Are your triage tools just paperwork?

Last weekend, I went back through the DEWS III diagnostic recommendations. Not looking for anything specific just trying to refresh my thinking.

What stood out wasn’t what changed. It was what didn’t. DEWS II and DEWS III are remarkably consistent when it comes to identifying dry eye early. We have validated tools. We have clear guidance. We have symptom surveys that take less than a minute to complete.

And yet, in practice, very little happens with that information. Most offices are already asking the right questions. They’re just not doing anything with the answers.

At Peeq Pro, the most-read blog is Dr. Chris Wolfe’s billing and coding piece. But if you look at the rest of the top 20, almost all of them are about drugs and dry eye.

That’s not random.

A huge number of commonly prescribed medications - beta blockers, antihistamines, antidepressants, birth control, dermatologic treatments - have dry eye listed as a side effect. In many cases, it’s not rare. Depending on the category, somewhere between 10–30% of patients report symptoms.

So let’s say a 40-year-old patient walks into your office and says: “I used Accutane when I was younger and my eyes have been uncomfortable ever since.” Everyone reading this knows exactly what to do next.

But that’s not the real scenario.

The real scenario is that the patient never says that - because why would they? Real life patients don’t know that their medications are affecting their eyes. This is why they don’t complete the medical history. This is why they don’t pre-emptively identify past behaviors (or current ones) as risk factors.

Instead, they write “no change” or list one medication when they are actually on a dozen. Maybe they say “watery eyes” or “discomfort” when they schedule. If you’re progressive, maybe they even complete an OSDI-6.

And then they get roomed. The exam starts. And unless they are extremely vocal about their symptoms, nothing meaningfully changes. Your office does not use the data or the opportunity to generate data to identify a patient who is suffering.

I’ve watched hundreds of exams at this point. The pattern is consistent.

If a patient isn’t practically announcing: “MY EYES ARE DRY AND ITCHY AND BURNING,” they often get a normal flow exam, a note in the chart, and no real intervention. They get prescribed a new prescription for evening fluctuations that are never really articulated well in the exam.

More importantly, the patient feels like their primary issue was simply unidentified. No one heard their quiet frustration with how their eyes feel and behave.

Dr. Wolfe talks about this as a kind of clinical tension - the moment where you may identify disease or maybe even the potential disease, but don’t act on it. So the question becomes: “Where is your line?”

At what point does something you learn about a patient actually change what you do?

The easiest place to fix this is not in the exam.

It’s before the exam ever starts.

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A Simple Framework That Actually Works

If you strip this down, there are really four moments where a practice can either capture opportunity or lose it.

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📝 COLLECT
This is the part most offices already do, but often passively.

Collecting well isn’t just about handing a patient a clipboard or sending a digital intake. It’s about being intentional with what you ask and how it’s presented. If you’re using something like OSDI-6, it shouldn’t feel like just another form. It should feel like a quick, relevant check on how their eyes are actually functioning day to day.

The best offices position this upfront. “We ask every patient a few questions about how their eyes feel so the doctor can tailor your exam.” That framing matters. It tells the patient this isn’t administrative. It’s clinical.

And importantly, it pairs symptom questions with context. Medications. History. Open-ended prompts like, “How do your eyes feel throughout the day?” Because patients don’t think in diagnoses, they think in experiences. Heck, most patients don’t really know what kinds of things an optometrist could even diagnose them with other than a new glasses prescription.

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🚩 FLAG
This is where most systems break.

If a patient scores above a 4 on OSDI-6… what happens? In many offices (probably even most offices), nothing. The score lives in the EHR. Maybe the doctor notices. Maybe they don’t.

Flagging means making the signal impossible to miss.

That can be as simple as a system of colored stickers on the primary paperwork - yellow for moderate, red for severe. It can live in the chart, on the schedule, or even physically if you’re still paper-based. Some offices build it into their workflow so that a flagged patient automatically gets a note in the exam plan.

The point is not sophistication. It’s visibility. The doctor should know if there is a flag with a moment’s glance, not substantial focus. Right now, most doctors need to search the chart to look at test results, intake forms, etc., and frankly, they miss stuff or choose not to act. 

Choose to make it impossible not to act for your set criteria.

If the data doesn’t interrupt your normal flow, it won’t change your behavior.

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💬 PRIME
This is the most underutilized and most powerful step.

Priming is what happens between collecting the data and the doctor walking into the room. It’s where you prepare the patient to actually hear and accept what comes next. 

Most offices skip this entirely. They collect information, but the patient has no idea that anything they said matters. Frequently, patients that we talk to on the phone reference how they FINALLY feel heard.

The best offices make that moment intentional for every dry eye sufferer.

Sometimes it’s as simple as the front desk or technician saying: “Hey, we noticed a few things in your intake that the doctor is going to take a closer look at today.”

That one sentence changes everything. Now the patient is curious. They’re paying attention. They’re ready. They feel heard.

Other times, it’s visual. Showing the patient their OSDI score and where it falls compared to normal. Letting them see, “Oh, I’m not just imagining this.”

Or it’s educational. A short, simple handout, nothing overwhelming, just enough to connect symptoms like watering or fluctuating vision to dry eye. Enough for the patient to start recognizing themselves in the description. The goal is not to diagnose but to educate so a diagnosis makes sense. Many patients don’t realize that watery eyes are a sign of dry eye because it is counter-intuitive in their mind.

You can even do this conversationally during workup: “Do your eyes ever feel worse at the end of the day or when you’re on screens?”

Now you’re not diagnosing. You’re helping the patient articulate what they’ve been experiencing.

Priming works because it aligns the patient with the diagnosis before it’s ever delivered.

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⚡ ACT
This is where everything comes together.

By the time the doctor walks in, the patient has already:

• Reflected on their symptoms.

• Seen that something may be off.

• Heard that the team is paying attention.

Now when the doctor says, “I am concerned about what I am seeing. You have signs of dry eye,” it doesn’t feel like a surprise. It feels like confirmation.

Acting doesn’t necessarily mean turning every exam into a full dry eye workup. It means having a defined threshold where you go deeper. In fact, the best offices use this a reason to bring the patient back for a full-on ocular surface disease evaluation. They don’t try to solve the problem on day one.

If you see it, you treat it.

But more importantly, if you flag it and prime it, you’re far more likely to actually see it. Dry eye is subtle, your workflows should not be.

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The reality is that dry eye is everywhere.

Somewhere between 5–10% of adults have diagnosed dry eye disease. Meibomian gland dysfunction may be present in up to 30–70% of patients. The symptoms are inconsistent, often subtle, and easy to miss if you’re waiting for patients to self-identify.

So instead of guessing or waiting, just ask: “How do your eyes feel?”

Then decide what you’re going to do with the answer.

Because if your triage tools don’t change behavior, they’re not triage tools.

They’re just paperwork.