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Drs. Fine, Hoffman & Sims Opthalmologists in Eugene Oregon

The Fine View: Winter 2008


From Pen to Screen
By Dr. I. Howard Fine
Dr. I. Howard Fine

For the past two years, our practice, along with our entire building, has been involved in studying, evaluating, and finally, implementing a transition to electronic medical records (EMR). As you may be aware from the media, in the medical field, the question of EMR (or electronic health records) is no longer a matter of “if”, but of “when”.

EMR are computer-based medical patient charts that are, essentially, paperless. Our process took 18 months of evaluating existing systems, and then modifying the system we chose, Centricity, by General Electric (GE). It has taken us the past six months to transition from paper charts to EMR in our office.

Paper charts are a thing of the past!

As of this newsletter, 100 percent of our patient visits are now electronically documented. While there is still an ongoing task of information transference as established patients return to our practice, we are realizing many efficiencies now. This was a daunting process and it took a lot of effort and living with some frustration for all concerned. However, what results with EMR is a much more complete and legible chart. It allows for multiple people to access the same chart simultaneously, as well as instantly, which has proven to be a large time saver for our medical records department as well as every staff member.

All exam rooms are equipped with
computer terminals to access EMR.

We have realized many positive workflow changes as a result of our conversion. EMR is much more efficient in a variety of ways, including the ease with which the chart can be accessed. One doesn’t have to wait for our medical records staff to retrieve the chart from the front office and bring it back to the examining room, or a technician on the telephone. It is much easier to compare historical data using EMR, instead of shuffling through multiple pages of a paper chart; data can be presented in flow sheet and graph form. Also there tends to be a much more complete reporting of the discussion between the physician and patient. There is great ease in prescribing; the prescription can go from the examination room, while the patient is having their appointment, directly to the patient’s pharmacy via facsimile, with the patient and pharmacy not requiring a paper prescription.

It is easier to exchange information between the offices of patients’ different physicians, compared to the utilization of paper charts. Frequently, in the past, paper charts were transmitted between physicians in summary form, or only after copying large volumes of paper and presenting the second physician’s office with the daunting task of having to decipher the chart, sometimes with poor legibility. EMR provides for quick and easy exchange with other physicians’ offices either by electronic faxing or quickly printing the patient record.

There is also better security, redundancy, and back-up of data, in addition to protection of patient confidentiality with EMR. One must have an authorized and secure password in order to enter a patient medical record. It is therefore less likely to be open to scrutiny by unauthorized personnel. In addition, due to our back-up protocol, patient data in EMR is far less likely to be accidentally lost or misplaced than with a paper chart.

Sue, one of our ophthalmic technicians
starting a patient visit in EMR.

Finally, there is great access to the chart from remote locations so that the on-call physician can answer a call from a patient in his home, bring up the patient’s chart, and give very accurate and precise recommendations, and have a record of that, which goes directly into the chart at the time it takes place.

All in all, while it is a difficult process to perform a conversion, we believe our significant investment in time,effort and expense will lead to more complete and accessible medical records, greater efficiency in medical offices. [ top ]

Risk and Reward: Challenging Yourself, Trusting Others
By Mark Packer, M.D.

Mark Packer, M.D

Nearly there, I had to rest. My right foot was planted 40 feet above the ground on the top of a very high pole. My right knee was fully flexed against my chest. My left foot supported my weight on a small protuberance nailed to the side of the pole just below the top. Both my hands gripped the top of the pole around the edge. I gathered my strength to stand up on the top of the pole as it swayed and wobbled. I thought about all the times I had stood up before, and all the effort I had ever asked of my right thigh. I knew that as I stood up I would have to let go with my hands. There would be nothing to hold on to. I would have to rely on my feet alone to keep me balanced.

Dr. Packer standing atop the
“Pamper Pole” about to jump.

