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| OPHTHALMOLOGY PRACTICE |
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| Year : 2000 | Volume
: 48
| Issue : 3 | Page : 237-43 |
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The impact of information technology on the practice of ophthalmology.
S Prasad, M Nagpal, OP Sharma, PN Nagpal
Royal Hallamshire Hospital, Sheffield, UK
Correspondence Address:
S Prasad
Royal Hallamshire Hospital, Sheffield, UK
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 11217260 
Information technology has had a tremendous impact on the outlook of our professional lives. The Internet has revolutionised the speed of access to information with touch of a button. This article discusses the various aspects of information technology which are changing and enhancing our professional lives. It provides tips to enable the busy practising clinician to use the available resources effectively. Problems such as reliability of information on the web and how to assess the quality of such matter are also discussed. Keywords: Humans, Information Systems, standards, trends, Internet, trends, Ophthalmology, methods, standards, Telemedicine, methods, trends,
How to cite this article:
Prasad S, Nagpal M, Sharma O P, Nagpal P N. The impact of information technology on the practice of ophthalmology. Indian J Ophthalmol 2000;48:237 |
In recent years there has been an exponential growth in information technology (IT) and its impact on our professional lives. In addition to the vast number of traditional publications, we now have an increasing array of electronic sources of information and interaction. In an earlier article in this journal we provided an introduction to the Internet for the ophthalmologist.1 This communication aims to highlight newer developments in IT and provide tips to enable the busy clinician to use these new resources effectively.
| The Internet and Electronic Journals | |  |
Various aspects of the Internet have evolved to make this medium increasingly useful to the ophthalmologist. We discuss some of the features in the following paragraphs.
A growing list of peer-reviewed journals, including the Indian Journal of Ophthalmology are now available on the World Wide Web (WWW). Most freely accessible sites offer a table of contents with abstracts; however, they may also provide the full text of some articles. In some cases full text is available to paying subscribers on entering their subscription details. A major advantage of this has been the early and simultaneous worldwide access to the journal, transcending international barriers, and avoiding postal delays. Another very useful feature is the provision of the current instructions for authors on most of these sites. The Internet addresses of some of these journals are provided in [Table - 1]. There is a welcome trend to amalgamate the contents of allied journals on to one site, as evidenced by the supersight project (http://www.supersight.com/) from where the contents and abstracts of the leading American journals, such as Ophthalmology, Archives of Ophthalmology and American Journal of Ophthalmology can be accessed.
Some traditional journals are now using the potential of the new medium to include additional content on the website, which is not part of the paper version. For example, the Archives of Ophthalmology publishes additional photo essays on its website and the American Journal of Ophthalmology offers an "authors interactive" forum where readers can ask questions of the author. There is an offer of a free subscription to the Asian Journal of Ophthalmology available on the WWW. The British Medical journal has been a leading innovator in this field. The BMJ (as the electronic version is called) contains details of studies not available in the paper version. Study protocols and details of statistical analyses are available online. They recommend that all letters to the journal be submitted electronically and these are posted on the website within 48 hours of receipt.[2] This allows a more meaningful and lively discussion than the traditional medium, where only a limited number of letters can be published, and that too a few months after the original article has appeared.
Others have gone a step further and started journals which are published solely on the Internet. The foremost amongst these is the Digital journal of Ophthalmology (http://www.djo.harvard.edu/). Another web-based journal is Molecular Vision which is extensively peer-reviewed and dedicated to the dissemination of research results in molecular biology, cell biology, and the genetics of the visual system (ocular and cortical). Molecular Vision publishes articles presenting original research that has not previously been published and comprehensive articles reviewing the current status of a particular field or topic. Access to Molecular Vision is free and unrestricted, allowing the widest possible audience for the published article (http:// www.molvis.org).
