom/bladeless LASIK but also paid for itself within one week.We love it!” said Rick Haley, administrator for Loden Eye Centers in Tennessee. Eyemaginations software is offered in several versions, including videos that can run on loops or at computer kiosks in office reception areas, interactive formats that allow doctors to stop and draw on the screen, and a new web version that allows doctors to incorporate animated education materials into their branded websites.About 7,000 practices worldwide use the software. In July, Eyemaginations opened a European unit based in Erlangen, Germany, to help Vision simulation software aids informed consent, risk management Before Paolo Vinciguerra, MD, of the Humanitas Institute Rozzano in Milan, Italy, began using Eyemaginations software to counsel patients, he used hand-drawn figures to explain eye conditions and procedures to patients. Trouble was he didn't always do it exactly the same. “After 10 times you get tired and maybe you leave things out.” Not only was that poor patient education, it exposed him to accusations and liability for failing to fully inform patients about the risks of surgery. Now that he uses the software, Dr Vinciguerra is confident that each patient receives the same information, and in a much more effective format. “When the patient receives information in words they retain maybe 25 per cent to 30 per cent, but with pictures it is more like 70 per cent.” Also, Dr Vinciguerra can document exactly what he told the patient. Animated vision simulation software from Eyemagination, Patient Education Concepts (PEC) and Eyeland Design Network all support informed consent, their producers say. Eyemaginations has certain packages that allow doctors to record notes and drawings they make on the screen when using their simulations to counsel patients, and sells a package specifically tailored to meet the needs of informed consent. PEC includes a consent form that must be signed at the end of its IOL Counselor software. “If there are problems afterwards, they can show the jury what they showed the patient,” says Eyemaginations president Jeff Peres. While many surgeons leave the animation presentation to nurses, surgical counsellors or other technicians, Dr Vinciguerra prefers to do it himself. “It takes about five minutes and I can usually finish the notes while it runs,” he says. Afterwards, Dr Vinciguerra talks to the patient to assess their level of understanding. “I want to look into their face and say ‘I explained it personally to you’. I want to make sure there is no excuse for misunderstanding. They cannot say ‘your colleague told me something else.’” Overall, Dr Vinciguerra believes the process saves him time. “There are patients who understand what you tell them and there are difficult patients who will never understand no matter how much I explain. With these patients the animation saves a tremendous amount of time.” [email protected] ophthalmologists incorporate the software into their patient counselling routine.“If you have well-educated staff, you can bring patients to the point where they might spend an extra Euro because they understand why it is better to have the multifocal lens or wavefront guided LASIK,” says Robert Habel, who heads European operations. A pilot study last year of a similar product from another firm demonstrated dramatic conversion rate improvements for multifocal IOLs. Practices that introduced the IOL Counselor, developed by Patient Education Concepts (PEC), Houston, US, in conjunction with Eyeland Design Network,Vreden, Germany, typically saw the percentage of eligible cataract patients choosing premium multifocal lenses rise from around five to seven per cent, to 20 to 30 per cent, says PEC president Robert D Watson. “The software is designed for one purpose alone – to increase the conversion rate for patients considering the monofocal lens to a premium lens,” Mr Watson says.“We built it to take someone who has never played a role in conversion or up-selling anything and make them proficient at it.” The IOL Counselor simulates the impact of presbyopia and cataracts on vision, and shows how various lenses will affect near, intermediate and distance vision using several scenarios including driving scenes day and night, grocery shopping, and sporting events. It also includes a module laying out charges and financing options, and ends by asking the patient either to choose the premium lens, or acknowledge that they were presented with the option and declined.With sponsorship from AMO and Alcon, the ASCRS sent 4,500 copies of the software to its members earlier this year. As of late September, about 2,500 copies had been activated.The software is also available in French, German, Spanish Portuguese, Russian, Chinese and Japanese, with other languages coming. One practice that participated in the pilot study, Pepose Vision Institute, St Louis, US, saw its premium IOL rate rise to 80 per cent in December, and averaged 70 per cent through the first half of 2007.“That is about 65 percentage points above the national average,” says Dawn Cavanaugh, chief operations officer of the clinic. The Pepose Vision Institute used a formal quality improvement approach, including process mapping and outcome measurement, to find the most effective way to integrate the software into its practice routine, Ms Cavanaugh says.“After testing our model several different ways we found we achieved our best result presenting the IOL Feature Process mapping – Your guide to improved performance We all want better outcomes for our patients and ourselves – better clinical results, better financial results and more fulfilling personal results. All these outcomes are the result of processes – care processes, administrative processes, human resource processes, financial processes. So improving outcomes is really a matter of improving processes. Before you can improve a process you must have a process. A good definition of a process is a series of connected steps that result or are intended to result in a particular outcome. A process can be as simple and straightforward as the proper steps to take an X-ray, or as complex and multi-channelled as the steps required to develop and execute a population-based health improvement plan. If all the steps are followed consistently, a process can be said to exist. Process mapping is an essential first step to process, and therefore outcomes, improvement. Process mapping is the method by which the steps in a process are identified and recorded so the process can be understood, analysed and improved. It is simply a matter of writing down each step and how it relates to the next step. Once the process is mapped and understood, you will begin to see gaps and opportunities for