I took a moment to rest and allow the wobbling of the pole to slow a bit as I got my breath back under control. I was in the woods atop Mount Pleasant, New York, at the Hoffman Challenge Course of Cornell University. I had almost climbed to the top of a “Pamper Pole.” This physical and mental challenge is “named for the popular diaper (a piece of protection that par t ici - pants claim is every bit as appropriate as a harness).”1 My son, Jefferson (age 16), and I were participating in the Cornell Adult University Summer Outdoor Adventure Program for Parents and Teens (some readers may have met Jefferson earlier this summer when he served as a volunteer at Oregon Eye Surgery Center). Jefferson stood on the ground somewhere below me, but my eyes sought out the gaze of Todd Miner, our instructor, executive director of Cornell Outdoor Education and, most important at that moment, the person who held in his hands the other end of the rope connected to the harness I wore.2 As I waited for strength to stand I glanced up at the trapeze hanging far out in front of me. My instructions were to climb the pole, jump from the top and try to grab the trapeze. All I had to do now was stand up. Standing up isn’t hard, I told myself. I do it hundreds of times a day. I took a very deep breath and pushed as hard as I could with my right thigh. Somehow, suddenly, I was standing (Figure 1).

I felt a rush of achievement, success and confidence. The hard part was over. I looked out in front of me at the trapeze. I waited just a second to appreciate again that I was standing on the top, that I had made it. I took a few more breaths, glanced down at Todd and then gathered myself together for one final effort. I jumped, pushing off as high and as far forward as I could, launching my body out into nothing but open space. For a moment I flew, and then I felt the harness rope go taut and catch my weight. I had missed the trapeze but it didn’t matter at all. I had conquered my fear, proved my strength and endurance, demonstrated my trust, understood the interdependence of life on earth and just for a second glimpsed my place in the universe. I could not have been happier.

Dr. Packer and his son, Jef, crossing the Burma Bridge with their eyes closed.

There were other challenges that day. My son and I crossed the Burma Bridge from opposite directions – with our eyes closed. (Figure 2) Getting around each other in the middle was the hard part. We each flew down the zip line and experienced the exhilaration of the flying squirrel, a game in which a team runs forward and lifts you rapidly up into the air. But once I had mastered the “Pamper Pole” I knew nothing could stand in my way – the rest was a piece of cake! I experienced and learned a lot about myself and my son that day and during the full week of the program. I already knew that Jefferson was an accomplished rock climber, but I didn’t know that he could be a leader among his peers. It made me proud to be able to share that with him. About myself, I realized that I am more courageous and more capable than I sometimes know. After all, I made it up the “Pamper Pole”, and I didn’t even need a diaper!

Life consists of one challenge after another. It seems sometimes we can never win, or at least not for long. This summer I learned that I have the ability, both physical and mental, to climb a 40 foot pole and jump off into space with only trust in the design of the harness and confidence in the person holding the other end of the rope to save my life. I know what it means to trust, and I want you to know that you can feel confident entrusting me with your sight. [ top ]

Customizing Refractive Surgery for the Individual
By Richard S. Hoffman, MD

Richard S. Hoffman, M.D.

Refractive surgery is the act of reducing or eliminating the refractive errors of the eye using implants or altering the power of the cornea with lasers. Nearsightedness, far-sightedness, astigmatism, and presbyopia (the need for reading glasses or bifocals over the age of 40) can be corrected with a number of different refractive surgery modalities. In our practice, we offer an array of different refractive procedures and try to customize the right procedure for each patient’s refractive error, age, and individual needs and expectations.

For patients under the age of 40, mild to moderate refractive errors can be easily addressed by changing the shape of the cornea with an excimer laser. These procedures are termed LASIK (laser-assisted in-situ keratomileusis) or PRK (photorefractive keratomileusis). When patients are over the age of 40, LASIK and PRK can still be performed. However, patients will need reading glasses for near work unless they leave one of their eyes with some nearsightedness. This is a condition referred to as monovision (one eye for near and one eye for distance). After several weeks to months of adaptation, the majority of patients will become comfortable with monovision.

For extreme amounts of nearsightedness, reshaping the cornea with an excimer laser is not feasible. These patients are excellent candidates for the Implantable Collamer Lens (ICL). The ICL is a soft, foldable, biocompatible lens – similar to a contact lens – that is implanted into the eye. It rests on top of the eye’s natural lens and never needs to be removed or cleaned. It is a wonderful technology and has offered many of our patients, who were not candidates for LASIK, the possibility of achieving excellent distance vision without the need for glasses.

