PATIENT FLOW AND EFFICIENCY
Lewis: The goal of this panel discussion is clear: how can we manage our glaucoma patients with quality and efficiency? We will start with their entrance into the office. Do you have any thoughts about the whole registration process and how to get it moving quicker?

Myers: I think most physicians do not know everything that happens to patients between the time they walk through the practice's door and when they sit in the exam chair. The inefficiency can be remarkable. For example, 8 years ago, I found a large box full of old receipts at my practice. My staff was keeping receipts for every patient. They were photocopying the actual cash that patients used for their copays in order to keep a record of the transaction. This was not an efficient use of paper, photocopiers, or my staff's and patients' time. Every so often, we need to freshly examine our procedures from top to bottom to identify opportunities for improved care and its delivery.

Mattox: The hospital-based clinical system has actually allowed for one efficiency: the patient referral system is all set up through the hospital ahead of time. The Department of Ophthalmology's staff does not have to acquire referrals. The hospital's staff calls the patients ahead of time, and that information flows into our separate system.

Lewis: Why don't we register patients online?

Shafranov: Due to the necessary security measures, I think it would be a much larger expense for the IT department. It is significantly less expensive to mail to patients a paper form that replicates your template in NextGen EMR (NextGen Healthcare Information Systems, Inc., Horsham, PA). A technician can then simply scan it into NextGen or transfer the dots and checkmarks into the system (Figure 1).

Lewis: Is anyone doing that before the patient arrives at the clinic?

Shafranov: I send the patient a packet, which my referring doctors also have. Some patients bring their actual charts from their referring doctors. I have found that a lot of inefficiency occurs when referring doctors do not trust the specialist. They are not sure they want to give you records. After working one-on-one with these doctors for 2 years, they now make every effort to send all of the information they have on a patient to me, because they know I have no intention of keeping that patient in my practice. After the initial consultation, I will develop a plan for management, and then the patient will return to the referring doctor. This understanding that I have with referring physicians greatly accelerates the registration process and patient flow.

Reynolds: I was going to speak about this exact subject. Patients would be sent to me for a consultation so that I could determine if their visual fields were worsening and/or if they required surgery. I would receive one visual field, usually the most recent one, and would have to schedule the patient back for another appointment after obtaining the rest of the necessary information. I have tried to teach my referral base that they can never give me too much information, and I have tried to address what I need to make first appointments be most useful for everyone. Doing so made a big difference for my practice's efficiency.

Moster: We have 15 doctors at nine locations in our practice, and almost all of them are subspecialists. For consultations, a request of some sort is required that states, "I am referring so-and-so to Dr. Marlene Moster for a glaucoma consultation." Because the request/form is necessary for correct billing, we have sent it to our referring doctors. Otherwise, our front desk staff must call referring doctors and ask their staff to fax a request for a consultation. That is tremendously inefficient, because we see so many new patients a day. To improve the system, we are planning to transition to NextGen EMR within the next 2 years.

Mattox: Usually, I receive a letter from referring doctors. If it comes without visual fields or advanced imaging tests, my secretary knows to leave the file on my desk. If I need more information, I try to get it before the patient's visit in order to boost efficiency.

Myers: The follow-up patient presents a different challenge: changes in insurers. How efficiently can your staff confirm the patient's health insurance and eligibility? Depending on your patient database, that may not be quick and easy for the front desk staff.

Reynolds: Does making the patient encounter more efficient cost you more in the long term? What I am getting at is the extra work involved in trying to gather information before the encounter.

Schuman: I think it is definitely costing us more. I think it is more expensive to have the electronic health record (EHR) system than not, but I also think EHRs promote better patient care. It is much easier to access historical information from anywhere in the world.

Shafranov: I agree. While traveling by train from New Haven, Connecticut, to Washington, DC, I got a call from a referring doctor about a patient I had seen once for a consultation in 2007. At that visit, the patient had iris neovascularization but an acceptable IOP. I had said that it would be fine to proceed with panretinal photocoagulation and that I would implant a tube when the IOP rose. From the train, I was able to review the patient's chart, images, test results, and list of medications, and I could provide a referring doctor with a plan for management, which included additional retinal laser treatment and the placement of a glaucoma drainage implant.

Schuman: EHRs are allowing us to save money in a couple of areas. We are closing down our medical records unit, so we will not require the space to store charts and the personnel to organize the files. Also, a single secretary can process and send the letters created by the EHR system instead of eight different secretaries for 25 faculty members.

