|Year : 1998 | Volume
| Issue : 3 | Page : 163-168
Computers in ophthalmology practice
L.V. Prasad Eye Institute, Hyderabad, India
L.V. Prasad Eye Institute, Hyderabad
Source of Support: None, Conflict of Interest: None
Computers are already in widespread use in medical practice throughout the world and their utility and popularity is increasing day by day. While future generations of medical professionals will be computer literate with a corresponding increase in use of computers in medical practice, the current generation finds itself in a dilemma of how best to adapt to the fast-evolving world of information technology. In addition to practice management, information technology has already had a substantial impact on diagnostic medicine, especially in imaging techniques and maintenance of medical records. This information technology is now poised to make a big impact on the way we deliver medical care in India. Ophthalmology is no exception to this, but at present very few practices are either fully or partially computerized. This article provides a practical account of the uses and advantages of computers in ophthalmic practice, as well as a step-by-step approach to the optimal utilization of available computer technology.
Keywords: Computers, ophthalmic practice, information technology, practice management
|How to cite this article:|
Rajeev B. Computers in ophthalmology practice. Indian J Ophthalmol 1998;46:163-8
The last few decades have seen a phenomenal growth in information technology including software, hardware, and communications systems. An ophthalmologist with little or no technical training is very often discouraged when confronted with these changes, and more often than not opts out of computerization. While this article aims to dispel any such apprehensions, it is recommended that the reader become familiar with basic computer operations.
The first question that comes to mind, logically enough, is: why buy a computer for an ophthalmology practice? Briefly stated, the right computer system can drastically reduce the time taken for many tasks in clinical practice by streamlining or reducing paper work and simplifying data management. Computers can provide faster communication, easy access to medical information, and above all, an add to patient satisfaction. Computers are designed and built in such a way that they rarely ever commit errors and have a high degree of reliability. Features that make this possible include increased data security, increased data legibility, reduced errors, data validation, easy data retrieval, easy data storage, and cost effectiveness.
Computers have a variety of applications in clinical practice [Table - 1]. Some of these are described in detail later in this article. Although all these applications can be started simultaneously, it is best to start with one application and gradually add on others based on need, economics, and usage. When starting in a phased manner, related applications can be grouped and each group can be implemented at a time [Table - 2].
| Decision Making|| |
Before opting for any form of computerization, some basic computer knowledge is essential and a beginners' computer course is recommended. Such courses are available in most cities and towns. Examples include 'Zed Point' from Zee Education and 'Leda' from NIIT. An alternative to this is unrestricted access to a motivated computer-literate person who can be relied on and will be available during decision making and all phases of implementation.
To begin with, remember that computerization will take time, money, and effort. If this issue is not approached in a structured manner, you will end up with an expensive system that does not justify the resources put in and that does not match the original goals. The sequence of events that must be followed are outlined below :
- The first step is to talk to somčone in the medical field whom you know and who has already implemented computerization. The most common error committed is to rely on only one opinion and that too from non-medical sources. Instead, talk to people who have a practice technique similar to yours and who have computerized recently.
- Visit clinics that use computers and ask for a demonstration of the software. Talk to the office personnel as well as the physician. Concentrate on features that are being actively used and not on features that "exist and will be used soon". Collate this information with the list in [Table - 1] to determine your immediate needs.
- Determine your needs based on these evaluations. Be realistic. You now have an idea of the benefits and how much each feature will cost. Identify the features that you want to implement in the first phase. [Table - 2] provides an example of stepwise implementation.
- Identify the software for your initial needs. See a demonstration of this software, preferably in a clinic where it is being used and not in the software vendor's office. While doing this concentrate on the speed of the software and hardware combination. Often the software will run fast in the vendor's office (on a faster computer) but may not run equally fast on the "budget" computer that is recommended for you.
- Decide on the hardware. Another major decision to be made is the number of computers you want to install and how you will link (network) these. Remember, networking has hidden costs including software to operate the network, hardware to connect the computers, etc. Make sure (again, ask for a demonstration) the software you have chosen runs equally well on a network. Once the software and number of computers is finalized, decide on the hardware. [Table - 3] lists the hardware components that must be individually tailored to meet the needs of the software you intend to use and/or the network needed.
- The next important decision is the backup that you need, both for power supply and for the data. An uninterrupted power supply is highly recommended. In case of any failure (including power, hardware, software) decide on how long you can tolerate a shutdown ("down time"). Backup features are available to avoid or minimise down time due to any power, software, or hardware failure. Devices for large volume data storage / backup on a regular basis are a must.
