- Email: [email protected]
Diabetic eye examination report
Optometry (2007) 78, 588-595
Diabetic eye examination report Sylvia L. Jones, O.D., M.S., and Kelly K. Nichols, O.D., Ph.D., M.P.H. The Ohio State University College of Optometry, Columbus, Ohio. KEYWORDS Diabetes; Public health; Standard of care; Documentation; Optometry
Abstract BACKGROUND: The purpose of this study was to revise a former American Optometric Association (AOA) Diabetic Eye Examination Report form and create a standard reporting form that could be implemented easily into clinical practice. METHODS: Ohio Optometric Association (OOA) members were recruited to complete the pilot Diabetic Eye Examination Report (DEER) on 5 consecutive diabetic patients. They were then instructed to send a copy of the completed form to the comanaging physician of the patient’s choice. The participating optometrists and comanaging physicians were surveyed regarding the content and format of the pilot DEER. RESULTS: The pilot DEER was revised based on the survey responses and comments from 51 participating optometrists and 75 comanaging physicians, existing diabetic retinopathy examination forms, and a literature review. In general, optometrists and comanaging physicians agreed on the importance of communication (100% in both groups, 51of 51 and 75 of 75). Eighty-eight percent (45 of 51) of optometrists and 95% (71 of 75) comanaging physicians found the form to be an adequate summary. Eighty-seven percent (65 of 75) of comanaging physicians expressed interest in receiving the pilot DEER as a standard communication form concerning their diabetic patients. CONCLUSION: The new form is now available through the OOA at www.ooa.org as an initiative of Healthy People 2010. In an electronic format, it is possible for the optometrist to type information directly onto the form, making it more professional and legible. Printed forms are also available through the AOA purchasing department. Optometry 2007;78:588-595
Diabetes recently has been called an epidemic. According to the American Diabetes Association, there are currently 20.8 million people, or 7% of the United States population, who have diabetes.1 Diabetes is a systemic disease that can lead to cardiovascular problems, neuropathy, nephropathy, and retinopathy. Diabetic retinopathy is the leading cause of new cases of blindness in the U.S. adult population, accounting for 12,000 to 24,000 of new blindness cases each year.1 The majority of persons with diabetes will experience some degree of diabetic retinopathy over Corresponding Author: Kelly K. Nichols, O.D., Ph.D., M.P.H., The Ohio State University College of Optometry, 338 W. 10th Avenue, Columbus, Ohio 43210. E-mail: [email protected]
time, with the incidence increasing with diabetes duration.2 Vision care is an integral component of diabetic care. Because optometrists are responsible for two thirds of the primary eye care services in the United States,3 optometry is well positioned to be the primary eye care profession for diabetic patients. Communication between optometrists and other health care providers is essential to prevent and adequately manage diabetic complications that affect the eye. The American Optometric Association (AOA) Optometric Clinical Practice Guidelines: Care of the Patient with Diabetes Mellitus (www.aoa.org/documents/CPG-3.pdf) states that appropriate communication with the patient’s primary care physician is critical for proper coordination of the patient’s care and that a written report is useful for accomplishing this task.3 There is also a growing require-
1529-1839/07/$ -see front matter © 2007 American Optometric Association. All rights reserved. doi:10.1016/j.optm.2007.05.011
Jones and Nichols
Clinical Research
ment of insurance companies for general physicians to obtain ophthalmic feedback for the diabetic patient’s medical record. Because of this growing need, a project was designed to create a universal diabetic retinopathy examination report form that could be implemented easily into clinical practice. The goal of this form is to improve and standardize communication among optometrists and other health care providers who care for diabetic patients. Because of the rapid growth of diabetes and the problems of efficiency as well as missing information associated with letters,4-6 a form previously designed by the AOA was revised, and a study was created to survey the optometrist, general physician, and endocrinologist about the information and format that should be contained in a form to satisfy all parties. The ultimate goal was to create a user-friendly tool that will improve communication and encourage better patient care.
Methods The creation and validation of a diabetes communication form was supported through grants from the National Institute of Health and the AOA Healthy Vision 2010 Community Awards Programs to The Ohio State University and the Ohio Optometric Association (OOA). This project was reviewed and approved by the Institutional Review Board of The Ohio State University. The managing optometrist was required to sign a consent form, and all patient data that were transmitted were in compliance with the Health Insurance Portability and Accountability Act (HIPAA). A pilot Diabetic Eye Examination Report (DEER) (see Figure 1) was created by revising an existing AOA diabetic examination form. Existing form letters, literature, and practitioner comments were used to create the pilot DEER. The form was printed as a triplicate carbon copy to allow for the examining optometrist to send a copy to the comanaging health care provider, to keep a copy for the patient’s record, and to send a copy to the research office so that the data could be analyzed. Data were collected over a 4-month period. Persons eligible for the study included all licensed OOA member optometrists who treated diabetic patients. Optometrists were recruited via a publication in the OOA newsletter and via 2 e-mails sent to the OOA’s member list serve. The recruitment goal was to obtain 50 completed packets from optometrists, where a complete packet included a signed consent form by the examining optometrist, a completed survey, and a copy of DEERs collected on 5 consecutive diabetic patients. The participating optometrists were instructed to complete the pilot DEER (triplicate carbon copy), separate the triplicate form, and send the copies to the appropriate recipients. The top white copy was to be placed in an enclosed stamped envelope and sent along with a survey to
589 the health care provider of the patient’s choice. The second yellow copy was to be kept by the optometrist and filed in the patient’s record. The third pink copy, with all the patient identifiers removed, was to be sent along with the optometrist’s completed survey and consent form back to the research office. The optometrist’s survey consisted of 16 questions designed to evaluate the subject’s attitude toward interdisciplinary communication and the subject’s opinion of the form. The comanaging physician’s survey was composed of 15 questions similar to the optometrist survey, yet more brief to improve response rate compliance. The questions contained within the survey were designed to assess various areas of the form and the referring and comanaging doctor’s opinion of the form’s usefulness. Survey questions were asked to elicit information about the referring and comanaging doctors’ communication activity with other health care providers and the importance of this communication. The form’s format and convenience also were assessed. The survey allowed the referring and comanaging doctors to specify areas deemed unnecessary and areas that needed to be added or expanded. The monetary value of the form to the optometrists willing to purchase printed forms was also evaluated. The study design required the optometrist to send a copy of the Diabetic Retinopathy Form along with a comanaging physician survey to the health care provider of the patient’s choice (generally the patient’s general physician or endocrinologist). The comanaging physician survey contained instructions for the health care provider to review the form, complete the survey, and return it in a postage-paid/selfaddressed envelope. The comanaging doctors who received multiple DEERs from optometrists were instructed to complete the survey only once. The pilot DEER was developed to evaluate all potential elements of a communication form; therefore, we knew at the onset that several items would be removed, clarified, or revised in the final version based on comments and data from pilot testing.