Mattox: I have a pet peeve about letters generated by an electronic system. The ones I receive that have been generated automatically by an electronic medical record (EMR) system are five-page lists of extraneous information, and I have trouble finding the data that I really need. Often, the referring doctor has been compelled to scribble in the margins to try to get his point across. I think there is lots of room for improvement to create letters with an EMR system that enhance communication between physicians rather than hamper it.

Shafranov: With NextGen, it takes time, but it is possible to customize the template for your letters.

Myers: I agree it is hard to do good EMR letters, but it is not impossible. I confess that my letters may occasionally sound a bit robotic, but they deliver the key information and do so quickly. We put the impression at the very top of the letter and include any other information for the referring clinician's interest thereafter. The important thing is that referring doctors receive the letter within 24 hours, because it leaves my office by fax or US mail that afternoon. They do not get it 6 weeks later, after the patient has already been back to the referring clinician. Some of you are trying to access patients' records when you are flying around the world. I am happy just to have the record available when I am in the office. Since we switched to EMRs, a lost chart is never a problem.

Heuer: I think that we are at the DOS [disk operating system] era in medical records. The efficiencies are not there, despite the hype. EMRs are more expensive than paper files. The records I get from people who have EMR systems, particularly Epic Software (Epic Systems Corporation, Verona, WI), are awful: they are not a letter but page after page of poorly organized and labeled information. All I really want to know is what the IOP has been and what the visual field tests have shown. I do not put much stock in anyone's subjective cup-to-disc ratios, even my own. The one advantage of EMRs would be if they gave to me a patient's IOP profile for the past 100 years and all of his visual field results.

Schuman: I disagree about being in the DOS level. A novice can use EHRs. He just may not be able to use their full power.

Lewis: To summarize, we can access information from anywhere in the world, but the process also slows us down. We are in the early stages, however, and the opportunities to improve communication are vast.

BILLING
Lewis: With a lot of electronic systems, providers can bill patients essentially automatically. How many of you are doing that?

Myers: In our office, physicians check off all the charges, but people in the billing department double-check claims before they are sent, because our physicians are not up on modifiers.

Moster: We routinely have the front desk staff check the modifiers to minimize the number of rejected claims.

Mattox: We are moving to an electronic billing system shortly. There are a couple of reasons why claims still need input from a physician or the billing staff. In order to bill testing, you need to have a medically necessary indication. A number of insurance companies will not pay for certain tests performed on the same day as something else, so there needs to be intelligence behind the billing. I do not think you can ever completely get away from that. That said, the electronic billing system we are planning to use will be a handheld type. The idea is that there will be coding rules already entered in the system that will be specific to payers. For example, one payer may not allow optical coherence tomography (OCT) and visual field testing on the same day, whereas another will. This system should be specific enough to account for those differences and will also prompt you to enter modifiers.

Heuer: That is great, but shouldn't that be done on the front end with scheduling? By the time patients get to me, they have often had both types of testing.

Mattox: You can do all the testing you want. It is whether you can bill for it. I agree, however, that you are ahead of the game if you properly schedule patients for testing from the start.

Shafranov: I use a simple rule of thumb: photographs one day, visual field testing and scanning laser polarimetry on another day. That works in a majority of patients.

Mattox: That may be true in Connecticut, but there are Medicare carriers in this country that have more complicated rules. You may not get paid for OCT on a patient who has advanced glaucoma or who is over 90 years of age, for example. You or your billing staff needs to be familiar with any local coverage policies and also the various rules of the third-party carriers with which you deal.

DELEGATION
Lewis: How do you use technicians, nurses, ophthalmic assistants, and other staff in your practice to make yourself more efficient?

Heuer: One of the mistakes we tend to make is having the least well-trained person perform every function. A bright person will learn the system and tell you, "Mrs. Jones could not do this test the last time. Why did you order it?" The best thing we can do is train our people to be as good as they can be. I have tried so far without success to get our hospital to recognize different levels of technicians in order to encourage them to get their ascending certification.

In the long run, having the smartest person do as much as possible is the most efficient approach, because 95% of the problems will have been worked out without your input.

Moster: We have rotating designated technicians who perform all visual field testing, confocal scanning laser ophthalmoscopy, digital photography, pachymetry measurements, and evaluations with the IOLMaster (Carl Zeiss Meditec, Inc., Dublin, CA). We have found this system really improves efficiency.

