By Pamela Miller, OD, FAAO, JD, FNAP
March 29, 2017
Delegating tasks to staff allows you to step back from the minutia of day-to-day practice operations, and become a practice leader. You can focus on overall practice performance and needed investments. As you decide what is, and is not, appropriate to delegate, keep in mind that there are some things only the doctor should do. As with all legal matters, it is best to consult with your attorney and state optometric board before making any plans to delegate to staff.
Staff Gathers Data; Doctor Interprets It
The basic rule in most states is that any staff member can be involved in data gathering, such as by administering a visual field test, or measuring refractive error via an auto-refractor, but they are not able to legally offer a medical opinion. Since they are not able to offer any opinion about the results, or exercise any medical judgment in conducting the test, they may not be able to do a test using an instrument like a phoroptor, or even trial lenses.
The rules about what an optometric staff member can do are different from what the law says an ophthalmologist’s staff can do. This is because, as an MD’s staff, their training is, at least in theory, supposed to be different than that of an OD’s staff. An MD is licensed and governed by the medical board, not the optometry board, so numerous discrepancies and differences can occur regarding what staff can legally do, since staff works under the doctor’s license. In fact, the staff training may be identical, but due to the optometry laws, optometric staff may be limited in their scope of employment, where there is no such limitation on the staff of a physician.
Staff Must Not Respond to Patient Medical Questions
Staff should be trained not to offer any response to the results of a test conducted as part of pre-testing. This can be hard because it’s reflexive for empathetic people to want to assuage the concerns of others, and make them feel better. The staff member’s long experience conducting a particular test may enable them to know on their own whether a test shows something worrisome, but because they don’t have an optometric license, and are not state board-certified themselves, they can’t tell the patient not to worry, or interpret the test results.
If a patient says, “Sue, how did I do on the visual field? Better than last year? Is my glaucoma worse?” the staff member can’t say, “No, nothing to worry about, it actually looks better than last year.” Instead, Sue would need to say: “Dr. Jones will go over everything with you, and answer your questions during your exam.”
Even when the test does not necessarily concern a serious medical eyecare issue, the staff member needs to simply refer the patient to discussion with the doctor in the exam room. “How did I do on the color vision test?” a patient might ask. The staff member might see clearly that the patient answered all questions on the test correctly, but they can’t tell the patient that. “Dr. Jones will review the results of all these tests in the exam room,” they should say.
Different Rules May Apply for “Dispensing Opticians”
In some states, employees designated as “dispensing opticians” can not only fit patients for eyeglasses, but can do contact lens fittings, as well, typically at the direction of a doctor’s written script or under their direct supervision. A Registered Dispensing Optician (RDO) is usually trained and licensed, as opposed to an office assistant or staff person. In addition to fitting the patient in contact lenses, following the doctor’s prescription, some states may allow dispensing opticians to decide which contact lens would best suit the patient.
If your state does not allow dispensing opticians to be involved in contact lens fitting, or decision-making, all requests by the patient for new, or different, contacts must be referred back to the doctor, who then would write a new prescription, including both the measurements of the contacts, along with the specific brand, the doctor would like the patient to wear. Many states specify that the patient is to be fit with the supervision of the doctor and must return to that doctor for appropriate follow up.
In most states, opticians can’t alter an eyeglass prescription written by a doctor. However, the doctor can allow for optician judgement, based on working with the patient, in the prescription that is written. The doctor might write, for example, “OK for PAL,” but also give the option for a single-vision lens, depending on which the patient ends up preferring. This direction does not allow the optician to formulate a different prescription however (ex. Computer correction).
Unless otherwise indicated by the doctor, the optician can determine with the patient the best material for the patient’s lens. If the doctor specifically wants a polycarbonate lens, they need to make that part of the prescription they write. Of course, a patient’s insurance vision coverage may limit what is actually covered and may not even allow the patient to upgrade for non-covered services. For example, AR coating for Medicaid patients may not be a covered option.
Train Staff to Safely Triage
By necessity, all practice owners have to delegate the triaging of patients who call, or e-mail, for appointments. Staff needs to understand the difference between a patient who “urgently” needs to see the doctor, and one who has an “emergency.”
For example, there is the patient, newly diagnosed with diabetes, who has never been examined by an eye doctor, who needs to see the doctor as soon as possible, versus the patient who calls and says she woke up this morning seeing flashes of light, indicating a possible retinal detachment. Staff needs enough training to know which symptoms signal a need for an immediate, same-day appointment, and which needs can be taken care of with the earliest available appointment.
Just Because You Legally Can Doesn’t Mean You Should
Some states allow support staff to refract patients, but each doctor has to decide whether they feel their patients will receive the best possible care that way. In states in which support staff can refract, the doctor still has to sign off on the final prescription, but you may question whether even the initial prescription should be arrived at without the doctor’s participation.
You may feel that the lifestyle conversation you have with the patient is just as, if not more, important than the acuity measurements. Therefore, basing your final prescription on what the staff tells you the refraction is, would not give your patients the best possible care.
Once you have determined what your staff can, and cannot, legally do, use your discretion to determine how you can best work as a team to give patients the care they need, while staying within the legalities of your state and the board of optometry. If in doubt, check with your legal counsel and the state board.
Pamela Miller, OD, FAAO, JD, FNAP, has a solo optometric practice in Highland, Calif. She has a law degree, holds a therapeutic license, is California State Board-certified and glaucoma-certified to prescribe eye medications, and offers comprehensive vision care, contact lenses, visual therapy and low vision services. To contact her: email@example.com.