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Year : 2020  |  Volume : 58  |  Issue : 3  |  Page : 145-147

Surgical audits, big data, professionalism, and patient-centric care

Department of Ophthalmology, National University Hospital, National University of Singapore, Singapore

Date of Submission29-Jun-2020
Date of Acceptance30-Jun-2020
Date of Web Publication14-Sep-2020

Correspondence Address:
Dr. Gangadhara Sundar
Head & Senior Consultant, Orbit & Oculofacial Surgery, Department of Ophthalmology, National University Hospital, National University of Singapore, 119228
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjosr.tjosr_82_20

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How to cite this article:
Sundar G. Surgical audits, big data, professionalism, and patient-centric care. TNOA J Ophthalmic Sci Res 2020;58:145-7

How to cite this URL:
Sundar G. Surgical audits, big data, professionalism, and patient-centric care. TNOA J Ophthalmic Sci Res [serial online] 2020 [cited 2021 Jun 16];58:145-7. Available from: https://www.tnoajosr.com/text.asp?2020/58/3/145/295005

Eye care is the most extensively and probably the most successfully delivered health care globally. Any health-care system involves a well-coordinated and efficiently run network that involves committed personnel, integration of technology at various levels, communication with internal and external customers, right siting of care of patients, and finally ensuring the best possible outcome,[1] with the most optimal cost–benefit ratio to the patient, the system, and the nation.

In advanced and mature health-care systems, it is imperative that periodic audits of outpatient and inpatient procedures be performed to ensure the appropriateness of indication of procedures, good documentation with appropriate documentation and informed consent process. Some examples of medical information documented and audited include diagnostic investigations such as fundus angiography (FFA and ICG), ocular coherence tomography (anterior and posterior segment), and therapeutic interventions such as peripheral iridotomy, cataract surgery, ptosis correction, vitrectomy, and open globe repair. Such audits should be performed not only to determine the appropriateness of intervention but also to monitor complications – both minor and major, including the final outcomes. While in solo and small-volume practices this may be an individual effort, in most large-volume practices and institutions, this has to be a conscious data-driven effort not only to ensure that the highest quality of care is delivered with the best-possible clinical outcome but also to benchmark individuals, subspecialty departments, and institutions against other such institutions regionally, nationally, and globally.

In this context, what becomes increasingly important are systems and processes beyond clinical and allied health-care professionals. In this world of big data and bioinformatics, robust information technology systems, be it, electronic medical records (EMRs), which incorporates patients' and surgical records, functional testing (e.g., automated perimetry), and imaging networks (photography and others including anterior segment optical coherence tomography [OCT], OCT, Heidelberg retina tomography, retinal nerve fiber layer analysis, ultrasound [A-scan, B-scan], computed tomography scan, and magnetic resonance imaging) coupled with Research Electronic Data Capture software technology,[2] aids not only capture millions of data points of patients but also aids analysis to make sense of the data captured. This big data can then be utilized to study the efficiency of eye care delivery. Features that can also be captured and analyzed include patient waiting time, longitudinal analysis of investigations, spectrum and volume of patient procedures, their duration, consumables, intraoperative complications, additional interventions, adverse events if any, unplanned or prolonged stay/recovery and finally, the outcomes as well.

As mentioned above, an aspect of ophthalmology that is rapidly evolving is the progressive adaption of big data and data mining from digital technologies. Once incorporated into diagnostic and eventually therapeutic devices, the application of artificial intelligence[3] has facilitated machine learning[4] which along with quantum computing has pushed deep learning sophisticated enough to potentially match diagnostic and therapeutic interventions as clinical professionals would do. While yet to be formally validated and fully integrated into clinical and surgical practice and yet to be formally approved by health-care authorities for the want of validation, it now holds promise to revolutionize the diagnosis of common conditions. This is starting to happen in the realms of diabetic retinopathy, age-related macular degeneration, retinopathy of prematurity, corneal curvature disorders, cataracts, and preoperative intraocular lens selection. It has the potential to make inroads into large academic medical centers and service and teaching hospitals globally, which have already had implementation of' to implemented fully integrated and complete EMR.

In such mature health-care systems, it is pertinent that we address the issues of adverse outcomes in eye care delivery. The concept of “adverse events, near misses, and medical errors” is not new to us professionals, but is often either ignored, suppressed, or trivialized unless they are serious adverse events. It is imperative that as technologically and technically advanced eye care professionals, both in private and public institutions, its leaders take the initiative to capture such misadventures, openly discuss each one of them without blame, critically follow through with root cause analysis[5] and most importantly, have open disclosures with patients and their families, and finally travel the distance with them until the best-possible outcome can be achieved and issues resolved. This is the final frontier of professionalism that we should all strive for, which promotes a healthier relationship not only between patients and health-care providers but also between professionals and institutions. Such an open and transparent process will also protect us against guilt, which is not uncommon among professionals, potential lawsuits, and also build a better relationship with our fellow colleagues regionally and nationally.[6],[7] The above process underscores the value and true meaning of a “Valid Informed Consent” which is not just a document that is signed by two parties, but a contract that is well understood by patients and their caregivers.

