Ophthalmic medical personnel are classified as allied health personnel and are defined as individuals with training and responsibilities that support, supplement, and assist physicians, including ophthalmologists and other health professionals providing patient care. Ophthalmic medical personnel include, ophthalmic assistants, ophthalmic technicians, ophthalmic medical technologists, refractionists, orthoptists, optometric assistants, opticians, contact lens technicians, ophthalmic nurses, ophthalmic photographers, and others. Other allied health occupations include medical assistants, dental assistants, radiology technicians, and sonographers. Recently, to standardize the classification of allied healthcare workers globally, the World Health Organization (WHO) established a classification of the eye care profession: allied ophthalmic personnel (AOP).
As vital members of the eye care team, AOP assist the ophthalmologist in providing quality care by gathering patient information. AOP perform tasks and testing under the direct supervision of an ophthalmologist, licensed to practice medicine and surgery. Governments may require licensure or certification, or certification of AOP may be voluntary. This chapter focuses primarily on the scope of practice of AOP who ophthalmic assistants, technicians, and medical technologists are.
Defining scope of practice
Various governmental agencies regulate physicians and their scope of practice, as well as the functions and procedures they can delegate to others under their supervision. The range of responsibilities and functions performed by AOP, as dictated by laws and regulations, and as specified by ophthalmologists, may be considered AOP’s “scope of practice.” Scope of practice regulations may determine medical reimbursement for healthcare services performed by ophthalmologists and their assistants.
Few statutes or regulations define the practice of nonlicensed AOP. Important issues concern what tasks can and cannot be delegated by the physician, and what can and cannot be performed by various AOP. AOP cannot diagnose disease, treat disease, or perform surgical procedures, whether using a blade, a laser, or any other instrument, technology, or modality. AOP should check local, state, or provincial laws, as well as institutional and practice policies.
Government agencies also may implement regulations requiring AOP licensure or certification to perform certain ophthalmic or administrative tasks. These regulations require that only certified personnel perform various tasks that are often based on patient safety, access to care, and government reimbursement for patient services, such as the ability to enter orders in electronic medical records for reimbursement by AOP.
Determining the scope of practice
AOP are employed in a multispecialty field that is comprised of ophthalmic assistants, technicians and technologists (with subspecialties in surgical assisting, imaging, biometry, and ultrasound) and other mid-level eye care team members. Today’s AOP function as part of an ophthalmologist-led eye care team ( Fig. 50.1 and Box 50.1 ).
Allied ophthalmic personnel (AOP) are eye healthcare professionals working under the supervision of a physician who is qualified or licensed to practice medicine and surgery specializing in ophthalmology. AOP are qualified to assist in the diagnostic evaluation, treatment and management, and care of patients with deficiencies and abnormalities that affect vision and the visual system. AOP scope of practice allows an assistant, technician, and medical technologist to perform tasks in accordance with laws and regulations that permit the physician to delegate.
AOP are individuals qualified through academic and clinic experience to provide patient care and assistance to ophthalmologists and may hold professional credentials. They perform assigned duties by the ophthalmologist and are not independent practitioners. AOP may not diagnose or treat eye disorders and may not prescribe medications. It is not within the AOP scope of practice to perform any injection technique or similar invasive procedures that involve the placement of needles, trocars, cannulas, or instillation devices within and beneath tissue surfaces.
The knowledge, skills, and interpersonal behaviors required of AOP include the following core competency domains :
Professionalism, interpersonal and communication skills
Technical and scientific skills
Community and health services
AOP responsibilities include assisting in the patient diagnostic evaluation, management, treatment, education, and care of patients with medical and surgical conditions affecting the visual system. AOP provide patient diagnostic and clinical data in the ophthalmic examination to the physician, and may assist in surgery, patient education, and compliance with prescribed treatment. Public, patient, and family education promote knowledge and understanding of the eye disease process, medical therapy and self-help and the promotion of visual and eye health and wellness.
AOP use evidence-based practices and the application of technology to optimize patient outcomes to prevent and manage patients’ diseases. Thus, the scope of allied ophthalmic health covers the individual, the family, and the community. Their scope of practice includes the use of protocols across all healthcare delivery sites including, but not limited to, the hospital, the clinic, and the physician’s office. They enter acquired clinical data and dictated information from the physician into paper or electronic medical records. These activities are supported by education, research, and administration.
AOP in countries other than Canada and the United States may have a scope of practice that looks very different. Some countries may combine AOP job roles and responsibilities. For example, in parts of Africa and the South Pacific, it is common for an ophthalmic nurse to have job tasks that are both surgical and clinical. AOP scope of practice as outlined will most certainly evolve, and most likely expand, as ophthalmic technology changes.
Changing scope of practice
With rapid changes occurring in the delivery of health care, ophthalmology practices know the importance of being as efficient as possible, and to constantly reassess processes to create improvements in how a clinic functions. As a result, sets of principles, such as “Lean management” and “Six Sigma” are being more commonly employed to improve process within clinics.
These processes reduce time wasting steps, to improve the use of resources and decrease expenses, while attempting to improve overall patient care results and patient satisfaction. Six Sigma is a metrics driven system to reduce medical errors and eliminate defects in how care is delivered. Lean management, conversely, is more focused on eliminating waste and making practices more efficient over time. Both concepts attempt to improve healthcare delivery by improving the value of patient visits, and decreasing overall waste. Through practice analysis, AOP can aid in reducing waiting times for patients, decreasing patient idle time, improving patient examination and surgical flow, minimizing required clinic inventory to prevent waste and expense, eliminating process and system failures that can lead to medical mistakes and misdiagnosis, and improving the use of medical records.
