To improve outcomes and reduce enhancements, it is absolutely vital to record acuities and manifest refractions for post-LASIK patients on a daily basis. I recommend using the desktop application Datagraph-Med (datagraph-med.com) for entering outcomes quickly and accurately, or DataLink from SurgiVision Consultants Inc.
Capture patient acuities at the 1-day, 10-day, 2-month, and 6-month postoperative visits. Capture manifest refractions at the 2-month and 6-month visits and at the 10-day visit if their vision is worse than expected.
I’ve found the best people to capture and maintain outcomes data are front desk personnel. Charts go into a rack or bin after check-out, and they enter data between patients. If you are using an EHR system, one staff member must be tasked with updating outcomes at the end of each day by reviewing appointment visit types, pulling electronic acuities and refractions from the EHR system, and entering it into the outcomes software. This ensures no key visit is missed, and every patient is reflected in your nomogram. Unfortunately, this systemization of outcomes collection missing in most LASIK practices. What are the common problems preventing 100% outcomes capture?
Often charts are held by a tech or are placed on the surgeon’s desk for review of something unrelated to outcomes tracking. This means the chart is bypassed in daily data entry, and gets re-filed without recording results. I recommend outcomes entry be done immediately upon patient check-out, before the chart is re-routed. When the tech or doctor walks the patient to the front desk, the chart is handed off with the patient. If re-routing is required, it is noted in the chart and will be transferred by the outcomes person(s) once data entry is complete. Set up a three-bin system to ensure compliance – “Outcomes Entry Pending”, “To Be Filed” and “Transfer To”. Once outcomes are entered, initials should be entered into the bottom corner of the post-op form for a quick view if a chart does get out of sequence. The only visits requiring outcomes entry are 1-Day, 10-Day, 2-Month and 6-Month post-ops (or similar) for both primary and enhancement cases. All other visits can go into the “To Be Filed” or “Transfer To” bins. We generally use the 2-Month visit as the most reliable for nomogram calculations
If a patient is happy and doing well, practices often forget or neglect to perform a manifest refraction. However, these are the most important patients to incorporate into your surgical nomogram. They are the patients who ended up (almost) perfect! A nomogram is a regression line of expected vs. achieved results and we must make sure that patients who end up spot-on are accounted for. We see perfect patients far less often because they are happy. They don’t want to attend post-op visits beyond two months, because they are seeing well. It is especially vital that we capture their refraction data when we can.
The difference between good LASIK and great LASIK is +/- 0.25D. When a 23-yr old presents with 20/20 vision, they still might have slight residual sphere or cylinder. A monovision patient will never have 20/20 vision in the near eye, yet we absolutely must know what the refraction is that allows them to read at J2. We need to know as part of our dataset for future surgical planning. We’re trying to create a nomogram that is as tight about the expected vs. achieved regression line as possible. Having 100% of patients with acuities (distance and near) and consistently-timed refractions is vital.
Data gaps often exist in practices that comanage LASIK cases with referring ODs. Usually, the surgeon is seeing the patient only at the One-Day post-op visit, and all other visits are provided by the comanager. What commonly occurs is that the only comanged data that exists in the surgeon’s database is that of unhappy patients, because they’ve been returned from the comanager.
I use two methods to ensure comanager outcomes data are returned to the surgeon’s practice. The simplest is a fax form with table showing patient name and key visits missing. At the beginning of each month, your outcomes entry staff checks off what they are missing, faxes it to the ODs office, and requests post-op forms be returned via fax to you. I’ve found the fax system more effective than a phone or email reminder for most OD offices. You should be able to easily run a Missing Data report in your outcomes tracking system to facilitate this fax creation. It is sent at the beginning of each month, so data lag for your nomogram is minimal.
If you try the fax-reminder approach and still have trouble with outcomes data return, tie comanagement payment to outcomes. Inform poor reporting ODs that their comanagement payment will be made upon return of 2-Month post-op data instead of the more customary 30-day payment. This usually solves the problem quickly.
The final problem I encounter in practices that have trouble accurately maintaining an outcomes database is that no one is made responsible for 100% compliance. Outcomes entry and tracking has been positioned as a difficult, mystical, surgeon-only activity, either by surgeons or by vendors providing the tracking software. I’ve found it’s not that complicated. Simplify or clarify your post-op form so that the area for recording acuities and refractions is crystal-clear and impossible to miss in the technician work-up. Teach every staff member what refractions and acuities mean so they understand what they are entering into the computer and they can logic-check the information promptly. Data entry is usually offered in simple row/column formats, similar to an Excel spreadsheet, which does not require surgeon expertise or time. We do our practices a disservice by limiting understanding and participation to surgeons or head technicians. In my experience, surgeons desperately want an accurate outcomes database and nomogram with which to improve their surgical results. However, they don’t want to be responsible for the daily, mundane, routine entry of this data. Assign a computer-literate, detail-oriented individual or team of individuals the responsibility for data entry. Senior members of the clinical team can quality-check the data before surgery plan development and before outcomes data is published for use in LASIK consultations.
If you get this first collection step right, all other uses and interpretations of this incredibly valuable data will create better LASIK outcomes, and happier LASIK patients, for your practice.