- Concentrate on after-sales support. Always budget for after-sales support, service contracts, and cost of training of office personnel. In this field service/support is vital and must be considered while choosing the vendor for both software and hardware.
- If you are having software developed for your clinic, it is preferable to wait till the software is ready before buying the necessary hardware. During software development you might add or modify features which may result in changes in the hardware configuration. Also, typically software development will take a few months and hardware prices will drop.
- Training of personnel is very often neglected. Try to employ at least one person with a background in computers who can concentrate on implementation and tackle minor problems. With the mushrooming of numerous computer training institutes it is very difficult to judge applicants. The best way to assess skills is to ask the applicant to work in your clinic for a few days. Cross training of staff is essential for ensuring smooth functioning of critical computer applications. This will ensure that routine but critical functions can be performed by more than one person. Also, for optimal resource utilization, stagger the work hours of staff where possible.
| Software|| |
"Application software" often refers to software that can be bought off the shelf. These packages are cheaper and the user has to adapt to the features available in the software. This might mean changing some of the established routines in your clinic. Some vendors may modify the features available (to suit your requirements), but at an extra cost. These packages need not be specific for a particular medical specialty. In contrast to such pre-packaged application software, "custom-built software" (as implied in this article) refers to software that has been exclusively developed and written for a particular clinic/practice. This usually applies to larger hospitals/clinics, is much more expensive, takes a lot of time and effort to develop and install, and has inbuilt extra costs for maintenance of software once it is working. For the past few years some Indian vendors have displayed (at the All India Ophthalmology Conference) application software for both front office management and clinical data management for ophthalmology clinics.
In general, try to avoid inflexible application software that you cannot customize (adapt to your needs) for minor functions. Choose a vendor who can provide good support and who is likely to survive the competitive market. For custom-built software packages negotiate with the software vendor for a copy of the "source code". The source code is the exact script of the program when it was written (the working copy that is given to you is an encrypted version). Knowing the code allows you the flexibility of hiring another programmer to modify it if needed. This is especially important if the original vendor goes out of business. Either type of software is made up of multiple units called "modules". Each module deals with a specific function such as appointments module, accounting module, stores module, and others.
In most instances for the initial basic functions [Table - 2], simple, easy-to-use, off-the-shelf spreadsheets (for example, Excel, Lotus) or databases (Access) can do a good job, especially in solo practices with minimal or no networking. With training, these spreadsheets and databases allow some amount of "programming", including formulas for calculations. For solo practices, it would be worthwhile to initially try this approach and then shift to more specific software.
| Hardware|| |
While buying a new computer system or upgrading your old one, plan to acquire a system that will meet your projected requirements for 2 or 3 years. When buying a computer, think in 3-5 year cycles. Once you decide on a software and hardware combination, in most cases it will usually suffice at least for 3-5 years. Irrespective of when you buy, hardware costs usually continue to drop. For backup devices such as the newer portable hard disk drives or ZIP drives, buy a external unit so that it can be shared between computers or even clinics/users. For modems, you can rely on the internet service provider's experience (check it out with other customers) and advice especially when it comes to speed. Some of the hardware features that can be tailored to your needs have been listed in [Table - 3].
| Computer Applications|| |
| Correspondence and Graphics|| |
Most clinics and ophthalmologists start using computers for word processing, to handle correspondence, and graphics software for preparing patient information brochures, and academic presentations. Using word processing software, letters and case histories /reports can be prepared and corrected automatically and presented in an elegant style. All these need not be stored in paper form but can be stored in the computer to be retrieved as and when required. Most word-processing packages allow the creation of 'templates' which make it easy for the secretary or ophthalmologist to generate a medical report for the referring doctor. A template is a standard format that can be reused every time, with only the patient name, vision, diagnosis, treatment, and other such data being changed.
| Front office management|| |
This typically deals with the entire sequence of events from giving an appointment to a patient, sending reminders, registering the patients once they come for an evaluation, collecting fees for services provided, to giving the next appointment. This helps optimize patient waiting time, providing appointment lists on a daily or specified time-bound basis, easy cancellation and rescheduling, and also enables follow-up of patients who do not show up for appointments. Over a period of time, data that accumulates includes the number and type of procedures/investigations performed, the number of patients seen, frequency of follow-up, drop out rate, etc., all of which can be used to plan and reorganize the practice. Since most practices vary in the work flow and appointment system, this software usually has to be developed exclusively for that clinic. Occasionally, existing software can be adapted (customized) to suit that clinic's specific needs.