One is, of course, faced with the task of keeping track of the numerous publications, both traditional and electronic. This is not easy. There are services which facilitate this task. An excellent service is the REVEAL table of contents offered by the UnCover company (http://uncweb.carl.org/uncover/unchome.html). UnCover Reveal is an automated alerting service that delivers the table of contents of your favourite journals directly to your e-mail box, for a charge. For an annual fee of US $ 25.00, one can nominate up to 50 journals. Once the account is set up the table of contents of the nominated journals are e-mailed to the recipient at regular intervals. One can then arrange to get copies of the full article through a fax service or through one's local library. A similar service called Contents Direct (http: // www.elsevier.nl/ locate/ ContentsDirect) is offered free of charge by Elsevier Science who publish many prominent ophthalmology journals. Registered users receive the table of contents of nominated journals produced by this publisher by email on a regular basis.
| Literature Searches | | |
It is essential for the modern ophthalmologists to develop skills in tracking down the best available current literature, especially with the current emphasis on "evidence-based medicine". Literature searches are no longer just a research tool, but have become an indispensable part of clinical practice. [3, 4] Widespread availability of computing resources including CD-ROMs and the Internet has led to a dramatic increase in the number of 'end-user' searches.[5] MEDLINE is by far the most popular and useful computerised database for the medical fraternity. The National Library of Medicine of the United States compiles this. Coverage dates back to 1966 and references to over 9.2 million records are now included with abstracts for about 70% of these records. Some 31,000 new citations from 3,800 journals are added each month.[6] MEDLINE and other databases are available on the Internet, with an increasing number of websites providing free access. [Table - 2] lists the Internet addresses of these sites and the databases available at each site.
Once one has located the articles of interest, bibliography software makes it easy to work with them. Programs such as Endnote (http://www.niles.com/) and Reference Manager (http:// www.risinc.com/) offer the ability to store references of interest locally and work closely with your favourite word-processing package to make the task of inserting and formatting references into a manuscript easier. Some Internet based access systems, such as Evaluated Medline (BioMedNet) and Healthgate now allow seamless integration with these programs, enabling references to be directly downloaded into specified libraries, for future use.
| Discussion Lists | | |
Electronic mail (e-mail) is the glue of communication on the Internet. Though much of this electronic communication takes place one-to-one, it is equally easy to communicate with hundreds {or thousands) of users who have a common interest. Discussion lists (or mailing lists) are subject-specific groups that are participated in and distributed by e-mail. Once one has joined a list, every message that is posted to this list is copied to his electronic inbox. A software package performs this task of copying and forwarding mail messages to every list member; thus the effort for the individual is the same as sending a single e-mail. Subscriptions to discussion lists are generally free. Discussion lists are an excellent way for health professionals to solicit opinion; air concerns and discuss matters of mutual interest. They offer a gold mine of information and are often way ahead of journals and bulletins; but a note of caution is needed here - the opinions posted on the lists represent the personal view of the contributor, and may or may not be based on evidence. For the ophthalmologist, there are general interest lists and special interest lists. The best example of the general interest lists include OPHTHAL (http://www.ophthal.org/; also available by email) with 1100+ subscribers from 64 countries; the ISOO Eyemail list (no longer operational) (http://www.isoo.org) from the International Society of Online Ophthalmologists. Indian Ophthalmology Online (http://www.isurgeon.org) maintains a focus on ophthalmic affairs in India and also offers an active mailing list with over 530 members. Subscription to all these lists is free. There are also lists which focus on a more circumscribed field, such as Eye Pathology, which discusses ophthalmic pathology (http: //www.mailbase.ac.uk/lists/eyepathology); generally the more specialised lists are restricted in that the access is only allowed to a defined user group.
| Websites | | |
There is a burgeoning number of websites dedicated to ophthalmic subjects. The information on these has not undergone peer review. They range from the sites maintained by learned organisations, well-established societies, faculties or colleges, which provide reliable information. Selected examples are provided in [Table - 3]. On the other hand, there are sites maintained by hospitals, departments, individual practitioners, or even interested patients. Most international meetings have online sites that contain useful information regarding program details, registration, abstract preparation and acceptance, travel, and accomodation-related information. This allows the busy professional to plan and organise the trip comfortably and well in advance. Information is usually accessible online before the paper version reaches the attendee. Details of the All India Ophthalmological Society Conferences are also available on the WWW (http://www.aios.org).
