AOA Registry MORE, Questions and Answers

0 541OOA Secretary-Treasurer Dr. Dave Anderson of Miamisburg provides answers to possible questions about MORE.

Have you signed up for MORE?

I signed up for MORE in June 2015 after attending Optometry’s Meeting in Seattle.

Why did you register for MORE?

After seeing the changes enacted by the U.S. Congress regarding CMS payment, it was clear that following any effort to unify healthcare was necessary.  After learning the details of MIPS (Merit-based Incentive Payment System) scoring, I knew that Registry membership was a key component of the new payment structure in the coming years.

How easy was it to sign up?

It was really simple to sign up, although it is important to understand that each doctor in a practice needs to sign up individually.  The first doctor of a practice signs up the practice with the EHR vendor details, but each doctor much assign their identification number to the system.  In total, it took five minutes.

Is your EHR is endorsed?

My EHR was one of the first to be endorsed by MORE, and I was aware of the registry from my vendor before the AOA announced the process for signing up.

Why should I sign up if my EHR is not endorsed?

Additional EHRs are being endorsed by MORE and, in time, all the major EHRs will be included.  The goal of MORE is to be inclusive of all EHRs and to fully represent all practicing ODs.  Even if your EHR vendor is not listed currently, the more people who sign up for MORE with an EHR that is not endorsed, the quicker MORE will work to integrate with that EHR system.

What is the cost?

Nothing. MORE is fully a FREE benefit of AOA membership.  This is the first time ever that membership directly impacts your future payments for the services you provide.  AOA created MORE to not only engage in the Electronic Health Initiative of CMS, but also to be a valuable member benefit.  If you are not a member of the AOA, the cost for MORE is $1,800 per year.

What diseases/diagnoses/codes are reported?

The registry is able to measure and compare outcomes of all areas of practice.  This includes diabetes, glaucoma, pediatric care, amblyopia treatment and contact lens complications.  Regardless of the way an optometrist practices, the registry is able to measure and compare all the key areas of eye care.

What if my practice only sees kids?

This is a perfect opportunity to showcase the benefits of primary eye care.  From amblyopia treatment outcomes, to learning and reading, a pediatric practice will be measured against outcomes of similar patients.  The payment model may appear to be only related to the Medicare population, but very quickly this model will be seen in private insurance plans and Medicaid plans as well.

What if I am in ophthalmology practice?

All the more reason to sign up.  In an ophthalmology practice, an Optometrist is seeing patients for post-op care and major systemic and eye diseases.  These are being watched very closely to help define better practice and clinical guidelines for overall better population health and outcomes within a specific population or disease.  What better way to show that an OD seeing patients alongside an ophthalmologist is at or above the top clinical care measures.

Does each Doctor in practice have to sign up?

In short, yes.  Although only those that wish to be measured and included in the registry to help determine the MIPS scoring.  Much like meaningful use and PQRS, this is optional and results shown are based on the specific provider.  Much like these other programs, our payments will be compared to others using this system and those who are highly performing will be paid significant bonuses while those who do not use this and other programs will see significant penalties.

Does MORE involve staff?

It can, but after signing up for MORE, the setup is finished and the doctor continues to see patients.  The real area where staff may be involved is related to the measured outcomes.  If a doctor sees he/she is falling short in a specific area, for example follow up care for diabetic patients, the staff may be charged to improve the recall system.  Otherwise, all the information collection is done based on the services done daily in your EHR.

Is anything about prices reported?

No, everything about fees is specific to the doctor.  There are no published results for an individual doctor.  Everything is accessible only to the doctor who signs up.  In fact, each doctor in a practice only sees their own measures and not the measures of the whole practice.

Is anything about dispensary reported?

No. The only information that will be pushed from each doctor’s EHR is the information related to billed procedures and the correlating ICD-10 codes and a demographic relationship as well as the medication information related to the provider, not specific patients.  For example, the information available would include the percentage of glaucoma suspects in the past 12 months and what medications are prescribed most frequently.

Will MORE save me money?

Ideally, this will not only save money by helping a doctor better understand practice norms, this will also help a provider earn more money based upon participation in a program that measures outcomes and will apply to the MIPS scoring and therefore future payment models.

What if I sign up and competitors in my town don’t?

