Optos a breakthrough in diagnostic imaging for the ophthalmic practice
Optos: A Breakthrough in Diagnostic Imaging for the Ophthalmic Practice 8 Shareef Mahdavi • SM2 Strategic • Pleasanton, CA 7Optos (Marlborough, MA) has built an ophthalmic technology from the physician and/or photographer, allowing thearound widefield diagnostic imaging of the fundus. With over physician to focus energy on interpreting data rather3,800 units installed worldwide, the Company’s devices have than collecting it. The image quality is described as beingbeen used to capture over 15 million patient images to date. more than sufficient to meet the needs of a busy oph-With the recent introduction of advanced risk based imaging, the thalmology practice.Company has begun commercializing its technology to ophthal-mology to complement its strong presence in optometry. New and better information SM2 Strategic was asked to conduct interviews with a These physicians are clear that the Optos device isgroup of ophthalmic surgeons who have incorporated the allowing them to detect pathology that they would oth-technology in their practices to better understand the utility erwise miss using an indirect during the exam or taking aof Optos in an MD practice. Further, the purpose of these standard fundus image out to 30 degrees. This has led tointerviews is to help ophthalmologists understand how earlier diagnosis and treatment of eye disease and greaterthis imaging technology differs from traditional methods of preservation of vision.capturing data about the fundus.Finally, we wish to describe how Interaction with patientsthe Optos device is influencing Optos Experience Patients are better able tophysician and patient behavior. understand their eye conditions The following pages contain Patient-Centric Device Design because they can visualize whatprofiles from interviews with five is happening by looking at theirsurgeons who represent an array Clinical and Experiential optomap® alongside their doc-of ophthalmic practice types — Benefits tor. The optomap serves to helpsolo vs. group, comprehensive vs. validate their complaint. This hasspecialty — as well as diversity in significantly impacted the quality Impact on Impact ongeography around the US. The of the discussion and the ability Practice Practiceprofiles describe how the technol- Behavior Economics to gain compliance with recom-ogy fits into the unique setting of mendations.each practice. A framework for defining the experience of Optos own- Better business modelership is shown in the figure above; six common attributes Because the company charges on a per-use basis rathercollectively described by these physicians underscore the than the traditional capital equipment sale, customerssuccess this technology has achieved in market adoption. know the company will never abandon them or their interests. If the device is down, the company and the prac-Patient-centric design tice suffer, which aligns the interests of both parties. The Optos platform was developed with the patientin mind and has succeeded in capturing high-quality ultra Patient acceptance of the feewidefield fundus images without the need for dilation. The When used with general exams, physicians are charg-data output has also been designed to facilitate the discus- ing a fee directly to the patient for the optomap retinalsion between doctor and patient, both in form and content. exam. Doctors are finding they don’t have to “hard sell” patients but simply explain the benefits of the procedure.Consistent and reliable data capture A very low percentage of patients decline; those who Digitizing and recording the fundus image has shifted have the test find high value in knowing what the datathe burden of collecting and recording the image away mean for their eye health.