| Teaching and continuing medical education (CME) resources | | |
The last-minute rush to prepare a presentation is familiar to many of us. Often one is at loss to find appropriate illustrations. The Internet provides useful resources to help in this situation. These include downloadable images from CIBAVision Ophthalmics (http:// www.cibavision.co.uk/graphics/nettr / images.htm}, the Robert Bendheim Digital Atlas of Ophthalmology at the New York Eye and Ear Infirmary (http://www.nyee.edu/diglib/cfm/index.htm) and an image library available at the Indian Ophthalmology Online site. An interesting tool is available at Eye Simulation (http:// cim.ucdavis.edu/eyes/ eyesim.htm). This application simulates eye motion and demonstrates the effects of disabling one or more of the eye muscles and /or the cranial nerves that control eye motion. This is useful when teaching medical students and practioners how the eye motion will change with pathology of the eye muscles and cranial nerves. It also teaches what to look for during a standard neurological eye exam. Colleagues involved in teaching can no longer afford to ignore this powerful medium.[7]
Besides access to journals and discussion groups, the Internet has other useful sites for CME. A prime example is that maintained by the Vitreous-Retina-Macula Consultants of New York (http://www.vrmny.com). In this site one can find a monthly quiz based on selected case histories, fully illustrated with fluorescein and indocyanine green angiograms. The Internet has also been used as a research tool,[8] and we foresee further applications in this field.
| Other Information Technologies | | |
| Telemedicine | | |
Ophthalmology is one of the medical disciplines which lends itself well to Telemedicine, other disciplines where telemedicine is useful are radiology and dermatology.[9] This is because a large part of the diagnostic work in these branches is image based. With appropriate compression algorithms, even fairly large image files can be transmitted easily over the Internet, or dedicated lines, enabling consultation from a distance. Teleradiology was the most common application: in 1997 when about 250,000 diagnostic teleradiology studies were done in the United States.[11] During the same period 46,231 interactive video and store-and-forward teleconsultations were also done. The most active specialties were psychiatry (17.9%), cardiology (16.7%), ophthalmology (9.6%), and orthopedics (5.7%).[l2] This technology has found useful applications in screening for diabetic retinopathy in remote communities, such as the aboriginal population in Australia. Similar programmes are functioning in Wales in the United Kingdom. The eye's small size and the high degree of training and skills required to provide adequate eye care translate into a steep learning curve for remote presenters learning to use video ophthalmic peripherals to capture high-quality images[13] The cost of converting ophthalmic peripherals to digital is also a barrier.
| CD-ROMs | | |
A number of leading textbooks are now available on CD-ROM. This medium has the capacity to hold the entire contents of a multi-volume work on one disk. The contents are also easily searchable, making it much easier to identify sections of interest when looking for information on a specific condition. Leading reference works available on CD-ROM include Duane's Ophthalmology, Albert and Jacobiec's Principles and Practice of Ophthalmology amongst others. Many journals now routinely include reviews of multimedia publications along with book reviews. Proceedings or highlights of various conferences are also now available on CD-ROM, giving one the opportunity to view presentations from the meeting, including the slides, speech and video clips at leisure. With the introduction of DVD (digital versatile disc), we anticipate that the use of multimedia will increase as this new medium offers increased capacity on a single disc, enabling the inclusion of additional features like high resolution, full motion video.
| Digital Imaging | | |
Wherever a high volume of imaging is needed, digital media are replacing traditional film-based media. They have been shown to be acceptable for clinical use, although film still offers a superior resolution in absolute terms.[14] Many studies have established the use of digital images in various fields of ophthalmology.[15] Instant availability, ease of archiving, instant retrieval and ease of transmission, low running costs, and increased patient comfort due to a reduced flash intensity have all contributed to make digital fundus photography and fluorescien angiography popular. Digital techniques have made the acquisition of new sources of clinical information possible, as evidenced by indocyanine green angiography, scanning laser ophthalmoloscopy, corneal topography and retinal tomography.