Results Optometrist survey responses Fifty-one optometrists completed the project successfully. Based on the optometrists’ survey responses (see Table 1), 100% (51 of 51) of the participating optometrists felt that communication between health care providers who treat a diabetic patient was important. Ninety percent (46 of 51) reported that they customarily send a letter of their ocular findings to their diabetic patients’ general physicians (GP). Seventy-eight percent (40 of 51) of participating optometrists found the form to be more convenient than a letter, whereas 84% (43 of 51) felt that the form was equal to or better than a letter. Eighty-eight percent (45 of 51) of optometrists found the form to
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Optometry, Vol 78, No 11, November 2007
Figure 1
Pilot Diabetic Eye Examination Report Form.
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Clinical Research
591
Optometrists’ survey responses Yes
1. Do you customarily send a letter of your findings to your diabetic patients’ general physician? 2. Do you feel that communication between all health care professionals that treat a diabetic patient is important? 3. Do you find the form to be more convenient than a letter? 4. How would you rank the form compared to a letter? 5. Did the form contain all the information needed to describe your findings of your diabetic patient? 6. Did the form help to classify any retinopathy that your patient may have had? 7. Are there any areas that you would add? 8. Are there any areas that you would delete? 9. Do you feel the form was easy to use? 10. Do you feel the spaces provided were large enough? 11. Does the form seem cluttered? 12. Does the form seem confusing? 13. Do you like the idea of simply attaching your business card in communication with other professionals in the management of your patient? 14. Do you feel this form could be easily incorporated into your practice? 15a. If this form were available for purchase, would buy it? 15b. If yes, how much would you be willing to pay for 100 forms?
No
No response
90%
10%
0%
100%
0%
0%
78%
22%
0%
—
—
2%
88%
12%
0%
88%
6%
6%
33% 47% 82% 78%
51% 41% 16% 18%
16% 12% 2% 4%
43% 27% 57%
57% 69% 41%
0% 4% 2%
88%
8%
4%
59%
31%
10%
contain all the information needed to describe the ocular findings of their patients. Similarly, 88% (45 of 51) found that the form helped them to classify their patients’ diabetic retinopathy. In assessing the format of the pilot DEER, 47% (24 of 51) of optometrists identified areas of the form they would delete, whereas only 33% (17 of 51) suggested areas to add. Forty-three percent (22 of 51) felt that the pilot form seemed cluttered, and 27% (14 of 51) felt that the form seemed confusing. Seventy-eight percent (40 of 51) responded that the spaces were large enough. Eight-two percent (42 of 51) reported that the form was easy to use, whereas 41% (21 of 51) disliked the idea of attaching their business card to the form. In assessing the practicality in clinical use of the DEER, 88% (45 of 51) of the participating optometrists responded that the DEER could be incorporated easily in their practices. However, only 59% (30 of 51) felt that they would purchase the form if it were available. On average, the optometrists surveyed were willing to pay $24.38 for 100 carbon-copy forms (range, $0 to $100).
Better
Equal
Not as good
51%
33%
14%
Average ⫽ $24.38
Comanaging physician survey responses Seventy-five comanaging physicians successfully completed the study. Based on the survey results (see Table 2) once again 100% (75 of 75) of the participating comanaging physicians felt that communication between health care providers that treat diabetic patients was important. However, only 51% (38 of 75) reported customarily receiving a letter from an optometrist summarizing the ocular findings of their diabetic patients. In evaluating the convenience of the DEER, 65% (49 of 75) of participating comanaging physicians found the form more efficient to review than a letter, and 81% (61 of 75) felt that the form was equal to or better than a letter. Ninety-two percent (69 of 75) of comanaging physicians found the form to contain all the information needed to properly assess the eye health of their patients. Eighty-three percent (62 of 75) found that the form helped them better understand their patient’s diabetic retinopathy. In assessing the format of the DEER, 12% (9 of 75) of comanaging health care providers identified areas of the
592 Table 2
Optometry, Vol 78, No 11, November 2007 Comanaging physicians’ survey responses Yes
1. Do you customarily receive letters from optometrists summarizing their findings of diabetic patients? 2. Do you feel that communication between all health care professionals that treat a diabetic patient is important? 3. Do you find this form to be more time efficient to review than a letter? 4. How would you rank the form compared to a letter? 5. Did the form contain all the information needed to properly assess the eye health of your diabetic patient? 6. Did the form help to classify any retinopathy that your patient may have had? 7. Are there any areas that you would have liked to be more detailed? 8. Are there any areas that you found unnecessary for you to manage your patient? 9. Do you feel the form was easy to review? 10. Do you feel the spaces provided were large enough? 11. Does the form seem cluttered? 12. Does the form seem confusing? 13. Do you find the attachment of the optometrist’s business card helpful? 14. Do you feel this form is adequate to serve as a summary of the optometrist’s findings? 15. Would you like to receive this form as a standard of communication from optometrists concerning your diabetic patients?