This is a national database registry, so there is no concern about other doctors and the data that is gained from their practice.  The data is used only as an aggregate and to compare the individual doctor to others nationally.

Here is a link to the AOA’s MORE site with more information and signup:

http://www.aoa.org/more?sso=y&ct=d8ab7a79ab573d941162eb02bfe49c2b319efe222cef9567f9986d55c0ac648a6227e687c3f27122a74246fd082e33dec034064bb2f775ad13f9a1a4316440c1

Contact info:

qualityimprovement@aoa.org, 1-800-365-2219

The deadline for enrollment for EHR Incentive Program Participants is February 29, 2016.

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BREAKING NEWS: Obama Signs MU Hardship Exemption Law

Written By: Dr. Jay Henry

If our members meet meaningful use for 2015 they need to attest.   If they did not meet MU for 2015 they can claim a hardship exemption before March 15, 2016 to avoid penalties in 2017.   The exemption will be approved based on the fact that CMS released the final rule so late in the year.

For up to date information visit us at www.ehrguru.net

Article:

On December 28, 2015, President Obama signed into law the Patient Access and Medicare Protection Act. The law states that the Center for Medicare & Medicaid Services (CMS) will approve hardship exception applications submitted by eligible professionals, hospitals, and critical access hospitals that did not meet Meaningful Use (MU) in 2015. Previously, hardship exceptions were individually reviewed and granted only if CMS determined that a provider demonstrated circumstances that posed a significant barrier to achieving MU. This year, submission of a timely hardship exemption application guarantees that the provider will avoid the 2017 penalty for not meeting MU in 2015. The bill was introduced by Senator Rob Portman (R-Ohio), and included legislative language based on the Meaningful Use Hardship Relief Act, sponsored by Rep. Tom Price, M.D. (R-Ga.), giving CMS the authority to grant hardship exceptions to affected providers for 2015

CMS did not publish the final rule for the 2015-2017 EHR Incentive Program until October 6, 2015. As a result of the delay, fewer than 90 days, which are required for a 2015 reporting period, remained in the calendar year. “The recent modifications rule for Stage 2 of the Meaningful Use program for electronic health records failed to offer physicians and hospitals enough time to actually comply with the new requirements,” said Price in a statement. “This much-needed relief will make the hardship application process much easier for doctors to avoid penalties stemming from the administration’s mistake, and thereby provide more time to care for patients.”

Section 4 of the bill states that eligible professionals must submit a hardship exception application no later than March 15, 2016 and eligible hospitals and critical access hospitals must submit an application before April 1, 2016. Application forms are not available at this time, but Quality Insights will notify providers when CMS posts information on its website.

Please Note:

Providers that meet MU in 2015 must submit an attestation to be eligible for an EHR incentive. The hardship exception is only for providers that were unable to meet MU in 2015.

The reporting period for all providers in 2016 is the full calendar year, except new providers entering the EHR program for the first time who will have a 90-day reporting period. Therefore, it is important to make sure all of the functionalities required for the entire reporting period are available beginning January 1 to meet MU in 2016.

Prior Authorization Standards Bill Passes Ohio Senate

By: Executive Director Keith Kerns, Esq.

Ohio’s healthcare providers and patients scored a victory in the Ohio General Assembly this week before the state legislature broke for its holiday break.  Senate Bill 129, a measure supported by the Ohio Optometric Association, Ohio State Medical Association and other provider groups, passed the Ohio Senate by unanimous vote.  If adopted the bill will establish common standards for health care prior authorization requests, including the establishment of time-frames in which third party payers must respond to requests.

Specifically, SB 129 would:

  • Require insurers to accept electronic submissions of prior authorization requests,
  • Require insurers to respond to prior authorization requests within 5 days and within one day for requests of an urgent nature,
  • Create a streamlined appeal process when a prior authorization request is denied.   The appeals process would first allow the provider to appeal to the individual who made the initial determination and then appeal to a panel that includes a clinical peer.  Finally, the provider may seek an external review if necessary.  The bill also creates expedited time frames which must be followed in the appeals process,
  • Require insurers to provide advance notice of any changes to the prior authorization process including providing detailed instructions should new information be required, and
  • Create a process to handle prior authorizations of new medical procedures and for medications for chronic conditions.