| Publishing | | |
The world of publishing is in the throes of a revolution due to the impact of IT. Publishers are increasingly demanding manuscript contributions on electronic media such as floppy disks. Electronic communication has the ability to speed up the process of peer review.[16] Novel methods of 'open' peer review have been tried by leading journals such as the British Medical Journal[17] The notion that non-peer-reviewed research can be posted on websites has come to be accepted,[18] even by the very journals that have advocated and practised some of the stingiest rules against such so-called prior publication.[19] It is causing the balance of power between authors and publishers to shift; giving authors greater rights to communicate their work in ways that they and not what their editors, see fit.[20] Online publications have the potential to bridge the North-South information gap and hence benefit the developing word.[21]
| Problems | | |
There are, of course, problems with the medical use of IT. For example, how do you define jurisdiction on this essentially global medium? The troubling question of the validity of medical licensure and registration across borders takes on a new dimension, when the patient may be consulting a clinician on another continent using the Internet. There is the question of security of confidential information relayed on these networks. Encryption technology may offer a solution to this problem.
How does one assess the quality of information available on the Internet? One must remember that much of what appears on the Internet has not undergone peer-review or any form of moderation. It is not possible to have any sort of centralised review process for more than 30 million pages.[22] The electronic databases that we rely upon, notably the bibliographic databases such as MEDLINE are not all comprehensive and some entries may be misclassified leading to incomplete results.[23] Efforts are being made to standardise and assess data on the Internet so as to help guide the user to reliable information.[24] A frontrunner is the use of 'Platform for Internet Content Selection' (PICS). PICS are the use of database labels [Table - 4] to describe a datasource which would aid in making a simple declaration of content and ownership.[25] The development of a medical vocabulary and rating system with PICS would greatly enhance the quality of retrieval and quality of surgical information on the Internet. However, what is still lacking is an international consensus on the actual vocabulary used. Another initiative is the creation of a browser extension that is being developed for doctors, who will be able to rate the information on the WWW while they surf.[26]
| The Future | | |
Future applications of information technology are tremendous. Some organisations are even thinking about the possibility of performing surgery from a distance! For example, the U.S. Army is already working on a telemedicine-based vehicle that would allow paramedic soldiers to rescue a wounded soldier in hostile territories. In this kind of environment, an organisation could bring together a group of experts based purely on a set of selection criteria, such as their particular expertise and reputation, regardless of the experts' geographic location. In other words, this virtual organisation could handpick experts from the best medical centres anywhere in the world and create a team that is unmatchable by any physical "Centre of Excellence" that exists today. Physicians interested in dealing with rare or difficult problems could hone their expertise by reaching not only patients residing or willing to travel to their geographic area, but also those from every corner of the world. Their experience in managing these conditions would increase dramatically, which would increase the demand for their service. The big winners from these interactions would be patients. Their access to such specific expertise would not be limited by physical distance or by their ability to travel to the physician's location.
Modern information technology has opened a world of instant communication and vast tracts of easily accessible information to the modern ophthalmologist. We envisage the future consultation chamber as a venue where clinician and patient can jointly consult electronic resources, and the clinician can guide his patient to online support groups while educating the patient about the importance of scientifically rigorous data. Information technology has the potential to transform the doctor-patient relationship into one of informed shared decision making.
