As Center Director of a busy eye care referral center, Omni Eye Surgery in New York, I have the luxury of access to most of the state-of-the-art diagnostic equipment available. Certainly, the ability to use these instruments to aid or confirm diagnoses, follow treatment or purely for academic/teaching purposes enhances the doctor and patient experience and, in some cases, lends confidence to clinical decision making.

But, how important is it to have these “high-tech” machines, and what do you do when you have an active practice without them? Are you meeting the standard of care in eye care?

While gathering information for this article, I tapped into the opinions of a number of colleagues for their thoughts on the topic of standard of care, and what their practice pattern is if the office does not house the technologies in question.

What is Your Standard of Care?
Craig Steinberg, O.D., J.D., Oak Park, Calif., says, “The legal standard of care does not come from case law. It is determined by the jury.” He continues on to advise that when negligence is at the heart of the issue, “the legal standard of care is what a prudent optometrist would do under similar circumstances.”

Complicating this broad notion is the fact that practitioners are often compared to colleagues in their communities, which makes the standard of care different from case to case and region to region, further blurring the lines of what is “standard.” Taking this a step further, eye care practitioners, such as Christopher Press, O.D., Bakersfield, Calif., note that we can “push the limit of what constitutes primary eye care in 2009.” He says that we can achieve this by using diagnostic technology akin to that of a retinal sub-specialist, for instance. Although diagnostics such as this may not be in the office of the “average” practitioner, this may differentiate the regular eye care office with the “latest and greatest” care. 

Opinions differ as to whether such advanced technologies as scanning and confocal laser devices are necessary for standard practice. Richard Hom, O.D., San Francisco, Calif., considers that advanced technologies are not essential to an advanced practice. He goes on to say that a clinician with “experience and excellent functional analysis instrumentation (e.g., a visual field unit) can still care for 80% to 90% of eye disease cases.”

There are times, however, when the “prudent practitioner” does determine that a technologically advanced diagnostic instrument is in order and that the information it provides is necessary—as opposed to merely useful. What recourse is there for this practitioner without the required technology in his or her practice?

Janet Carter, O.D., Las Vegas, says that, if she feels the information gleaned from a high-technology diagnostic tool is warranted for her patient, she will inform the patient of the required testing and outsource that patient to receive the evaluation. Dr. Carter sometimes refers to a colleague and other times to an ophthalmologist’s office. She goes on to say that if her informed patient chooses not to have the recommended testing, she continues to treat the patient based on her clinical examination, the instrumentation she has available and her expertise. 

On the flip side, doctors who own advanced technologies, such as Christine Cook, O.D., Virgina Beach, Va., examine referred patients from nearby offices, billing the “technical component” for the service rendered and send the results to the referring doctor for him/her to interpret. In these cases, it is necessary for the referring doctor to understand the information provided, even though the instrument that generated it is not available in their own practice.

The Alternative to Owning High Tech
Leasing or renting equipment is another option open to consideration for offices in need of specialty equipment. Several leasing services with short or long term contracts are currently available around the country.

Alternately, mobile diagnostic units, such as a GDx (Carl Zeiss Meditec), HRT, (Heidelberg Retinal Tomograph, Heidelberg Engineering), optical coherence tomography (OCT) and/or various corneal topographers can be rented on a daily basis with or without a technician to administer testing. The primary advantage to equipment rental is the lack of initial capital outlay. An added benefit of rental is that staffing and/or staff training for the new procedure is mitigated by the rental process. Additionally, no dedicated space is required for the equipment, which may be an issue for practices with limited office space.

The Role of IOLs in Your Practice
The discussion of high technology in eye care goes beyond diagnostic instrumentation. Advanced technology intraocular lenses (IOLs) are an expanding frontier in cataract surgery, allowing surgery patients to achieve spectacle independence for most activities. These so-called “lifestyle lenses” have been embraced by leading cataract surgeons.

The practitioner whose practice includes cataract surgery comanagement would best serve patients by knowing that the referred surgeon offers these lenses to patients and is facile in the surgical technique necessary to implant them.

Similarly, the referring surgeon should have up-to-date instrumentation for biometry and topography for accurate IOL power calculations. Multifocal, accommodating and toric IOL technologies should be available to those patients in your practice who have been appropriately identified to benefit from them. As the referring provider, you must be prepared to discuss this technology with your patients and to manage postoperative concerns or difficulties in more challenging cases.

When Things Go Wrong
The concern for medical malpractice looms over every healthcare practitioner. New diagnostic tools can give us false comfort and make us believe that they can protect us if we’re sued. Remember: Advanced technologies are not the legal standard of care. Culpability in a malpractice case will be determined by the jury that evaluates the testimony of one expert against the other on the circumstances of a particular case.

Standards of care are evolving and remain ill-defined. Christopher Quinn, O.D., Iselin, N.J., President of Omni Eye Services, stresses: “Advanced instrumentation is not a substitute for professional clinical judgment. Instruments can augment and refine clinical decision-making, but rarely should advanced instruments be considered a substitute for standard examination techniques.”

Bottom line: Providing your best care is paramount. That, dear colleague, is your charge!

Dr. Mastrota thanks the doctors on the OptCom list who contributed to this article. Dr. Mastrota is Center Director at the New York Office of Omni Eye Services. Additionally she serves as secretary of the Ocular Surface Society of Optometry (OSSO).