Patients who are over the age of 40 and have large amounts of farsightedness or nearsightedness are good candidates for refractive lens exchange (RLE). With a RLE, the natural crystalline lens is removed from the eye and replaced with either an accommodating intraocular lens (IOL) (crystalens) or a multifocal IOL (ReZoom™ or ReStor™ lens). Each lens has its advantages and disadvantages and by evaluating each patient’s needs and expectations, the proper RLE lens or combination of lenses can be customized for the individual. As patients who desire refractive surgery are increasing in age and starting to develop small degrees of cataract (lens hardening), the appropriateness of performing a RLE as the refractive procedure increases. In these patients, a RLE both eliminates the progression of cataract and the refractive error. Accommodating and multifocal IOLs are designed to eliminate nearsightedness and farsightedness in addition to aiding up-close vision so that patients are much less dependent or completely independent of the need for reading glasses. If everything goes as planned, it is possible that a patient undergoing a RLE may never need glasses for the remainder of their lives.

We have had extensive experience utilizing a multitude of refractive surgery modalities to correct refractive errors. One procedure is not the ideal technique for every patient. The saying goes that “if you are a hammer, everything looks like a nail”. In our practice, we like to think of ourselves as an extensive toolbox with a wide-range of tools that can be customized for each individual patient. In this way, we can optimize the correct procedure for our patients. [ top ]

Honors and Awards
By Sherrie Brunell, MS

Dr. Fine was thrilled to be appointed to the board of directors for the Pan- American Association of Ophthalmology (PAAO). The PAAO “is a non-profit organization whose mission is the continuing education of ophthalmologists, the prevention of blindness, and the promotion of scientific and cultural exchange among ophthalmologists in the Western Hemisphere and the world.”

Drs. Fine and Packer were delighted to be named two of the country’s top ophthalmologists by the Consumers’ Research Council of America. Drs. Fine and Packer were honored to be listed in the 2008 edition of the Best Doctors in America. Dr. Packer was also recently named an appointed member of the editorial advisory panel for the Expert Review of Ophthalmology.

In September, our entire front office team, Brandy Hunt, Carolyn Ketch, Ricki Shipway, Sharon Clatte-Seiler, Joan Phillips, Michelle Ryan, and Sherrie Brunell, completed a three-exam course to become Certified Practice Management Specialists (CPMS). This means that each member of the front office staff is proficient with our computerized practice management system, and should be capable of assisting any patient in a variety of tasks including making appointments, inputting patient information, and fielding insurancerelated questions.

Belinda Baldwin, Laurie Brown, Peggy Coffman, Jon Cassidy, Amber Ambrozaitis, Joan Phillips, Sue Stuhr and Patty Kimbell earned their Ophthalmic Coding Specialist (OCS) certification this year. This means that they understand how the various elements of an ophthalmic examination are coded by the medical community, and the appropriate methods for proper insurance billing.

Congratulations to all! [ top ]

New Fellow

Dr. Fabris with Dr. Fine at the Oregon coast.

Those of you who visited the clinic from mid-September through early November had the opportunity to meet a special fellow-observer, Dr. Caroline Fabris. Dr. Fabris is an ophthalmologist practicing in Brazil who came to observe Drs. Fine, Hoffman and Packer in the clinic and surgery. Not only is she an extremely bright and talented physician and surgeon, she is a kind and generous person who brings joy to all. We miss you already, Dr. Fabris!   [  top ]

New Faces

We are happy to welcome Aubree to our practice. She has optometric practice experience, where she was a referral and benefits coordinator. She enjoys all outdoor activities and spending time with friends and family. She is very excited to be working for such a unique and groundbreaking practice. [ top ]


New Lens Yields Great Results!
After years of glasses, contacts, and finally cataracts, I was excited to be accepted into the clinical evaluation of the Tecnis Multifocal Intraocular Lens, Model ZM900. The procedure on each eye was quick and painless, and by the next morning my vision was 20/20. I am now truly able to see up close, far away, and everything in between, with NO GLASSES. Driving, reading books and working on the computer are again enjoyable.

Dr. Packer was great and his entire surgical staff set me at ease and made me feel relaxed. Their sense of humor relieved any tension on my part. I would highly recommend this procedure for anyone considering it. --Marilyn Fast   [ top ]

Mellow Experience
Within days my vision was really good. The LASIK surgery process was very easy. In fact it was sort of a “mellow experience”.

I am so happy not to deal with contacts and solutions anymore. What a hassle. When I’m in the shower I can identify the different shampoo and conditioner bottles. Before I had to grab a bottle and hold it a few inches away to read it.