| References | | |
| 1. | Prasad S, Nagpal M, Nagpal PN. Ophthalmology on the information superhighway: An introduction to the Internet. Indian J Ophthalmol 1997;45:181-87.  [ PUBMED] |
| 2. | Crossan L, Delamothe T. The new order - Please respond to articles using website, email, or disk but not paper (letter). BMJ 1998;316:1406-10. [ PUBMED] [ FULLTEXT] |
| 3. | Lindberg DA, Siegel ER, Rapp BA, Wallingford Wilson SR. Use of MEDLINE by physicians for clinical problem solving. JAMA 1993;269:3124-29. |
| 4. | Klein MS, Ross FV, Adams DL, Gilbert CM. Effect of online literature searching on length of stay and patient care costs. Academic Medicine 1994;69:489-95. [ PUBMED] |
| 5. | Wildemuth BM, Moore ME. End-user search behaviors and their relationship to search effectiveness. Bull Medical Library Association 1995;83:294-304. [ PUBMED] [ FULLTEXT] |
| 6. | Fact Sheet NLM. Online Databases and Databanks: National Library of Medicine, http:/ / www.nlm.nih.gov/ pubs/factsheets/online_databases. Html#nedkubel (accessed 05 September 1999). |
| 7. | Chodorow S. Educators must take the electronic revolution seriously. Acad Med 1996;71:221-26. [ PUBMED] |
| 8. | Borer M), Hebert TE, Breshears D. Cost and demand analysis of excimer laser use: first World Wide Web Internet survey of the interest in refractive surgery. J Cat Refr Surg 1996;22(6)709-12. |
| 9. | D'Souza M, Shah D, Misch K, Ostlere L. Dermatology opinions via intranet could reduce waiting times (letter). BMJ 1999;318:737. |
| 10. | Mezrich RS, DeMarco IK, Negin S, Keller I, Schonfeld S, Safer I. Radiology on the information superhighway. Radiology on the information superhighway. Radiology 1995;195:73-81. |
| 11. | Allen A, Patterson JD. Annual survey: Teleradiology service providers. Telemed Today 1997;5:24-25. |
| 12. | Allen A, Grigsby B, 1998; 6(5):18-19 TT. Fifth annual program survey, part 2: Consultation activity in 35 specialities. Telemed Today 1998;6:18-19. |
| 13. | Li HK. Telemedicine and Ophthalmology. Survey Ophthalmol 1999;44:61-72. |
| 14. | Prasad S, Bannon P, Clearkin LG, Philips RP. Digital fundus imaging: A quality and cost comparison with 35-mm film. Acta Ophthalmologica Scandinavica 1999;77:79-82. |
| 15. | Young S, George L, Lusty J, Owens D. A new screening tool for diabetic retinopathy: the Canon CR5 45NM retinal camera with Frost Medical Software RIS-Lite digital imaging system. Journal of Audiovisual Media in Medicine 1997;20:11-14. |
| 16. | Allan B, Morlet N, Wormald R. Journals and the Internet. Use of the Internet for on line peer review must be explored further (letter). BMJ 1997;314:1352. |
| 17. | Whalting P. Having non-medical readers of papers on internet will enhance peer review (letter). BMJ 1999;318:1144-45. |
| 18. | McConnell J, Horton R. Having electronic preprints is local. BMJ 1998;316:1907. |
| 19. | Kassirer JP. Posting presentations at medical meetings on the Internet. New England Journal of Medicine 1999;340:803. |
| 20. | Bachrach S, Berry RS, Blume M, et al. Who should own scientific papers? Science 1998;281:1459-60. |
| 21. | Canhos V, Chan L, Giaquinto F, Kirsop B, O'Donnell A, Ugonna J. Close the South-North knowledge gap. Nature 1999;97:201. |
| 22. | Silbert WM, Lundberg GD, Musacchio RA. Assessing, controlling and assuring the quality of medical information on the internet. Caveat lector and viewor-Let the reader and viewer beware. JAMA 1997;227:1244-55. |
| 23. | Greenhalgh T. How to read a paper: The Medline database. BMJ 1997;315:180-83. |
| 24. | Kim P, Eng TR, Deering MJ, Maxfield A. Published criteria for evaluating health related web sites: Review. BMJ/i> 1999;318:647-49.
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| 25. | Armstrong C. Metadata, PICS and quality. Centre for Information Quality Management; 1997 http:// www.ariadne.ac.uk/issue9/pics (accessed 05 September 1999). |
| 26. | Mckinley J, Cattermole H, Oliver CW. The quality of surgical information on the Internet. J R Coll Surg Edin 1999;44:265-68. |
[Table - 1], [Table - 2], [Table - 3], [Table - 4]
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