SB 129 was introduced by Sen. Randy Gardner (R-Bowling Green) in March.  The OOA testified in support of the bill last month before the Ohio Senate Insurance Committee.  The bill will now move to the House for consideration.  To learn more about OOA legislative priorities, please visit: OOA Advocacy Page

November Legislative Update

Written by: Executive Director Keith Kerns, Esq.

HB 213

This month, the Ohio House Commerce and Labor Committee began deliberations on House Bill 213, a measure that would require that all professional licenses be renewed on a biennial basis.  HB 213 was introduced by State Representative Tom Brinkman (R-Cincinnati) last spring.

The bill would impact several regulated professions, including: auctioneers, pawn brokers, real estate agents and appraisers, sanitarians, hearing aide dealers, private investigators, nursing home administrators, contractors, dieticians, pharmacists and opticians and optometrists.  Physicians, dentists and other health professionals currently renew on a biennial basis and are not included in the bill.

The OOA has serious concerns with the legislation and has requested to have optometry removed from HB 213.  This week, I submitted testimony to the House Commerce and Labor Committee on behalf of the OOA on this issue.  To view the testimony, click here.  Be sure to visit www.ooa.org to view the latest updates this and other important legislative issues.

Sales Tax Repeal Bill Pending In Ohio Senate

Recently, State Senators Dave Burke (R-Marysville) and Randy Gardner (R-Bowling Green) introduced Senate Bill 216 into the Ohio legislature.  SB 216 would exempt the first $500 of the sale of a prescriptive optical aide or component from the state sales tax. The Ohio Optometric Association strongly supports the legislation.  The bill has been assigned to the Ohio Senate Ways and Means Committee for deliberations.

Ohio currently requires retailers of prescriptive eyewear to collect and remit sales tax on prescriptive eyewear and other optical aids which creates an unnecessary barrier for patients and places Ohio-based retailers at a competitive disadvantage. 42 states exempt these products from sales tax.

To learn more about SB 216 and to get involved, Read More about SB 216 

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Scheduled Narcotics

Written by: Dr. Elizabeth Muckley

As you should be aware of by now, the FDA rescheduled hydrocodone from a Schedule III controlled substance to Schedule II controlled substance.  Our law was amended to address this issue and became law on March 23, 2015 (see below), so you didn’t lose any prescribing rights that you previously had before the change. YOU MUST NOW UPDATE YOUR DEA CERTIFICATE.

If you go to DEA’s website, www.DEAdiversion.usdoj.gov and review the mid-level practitioner chart (see below) you will find that DEA has already identified O.D.s in Ohio as having schedule II, III and IV authority.

Since the law has now been amended and you have authority to handle schedule II narcotic controlled substances (if you have a valid DEA certificate), then you can use the following web link to add schedule II to your DEA registration.  You should also add Schedule IV because Tramadol was rescheduled also by the FDA.

You will need information obtained from your DEA certificate in order to log on.

https://www.deadiversion.usdoj.gov/webforms/jsp/regapps/common/updateLogin.jsp

If you need assistance with the log on, please call 1-800-882-9539.

If you don’t complete the update, your scripts may get denied by the pharmacy. 

Everything else regarding your prescribing authority remains the same as before the change.

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The Rudiments of Leadership

By Dr. Gregory Hopkins

Hopkins Blog PictureWe have, as optometrists, so many opportunities to display leadership! Take a look at the “word cloud” pictured above. Perhaps you would like for those characteristics to describe your habitual demeanor in the exam room with patients, during staff meetings, teaching students/residents, managing your household, raising your children (if applicable), etc.? Leadership is certainly an important topic—a google search will net >151,000,000 books on the subject (and counting). Leadership is the process of dealing with change, and our world is changing at an ever-accelerating pace. Certainly, we all do our best to manage this change, but there is a difference between leadership and management. We need both processes to succeed, and all of us have a distinct set of strengths and values to bring to the table. Let the unique reasons “WHY” you practice optometry drive “HOW” you set the culture of your practice. In the end, “WHAT” you do in your office reflects on your beliefs regarding the style of eye care you provide. Work outwards from the vision you have for your practice and you’ll be sure to attract loyal patients and staff—best of luck!