No
No response
51%
49%
0%
100%
0%
0%
65%
28%
7%
— 92%
— 5%
8% 3%
83%
4%
13%
4%
84%
12%
12%
76%
12%
85% 84% 24% 15% 67%
13% 8% 75% 83% 27%
2% 8% 1% 2% 6%
95%
4%
1%
87%
9%
4%
form they would delete, whereas only 4% (3 of 75) identified areas in which they would like more detail. Only 24% (18 of 75) felt that the form seemed cluttered, whereas 15% (11 of 75) felt that the form seemed confusing. Eighty-four percent (63 of 75) responded that the spaces were large enough, and 85% (64 of 75) said that the form was easy to use. Twenty-seven percent (20 of 75) disliked the idea of the optometrist attaching the business card to the form. In assessing the practicality in clinical use of the DEER, 95% (71 of 75) of the comanaging doctors responded that the DEER was an adequate summary of the optometrist’s findings. Importantly, 87% (65 of 75) of comanaging physicians expressed interest in receiving this form as a standard communication form concerning their diabetic patients.
Optometrist comments The survey provided to the optometrists included blanks and a comment box for participants to expound on their opinions. Although there were numerous comments, there were a few comments that were stated by multiple participating optometrists. The top 5 comments of optometrists will be addressed in this section. The number one suggestion of optometrists for the improvement of the DEER concerned the attachment of the
Better
Equal
Not as good
44%
37%
11%
business card to the form. In the development of this form, the attachment of the business card seemed like a good idea because it would provide the recipient doctor with all the information needed to contact the optometrist; however, 31% (16 of 51) of participants commented on this area. The responding doctors felt that the attached business card would make the form bulky and difficult to file. Respondents added that their name and address should be permanent on the form. Some suggested having the form preprinted with their information or simply an area for a stamp or address sticker. The next most common suggestion centered on the patient information section of the DEER. Twenty-nine percent (15 of 51) of participating optometrists commented on this area. Many of the participants felt that this area of the form contained too much information. It was suggested that blood pressure, blood cholesterol, and glycosylated hemoglobin (HbA1C) be deleted from the form. The logic behind these suggestions was that most of the forms are sent to the patient’s general physician. Consequently, the general physician should already have this information. Participating optometrists also stated that most patients are unaware of these numbers, especially the HbA1C. Participating optometrists also commented that having both the age and date of birth was redundant.
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Clinical Research
Eighteen percent (9 of 51) of participants commented that the glaucoma area was confusing. Participating optometrists felt that it was hard to tell if the box for normal in the examination findings section referred to glaucoma or refractive changes. Some suggested that this section be divided by a vertical line or separated in some other fashion to help clarify the intent. Similarly, 18% (9 of 51) of participants suggested that the blank to specify dilating drops and time be eliminated. Some participants felt that specifying that the patient was dilated was more significant than the specific drops used. It was suggested that this area be replaced with a simple check box to acknowledge that a dilated fundus examination was conducted. Finally, the fifth most common suggestion was to enlarge the management and additional comments areas. Sixteen percent (8 of 51) of participants made this suggestion. All comments were considered in the revision of the form after the study’s completion to create a more user-friendly tool.
Comanaging physician comments The comanaging physician survey provided space for the doctor to comment on areas to add or delete; however, there was not an actual comment box as in the optometrist’s survey. Because of this, the comments of the comanaging physicians were limited. The top comment of the comanaging physicians was that the pilot DEER was too complex. The recipients stated that they “just needed a summary”; however, only 8% (6 of 75) of respondents made this comment. Many of the comments made paralleled those of the optometrists. Like the optometrists, the comanaging physicians commented on the attachment of the business card. Comanaging physicians were concerned that the card would get separated and lost from the chart. Recipient doctors also felt that the write-in areas on the form should be enlarged and that specifying the dilating drops used was unnecessary. Interestingly, a few of the doctors commented that it was nice to receive any ophthalmic feedback concerning their diabetic patients. These physicians stated that they are evaluated by other health care entities on whether they have ophthalmic feedback in their charts, and receiving communication was beneficial.
Discussion The goal of this study was to create a tool that could be used by optometrists to efficiently communicate with a diabetic patient’s health care team. Based on the information received from the survey and information contained within the literature, a usable form has been created. The reasons for the deletions, additions, and reformatting of the pilot DEER will be discussed in this section starting from the top of the form and moving to the bottom.
