Computer technology is relatively young, the first digital computer as we know it having been built in 1937. However, the computerization of the world has had an enormous effect on nearly every aspect of contemporary daily life and a major effect on the way ophthalmology is practiced. It is estimated that more than 95% of all ophthalmic offices use computers for such tasks as insurance billing, practice management reporting, payroll, sending recall notices, or even calling patients automatically to remind them of missed appointments or to notify them that their contact lenses have arrived. Beyond the myriad practice-centered uses of desktop, laptop, and tablet or handheld computers, computerization not only controls data acquisition but also aids in interpreting the results of many of the instruments commonly used in direct patient care, including the lensometer, keratometer, phoropter, perimeter, ocular coherence tomography, ultrasound, and optical biometry, as well as non-ophthalmic but otherwise critical tools, such as Internet-based telephone (Voice Over Internet Protocol [VOIP]), digital copy machines, and the cell phone. Thus computers increasingly contribute to better patient care as well as increased office productivity.
The effect of computers in the field of ophthalmology is a reflection of an accelerating trend towards office automation. Universal acceptance of computer technology by worldwide industries, coupled with markedly decreasing costs and widespread availability of increasingly sophisticated computer hardware and software programs, has defined a new era in computer-assisted medical care. Well-used computerization is a boon to quality patient care, staff efficiency, and practice success at all levels. This chapter is designed to expand the ophthalmic assistant’s knowledge base about computers, how they work, and what they can do for an ophthalmic office and its personnel.
A computer is a device capable of accepting, storing, retrieving, and manipulating or processing information automatically at high speeds by applying a sequence of logical arithmetic or textual operations. In simpler terms, a computer is able to execute a series of instructions that allow the user to ask questions as simple as “What does Fred Smith owe on his account?” The ability to instantly and invisibly respond to sequential instructions at ever increasing speeds allows computerization to aid in more sophisticated tasks, such as the analysis of complex data generated by the automated lensometer, autorefraction, retinal tomography, or corneal topography. With mounting hardware speed, complexity, and capability, computers can even make some complex decisions and predictions through the use of artificial intelligence. By comparing new patient data with stored historical databases of comparable results from normal patients, computers are able to aid in the interpretation of visual fields, corneal topography, intraocular lens (IOL) calculations, or optic nerve analysis. This ongoing evaluation process not only aids in the initial diagnosis of disease but also helps track clinically significant changes, such as those involved in monitoring glaucoma, keratoconus, and macular edema.
The physical components of a computer are referred to as the hardware and the programs that instruct the computer what to do are known as software . Computer hardware includes four major parts: the central processing unit (CPU), input devices, output devices, and storage devices. These elements are common to all computer devices, from smartphones and tablets to the largest mainframe servers.
Central processing unit
The CPU is the brains of the computer. It performs logical and mathematic functions, such as addition and subtraction, as well as comparing numbers or names. The CPU also controls the flow of information within the computer, retrieving and storing information at the same time it is processing data. The CPU is closely integrated with the temporary memory known as random access memory (RAM).
Despite the popularity of alternative input devices, such as the mouse, touch screen, character recognition, and voice recognition, the keyboard remains the most commonly used device for input of alphanumeric data into computers. Predominantly, the keyboard is used as a text entry interface, although software may alter the interpretation of each key. The mouse is a popular and efficient input tool used to manipulate data on the computer screen, perform additions or deletions in word processing, and drawing or altering graphics. Sophisticated mouse technology allows accurate forward and reverse scrolling, together with programmable functions for the mouse-actuating keys. Most offices now use scanners to capture images or digitize text through optical character recognition (OCR). Increasingly, computer input is achieved by light pens, touch screens, barcode scanners, and various wireless devices to enter data and images, as well as to control computer operation.
Networking of computers and diagnostic equipment allows the ophthalmic assistant to enter the output of devices, such as an automated lensometer, visual field machine, or corneal mapping device directly into the computer. Broadband Internet, shared remote data storage known as “cloud” storage, and related technologies allow users to enter data remotely, as well as review shared charts, images, and other vital data whether it is in the next room or a satellite office hundreds of miles away. Remote cloud storage can include processing such that the practice works on virtual desktops while both data and all processing occur on remote servers.
Voice recognition technology is used in some ophthalmic offices for medical record entry, transcription of professional correspondence, and even to control equipment such as the operating microscope. This technology allows automated translation from the spoken word to a desired action, or simply the entry of text into the intended medical record or program.
The two main output devices of a computer are monitors and printers. Along with most technologic advances, monitors have become thinner and larger and present higher resolution while also becoming more affordable. The need for printers has rapidly evolved in the medical practice. While ink-jet and laser printers are common they are rapidly being replaced by electronic transmission of professional correspondence and medication prescriptions, and billing is done by direct transfer of information electronically by direct upload and download of claims-related data, or by transfer over the Internet.
Storage devices (memory)
With increasing computerization throughout the ophthalmic office, there is a commensurate explosion of data, especially from diagnostic technologies that generate large image files. The contemporary ophthalmic practice is likely to have multiple digital imaging systems for corneal topography, slit lamp photopgrahy, optic nerve tomography, and retinal photography and tomography. Such increasing storage needs can be met by increasingly large hard drives, as well as secondary storage to optical discs or alternative drive technologies, or more commonly now to remote cloud storage.