| Back office management|| |
This segment deals with all functions that are typically performed by the accounts, stores, and personnel departments (in larger hospitals). This can be used for keeping track of comsumables stock (such as IOLs, contact lenses) as well as for costing of procedures / surgeries based on cost price of materials used and previously defined parameters (such as surgeon's fees). In most instances this software is readily available and does not need much modification since most clinics do not vary much in these functions. However, if one is planning on full computerization eventually, then integration and data sharing or data transfer between various modules must be taken into consideration in the initial stages itself. As the Indian health-care system comes closer to that of the developed countries (especially insurance and company billing) the complexity of the billing process will increase. Computerisation of advance payment, part payments, insurance policies, and refunds will streamline accounts and minimize losses.
| Clinical data management|| |
Collection, storage, and retrieval of clinical data including patient details and the entire medical record (including images) is the most expensive application. Currently front and back office management are the most used applications. Clinical data needs more resources especially because in ophthalmology it involves multiple images at each visit. Also, data entry (particularly drawings) needs relatively more expertise and often has to be done by the ophthalmologist, adding to the time spent for each patient. The recent decrease in hardware costs and increased usage of user-friendly Windows-based software have made computerization of medical records simpler and less expensive. Instead of drawing, with the touch of a key one can now download images directly from many of the diagnostic instruments (slitlamp, fundus camera) used in ophthalmology. These images can be stored, archived, retrieved for chronological comparison, and even printed when necessary. Advances in voice and handwriting recognition will make data entry easier in the future.
Irrespective of the type of data input chosen, it is very important that a thorough evaluation be done prior to opting for computerized medical records. If you are planning to collect data directly from diagnostic instruments, make sure that the patient record system is compatible with all input devices such as slitlamp, fundus camera, ultrasonography machine, and so on. Also, avoid a system that forces you to type your findings each time. Instead, choose one which allows you to choose from a list of commonly occurring symptoms and signs. For images such as retinal drawings, a set of stock drawings, the contents of which can be easily changed, is preferred.
A computerized patient record system will provide increased access to patient information and images can be transmitted for specialty opinion. Data can be retrieved and reported faster; it will be more legible, will take up less space, and also increase patient satisfaction. To develop an effective system, all the computers in the clinic must be networked and each examination room must have a computer. This will include special drawing devices and high resolution colour monitors. Increased patient awareness and need for quality documentation will eventually make computerized patient records imperative, but given the economics of ophthalmology practice in India, routine usage of this form of documentation is still many years away. As an interim measure, electronic scanning of paper records to give a digitized (computer) image that can be easily stored, archived, and retrieved can be considered.
An additional feature in this category of applications is the printing of medical and spectacle prescriptions. Drug interactions and allergies, as well as potential side effects and warnings for patients can be stored and printed with each prescription. Such a module can also help in calculating drug dosage.
| Communications and Internet|| |
The availability of ophthalmology-specific information on the internet is yet to be fully exploited by ophthalmologists in India. The internet is a network of computers spread across the world by linking numerous computers or hundreds of computer networks. The internet features various modes of communication and information sharing including Telnet (remote login), FTP (file transfer protocol), E-mail (electronic mail), Newsgroups or Bulletin Boards (Usenet), Archie (searching public domain free software), WWW (world wide web), and Mailing list or Listserve. Prasad et al have described in detail some of these features of the information superhighway.
E-mail is one of the most basic and useful applications of the Internet. Electronic mail allows you to exchange messages with anyone with an e-mail address. Using a mail program you can type in a message just as if you were typing a letter and send your message electronically to a another computer on the Internet in minutes or seconds. An increasing number of ophthalmologists are using the Internet as an alternative and cheaper communications tool. E-mail allows one to read and write messages at any time, facilitates transmission of text and images, and makes responding convenient and quick.
Ophthalmologists from around the world can consult each other by subscribing to a mailing list or a listserv. These are discussion groups that communicate via e-mail (mailing lists are updated manually; listservs are updated automatically). Subscription is usually free. To communicate or to 'post a message', one sends a message to the listserv address which is usually a central computer. The computer sends copies of all the messages it receives to the other subscribers. Even if you have no message or queries, you can still read the queries and suggestions of other subscribers. Some listservs are "moderated", meaning that the messages and requests for subscriptions are reviewed by a human moderator to keep the listserv specific to that topic and screen out basic questions from non-professionals. Ophthalmology specific discussion groups or forums deal with various topics such as clinical alerts, ophthalmic photography, color vision research, oculoplastics, medical images, retinitis pigmentosa, and most of the subspecialties including cornea, retina, and glaucoma. Ophthalmologists can share experiences and even get medical advice by e-mail. This is especially useful for those located in remote areas.