Opportunities abound to develop our leadership skills! Find mentors in your community, attend local zone meetings, volunteer to give RealEyes Presentations, serve your zone or seek positions on OOA committees or the board. There’s always great CE to be found on the topic of leadership at EastWest Eye Conference. The OOA Board runs a Leadership Academy for New Optometrists, with 40 new member-doctors poised to spend the coming year performing committee work and attending OOA events. If you graduated in optometry 2008 or later and would like to be part of the Leadership Academy, contact the OOA.

October Legislative Update

By Executive Director Keith Kerns, Esq.

Ohio Vision Services Act

House Bill 275, an initiative promoted by the Ohio Optometric Association, will help preserve the sanctity of the doctor-patient relationship and protect Ohio small businesses by focusing on three key issues:

  • Choice of Laboratories. The bill ensures that optometrists and patients are able to utilize the laboratories of their choice when purchasing eyewear and other materials.
  • Noncovered Services and Products. The bill will prohibit forced pricing on the sale of vision materials and services that are not reimbursable under a benefit plan. This tactic effectively removes contracted providers from the marketplace and forces patients to obtain medical devices from other retailers, some of whom may be located outside the state.
  • Choice of Plans. The bill ensures that providers are only obligated to participate in health care contracts and discount plans which they voluntarily choose to participate.

To learn more about HB 275 and get involved, click here.

Sales Tax

Ohio currently requires retailers of prescriptive eyewear to collect and remit sales tax on these medical devices. This creates an unnecessary barrier for patients and places Ohio-based retailers at a competitive disadvantage. Senate Bill 216, introduced last week into the Ohio General Assembly, would exempt the first $500 of the sale of a prescriptive optical aide or component from the state sales tax.  The Ohio Optometric Association strongly backs the legislation.

To learn more about SB 216 and get involved, click here.

CMS issues EHR Incentive Programs final rule

Change is coming to the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs with new rules that the Centers for Medicare & Medicaid Services (CMS) say indicate a move toward simplicity and flexibility, but AOA believes even more could be done to make the program work.

AOA urged CMS to structure the program in a way that is less burdensome and more helpful.

CMS announced the final rule Oct. 6, noting that the agency took under consideration providers’ concerns regarding the challenges and burdens with using the technology in major changes that ease reporting, support interoperability and improve patient outcomes. Several of the changes finalized were in response to issues and concerns communicated in AOA’s outreach to the agency.

However, the AOA still has serious concerns with how CMS operates the EHR Incentive Programs, and for the second year in a row, the agency has made last-minute changes just months before the end of the current year’s reporting period. These last-minute changes force physicians to scramble to get up to date on program changes and to quickly implement them in their practice.

Since the program’s inception, AOA has urged CMS to structure the program in a way that is less burdensome to physicians and more helpful to patients. The AOA understands the significant time and resource commitment needed to meet the meaningful use requirements and hopes the changes for the 2015 program year, late as they are, will provide some relief.

For doctors of optometry planning to participate in the program this year, there are several changes to take note of immediately, including:

  • 90-day reporting period.Physicians may now choose any 90-day reporting period for 2015. CMS previously intended to require a 12-month reporting period in 2015, but physicians now have the flexibility to select any 90-day reporting period in 2015.
  • Patient electronic access. Physicians are now required to have only one patient view, download or transmit (VDT) to a third party their health information. CMS previously required that 5 percent of a physicians’ patients VDT information. This is a significant reduction that will hopefully provide relief for many doctors of optometry.
  • Secure electronic messaging. Physicians are now required only to have the capability for patients to send and receive a secure electronic message fully enabled during the reporting period. CMS previously required that 5 percent of patients use secure electronic messaging. AOA has often heard from doctors of optometry regarding the difficulty of the secure messaging measure and this change should make this a less onerous requirement.

The AOA will provide more specific information on these changes and Stage 3 program requirements in future updates. If you have questions, please contact Kara Webb, associate director for Coding and Regulatory Policy, at kcwebb@aoa.org.

More about CMS’s changes to the EHR Incentive Programs
The final rules reflect insight from the AOA and more than 2,500 comments with physicians and other providers describing real-world difficulties in making the technology work well for their individual practices and their patients.