Mattox: We have also designated people for specific tasks, and they are working alongside us physicians during the clinical day. They get very good at what they do. That allows patients to receive their testing on the same day as their appointment with me. Our optometrists are in a separate system. They do not work within our specialty clinics. We do not use them as technicians or refractionists.

Schuman: This industrialization of medicine works well. My philosophy is that doctors should not be limited in the number of patients they can see by the number of technicians they have.

Mattox: At what point do you decide that you do not have enough people executing a task?

Schuman: When the waiting times get long, because the patients are queued up for testing. Our problem is that there just are not enough qualified people to hire to allow us to catch up with the volume of testing we need to complete.

Reynolds: I am going to come at this issue with a different perspective. I made a transition from a very large academic/private practice to a relatively small practice in which I split my time fairly evenly between glaucoma and general ophthalmology. I am usually in a clinic as the only medical doctor. I have found that, the more I can do myself in this setting, the more efficient it seems that things become. I perform refractions. I am usually just as good or better at refractions than most of my technicians.

I can run 60 patients a day through my clinic with two technicians and one front-office person. To be that efficient, I have to do a great deal more than I did in a large academic setting. While one of my technicians is performing visual field testing, for example, I am checking a patient in and refracting that person.

Heuer: If you had another technician, you could probably see at least three more patients per half-day.

Reynolds: In a practice like mine, it seems that I would have to generate a much higher volume than I currently have in order to justify that, and I am not sure I would even want to.

Lewis: You are the most highly paid employee, so what is the best utilization of your time? Should you have another technician?

Shafranov: You pretty much have to be able to run the whole process yourself. You should at least understand the entire process, from check-in to billing. Then, you can hire and assign people to perform specific tasks that you find to be an inefficient use of your time. For example, conducting visual field testing is a significant waste of a doctor's time. In contrast, performing flash fundus/disc photography through a dilated pupil is not time consuming, and it gives me an immediate high-resolution view of the optic disc.

Moster: There is a fine balance. I require enough technical support to allow me to see efficiently as many patients as I wish to during the day. For example, I often give patients a sample when starting a new drug. For me to leave the room to search for the sample once, let alone 45 times a day, is a terrible waste of my time.

Heuer: One of the things that made a huge difference when we renovated our clinic was that we put in a light-signaling system (Room Status System; Expeditor Systems, Inc., Alpharetta, GA). I used to spend time looking for a technician to find the sample medicine and review the directions for the medication with the patient. Now, I push the button, and a bell sounds. At first, I drove my staff crazy, but the system works.

Moster: The key is not wasting time on repetitive tasks. Moreover, I find it is more efficient to block time for laser treatments just as I do for surgery rather than to bounce back and forth between lasers and returning patients' visits. Obviously, when emergencies occur, those patients are seen in a timely manner, regardless of where we are in the day's schedule. There is no getting around that.

Schuman: Does anybody think that the best use of a physician's time is not face time with the patient?

Myers: I believe that the clinician's role is to spend time with the patient. Face time may not be efficient, but it is crucial. The quality of that interaction is usually how we are judged by our patients. If they do not understand your involvement, your caring, then the art of medicine is lost.

Heuer: One of the problems with EMRs, at least the way I have seen them used in most places, is that doctors now are behind or beside the patient with their heads bent over a keyboard.

Schuman: You want to set it up so you are facing the patient while you are typing and looking at the monitor. Then, you can turn the monitor to show the patient what is on the screen. My point, however, was that the time that patients appreciate the most is when you are paying attention to them and they feel like they are your only concern. The 3 hours taken to gather all of the information you are going to use to make a decision is made up for in the 5 or 10 minutes that you spend talking to them about what they are going to do.

Heuer: During the last weeks of his life, one of the pearls that Douglas Johnson, MD, shared with a young member of the American Glaucoma Society was about exactly how to deal with a patient who needs more time. He said that you are occasionally going to have a patient who needs more time than you have blocked for him. Dr. Johnson said it had never been a problem for him. He would say, "Mr. Jones, your problem is a little more complex than we can deal with right now. If you are willing to come back at 5 o'clock, I will spend as much time as you need to go over that." He found that almost nobody came back at 5 o'clock, but he had met the patient's need when it occurred. That is efficiency.