Where should any technically and technologically advanced eye care system lead us to? Obviously, it should be “better patient outcomes,” with the goal being not only “customer satisfaction” but also possibly customer delight and hopefully even “customer ecstasy.” However, unlike dealing with individual patients where only the final outcome matters regardless of cost, when we deal with hundreds of customers on a daily basis in any patient population and millions worldwide, we should keep in mind the needs and expectations of the discerning “common man” – one with limited resources who has more to lose from untoward incidents and complications with delayed recovery and/or poor outcomes whose daily living depends on the earliest restoration to normal. The “triad of equity, efficiency, and effectivity of health care” is then called into question. In this context, the concept of patient-reported outcome measures[8] or value-driven outcome is to be constantly kept in mind and in fact pursued. High-volume ophthalmic centers, which have been delivering population and community-centric volume-based care, are rightly evolving toward value-based care where true value is derived not only by the outcomes but also by the cost incurred.

Interestingly, a recent editorial[9] brought up the issue of the value of femtosecond laser technology for routine cataract surgery, highlighting the controversy of its value in routine cataract surgery with cost–benefit ratio considerations. Similar examples include the role of image-guided navigational surgery and patient-specific implants in orbital reconstruction.[10] There is no denying benefits from constantly and rapidly evolving technology in whichever form it may be, both in daily life and clinical practice, and there is no escaping it. However, value-based technological applications, especially for the discerning patient with limited resources, should be kept in mind. Periodic review of the resources put in, service-provided patient outcomes, and societal benefits is therefore mandatory.[11],[12]

Finally, when dealing with large populations, the public–private divide should be transformed into a public–private partnership where they learn from each other, share the workload and practices, and identify centers of excellence. Traditionally large institutions have been either high-volume low-cost community-centric institutions or advanced medical centers where cutting edge technology and expertise is readily available for rare, complex, and challenging cases that are focused more on the outcomes and creating new knowledge than just on costs. This struck a good balance with cost-effective care to the larger community and sophisticated care for complex cases without compromise on the outcomes. Unfortunately, in this capitalistic era of progressively higher costs and bottom-line-driven establishments with increasing expectations of “customers” (patients), it is sometimes hard to find a balance between investment in the latest technology, given its potential for medical outcomes and marketing.

In summary, ophthalmic health care is a complex industry caught between the never-ending pursuit of excellence and advanced technology on one end and the equitable, affordable, and satisfying quality care on the other. Gray zones of health care include the “triad of ethics, legal aspects, and professionalism” which are either not taught or given enough emphasis in medical schools and unfortunately often learnt the hard way. The onus to impart the value and nuances of this aspect of medical education and training then falls within the goals of regional and national professional ophthalmic associations and societies. Leaders of successful practices and major institutions – public and private – should take up this cause under the auspices of professional societies, to impart holistic approaches to ophthalmology, incorporating the “Science (as taught in residency and fellowship programs), the Art (as is practiced by successful individuals), and Philosophy,” the final frontier, where there is limited evidence but why things are done the way they are based on individual experiences and belief (the SAP of Medicine).

“2020” promised to be a great year for ophthalmology which, however, had been upstaged by the global COVID-19 pandemic. This has challenged humanity globally, not only individuals and their families but also nations and ophthalmic practices and institutions. When every other industry and profession took a back seat, it was the health-care industry which has bravely stood at the frontline and delivered, especially when it mattered the most, sometimes at the cost of their own lives. Likewise, it is among adversity that opportunity is created, not only to overcome the challenges but also rise and shine beyond any unforeseen obstacles. Despite temporary setbacks, the future of ophthalmology is bright, and it is the dynamic young ophthalmologists of today who will be the pioneers for the rest of the 21st century and beyond.

  References Top

Available from: http://www.icoph.org/downloads/icoethicalcode.pdf. [Last accessed on 2020 Jun 15].  Back to cited text no. 1
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377-81.  Back to cited text no. 2
Available from: https://eyewiki.aao.org/Introduction_to_Artificial_Intelligence_in_Ophthalmology. [Last accessed on 2020 Jun 15].  Back to cited text no. 3
Lee A, Taylor P, Kalpathy-Cramer J, Tufail A. Editorial: Machine learning has arrived! Ophthalmology 2017;124:1726-8.  Back to cited text no. 4
Pierscionek B. Law and Ethics for the Eye Care Professional. Law and Ethics for the Eye Care Professional; 2008.  Back to cited text no. 6
Dissanayake MM. Professionalism and ethics in ophthalmology. J Coll Ophthalmol Sri Lanka 2014;20:71-3.  Back to cited text no. 7
Braithwaite T, Calvert M, Gray A, Pesudovs K, Denniston AK. The use of patient-reported outcome research in modern ophthalmology: Impact on clinical trials and routine clinical practice. Patient Relat Outcome Meas 2019;10:9-24.  Back to cited text no. 8
Arulmozhivarman NV. Quo Vadis? TNOA J Ophthalmic Sci Res 2020;58:3-4.  Back to cited text no. 9
Udhay P, Bhattacharjee K, Ananthnarayanan P, Sundar G. Computer-assisted navigation in orbitofacial surgery. Indian J Ophthalmol 2019;67:995-1003.  Back to cited text no. 10
[PUBMED]  [Full text]  
Chao TE, Sharma K, Mandigo M, Hagander L, Resch SC, Weiser TG, et al. Cost-effectiveness of surgery and its policy implications for global health: A systematic review and analysis. Lancet Glob Health 2014;2:e334-45.  Back to cited text no. 11
Brown MM, Brown GC, Lieske HB, Lieske PA. Financial return-on-investment of ophthalmic interventions: A new paradigm. Curr Opin Ophthalmol 2014;25:171-6.  Back to cited text no. 12


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