According to a CMS fact sheet, significant changes include:

  • “Check box” process measures removed.CMS hopes this will shift emphasis of health IT to a tool for care improvement, rather than as an end in itself.
  • Reduced objectives.CMS cut objectives—from 18 to 10 for 2015 through 2017. For Stage 3 meaningful use in 2017, there are 8 objectives for doctors. CMS indicates physicians also will have to report clinical quality measures (CQMs) only once to receive credit for other programs, aligning CQMs with other CMS quality reporting programs.
  • Extended reporting periods.CMS allows 90-day reporting periods for all physicians in 2015, 90-day reporting periods for physicians new to the program in 2016 and 2017, and to anyone choosing to adopt 2018 measures a year early.
  • Program start date.CMS set the Stage 3 start date to Jan. 1, 2018.
  • Interoperability key.CMS claims they want to put the emphasis on interoperability over data entry. Given the current and significant infrastructure problems that impede interoperability, the AOA is concerned that CMS may again be moving too fast too soon with increasingly difficult program requirements.

Additionally, CMS announced a 60-day public comment period to garner supplementary feedback about Stage 3, specifically as it relates to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This act established the new Merit-based Incentive Payment System (MIPS) to consolidate aspects of federal programs and quality measurements into a more efficient system. Feedback from the public comment period will facilitate rulemaking for MACRA—of which CMS expects new rules released in early 2016.

Click here to find more information on the final rules and the CMS EHR Incentive Programs.

“Bent, Breaking, and Broken”

By: Ryan P. Ames, OD, MBA and Charles B. Brownlow, OD, Medical Records Consultants

ICD-10 Has Arrived…

For the procrastinators among us (or for Rip Van Winkle, OD), ICD-10 is in full swing as of October 1, 2015. It is two years after its original ‘due date’, so we’ve all had plenty of time to prepare, but with the ups and downs; “it’s going to be delayed a year”, “It’s going to be delayed two years”, etc.; it’s no surprise that many doctors and staff put off their preparation, almost expecting a last minute reprieve.  The ‘last minute’ has passed…No reprieve…No excuses.  ICD-9 codes must be used for all services provided on or before September 30, 2015, even if the claim is submitted after October 1.  ICD-10 codes must be used for all services provided on or after October 1, 2015.  We have no idea how you will manage without resources, but there are tons of resources available.  Our recommendation is to buy the AMA version, 2015 ICD-10 (about $100, amastore.com, 800-621-8335), and possibly supplement it with the AOA Codes for Optometry (aoa.org/marketplace. 800-365-2219).  The AOA document is a ‘condensed’ version of the full ICD-10, which will be useful, but no one should enter this brave new world of coding without the full version of ICD-10 codes.  We’ll continue to help you with the occasional strange diagnosis, but we certainly won’t be able to provide a ‘look-up service’ for doctors who don’t care to buy the actual references.

PQRS Reporting Switches to ICD-10 on October 1, Too…

It was not until September 23 that we got our first question about the use of ICD-10 for PQRS.  A quick online search provided us with key information.  Of course all the PQRS measures are based on each patient’s diagnosis, so ICD-10 codes must be used for PQRS reporting on and after October 1, 2015.  AOA was all over this one, too, and offers a new chart, with ICD-10 codes replacing the ICD-9 codes.  It can be downloaded at:

http://www.aoa.org/Documents/2015%20PQRS%20EYE%20CARE%20MEASURES%20FOR%20OPTOMETRISTS%20ICD%2010%20Update.pdf

You’ll find lots of information regarding PQRS reporting at aoa.org/pqrs.  There are still a few ODs who are not participating in PQRS, but that will soon be nearly impossible.  Health care leaders are focusing on outcomes and are rewarding doctors based on reporting…In some cases, requiring doctors to report in order to even participate in their plan.  Those rewards will soon turn to penalties for those choosing to not report.

As an aside, there are lots of reasons to be using electronic health records in 2015 and beyond, and PQRS reporting is certainly one of them.  The use of EHR permits nearly automatic, once per year reporting of PQRS compliance via a ‘registry’, rather than the ‘claims based’ reporting required for doctors with paper charts and claims.  If you are still using paper charts, it’s definitely time to consider going electronic.

The Changing of the Guard—PMI, LLC. Became Foresight, LLC on October 1

After nearly five years of working together to assist doctors and staff with their issues related to medical records, coding, life with third parties, etc., Dr. Ryan Ames and Dr. Charles Brownlow have formally merged their efforts.  On January 1, Dr. Ames will be taking over the lion’s share of answering emails, writing articles, providing education, etc., while Dr. Brownlow will continue to provide support as needed.  The current plan has Dr. Brownlow  involved with the new venture, Foresight, LLC, through the end of 2018, though the extent of his involvement will definitely taper off significantly over the next three years.