Schuman: Another technique in terms of communicating with patients is to use a physician extender. Perhaps a scribe or other staff member sees patients with you. You speak with the patients and answer their questions. When it is time for more routine information, the technician can take over. That allows you to leave the room. The patient's needs are still met.

Lewis: Quality time can be just a couple of minutes. The key here is to balance efficiency and caring.

SCHEDULING
Lewis: What is the optimal schedule?

Reynolds: I have been struggling with this area lately because of some logistical issues in my practice. Do the rest of you perform diagnostic testing on the same day as you see patients or on a different day? What are the pluses and minuses of doing it one way or the other?

Mattox: We have historically performed testing on the same day, partly because many of our patients travel a long distance, they do not want to pay for parking again, they do not want to come back on another day, or they want same-day test results. Several years ago, I tried to figure out how long it took for a glaucoma consultation with all of the testing. I created a schedule for myself with 15-minute increments. At first, it actually worked pretty well. The problems hit when the front desk staff tried to sneak in an extra appointment or when a patient presented who had skipped his follow-up visit and now needed a visual field test, because it had been more than a year.

Lewis: I have patients with stable, established glaucoma come back at a certain interval for visual field testing, and they only see a technician. They return 6 months later and see me. This approach will not work for every practice.

Mattox: How do you do the interpretation and get the results back to them?

Lewis: I look at all of the visual fields later, but the test is done.

Reynolds: That is how I do it, too. You bill for the diagnostic test as a separate visit, and you interpret it and put it in context later during review and interpretation. You do not talk to the patient about it until you see him at the follow-up visit. If there is an issue of concern, I reschedule the patient earlier or call him on the phone.

Myers: If you do not have sufficient staff to allow testing and visits on the same day, it is not a convenience you can offer to patients without disrupting the office. If you have a half-day when you do not have a doctor seeing patients but you have extra technicians, then having that as your testing day will work well, if your patients are willing to make separate visits.

At my office, we have built into our scheduling system the visual field test and examination. The timings are set up so that if patients return for a visual field and examination, the timing is different than if they are just there for an IOP check. A new patient, unless a visual field has been forwarded, is always scheduled as a visual field followed by a consultative examination. It is built into the schedule.

Lewis: How many new patients will you see compared with how many follow-up patients in a half-day?

Myers: On a half-day, we have on our template a limit of three new patients. That means I rarely see more than six patients in a full day, except with emergencies. As Dr. Mattox said, you create a perfect system. Then, you go away for a week, somebody calls with an IOP of 41 mm Hg, and he must be seen. We have an emergency add-in that is not supposed to be used until the week before.

Heuer: I think it varies by doctor and practice. I find that the emergency slots are gone 4 weeks ahead of time, so, on the actual day, we are using "double-secret super-emergency spots." We almost ought to go back to the 8- and 1-o'clock slots, just have everyone show up at the clinic as if it were a bus depot. I think we have to try to do less and just spend more time with the patient. Everything is going to become automated. We are going to sit with patients in a room and go over results. I do not know how we will even have time to do the slit-lamp examination.

Moster: We actually had someone clock us, including how much time we spent moving away from the room to answer physicians' phone calls in the middle of the day. We found that telephone calls, visits from sales representatives, signing papers, and the like eroded even the "perfect" schedule.

Myers: We have the receptionist ask the person on the phone, "Is this about a patient that Dr. Myers will be seeing today, or may he call you back at the end of the day?" This approach has helped but has not eliminated the problem.

Moster: I find that my workday may be longer than that of my referring doctors, so responding at the end of the day is often impossible. I take all calls from doctors as they come in and accept new patient "add ons—must see" that cannot be helped. As in Dr. Myers' experience, this can often double the number of new patients in any one session. We have some wiggle room in the template to allow for that, but it often pushes the limits of our system.

Heuer: If you do not talk to a doctor on the phone, you end up playing phone tag.

Schuman: Or, they immediately call the next person on their list.

Heuer: How do you deal with the logistical issues? My patients travel a long way and have to pay for parking, which they hate, because they never pay for parking anywhere else.

Reynolds: Most of my patients undergo diagnostic testing 2 to 3 weeks before I see them when it is necessary. I review the results before I see them. I do these interpretations after regular office hours, usually.