593 The first change was made in the area for the business card attachment. The participants were concerned that the business card could be separated and lost from the patient’s record or would make the record bulky. This area was replaced with a space to either type in the optometrist’s information or to apply a stamp. Next, the patient information section was condensed. The patient’s age was removed because of the redundancy of including both age and date of birth. The patient’s blood cholesterol and blood pressure were also deleted. Optometrists commented that this information was unwarranted because the recipient would already have this information. Similar comments were made regarding the HbA1C levels. However, because of the overwhelming support in the literature of the importance of HbA1C in predicting progression of diabetic complication,7-11 a check box for recording the patient’s knowledge of this measurement was kept on the form. The examination findings area of the study form was also revised and shortened to exclude extraneous data. The reason for the visit and presenting symptoms were deleted to help focus the form as a diabetic report and less as an examination form. The boxes concerning refractive changes, cataracts, extraocular muscle restriction, and glaucoma were also omitted. This area was replaced with a large box labeled “additional ocular findings.” On the new form, the optometrist has the opportunity to report any ocular findings that may be significant without being limited to those listed above. The dilated fundus examination section was merged with the examination findings (visual acuities and intraocular pressure) section on the new form. Both optometrists and comanaging physicians suggested that the specific dilating drops and time be eliminated. These blanks were replaced by a simple check box to indicate that a dilated fundus examination was performed. To reduce complexity in favor of providing a summary, the section indicating the severity of diabetic retinopathy was greatly simplified. As suggested from the comments of the comanaging physicians, the area that states “no diabetic retinopathy” has been enlarged and made more prominent. The findings included within each level of retinopathy were deleted and replaced with severity levels only. (Many of these ocular terms may be foreign and unnecessary for the general physician.) Finally, a space was provided for the doctor to write in any additional testing ordered and the treatment plan for the patient. All write-in areas were enlarged. Various studies from other disciplines have shown the benefit of using forms in place of letters. A study of referral letters in oral medicine found that forms were more complete and contained information commonly absent in letters.4 Another study looked at referral letters of general physicians to various specialists and found that the introduction of a pro forma letter (form) improved the quality of the letters.12 The fact that more than 5 versions of a diabetic retinopathy form were found and that both optometrists and GPs use them shows that there seems to be an acceptance of forms within the health care community. However, the
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Optometry, Vol 78, No 11, November 2007
Figure 2
Revised Diabetic Eye Examination Report Form.
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Clinical Research
acceptance is limited to whether the form contains necessary information and is easy to use.12
595 2005) and the AOA Healthy Eyes Healthy People™ Healthy Vision 2010 Community Awards program (2005).
References Conclusion Previous studies have found that communication forms usually contain more information than letters and are more time efficient.4-7,12-16 Because of the growing incidence of diabetes in this country and growing stress on the health care team, this study was designed to create a standard form to facilitate communication among the members of this team. In developing the new form, the following were assessed: diabetic retinopathy classification systems, existing DEERs, the opinions of optometrists, the opinions of comanaging doctors, the literature on diabetes, and the literature on communication methods. Both optometrists and general physicians desire a form that is user friendly and easy to understand. Based on the information provided by optometrists and the comanaging doctor, the revised DEER was created (see Figure 2). The new form is now available through the AOA at www.aoa.org in support of the Healthy Eyes Healthy People™ initiative. It is available in an electronic format as a fillable PDF making it possible for the optometrist to type information directly onto the form and print making it more professional and legible. Plans are under way to monitor and track usage and comments related to this form.
Acknowledgments The authors thank both the OOA and The Ohio State University for their assistance and support of this project. This project was funded through the National Eye Institute Healthy Vision 2010 Community Awards program (2004,
1. All about diabetes. 2007, American Diabetes Association. http:// www.diabetes.org/home.jsp. Last accessed October 2, 2007. 2. Klein R. Vision disorders in diabetes. NIH Publications, 1995; Chapter 14. No. 95-1468. 3. Alexander L. Care for patients with diabetes mellitus. AOA Clinical Care Guidelines 2002. 4. Navarro CM. Referral letters in oral medicine: standard versus nonstandard letters. Int J Oral Maxillofac Surg 2002;31(5):537-43. 5. Tattersall MH. Improving doctors’ letters. Med J Aust 2002;177(9): 516-20. 6. Epstein RM. Communication between primary care physicians and consultants. Arch Fam Med 1995;4(5):403-9. 7. Edelman D. Utility of hemoglobin A1c in predicting diabetes risk. J Gen Intern Med 2004;19(12):1175-80. 8. Lloyd CE. The progression of retinopathy over 2 years: the Pittsburgh Epidemiology of Diabetes Complications (EDC) Study. J Diabetes Complications 1995;9(3):140-8. 9. Corpus RA. Relation of hemoglobin A1c to rate of major adverse cardiac events in nondiabetic patients undergoing percutaneous coronary revascularization. Am J Cardiol 2003;92(11):1282-6. 10. Klein R. The Wisconsin Epidemiologic Study of Diabetic Retinopathy: XVII. The 14-year incidence and progression of diabetic retinopathy and associated risk factors in type 1 diabetes. Ophthalmology 1998;105(10):1801-15. 11. Couper ID, Henbest RJ. The quality and relationship of referral and reply letters. The effect of introducing a pro forma letter. S Afr Med J 1996;86(12):1540-2. 12. Hodge JA. Medical clinic referral letters. Do they say what they mean? Do they mean what they say? Scott Med J 1992;37(6):179-80. 13. Newton JM, Hutchinson A. Communication between general practitioners and consultants: what should their letters contain? BMJ 1992; 304(6830):821-4. 14. Young DW. Out-patient letters: requirement and contents. Eff Health Care 1985;2(6):225-9. 15. McAndrew R. Opinions of dental consultants on the standard of referral letters in dentistry. Br Dent J 1997;182(1):22-5. 16. Navarro CM, Onofre MA, Sposto MR, Referral letters in oral medicine: an approach for the general dental practitioner. Int J Oral Maxillofac Surg 2001;30(5):448-51.