improvement. To map a process, first define it in terms of its starting point and ending point. For example, the process of a patient receiving an X-ray might start with the doctor determining the test is needed and end with the patient receiving the X-ray. Sit down with your staff and brainstorm all the steps. The simplified map might look like this: n n n n n n n Doctor examines patient and determines need for X-ray; Doctor tells patient they need an X-ray; Doctor fills out X-ray request; Doctor tells patient to wait for appointment in the post; Patient receives X-ray appointment; Patient travels to X-ray lab; Patient receives X-ray. With this map in hand, you can begin to ask questions, such as: Does the process result in timely care? Is it efficient for the patient and the doctor? How much does each step cost? What could be done to make it easier, quicker, cheaper, or more efficient? You and your staff may be surprised by how many steps many common processes take – and how difficult they are for patients and staff to follow. Often, opportunities for improvement will be immediately evident. Adapted from the UK NHS Modernisation Agency, www.modern.nhs.uk Counselor after the patient had met with the surgeon. Patients were more apt to absorb the information on the back end. Our findings pointed out on the front end the patient was more nervous and less focused, than at the end of the visit after our clinic had taken the time to educate the patient and their families.” The process of promoting multifocal lenses starts with identifying potential candidates and informing them throughout their diagnostic work-up and examination that multifocals may be a good option.After patients are examined by the surgeon who determines if the patient is in fact a candidate, the patient along with their family meet with a surgical counsellor, who goes through surgical availability, consents and Care Credit financing options. In this environment, the IOL Counselor serves as a closing tool, giving patients already familiar with the multifocal concept the confidence to proceed ahead with a once in a lifetime opportunity, Ms Cavanaugh says. In addition to its work on the IOL Counselor, Germany's Eyeland Design Network offers a wide range of animated graphics and stock images, says Karl Brasse, MD, a practising general ophthalmologist who heads the firm along with designer Guido Schulte.These include a vision simulator package that has been distributed to 20,000 practices in Europe by Pfizer, and is available on the web at www.visionsimulator.com; and a host of animations of symptoms, treatments and outcomes for conditions including cataracts, glaucoma and macular degeneration. Dr Brasse emphasises the detail incorporated into the firm's 3-D images, Images that show patients what they are missing, such as these illustrating the impact of macular degeneration from Eyeland Design Network in Germany, can help convince patients to curtail driving and other potentially hazardous activities which he says exceeds what can be done with photography because it is not limited by depth of field issues.“We are design focused,” Dr Brasse says.“The images can be used for patient education or grand rounds at Harvard.” The firm's work has won many awards, including an Oscar at last year's ASCRS Film Festival. Beyond their educational, aesthetic and emotional appeal, these products also can help convince patients of the value of technologies such as HRT and even pharmaceuticals such as Macugen and Lucentis, which may not be fully covered by German state health plans, Dr Brasse says. Understanding the conditions and available diagnostic technologies and treatments not only relieves patient anxiety, it encourages patients to invest in extra-cost services to protect their eye health. Improving diagnosis and staff understanding Beyond improving patient understanding and increasing sales, some surgeons find animated vision simulation can help diagnose and monitor vision problems.“I am basically a refractive surgeon and with the myopes we are very aware of retinal detachment,” says Arthur Cummings, MD, of the Wellington Eye Clinic, Dublin, Ireland.“If they get light flashes or floaters they need to be checked out.” But patients may not recognise these symptoms. Being able to show a patient what they look like helps, he adds.“The patient knows when they need to seek care.” Since installing Eyemaginations software on one in-office computer and on his website five years ago, Dr Cummings also has found it a valuable training tool for staff.“Everyone better understands what the patients are experiencing and what they are talking about. It helps people feel they are in a place of higher quality and it helps the staff provide a better quality of service.” He is in the process of putting the software on computers throughout his office, which recently moved into a new location. PEC also sells an internet version of the IOL Counselor that allows individual practices to promote presbyopia correcting IOLs on their websites.“The more you educate patients about presbyopia correcting IOLs before they enter your practice, the easier it is for them to decide to spend the extra money for them,” says Mr Watson. It is also available in eight different languages and three different sizes so it will easily install into most web formats. Ms Cavanaugh says that animations give her staff valuable insight.“The younger staff said 'I never realised what they were talking about when patients complained about muted tone.' They were shocked to see what it looked like on the IOL Counselor. It really put it together for them.” The clinic held a Saturday training session to introduce the software, and formally trains all new employees on it. Dr Alió also believes that animation is an essential tool for building a high-end practice. “If you want to be at the top, this kind of information is more and more necessary.” Eyeland's Dr Brasse, who maintains an active ophthalmic practice in addition to producing animations, believes animations can be a valuable, even life-saving, addition to any practice. For example, vision simulations can help visually impaired patients understand the implications of reduced acuity, making it easier to convince them to give up driving or other hazardous activities when necessary. “I used to use images of churches and skylines to show how conditions can impair vision,” Dr Brasse says.“Now we use images of children on the road. In my experience these images of kids are very effective in getting the message across. If a picture is worth 1,000 words, these animations are worth 10,000.” Or, as Dr Cummings puts it:“This is the ultimate tool for explaining what is going on.” [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] 49