Unlike the specialty discussion forums, newsgroups (bulletin boards) are less restricted and can provide many people without medical training some advice on medical issues. When you subscribe to a newsgroup you do not receive messages in your e-mail. Instead, you use a program called a newsreader (available through your Internet provider) to log into the newsgroup of your choice. Once you log on to a particular newsgroup, you can choose from a menu of subtopics, or "articles," and correspond with the writers of those articles. Ophthalmology-related information can be read in the 'sci.med.vision' newsgroup.
The world wide web (WWW) provides access to an enormous amount of data and knowledge right from your office and is the most interesting because of the multimedia content (combination of text, graphics, audio and video) and ease of accessibility. The Web is made up of pages of information, many of which are free for viewing and downloading. You can navigate through the Web by clicking on text "hyperlinks" which move you to pages with related information. To view the Web, you need a software called a "web browser" which the Internet service provider will most likely recommend, download (almost all browsers are free of charge) and install.
Using the WWW one can access information from web sites (home pages) maintained by ophthalmology societies to disseminate information to their members and to the public. Web sites can include case discussions, grand rounds, news, activities, abstracts of meetings and journals, full articles of journals that are already in print (paid access), outcomes data, clinical alerts, patient handouts, slides of interesting cases and public information material about eye care. Recent additions include online or electronic journals (internet digital journals) and even online scientific meetings via the internet.
You can even have your own private home page to include information about your practice, educational information for patients, etc. Internet providers that will design this page for you and place your web site on their computers for a fee are now available in India.
| Internet access|| |
For access to the internet first choose a 'internet service provider'. These vendors allow connections to their computers (through a telephone line, using a modem), which are in turn connected to the Internet. Prasad et al provide a detailed account of e-mail and other internet services and service providers in India.
| Telemedicine|| |
Teleconferencing (videoconferencing) and telemedicine will be increasingly used in the coming decade. Ophthalmologists can sit at computers in their own clinic and conduct discussions by exchanging messages/images through the local network, internet, or telephone lines. Clinical images can be electronically transferred over long distances for expert or second opinion saving money, time, and energy. This technology will be an offshoot of computerized clinical data management and will take a few years to be available for routine usage. Individuals can however improvise and send patient images as attachments to e-mail (some programs allow this easily) but the speed of the existing telephone lines will be a limiting factor.
| Medical informatics|| |
Until now the dissemination of information has been the prerogative of the print and audio-visual media. The ability of computer-based electronic publishing to package this information in a multimedia format (print, video and audio) along with simplified storage, retrieval, and dissemination, has ensured a gradual shift from mailed journals, textbooks and scientific meetings to electronic publishing. Electronic versions of ophthalmic or medical literature such as the Medline database are prime examples. Many ophthalmology textbooks and journals are now also published on CD ROM's. Multimedia provides the opportunity for incorporating sound and motion in addition to images, in the electronic version. In image intensive literature such as ophthalmic pathology, the electronic version scores over the hard copy material in terms of the number of colour images that can be incorporated without increasing costs. Other advantages include the compact portable size of the disc, ability to enlarge and view images, easy cross reference to chapters or paragraphs elsewhere in the text, and round-the-clock accessibility.
For patient education and information, some Indian vendors have developed multimedia programs that explain common ophthalmic problems such as cataract and retinal detachment in many Indian languages (sound track). Some of these have been demonstrated at the All India Ophthalmology Society meetings in the last two years. A multimedia computer with this software can be kept in the patient waiting area or in the ophthalmologist's office.
To conclude, it is obvious that use of computers and easy access to information will make a qualitative difference in eye-care delivery. Though it is a difficult task, if you do your ground work, insist on live demonstrations, and make an informed decision, chances are you will be more than satisfied with the results.
Note: The author does not endorse nor have any proprietary interest in products or services mentioned in this article. Those mentioned are meant to serve as examples, and do not form an exhaustive list.
| References|| |
White R. How Computers Work
. With Interactive CD-ROM. 2nd ed. New Delhi: BPB publication; 1996.
Prasad S, Nagpal M, Nagpal PN. Ophthalmology on the information superhighway: an introduction to the Internet. Indian J Ophthalmol
[Table - 1], [Table - 2], [Table - 3]