Diabetic eye examination report Sylvia L. Jones, O.D., M.S., and Kelly K. Nichols, O.D., Ph.D., M.P.H. The Ohio State University College of Optometry, Columbus, Ohio. KEYWORDS Diabetes; Public health; Standard of care; Documentation; Optometry
Abstract BACKGROUND: The purpose of this study was to revise a former American Optometric Association (AOA) Diabetic Eye Examination Report form and create a standard reporting form that could be implemented easily into clinical practice. METHODS: Ohio Optometric Association (OOA) members were recruited to complete the pilot Diabetic Eye Examination Report (DEER) on 5 consecutive diabetic patients. They were then instructed to send a copy of the completed form to the comanaging physician of the patient’s choice. The participating optometrists and comanaging physicians were surveyed regarding the content and format of the pilot DEER. RESULTS: The pilot DEER was revised based on the survey responses and comments from 51 participating optometrists and 75 comanaging physicians, existing diabetic retinopathy examination forms, and a literature review. In general, optometrists and comanaging physicians agreed on the importance of communication (100% in both groups, 51of 51 and 75 of 75). Eighty-eight percent (45 of 51) of optometrists and 95% (71 of 75) comanaging physicians found the form to be an adequate summary. Eighty-seven percent (65 of 75) of comanaging physicians expressed interest in receiving the pilot DEER as a standard communication form concerning their diabetic patients. CONCLUSION: The new form is now available through the OOA at www.ooa.org as an initiative of Healthy People 2010. In an electronic format, it is possible for the optometrist to type information directly onto the form, making it more professional and legible. Printed forms are also available through the AOA purchasing department. Optometry 2007;78:588-595
Diabetes recently has been called an epidemic. According to the American Diabetes Association, there are currently 20.8 million people, or 7% of the United States population, who have diabetes.1 Diabetes is a systemic disease that can lead to cardiovascular problems, neuropathy, nephropathy, and retinopathy. Diabetic retinopathy is the leading cause of new cases of blindness in the U.S. adult population, accounting for 12,000 to 24,000 of new blindness cases each year.1 The majority of persons with diabetes will experience some degree of diabetic retinopathy over Corresponding Author: Kelly K. Nichols, O.D., Ph.D., M.P.H., The Ohio State University College of Optometry, 338 W. 10th Avenue, Columbus, Ohio 43210. E-mail: [email protected]
time, with the incidence increasing with diabetes duration.2 Vision care is an integral component of diabetic care. Because optometrists are responsible for two thirds of the primary eye care services in the United States,3 optometry is well positioned to be the primary eye care profession for diabetic patients. Communication between optometrists and other health care providers is essential to prevent and adequately manage diabetic complications that affect the eye. The American Optometric Association (AOA) Optometric Clinical Practice Guidelines: Care of the Patient with Diabetes Mellitus (www.aoa.org/documents/CPG-3.pdf) states that appropriate communication with the patient’s primary care physician is critical for proper coordination of the patient’s care and that a written report is useful for accomplishing this task.3 There is also a growing require-
1529-1839/07/$ -see front matter © 2007 American Optometric Association. All rights reserved. doi:10.1016/j.optm.2007.05.011
Jones and Nichols
Clinical Research
ment of insurance companies for general physicians to obtain ophthalmic feedback for the diabetic patient’s medical record. Because of this growing need, a project was designed to create a universal diabetic retinopathy examination report form that could be implemented easily into clinical practice. The goal of this form is to improve and standardize communication among optometrists and other health care providers who care for diabetic patients. Because of the rapid growth of diabetes and the problems of efficiency as well as missing information associated with letters,4-6 a form previously designed by the AOA was revised, and a study was created to survey the optometrist, general physician, and endocrinologist about the information and format that should be contained in a form to satisfy all parties. The ultimate goal was to create a user-friendly tool that will improve communication and encourage better patient care.
Methods The creation and validation of a diabetes communication form was supported through grants from the National Institute of Health and the AOA Healthy Vision 2010 Community Awards Programs to The Ohio State University and the Ohio Optometric Association (OOA). This project was reviewed and approved by the Institutional Review Board of The Ohio State University. The managing optometrist was required to sign a consent form, and all patient data that were transmitted were in compliance with the Health Insurance Portability and Accountability Act (HIPAA). A pilot Diabetic Eye Examination Report (DEER) (see Figure 1) was created by revising an existing AOA diabetic examination form. Existing form letters, literature, and practitioner comments were used to create the pilot DEER. The form was printed as a triplicate carbon copy to allow for the examining optometrist to send a copy to the comanaging health care provider, to keep a copy for the patient’s record, and to send a copy to the research office so that the data could be analyzed. Data were collected over a 4-month period. Persons eligible for the study included all licensed OOA member optometrists who treated diabetic patients. Optometrists were recruited via a publication in the OOA newsletter and via 2 e-mails sent to the OOA’s member list serve. The recruitment goal was to obtain 50 completed packets from optometrists, where a complete packet included a signed consent form by the examining optometrist, a completed survey, and a copy of DEERs collected on 5 consecutive diabetic patients. The participating optometrists were instructed to complete the pilot DEER (triplicate carbon copy), separate the triplicate form, and send the copies to the appropriate recipients. The top white copy was to be placed in an enclosed stamped envelope and sent along with a survey to
589 the health care provider of the patient’s choice. The second yellow copy was to be kept by the optometrist and filed in the patient’s record. The third pink copy, with all the patient identifiers removed, was to be sent along with the optometrist’s completed survey and consent form back to the research office. The optometrist’s survey consisted of 16 questions designed to evaluate the subject’s attitude toward interdisciplinary communication and the subject’s opinion of the form. The comanaging physician’s survey was composed of 15 questions similar to the optometrist survey, yet more brief to improve response rate compliance. The questions contained within the survey were designed to assess various areas of the form and the referring and comanaging doctor’s opinion of the form’s usefulness. Survey questions were asked to elicit information about the referring and comanaging doctors’ communication activity with other health care providers and the importance of this communication. The form’s format and convenience also were assessed. The survey allowed the referring and comanaging doctors to specify areas deemed unnecessary and areas that needed to be added or expanded. The monetary value of the form to the optometrists willing to purchase printed forms was also evaluated. The study design required the optometrist to send a copy of the Diabetic Retinopathy Form along with a comanaging physician survey to the health care provider of the patient’s choice (generally the patient’s general physician or endocrinologist). The comanaging physician survey contained instructions for the health care provider to review the form, complete the survey, and return it in a postage-paid/selfaddressed envelope. The comanaging doctors who received multiple DEERs from optometrists were instructed to complete the survey only once. The pilot DEER was developed to evaluate all potential elements of a communication form; therefore, we knew at the onset that several items would be removed, clarified, or revised in the final version based on comments and data from pilot testing.