While Dr. John Kitchens gain a wide field view by performing “click, move cam- had heard about Optos era, click, move camera” with a traditional fundus imag- during his residency and fel- ing device. lowship, it was only when As a result, Dr. Kitchens is able to treat earlier, not a colleague showed him the only with the primary eye but in the fellow eye as well, device firsthand that he felt which “looks good upon examination but then I discover its potential. “Up until then, issues revealed by Optos that can also be treated in a tar- my impression had been geted manner.” For example, when imaging for Uveitis, John Kitchens, MD that the technology was he says he commonly finds peripheral vascular leakage, an Retina Associates of Kentucky an OD screening device; I indication of underlying inflammation that is persistently Lexington, KY was amazed to see fundus active but not clinically apparent on exam or with stan- Years in Practice: 4 images just like traditional dard angiography. This may result in progressive damage Focus: Retina fluorescein angiography.” and eventual vision loss if not properly addressed early Having joined an and in its entirety. Drs on Staff: 4 MDs already busy group of 3 ret- “Optos has really educated me about disease and the Experience with Optos: 1 year ina specialists, Dr. Kitchens impact of my treatment because I can see it, especially acquired the Optos device with laser therapy,” noted Dr. Kitchens. With the opto-and says it has fundamentally changed the way he prac- map images, he can use the laser “in the same manner atices medicine both diagnostically and therapeutically. chef adds salt to a recipe,” allowing for optimal dosage As a diagnostic, the P200MA provided images that without over-treating the patient. His usage of the devicewere not distorted and can be accurately obtained. “It has created a complete feedback loop to patients. “Thiswould take a novice photographer six months or more of is where Optos really shines, as my patients can literallytraining to begin to acquire the quality of images that are ‘see’ the results of their treatment.”available immediately from the Optos system” noted Dr. From an economic standpoint, Dr. Kitchens says theKitchens. His practice has adopted the Optos as their pri- additional information he gets from Optos is worth themary fundus camera, achieving much greater consistency extra cost relative to standard fundus photography. He’sthan the traditional method of relying on the skill of fun- taking more images now than with FA because theydus photographers. “With photographer variability taken help him more. “Where OCT tells me what is happen-out of the equation, the practice is achieving consistently ing, Optos tells me why it’s happening,” commentedbetter images, leading to more effective and efficient treat- Dr. Kitchens in describing how these two technologiesment of patients. work together. With OCT helping explain the story, Dr. Second, Dr. Kitchens realized that what he was see- Kitchens says he has the data to start acting pre-emptively,ing in clinic (via indirect ophthalmoscopy and 90 diopter which has helped him treat his patients more effectively.fundus examination) was “grossly underestimating” whatwas happening inside the eye. “As a retina specialist, I Complementary Technologiesam highly sensitive to changes such as macular edema indiabetic retinopathy patients. The Optos device is allow- for Retinal Imaginging me to pick up subtle peripheral changes much earlier OCT Optosthan before.” Noting that most disease starts in the mid- (Ocular Coherence Tomography) (Wide Field Imaging)periphery, having a single simultaneous photo out to 200 • View of Macula • View of entire Retina °rees (as compared with the 30 or 50 degree view given Vasculatureby traditional flourescien angiograpy) has given him a • Presence of a clinical finding • Reasons for the finding (what is occurring) (why it’s occuring)jump-start in developing a therapeutic plan. “I’m learning • Centrally-based disease • Macular & mid-peripheral diseasea lot more about what happens in peoples’ eyes than I did – AMD – Retinal Holes/epiretinal membrane – Diabetic Retinopathy – Uveitispreviously.” He also added that from an image capture • Anatomical understanding • Physiological understandingstandpoint, the single simultaneous photo provided byOptos is far superior and more reliable than attempting to Source: John Kitchens, MD
Don Serafano, MD has 2008 being a higher revenue year than 2007. been a fixture in the Dr. Serafano first became aware of the Optos device south bay section of Los as a result of mentions by patients coming from refer- Angeles, serving the com- ring optometrists and his in-house Optometrist suggest- munity both as a cataract ing they add it to the practice. He decided to involve the surgeon and with a laser entire staff in developing the process of offering this to center to perform LASIK. patients since it would require an out-of-pocket expen- Having used Optos P200 diture. While his technicians became fluent in describing Donald Serafano, MD in his practice for 6 years, the benefits of a non-dilated fundus exam, they don’t Comprehensive Ophthalmology Dr. Serafano believes it try to “sell” the test to patients but rather announce it Los Alamitos, CA has created a new level of using a “matter-of-fact” tone. This training has paid off Years in Practice: 30 trust in the doctor-patient in other ways for the