These types of changes to clinic flow and processes have become especially important with the COVID-19 pandemic because clinics have significantly changed in how ophthalmology care is delivered. Examples where AOP can assist in adapting to rapid changes include maintaining proper cleaning of examination rooms and equipment, proper physical distancing of patients within the clinic flow, appropriate ordering and use of personal protective equipment (PPE). AOP input is crucial to initiating such rapid change, while guaranteeing the success and sustainability of these significant changes in ophthalmology care delivery.
Direct AOP input into quality eyecare delivery is in the relatively new burgeoning telemedicine field in ophthalmology. Telemedicine techniques are slowly becoming accepted in ophthalmology, especially as computer technology has improved. The use of telemedicine and AOP for coordinating retinopathy of prematurity (ROP) evaluations with RetCam images is a good example of how AOP are being successfully integrated into telemedicine techniques. Again, as a result of the COVID-19 pandemic, telemedicine has been pushed rapidly to the forefront in an effort to effectively deal with patient care delivery in this new environment. AOP have already demonstrated they are extremely effective in telemedicine by gathering scheduling information for patients, history taking, measuring visual acuity, and some basic examination gathering, all through the virtual domain, as well as patient education and scribe tasks for physicians during patient virtual visits. AOP have an important role in the time-consuming information gathering, thus allowing the ophthalmologist to deal directly and more efficiently with patient diagnosis and treatment.
Licensure and certification
Licensure and certification are two processes that govern scope of practice in the medical profession. Licensure is defined and understood as having been granted authority or legal permission to practice as regulated by federal, state, or provincial governmental agencies. Certification denotes that a person is recognized by the private sector as having achieved standards set by the profession. Certification is generally granted by an independent organization but may also be mandated by a government regulation. For example, AOP, such as ophthalmic nurses, are licensed as well as certified. Registration is another term that recognizes government regulation of AOP.
Most AOP are not licensed by government agencies but may be voluntarily certified, based on their knowledge and skill levels, to perform delegated tasks and procedures. The International Joint Commission on Allied Health Personnel in Ophthalmology (IJCAHPO) certifies AOP at three core levels: ophthalmic assistant, ophthalmic technician, and ophthalmic medical technologist. The IJCAHPO is an internationally recognized, accredited organization by the National Commission of Certifying Agencies. Certificates of completion and microcredentials are also recognition that AOP have obtained specific knowledge and skill levels in particular areas. The Ophthalmic Photographers’ Society (OPS), American Orthoptic Council (AOC), Canadian Orthoptic Council (COC), National Contact Lens Examiners (NCLE), and American Board of Opticianry (ABO) are other examples of organizations that certify their respective cadres.
AOP certified at one of IJCAHPO’s three core certification levels may perform similar duties. However, AOP with higher levels of certification are expected to perform the tasks at an advanced level of expertise, and to exercise considerable technical clinical judgment as they perform these tasks. This applies both in the clinic and virtually.
Certification establishes national and global standards on AOP tasks performed. These standards are based on statistically valid, reliable data collected through research studies of job incumbents, employers, and ophthalmologists. This extensive research provides data on the importance of tasks, the frequency that tasks are performed, and the task difficulty level. Certification examinations test the knowledge and skills needed for minimal competency on these tasks by job descriptions and used by ophthalmic practices to grade the level of AOP status obtained.
Patient information and privacy practices
There is a complicated balance between patient privacy, and healthcare providers’ need to use and disclose medical information. Health information may be disclosed to law enforcement agencies and public health agencies as required by law. In most countries, national privacy standards regulate patient health information rights. These include the right to:
Request restrictions on the use and disclosure of health information
Receive confidential communication concerning the patient’s medical condition and treatment
Inspect and copy health data and information
Amend and/or submit corrections to health information
Receive an accounting of how and to whom health information has been disclosed
Receive a printed copy of the privacy practice of the healthcare provider
AOP, as part of the healthcare provider team, are required to maintain the privacy of the patient’s protected health information and to provide the patient with notice of the privacy practices of the provider. Notices typically address the uses and disclosure of health information and what may be used by staff members or disclosed to other healthcare professionals for the purpose of evaluating the patient’s health, diagnosing medical conditions, providing treatment and insurers for payment. The patient’s health information may be used to support the day-to-day activities and practice management of the provider.
Insurance risk and malpractice
AOP should always ascertain that they are insured under the umbrella of their employer’s medical malpractice policies. In addition, they should seek expressed, written indemnification from their employers for all activities performed, within the scope and capacity delineated by their supervisors and employers.
Ethics and scope of practice
The hierarchy of values and standards of conduct for the medical profession and all allied healthcare workers, become the code of conduct and ethical guidelines for AOP. AOP require an excellent understanding of medical ethics to serve the best interests of both the patient and the practice. The ophthalmologist who allows AOP to treat patients without adequate supervision compromises the licensing standards set by the government and erodes the standards of patient care. The eye care team must never neglect patient safety in the pursuit of efficiency for the practice.
Major shifts in health care are driven by rapidly advancing technology, by the pressure on lawmakers for open access to medical systems, by telemedicine, and by the desire to cut healthcare costs. These issues become even more important in times of crisis, such as the recent COVID-19 pandemic. New laws are often supported by third-party payers to save money, reduce premiums, and reimburse nonphysicians’ services at a lower rate.
In this changing environment, ophthalmologist’s shifting of tasks and delegation of responsibility and authority to the eye care team will progressively increase to prevent overworking the ophthalmologist, to increase the practice’s efficiency, to manage the costs of eye care to the public, third-party payers, and government requirements. As important physician extenders, AOP are a critical part of the eye care team in providing quality patient care.