Results Optometrist survey responses Fifty-one optometrists completed the project successfully. Based on the optometrists’ survey responses (see Table 1), 100% (51 of 51) of the participating optometrists felt that communication between health care providers who treat a diabetic patient was important. Ninety percent (46 of 51) reported that they customarily send a letter of their ocular findings to their diabetic patients’ general physicians (GP). Seventy-eight percent (40 of 51) of participating optometrists found the form to be more convenient than a letter, whereas 84% (43 of 51) felt that the form was equal to or better than a letter. Eighty-eight percent (45 of 51) of optometrists found the form to
590
Optometry, Vol 78, No 11, November 2007
Figure 1
Pilot Diabetic Eye Examination Report Form.
Jones and Nichols Table 1
Clinical Research
591
Optometrists’ survey responses Yes
1. Do you customarily send a letter of your findings to your diabetic patients’ general physician? 2. Do you feel that communication between all health care professionals that treat a diabetic patient is important? 3. Do you find the form to be more convenient than a letter? 4. How would you rank the form compared to a letter? 5. Did the form contain all the information needed to describe your findings of your diabetic patient? 6. Did the form help to classify any retinopathy that your patient may have had? 7. Are there any areas that you would add? 8. Are there any areas that you would delete? 9. Do you feel the form was easy to use? 10. Do you feel the spaces provided were large enough? 11. Does the form seem cluttered? 12. Does the form seem confusing? 13. Do you like the idea of simply attaching your business card in communication with other professionals in the management of your patient? 14. Do you feel this form could be easily incorporated into your practice? 15a. If this form were available for purchase, would buy it? 15b. If yes, how much would you be willing to pay for 100 forms?
No
No response
90%
10%
0%
100%
0%
0%
78%
22%
0%
—
—
2%
88%
12%
0%
88%
6%
6%
33% 47% 82% 78%
51% 41% 16% 18%
16% 12% 2% 4%
43% 27% 57%
57% 69% 41%
0% 4% 2%
88%
8%
4%
59%
31%
10%
contain all the information needed to describe the ocular findings of their patients. Similarly, 88% (45 of 51) found that the form helped them to classify their patients’ diabetic retinopathy. In assessing the format of the pilot DEER, 47% (24 of 51) of optometrists identified areas of the form they would delete, whereas only 33% (17 of 51) suggested areas to add. Forty-three percent (22 of 51) felt that the pilot form seemed cluttered, and 27% (14 of 51) felt that the form seemed confusing. Seventy-eight percent (40 of 51) responded that the spaces were large enough. Eight-two percent (42 of 51) reported that the form was easy to use, whereas 41% (21 of 51) disliked the idea of attaching their business card to the form. In assessing the practicality in clinical use of the DEER, 88% (45 of 51) of the participating optometrists responded that the DEER could be incorporated easily in their practices. However, only 59% (30 of 51) felt that they would purchase the form if it were available. On average, the optometrists surveyed were willing to pay $24.38 for 100 carbon-copy forms (range, $0 to $100).
Better
Equal
Not as good
51%
33%
14%
Average ⫽ $24.38
Comanaging physician survey responses Seventy-five comanaging physicians successfully completed the study. Based on the survey results (see Table 2) once again 100% (75 of 75) of the participating comanaging physicians felt that communication between health care providers that treat diabetic patients was important. However, only 51% (38 of 75) reported customarily receiving a letter from an optometrist summarizing the ocular findings of their diabetic patients. In evaluating the convenience of the DEER, 65% (49 of 75) of participating comanaging physicians found the form more efficient to review than a letter, and 81% (61 of 75) felt that the form was equal to or better than a letter. Ninety-two percent (69 of 75) of comanaging physicians found the form to contain all the information needed to properly assess the eye health of their patients. Eighty-three percent (62 of 75) found that the form helped them better understand their patient’s diabetic retinopathy. In assessing the format of the DEER, 12% (9 of 75) of comanaging health care providers identified areas of the
592 Table 2
Optometry, Vol 78, No 11, November 2007 Comanaging physicians’ survey responses Yes
1. Do you customarily receive letters from optometrists summarizing their findings of diabetic patients? 2. Do you feel that communication between all health care professionals that treat a diabetic patient is important? 3. Do you find this form to be more time efficient to review than a letter? 4. How would you rank the form compared to a letter? 5. Did the form contain all the information needed to properly assess the eye health of your diabetic patient? 6. Did the form help to classify any retinopathy that your patient may have had? 7. Are there any areas that you would have liked to be more detailed? 8. Are there any areas that you found unnecessary for you to manage your patient? 9. Do you feel the form was easy to review? 10. Do you feel the spaces provided were large enough? 11. Does the form seem cluttered? 12. Does the form seem confusing? 13. Do you find the attachment of the optometrist’s business card helpful? 14. Do you feel this form is adequate to serve as a summary of the optometrist’s findings? 15. Would you like to receive this form as a standard of communication from optometrists concerning your diabetic patients?