practice. “Our success in offering Focus: Cataract, Refractive and relationship. “The patient Optos to all patients who come in really made it easy General Care feels validated when they for us once premium IOLs became available,” noted Dr. Drs on Staff: 4 MDs, 1 OD come to see me,” explained Serafano, whose practice enjoys a 35% conversion rate Experience with Optos: 6 yrs Dr. Serafano. “This device of patients choosing to pay more for premium IOL tech- authenticates their com- nology.plaint.” Indeed, what began as an optional screening tool As good as the technology is, Dr. Serafano cautions histhat was offered to patients has now become a mainstay colleagues to be careful and not let Optos substitute forin the practice. the exam. Nor does he see it as a replacement for other For years, he examined the fundus using indirect oph- high technology devices such as HRT or OCT, whichthalmoscopy and then drew a picture he could refer to he believes are better suited to foveal analysis includingin future exams. The digital capture by the Optos device assessing cup to disc ratio for glaucoma suspects.gives him a landmark for comparison which he believes The Optos device fits in well with his practice andis far superior to his drawings and elevates the level of his personality: “Because I enjoy people, Optos affordsclinical care and diagnosis he is providing. As important me a great conversation with the patient,” concluded Dr.is the response he is getting: “Patients love it and are fas- Serafano, who recognizes the value of putting patientscinated by seeing their retina and the changes I can point ‘on stage.’ “By giving them data and explaining it inout that have occurred between office visits.” There is ways that make sense to them that they can now visual-a ripple effect that also occurs once the patient leaves. ize, my patients take their eye care more seriously and“I get to send them out with a ‘story’ about their visual feel as if I’m their advocate. I really like that role.”complaint that they now have and can use when theirfamily asks, ‘what did the doctor say?’” Dr. Serafano firmly believes that Optos technologyhas helped with patient retention, a vital component of Summary of Experientialthe general ophthalmology practice. Once patients haveexperienced the ease of the Optos exam and the digi- Benefitstal image up on the viewing screen in the exam room,they have a greater sense of connection to the practice Patient Physicianand greater likelihood to schedule and come in for their • Dilation neutral • Less skill requiredannual exam. “Patients traditionally return to their (vs.retinal photographer) • Can view imagesame doctor because he has the records on file. This is • Focus on interpreting • Can see results of treatment data vs. collecting datathat same concept to a much higher degree,” added Dr. • Validation of complaint(s) • Conversation starterSerafano. With a fee of $45 billed directly to the patient, • Greater understanding • Practice builderthe revenue from the Optos fundus exam has improved of eye healthcash flow, especially in periods when medicare payments • Patient retentionare delayed. And the revenue contributed significantly to
Dr. George Waring has been both to get a look at the fundus and then to perform a a pioneer in refractive sur- cycloplegic refraction as a double-check on their mani- gery, helping establish the fest. “Nobody operates on a cycloplegic refraction unless science for re-shaping the we’re dealing with a young hyperope,” he remarked. cornea as a primary inves- “We triple check our manifest and use the Optos to give tigator for the PERK study us the fundus image we need.” As a result, he feels the as well as clinical stud- Optos device allows the physician to responsibly exam- ies on excimer lasers. His ine the fundus with less time and effort. George Waring, MD practice is equally divided From a business perspective, Dr. Waring has made the InView Vision between refractive surgery Optos test part of his refractive surgery global fee. When Atlanta, GA on the lens and on the cor- patients have been to several other laser centers and then Years in Practice: 35 nea. As a surgeon who has come in for a consultation, they indicate a strong Focus: Anterior Segment prided himself on utilizing appreciation for both the technology as well as the single advanced technology with fee approach. “Optos helps us convert patient interest as Drs on Staff: Solo Practice patients, the Optos P200 part of the whole experience,” added Dr. Waring. Experience with Optos: 5 yrs has become highly valuable In addition, Dr. Waring performs regular eye examsclinically as well as from a business perspective. and bundles the charge for Optos into the overall exam Using the optomap as a pre-surgical screening tool, Dr. fee, with little resistance from patients. The optomap,Waring makes the digital fundus image a cornerstone of which patients get to keep a copy of, gives every patientthe refractive consultation, noting that it brings a “wow” “bragging rights” back at their office where they canfactor to the pre-operative experience. Prior to Optos, he show colleagues a picture of the inside of their eye. Thiswould routinely dilate the pupil and then perform binocu- serves as a form of “brand extension” for Dr. Waringlar (BIO) indirect ophthalmoscopy. back into the community.