Schuman: Unless you perform no surgery and have no emergencies, you cannot have a perfect schedule. In terms of advance testing, we do it during downtime for the clinic, but we also perform testing remotely. Each of our satellite clinics has the same sort of equipment and the same EHR system that we have in the University of Pittsburgh Medical Center Eye Center. Tests are uploaded and transmitted to our EHR system via the Internet. Patients undergo testing 1 or 2 weeks before their visit.

Reynolds: Here is a big question. Have you contemplated the next step—not actually seeing patients at all? I am referring to practicing glaucoma management in a telemedical format.

Schuman: I am very interested in tele-ophthalmology. In terms of ophthalmic technology, we can do a complete eye examination without ever seeing a patient. Yes, we will miss some very subtle things, such as pathology hiding in the far periphery of the retina, but we can do a fairly comprehensive examination using technicians and technology. A technician can do an intake examination, just like in our offices. Technicians can check IOP with a Goldmann applanation tonometer or a digital tonometer. Anterior-segment OCT will show what the angle looks like. The same camera can take anterior segment photographs and nonmydriatic fundus photographs. Advanced imaging technology can provide information on the optic nerve head and the macula. In 99% of cases, you have all of the information that you need to make a diagnosis and send it with a consultative assessment to the patient's referring doctor.

The good news for referring doctors is they minimize the risk of losing patients, because they never actually see you. Tele-ophthalmology is also more convenient for patients than coming into the city. The big downside is that you do not have face-to-face time with the patient, which is less fulfilling and satisfying for both the doctor and the patient. Additionally, there are problems with billing, because, in Pennsylvania, as in many states, tests have to be ordered by the physician who physically sees the patient.

DEALING WITH INTERRUPTIONS
Lewis: How do you deal with interruptions? At my practice, sales representatives may only see me at certain times of day by appointment.

Schuman: At the University of Pittsburgh Medical Center Eye Center, representatives have to be invited to visit, and they must pass a test before an invitation may be extended. Remarkably, they were not upset with me, because they realized it was a system-wide policy decision. Additionally, we are no longer allowed to give samples to patients unless we do what we were supposed to be doing all along, which is keeping a log of every sample that comes in and to whom each is dispensed.

Moster: We have a rotating designated technician practice-wide who takes calls off the patient-care line. Every phone call is documented, and, if necessary, the chart is made accessible. If the technician is unsure how to answer a question, especially regarding changes in therapy, it is funneled to the appropriate doctor on a written sheet to be answered between patients. The doctor almost never gets on the phone with a patient during the day, yet all questions are answered in a timely manner.

Heuer: I spoke earlier of having a better person do things. My former administrator thought that we ought to have triage nurses, which is a little unusual in ophthalmology. The nurses who run our outpatient surgery area and understand ophthalmology take patients' calls during the day and are able to handle about 90% of them. They bring back the sheet on the remaining 10%, and the doctors make calls between patients or at the end of the day.

Schuman: We also have triage nurses, and the system really works well. Also, every patient who calls is offered an appointment within 72 hours. The appointment may not be with the doctor of his choice; it could be any ophthalmologist in the practice. For true emergencies, patients are connected to the appropriate subspecialty service.

Lewis: Pharmacy renewals are another constant source of interruptions. How do you deal with them?

Heuer: In a hospital setting like mine, we cannot process renewals automatically. Within the glaucoma service, we have a protocol managed by our triage nurses. Patients who have not missed appointments may obtain a year's worth of refills for their glaucoma medications whenever they need them. Someone who has frequently missed appointments or who has not been seen recently will be given a one-time-only 1 month's renewal, but then he must schedule an appointment. One type of medication to be careful about extending refills ad lib for is corticosteroids.

Myers: Our technicians handle renewals. They make sure patients were seen recently, and the on-call physicians have a policy of not refilling medications on weekends when patients' charts are not available. This approach takes a lot of the technicians' time, however, and we are in the process of moving to electronic prescribing. With electronic prescribing, patients identify their preferred pharmacy. Then, rather than call the pharmacy and sit on hold for 10 minutes, technicians click a button on the computer screen, and that submits the refill electronically (Figure 2).

Lewis: Another tip is to encourage patients to get their prescriptions when they are in the office and to have technicians write out the forms for you to sign. Patients are then set for the year. It always bothers me, however, when patients are walking out after their examinations and say, "By the way, can you renew my four glaucoma medications?"

Schuman: EHRs are really helpful for renewals. You can just highlight the medications and click through.