I had the surgery in February of last year with Dr. Fine, and I find myself still reaching for my glasses when waking up in the mornings. I still haven’t broken that habit. [ top ]

Drs. Fine, Hoffman, & Packer Travel/Teaching Schedule —

January through June 2007

January 15-19: Kauai, HI
Dr. Packer and Laurie Brown, COMT, COE, attended the Royal Hawaiian Eye Meeting. Dr. Packer gave presentations on Customizing Selection of Wavefront Intraocular Lenses and Cataract Surgery in the Age of Presbyopia Correction. Laurie Brown spoke at the administrators’ meeting regarding our practice’s recent experience converting to electronic medical records, and incorporating new technology lens implants into an ophthalmology practice.

January 18-19: Seattle, WA
Dr. Fine was an invited guest speaker at the monthly meeting of the Washington Academy of Eye Physicians and Surgeons. In addition to lecturing on the new practice patterns in ophthalmology and refractive lens exchange, Dr. Fine was a guest professor and participated in resident training.

January 24-26: Park City, UT
Dr. Fine was a prolific speaker at the annual Park City Symposium on New Techniques and Controversies in Cataract Surgery. Dr. Fine spoke on such varied topics as clear corneal incisions as demonstrated by optical coherence tomography, microincision cataract surgery, and mixing and matching IOLs.

February 2-4: Hawaii
Dr. Hoffman was a guest speaker at the 23rd Annual Hawaii Ophthalmological Spring Update. He lectured on new phacoemulsification technology, refractive lens exchange, difficult & challenging cases in phacoemulsification, and management of decentered intraocular lenses.

March 8-10: Boston, MA
Dr. Hoffman was an invited guest of honor at the meeting of the New England Ophthalmological Society (NEOS). Dr. Hoffman lectured on bimanual phacoemulsification instrumentation and surgical approaches for difficult & challenging cases.

March 22-24: Kyoto, Japan
Dr. Fine participated in the biannual retreat of the International Intraocular Implant Club (IIIC). Dr. Fine gave a presentation on refractive multifocal IOLs and moderated a session on advances in intraocular lens implantation. Dr. Fine was particularly honored as he is now the president-elect of the IIIC.

March 30-31: Seattle, WA
Dr. Packer was an invited guest speaker at the Washington Academy of Eye Physicians & Surgeons Annual Meeting. Dr. Packer gave four presentations, covering refractive cataract surgery, challenging cases, All exam rooms are equipped with computer terminals to access EMR. astigmatism management, and next generation intraocular lens technology.

April 18-20: Washington, DC
Dr. Packer attended the annual American Academy of Ophthalmology (AAO) Mid-Year Forum as the representative of the American Society of Cataract and Refractive Surgery. He met with Rep. Peter DeFazio and other congressional leaders to discuss the future of the Medicare program and the quality of medical care in the United States.

April 28-May 2: San Diego, CA
Drs. Fine, Hoffman, and Packer were a strong presence at the annual meeting the American Society of Cataract and Refractive Surgery. All three gave multiple presentations on topics such as refractive lens exchange, accommodative IOLs, the new DSAEK procedure, and bimanual microincision phacoemulsification. Laurie Brown, COMT, COE, also gave a presentation on how to successfully implement new technology intraocular lenses into your practice. Dr. Fine was particularly honored to give a presentation in the Innovators Session. He spoke on the profiles of clear corneal incisions as imaged by optical coherence tomography. Dr. Packer presided at the Clinical Carry Out, a wrap up finale featuring high profile surgeons discussing the latest developments in a roundtable format.

May 25-26: Vancouver, Canada
Dr. Packer was an invited guest speaker at the 1st Annual Canadian Society of Cataract & Refractive Surgery Western Canada Meeting (CSCRS). Dr. Packer provided insight into micro incision cataract surgery and aspheric intraocular lens technology.

June 9-12: Vienna, Austria
Dr. Fine was an invited keynote lecturer at the joint congress of the European Society of Ophthalmology (SOE) and the American Academy of Ophthalmology (AAO). Dr. Fine’s keynote lecture addressed the use of bimanual microincision phacoemulsification in difficult and challenging cases. In addition to his keynote lecture, Dr. Fine also spoke in several courses on topics such as refractive lens exchange and the management of intraoperative floppy iris syndrome.

June 14-15: Bordeaux, France
Dr. Fine was honored to perform two live cataract surgeries at the University of Bordeaux, School of Medicine. The event was sponsored by Advanced Medical Optics, and the University of Bordeaux, School of Medicine, Professor Joseph Colin, Chair.

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