“This requires the physician’s brain to record the image Indeed, Dr. Waring’s experience demonstrates that theand then translate that to paper; the Optos P200 lets the Optos device serves multiple purposes, both as an effec-computer record digitally, allowing the physician to con- tive screening tool as well a tool that enhances the over-centrate his effort on interpreting (rather than recording) all patient experience. These elements meld well togetherwhat he sees. This is a big advance,” said Dr. Waring. and have become essential as part of the “medical retail” Optos has also allowed Dr. Waring to challenge long- environment that has emerged with the development ofheld assumptions about dilating the pupil for a refrac- refractive surgery.tive exam. He notes that surgeons do this habitually, PRACTICE ECONOM ICS Revenue Impact of Optos Different Optos models allow for increasing AVERAGE NUMBER OF OPTOMAPS PER MONTH Estimated imaging capabilities Basic Advanced Fluorescein Fee Per Annual Physician Screening Imaging Angiography Patient Revenue 9 Basic Screening 9 Advanced Imaging Serafano 141 $45 $76,000 9 Fluorescein Angiography u Each model is offered with a monthly lease plan Henderson 158 86 $37 $109,000 that includes service, upgrades and a specified number of images (minimum per month) Kitchens 27 47 $58-208* $130,000 u Images above the minimum are billed to Waring 171 Bundled N/A the practice u The cost per image decreases as the monthly Neatrour 239 177 $49 $244,000 volume commitment increases u Gross margin (revenue less cost to perform) *Reimbursed by third party insurance/medicare ranges from 40-70%, depending on patient fee charged and number of tests performed
Dr. Tom Henderson has a helps solve patient complaints, this time of a 10 year busy solo ophthalmology old twin complaining of headaches for several weeks. practice in Austin, Texas A quick Optos photo taken of the child revealed an and typically sees 40-50 elevated optic nerve head as a result of an impinging patients per day, something tumor. Taking the same photos of the twin’s sibling (who he considers a real privi- was normal) helped reinforce the gravity of their remark- lege. His outlook was put ably stoic childs situation to the parents. This lead to to the test several decades an immediate trip to the emergency room. The child had Thomas Henderson, MD into his career; the practice surgery and a full recovery following complete resection Eye Clinic of Austin was nearly decimated as a of a benign cystic astrocytoma. Austin, TX result of joining a physi- When it comes to revenue and profitability, Dr. Years in Practice: 30 cian practice management Henderson acknowledges that Optos is profitable, yet he Focus: Cataract, Refractive and group, leaving him looking views this as a bonus rather than a requirement. “There General Care for ways to provide better is a misconception that this is simply a ‘money making Drs on Staff: Solo Practice service and income to the device,’” he noted. “Its real benefit is in enabling me to practice. The Optos P200C document pathology better and find things I might other- Experience with Optos: 4 yrs filled that bill, and today wise have missed.”he uses the device primarily to follow known pathology As illustrated in the two case examples, the Optos(80%) and secondarily as a screening tool during the device has significantly impacted how he interacts withregular eye exam (20%). patients. “By showing, not telling, them what I see, I can “There was no good way to document the inside of involve my patients deeper in the therapeutic optionsthe eye until Optos,” claims Dr. Henderson. The ability before we decide a course of action.”to document pathology without having to dilate the eye As a result, Dr. Henderson uses this 5-10 times perhas been key to (re)building his practice. “I’m able to day and instructs staff never to push this on those com-explain to patients what I’m seeing,” which has enhanced ing in for their regular exam. “It’s a convenience, and notboth his credibility as well as the patient’s understanding. everyone needs it every year.” But for those who do, it’s“The Optos images have immensely improved patient proven to be a true asset in the clinical practice.education and compliance,” he added. “This breaks the‘disbelief barrier,’ where patients think, ‘the doctor is justtelling me something that’s not important.’” Indeed, hebelieves there is much higher compliance with his recom-mendations, especially with glaucoma patients. Of concern with any imaging technology is the abil-ity to accurately distinguish pathological change fromartifact. “I see things on the optomap that I don’t see onindirect (ophthalmoscopy), which gives this device a lot Summary of Clinical Benefitsof value.” Referrals to retina specialists have rarely comeback as a false alarm. To the contrary, Dr. Henderson • Dilation neutralrelated a case example of a patient he diagnosed with • 200˚ wide field-of-viewmelanoma along the superior arcade and sent to theretina specialist, who then sent the patient to a university • Digital documentation of retina and ability to have objective reference pointssetting for removal of a tumor. Following treatment andreturn, Dr. Henderson was able to re-photograph and • Earlier detection of pathologydocument that approximately one-quarter of that tumor • Education about disease progressionhad not been removed during TPTT (transpupillary ther- • Improved patient compliance with recommendationsmotherapy). Another case study underscores how the Optos device