Impact of Information Technology on ophthalmology

By Vivian Balakrishnan

SINGAPORE: We are living on the cusp of a profound fundamental revolution. The Information Technology (IT) revolution is perhaps the defining development of the 20th century, and we will reap its full benefits in the 21st century. Ophthalmology has always been highly technology driven and will therefore be radically affected by all these seismic changes.

The personal computer (PC) represented the initial wave of this revolution just over 20 years ago. It has become a standard office fixture. However, we often fail to realize just how essential and ubiquitous it has become to what we consider "standard" ophthalmology practice. Consider the following examples.

Glaucoma diagnosis and monitoring have irrevocably changed with the advent of automated perimetry. The PC has enhanced reproducibility of the perimetric data and, more importantly, provided means of analyzing the data to facilitate diagnosis and follow up.

Modern corneal topography and wavefront analysis of the optics of the eye would be impossible without microcomputers to analyze the huge amount of data generated. The most rapidly expanding field in ophthalmology -- refractive surgery -- could not have existed in a precomputer age.

In fact, refractive surgery represents the first ubiquitous form of robotic surgery, all controlled by a computer, with the surgeon reduced to inputting desired refractions and performing preliminary incisions. The actual calculations and execution of the ablation profiles are directly controlled by a PC.

Phacoemulsification has taken cataract surgery by storm. Although phacoemulsification predates the PC, the current widespread adoption of phacoemulsification has occurred because of the increased safety margins of modern machines which interface a PC between the surgeon's foot pedal and the phaco probe. The most obvious benefit has been better anterior chamber stability due to real time better control of the fluidics by the computer. I have always been somewhat amused to notice that the Storz Millennium machine is nothing more that a PC running Windows 95!

The network

However, the PC is only the initial wave. The real tidal wave is the network. The Worldwide Web (WWW) is the colorful multimedia interface of the Internet with humans. It is worth noting that this technology is only seven years old. Despite this, it has profoundly altered the pattern and nature of human interactions and business processes.

The effect of a network grows exponentially with the number of nodes. For example, a single telephone on its own is useless. A network with only two telephones has limited use for providing point-to-point communications. However, a network with multiple telephones, all capable of communicating with one another, becomes really useful, and the usefulness grows exponentially with the number of nodes.

The next big thing in the Internet is the rapid development of wireless technology and handheld intelligent devices which will make the network even more pervasive and powerful.

Medicine and ophthalmology have not been spared. The next few decades will see sweeping changes in the way we practice and relate to patients because of the Internet. Consider the following examples.

Electronic medical records (EMR) have been proposed for over 30 years as a way to improve clinical data recording, retrieval and analysis. Despite the obvious advantages, EMR has not taken off, due primarily to physician resistance. Data entry remains a key stumbling block. Paper and pen are still the most efficient method for data entry, and physicians often record more information that would be captured digitally using a keyboard and mouse.

However, the next two years to three years will see major improvements in voice recognition and data entry tablets that recognize handwriting. This will ameliorate the current limitations of data entry.

In addition, further legislative and technological developments will be needed to protect patient confidentiality and security.

Another potential source of resistance from physicians will be the perceived loss of control of clinical data. This data will be used by administrators to monitor outcomes, relative performance of physicians and to control health expenditure. Nevertheless, I believe that this will be an inevitable trend, and physicians will have to learn to cope with it.

Clinical decision support systems will develop in tandem with EMR, and this will perhaps be the most useful aspect of an EMR system. The explosion of clinical information exceeds the capacity of all of us, and judicious use of technology to enhance clinical decisions will bring enormous benefits to both patients and physicians. Hopefully, errors will be reduced.

Computerized prescriptions is another area that will exploit IT to reduce transcription errors due to illegible handwriting, and automatically check for drug interactions.

Another phenomenon that we will face with increasing frequency is the patient who walks into the clinic with printouts from the Internet purporting to contain the latest information on their specific conditions.

This poses a challenge on several levels. First, the patient may sometimes have more specific information than the doctor can remember himself. Second, it changes the nature of the patient- doctor relationship by altering the balance of information between the two. Physicians will have to adopt a more consultative rather than prescriptive relationship with their patients.

Training systems will also be radically altered with increased use of virtual reality simulators for surgery, similar to the systems used to train pilots.

Telemedicine and home monitoring has been another much touted goal for rural areas with limited medical manpower. It is currently limited because the devices used to capture the raw data are still relatively expensive. It also requires trained personnel to use the equipment.

Paradoxically, the rural areas which need telemedicine most are also the areas lacking sophisticated equipment and trained personnel. Consequently, telemedicine would only take off when the capture devices become cheap and easy to use.

The Human Genome Project which will unravel the ultimate software program for life itself will be completed shortly.

Sequencing the billion DNA base pairs is a task that would have been impossible without the use of computers

The accelerating pace of change will present new challenges and problems. The half life of knowledge will be shortened considerable, and the advantages of seniority and incumbency will be reduced.

This article is adapted from a paper delivered by Vivian Balakrishnan, a doctor with the Singapore National Eye Center and associate professor at the National University of Singapore, at the recent International Eye Conference organized by the Parkway Group Healthcare.