Mattox: It is likely that an electronic prescribing mandate is going to pass before the electronic health mandate does.

Lewis: What are the implications for practicing physicians?

Mattox: There could be a reduction in your payment by a certain percentage if you are not offering electronic prescriptions (see Medicare Offers Incentives for Electronic Prescriptions).

BEARING UP UNDER PRESSURE
Lewis: How do you deal with all of the frustrations of our specialty?

Heuer: First, decide if this is really what you love doing. If not, you probably ought to stop.

Myers: Or, find a way to love it again. Try to figure out what about it is no longer good for you.

Heuer: I think Dr. Myers has something there. Sometimes, doctors are not getting the quality time they went into medicine for. It has become a business. For instance, I find coding impossible. I want to be a physician, not a bean counter, so I concentrate on the positives in the doctor/patient interactions rather than the administrative issues of patient care.

Mattox: I think we are lucky because glaucoma in general is not a rote specialty in which you are doing the same thing over and over again. There is so much variety. Also, I really enjoy being around residents and fellows whom I am teaching daily. That keeps me interested. It is fun to see them get excited (or even depressed) about what we do.

Shafranov: Community doctors observe me on a fairly regular basis. It is fun to teach already practicing ophthalmologists or optometrists how glaucoma is managed, how I make decisions, and how I analyze the tests.

Schuman: Our patients are long term. That is one of the things I love about this specialty. I like building a relationship with patients and seeing them over a course of years.

Moster: I have been in practice for 24 years now. It has been a tremendously rewarding experience helping people retain their sight. Unfortunately, the business aspect can be very challenging, but, as a whole, being a glaucoma specialist—even with all of its problems—has been totally fulfilling.

Myers: I really enjoy the fact that I share life events with my patients—good and bad.

Shafranov: For me, a key was changing my environment. I found full-time academic life too inflexible, so I am now building my own practice and finding it to be a gratifying experience.

Lewis: The challenges of a glaucoma practice are real although not unique. As we strive for efficiency, maintaining quality care is essential. This panel of subspecialists has offered some unique insights into achieving both goals as we continue down the path of advancing technology.

Richard A. Lewis, MD, moderator, is Chief Medical Editor of Glaucoma Today and is in private practice in Sacramento, California. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Lewis may be reached at (916) 649-1515; rlewiseyemd@yahoo.com.

Dale K. Heuer, MD, is Professor and Chair of Ophthalmology at the Medical College of Wisconsin in Milwaukee. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Heuer may be reached at (414) 456-7915; dheuer@mcw.edu.

Cynthia Mattox, MD, is Vice Chair, Ophthalmology, at the Tufts University School of Medicine and is Director of the Glaucoma and Cataract Service at the New England Eye Center in Boston. She acknowledged no financial interest in the products or companies mentioned herein. Dr. Mattox may be reached at (617) 636-8108; cmattox@tufts-nemc.org.

Marlene R. Moster, MD, is Professor of Ophthalmology at the Thomas Jefferson Medical College and is an attending surgeon at Wills Eye Institute in Philadelphia. She acknowledged no financial interest in the products or companies mentioned herein. Dr. Moster may be reached at (484) 434-2717; moster@willsglaucoma.org.

Jonathan S. Myers, MD, is an associate attending surgeon at Wills Eye Institute and is Assistant Professor of Ophthalmology at Thomas Jefferson Medical College in Philadelphia. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Myers may be reached at (215) 928-3197; myers@willsglaucoma.org.

Adam Reynolds, MD, is in private practice in Boise, Idaho. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Reynolds may be reached at (208) 608-2476; adamreynolds@cableone.net.

Joel S. Schuman, MD, is the Eye and Ear Foundation Professor and Chairman of Ophthalmology at the Eye and Ear Institute of the University of Pittsburgh Medical Center Eye Center, and he is Professor of Bioengineering at the University of Pittsburgh School of Engineering. He has received research funding, research equipment, honoraria, and/or payment of travel expenses from Carl Zeiss Meditec, Inc. Dr. Schuman may be reached at (412) 647-2205; schumanjs@upmc.edu.

George Shafranov, MD, is in private practice in Guilford, Connecticut. He acknowledged no financial interest in the products or companies mentioned herein. Dr. Shafranov may be reached at (203) 458-1221; shafranov@glaucomacaremd.com.