When asked if this change means that he will be retiring from the profession he’s been involved with for nearly a half century, Dr. Brownlow responded, “I know, I know…I don’t look old enough to retire, but the calendar doesn’t lie.  I certainly am not ‘old’, but 1946 was a long time ago.  I will continue to be devoted to my colleagues and this profession for several years, but in a greatly reduced capacity.  Of all the people that have said ‘I’ll believe it when I see it’, when considering my retirement, my wonderful wife, Sherry, has been the most insistent.  It really is time for us to share more time together and with our children, grandchildren, and friends.  I love all of you (well, most of you), and I’ll be around if you really need me.  I’m confident that won’t be often, though, and I’ll bet it won’t be for long.  According to the Book of Ecclesiastes…”For everything there is a season”.  For me, the season is now autumn!  Thanks for all the support and friendship so many of you have provided me during my career… Optometry is small in numbers but it has proven itself enormous in accomplishments!  Please make me proud by always pushing the envelope of the scope and range of the services you provide to each patient you see.

Remember…As an association member, you and your staff are able to send questions directly to Dr. Ames at drames@pmi-eyes.com or Dr. Brownlow at drbrownlow@pmi-eyes.com

Back to School Eye Exams are a Must

By Dr. Ann Morrison,  Binocular Vision and Pediatrics Advanced Practice Fellow at Ohio State College of Optometry.

As school starts back up in the next couple of weeks, you should be advocating the importance of regular back to school eye examinations to your patients. It has been estimated that up to 80% of learning is visual. This should be a statistic that you promote to your patients, as it is a true testament to the importance of having good vision in the classroom.

As we all know, having good vision is more than reading 20/20 on an acuity chart. According to the Center for Disease Control, vision disabilities are one of the most prevalent disabling conditions among children. Many studies have linked poor academic performance with ocular problems [1-3].

Parents are always amazed at the responses their children will give me when I ask them questions about their eyes during an examination. Some of the questions I might ask a child are: “Do you ever see the words on the page split in to two? Do they get fuzzy sometimes? Do they ever look like they are swimming?”. When a child responds “yes” to any of these types of questions, the parents quickly justify that their child never complained of those things to them. I reassure them that they are not bad parents and that children often assume that everyone else sees the way they do. I explain that unless someone explicitly tells them that these types of symptoms are not normal, a child typically will not complain.

When I have a discussion with my patients about the importance of comprehensive eye exams, I cannot begin to count how many of them think that the vision screening administered at their child’s school or at their pediatrician well-visit is counted as a comprehensive eye examination. While screenings are a great public health implementation, it is important to spend the time educating your patients on the value of a comprehensive dilated eye examination and explain that many disorders including far-sightedness, eye teaming and focusing problems are often missed in screenings that take place in the school or at their pediatrician’s office. These types of disorders can impede a child’s ability to focus and keep up with the rest of their peers.

These conversations are a great segue into discussing the Infant-See program, explaining that comprehensive eye care should start by the time a baby is one year old. This topic also sheds light on the importance of the Realeyes program, as it educates children about their eyes and the importance of visiting an eye doctor. Make sure you are making your patients aware of these programs!

I’ll leave you with a link to fantastic video put together by the One Sight program who has set up a full service optical center and exam lane inside the Oyler School in Cincinnati. What they are doing in this school is a testament to how powerful a single pair of glasses can be for a child in need.

https://vimeo.com/65595152

Sources:

  1. Narayanasamy, S., et al., Impact of Simulated Hyperopia on Academic-Related Performance in Children. Optom Vis Sci, 2014.
  2. Quaid, P. and T. Simpson, Association between reading speed, cycloplegic refractive error, and oculomotor function in reading disabled children versus controls. Graefes Arch Clin Exp Ophthalmol, 2013. 251(1): p. 169-87.
  3. Rosner, J. and J. Rosner, The relationship between moderate hyperopia and academic achievement: how much plus is enough? J Am Optom Assoc, 1997. 68(10): p. 648-50.