No
No response
51%
49%
0%
100%
0%
0%
65%
28%
7%
— 92%
— 5%
8% 3%
83%
4%
13%
4%
84%
12%
12%
76%
12%
85% 84% 24% 15% 67%
13% 8% 75% 83% 27%
2% 8% 1% 2% 6%
95%
4%
1%
87%
9%
4%
form they would delete, whereas only 4% (3 of 75) identified areas in which they would like more detail. Only 24% (18 of 75) felt that the form seemed cluttered, whereas 15% (11 of 75) felt that the form seemed confusing. Eighty-four percent (63 of 75) responded that the spaces were large enough, and 85% (64 of 75) said that the form was easy to use. Twenty-seven percent (20 of 75) disliked the idea of the optometrist attaching the business card to the form. In assessing the practicality in clinical use of the DEER, 95% (71 of 75) of the comanaging doctors responded that the DEER was an adequate summary of the optometrist’s findings. Importantly, 87% (65 of 75) of comanaging physicians expressed interest in receiving this form as a standard communication form concerning their diabetic patients.
Optometrist comments The survey provided to the optometrists included blanks and a comment box for participants to expound on their opinions. Although there were numerous comments, there were a few comments that were stated by multiple participating optometrists. The top 5 comments of optometrists will be addressed in this section. The number one suggestion of optometrists for the improvement of the DEER concerned the attachment of the
Better
Equal
Not as good
44%
37%
11%
business card to the form. In the development of this form, the attachment of the business card seemed like a good idea because it would provide the recipient doctor with all the information needed to contact the optometrist; however, 31% (16 of 51) of participants commented on this area. The responding doctors felt that the attached business card would make the form bulky and difficult to file. Respondents added that their name and address should be permanent on the form. Some suggested having the form preprinted with their information or simply an area for a stamp or address sticker. The next most common suggestion centered on the patient information section of the DEER. Twenty-nine percent (15 of 51) of participating optometrists commented on this area. Many of the participants felt that this area of the form contained too much information. It was suggested that blood pressure, blood cholesterol, and glycosylated hemoglobin (HbA1C) be deleted from the form. The logic behind these suggestions was that most of the forms are sent to the patient’s general physician. Consequently, the general physician should already have this information. Participating optometrists also stated that most patients are unaware of these numbers, especially the HbA1C. Participating optometrists also commented that having both the age and date of birth was redundant.
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Clinical Research
Eighteen percent (9 of 51) of participants commented that the glaucoma area was confusing. Participating optometrists felt that it was hard to tell if the box for normal in the examination findings section referred to glaucoma or refractive changes. Some suggested that this section be divided by a vertical line or separated in some other fashion to help clarify the intent. Similarly, 18% (9 of 51) of participants suggested that the blank to specify dilating drops and time be eliminated. Some participants felt that specifying that the patient was dilated was more significant than the specific drops used. It was suggested that this area be replaced with a simple check box to acknowledge that a dilated fundus examination was conducted. Finally, the fifth most common suggestion was to enlarge the management and additional comments areas. Sixteen percent (8 of 51) of participants made this suggestion. All comments were considered in the revision of the form after the study’s completion to create a more user-friendly tool.
Comanaging physician comments The comanaging physician survey provided space for the doctor to comment on areas to add or delete; however, there was not an actual comment box as in the optometrist’s survey. Because of this, the comments of the comanaging physicians were limited. The top comment of the comanaging physicians was that the pilot DEER was too complex. The recipients stated that they “just needed a summary”; however, only 8% (6 of 75) of respondents made this comment. Many of the comments made paralleled those of the optometrists. Like the optometrists, the comanaging physicians commented on the attachment of the business card. Comanaging physicians were concerned that the card would get separated and lost from the chart. Recipient doctors also felt that the write-in areas on the form should be enlarged and that specifying the dilating drops used was unnecessary. Interestingly, a few of the doctors commented that it was nice to receive any ophthalmic feedback concerning their diabetic patients. These physicians stated that they are evaluated by other health care entities on whether they have ophthalmic feedback in their charts, and receiving communication was beneficial.
Discussion The goal of this study was to create a tool that could be used by optometrists to efficiently communicate with a diabetic patient’s health care team. Based on the information received from the survey and information contained within the literature, a usable form has been created. The reasons for the deletions, additions, and reformatting of the pilot DEER will be discussed in this section starting from the top of the form and moving to the bottom.
593 The first change was made in the area for the business card attachment. The participants were concerned that the business card could be separated and lost from the patient’s record or would make the record bulky. This area was replaced with a space to either type in the optometrist’s information or to apply a stamp. Next, the patient information section was condensed. The patient’s age was removed because of the redundancy of including both age and date of birth. The patient’s blood cholesterol and blood pressure were also deleted. Optometrists commented that this information was unwarranted because the recipient would already have this information. Similar comments were made regarding the HbA1C levels. However, because of the overwhelming support in the literature of the importance of HbA1C in predicting progression of diabetic complication,7-11 a check box for recording the patient’s knowledge of this measurement was kept on the form. The examination findings area of the study form was also revised and shortened to exclude extraneous data. The reason for the visit and presenting symptoms were deleted to help focus the form as a diabetic report and less as an examination form. The boxes concerning refractive changes, cataracts, extraocular muscle restriction, and glaucoma were also omitted. This area was replaced with a large box labeled “additional ocular findings.” On the new form, the optometrist has the opportunity to report any ocular findings that may be significant without being limited to those listed above. The dilated fundus examination section was merged with the examination findings (visual acuities and intraocular pressure) section on the new form. Both optometrists and comanaging physicians suggested that the specific dilating drops and time be eliminated. These blanks were replaced by a simple check box to indicate that a dilated fundus examination was performed. To reduce complexity in favor of providing a summary, the section indicating the severity of diabetic retinopathy was greatly simplified. As suggested from the comments of the comanaging physicians, the area that states “no diabetic retinopathy” has been enlarged and made more prominent. The findings included within each level of retinopathy were deleted and replaced with severity levels only. (Many of these ocular terms may be foreign and unnecessary for the general physician.) Finally, a space was provided for the doctor to write in any additional testing ordered and the treatment plan for the patient. All write-in areas were enlarged. Various studies from other disciplines have shown the benefit of using forms in place of letters. A study of referral letters in oral medicine found that forms were more complete and contained information commonly absent in letters.4 Another study looked at referral letters of general physicians to various specialists and found that the introduction of a pro forma letter (form) improved the quality of the letters.12 The fact that more than 5 versions of a diabetic retinopathy form were found and that both optometrists and GPs use them shows that there seems to be an acceptance of forms within the health care community. However, the
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Optometry, Vol 78, No 11, November 2007
Figure 2
Revised Diabetic Eye Examination Report Form.
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Clinical Research
acceptance is limited to whether the form contains necessary information and is easy to use.12
595 2005) and the AOA Healthy Eyes Healthy People™ Healthy Vision 2010 Community Awards program (2005).
References Conclusion Previous studies have found that communication forms usually contain more information than letters and are more time efficient.4-7,12-16 Because of the growing incidence of diabetes in this country and growing stress on the health care team, this study was designed to create a standard form to facilitate communication among the members of this team. In developing the new form, the following were assessed: diabetic retinopathy classification systems, existing DEERs, the opinions of optometrists, the opinions of comanaging doctors, the literature on diabetes, and the literature on communication methods. Both optometrists and general physicians desire a form that is user friendly and easy to understand. Based on the information provided by optometrists and the comanaging doctor, the revised DEER was created (see Figure 2). The new form is now available through the AOA at www.aoa.org in support of the Healthy Eyes Healthy People™ initiative. It is available in an electronic format as a fillable PDF making it possible for the optometrist to type information directly onto the form and print making it more professional and legible. Plans are under way to monitor and track usage and comments related to this form.
Acknowledgments The authors thank both the OOA and The Ohio State University for their assistance and support of this project. This project was funded through the National Eye Institute Healthy Vision 2010 Community Awards program (2004,
1. All about diabetes. 2007, American Diabetes Association. http:// www.diabetes.org/home.jsp. Last accessed October 2, 2007. 2. Klein R. Vision disorders in diabetes. NIH Publications, 1995; Chapter 14. No. 95-1468. 3. Alexander L. Care for patients with diabetes mellitus. AOA Clinical Care Guidelines 2002. 4. Navarro CM. Referral letters in oral medicine: standard versus nonstandard letters. Int J Oral Maxillofac Surg 2002;31(5):537-43. 5. Tattersall MH. Improving doctors’ letters. Med J Aust 2002;177(9): 516-20. 6. Epstein RM. Communication between primary care physicians and consultants. Arch Fam Med 1995;4(5):403-9. 7. Edelman D. Utility of hemoglobin A1c in predicting diabetes risk. J Gen Intern Med 2004;19(12):1175-80. 8. Lloyd CE. The progression of retinopathy over 2 years: the Pittsburgh Epidemiology of Diabetes Complications (EDC) Study. J Diabetes Complications 1995;9(3):140-8. 9. Corpus RA. Relation of hemoglobin A1c to rate of major adverse cardiac events in nondiabetic patients undergoing percutaneous coronary revascularization. Am J Cardiol 2003;92(11):1282-6. 10. Klein R. The Wisconsin Epidemiologic Study of Diabetic Retinopathy: XVII. The 14-year incidence and progression of diabetic retinopathy and associated risk factors in type 1 diabetes. Ophthalmology 1998;105(10):1801-15. 11. Couper ID, Henbest RJ. The quality and relationship of referral and reply letters. The effect of introducing a pro forma letter. S Afr Med J 1996;86(12):1540-2. 12. Hodge JA. Medical clinic referral letters. Do they say what they mean? Do they mean what they say? Scott Med J 1992;37(6):179-80. 13. Newton JM, Hutchinson A. Communication between general practitioners and consultants: what should their letters contain? BMJ 1992; 304(6830):821-4. 14. Young DW. Out-patient letters: requirement and contents. Eff Health Care 1985;2(6):225-9. 15. McAndrew R. Opinions of dental consultants on the standard of referral letters in dentistry. Br Dent J 1997;182(1):22-5. 16. Navarro CM, Onofre MA, Sposto MR, Referral letters in oral medicine: an approach for the general dental practitioner. Int J Oral Maxillofac Surg 2001;30(5):448-51.