Computers should be backed up on a regular basis to prevent loss of data. This is especially true for practices which have implemented electronic health records (EHRs). One cannot stress enough how critical multiple backups are to make sure that data are never lost or compromised. There are numerous protocols and technologies for backing up office data. Data are initially stored on network servers or on cloud storage. These servers are then backed up to storage media, such as tape drives or remotely located disc drives. Although slower than some alternatives, tape drives can hold large amounts of data retrieved from multiple networked computers. Alternative backup technologies include writing to CD, DVD, or flash drives as well as optical drives, or even direct off-site storage achieved by broadband transfer of data copies to contracted data storage enterprises. Duplicate backups are often a feature of remote cloud storage.
Whatever the combination of technologies used to back up data, the regular and consistent commitment to creation of data copies is critical for each and every device because eventually one or more will fail or become corrupted in hardware failures or even virus or malware attacks. Such unexpected failure leaves the practice totally reliant on a backup of data to avert loss or corruption of critical practice data of all kinds.
Computers can perform a variety of tasks in an ophthalmic office, including billing patients, scheduling appointments, keeping medical records, sending insurance forms to Medicare and other health insurance companies, and tracking their subsequent payment. Computers aid physicians in statistical analysis of their surgical results, managing complex practice finances, modeling cost–benefit considerations of equipment purchases, coordinating projects, writing journal articles, or doing literature searches. Computerization of the ophthalmic office significantly increases practice productivity and staff efficiency by automating many of the ophthalmic assistant’s routine tasks, such as history taking, patient testing, and ordering contact lenses. Telemedicine uses computerization or phone exclusively as tools to perform a technology-facilitated patient examination and virtual appointment with minimal, or even no in-person physical contact with the patient. Software packages specifically written for ophthalmic offices are becoming increasingly available. Properly designed and installed computer hardware and software should make the ophthalmic assistant’s task of seeing and treating patients easier and more rewarding.
General office software
Many general office software products find powerful utility in the ophthalmic practice. Software is widely available for word processing, spreadsheets, contact management, computer presentation, website authoring, project management, and accounting. Such software tools are often integrated into powerful, successful, and familiar product packages available off the shelf that are immediately adaptable for the ophthalmic practice. However, many needs of the ophthalmic office are unique and create an opportunity for customized software applicable to the medical office in general and the ophthalmic practice in particular.
Practice management software
There is a growing array of choices for sophisticated software packages designed specifically for the ophthalmic practice. Increasingly, this means resources to handle billing, accounts receivable, and appointments. The availability of the electronic medical record is an expanding option in ophthalmic practice. As the community practice of ophthalmology evolves, such dedicated software packages meet expanding practice needs through increasingly available modules to address various departments with specific and unique needs. Such modules can address the needs of the contact lens practice, inventory and laboratory management for optical departments, and even the demanding needs of running an ambulatory surgery center.
The use of computers for scheduling is almost universal regardless of practice size. Larger practices with several offices and multiple physicians find it mandatory to use networking resources to centralize appointment scheduling. Such software makes it relatively easy to answer a quick patient question, such as your next available routine appointment or to identify the exact time and date of a previously made appointment. For the computerized office, it is hard to imagine having to manually search pages of appointments to find one name. The computer can also be programmed to track insurance benefits and required referrals or copay amounts; produce patient reminders; keep clinical records; track allergies, medications, and contact lenses; and flag patients who repeatedly miss appointments. Computers also can call attention to patients who are receiving critically needed drugs and fail to return for routine follow-up visits. Such software also directs general periodic recalls either by email or by self-dialing computerized calling equipment. Upon arrival to the practice a patient may now check in by a computerized kiosk or by mobile phone, automating yet another step in the patient encounter.
Billing and accounting
Accounts receivable software allows an office to easily prepare bills, convert codes for services into statements, submit claims electronically or by hard copy, produce reminder letters for delinquent accounts, and analyze accounts and referral sources. This is a formidably complex task made manageable only through well-developed software and computerization.
Because most patients have some form of insurance, it is imperative to have a way to properly complete insurance documents, direct its receipt to the appropriate entity, track payments, and alert the office staff when claims are not paid promptly and completely. Billing software has been written to automate many tasks that previously had to be performed manually, such as checking for appropriate coding, posting charges and payments, sending claims to insurance companies, and closely monitoring accounts receivable.
Many medical billing packages include software to write checks, maintain payroll, and keep the general ledger. Other software may facilitate electronic transfer of billing data offsite where accounting services may be performed remotely or otherwise outsourced. When any practice employee writes a large number of checks each month to the same people, computerization can provide precision and efficiency while saving tedious work and, in the long run, can save practice expense by automating the monthly payment and posting functions.
Historically, the main reward of computerizing a medical office has been that of more efficient use of the data collected daily in the business office. Such data include patient names, zip codes, referral sources, diagnoses, and procedures done. Thus computers make it possible for office management to easily determine where patients are coming from, whether a marketing program is successful, and how well office costs are being controlled. Computers make it relatively easy to produce reports showing all delinquent accounts so that a staff member can call delinquent payers—be they insurance companies or patients—to prompt them to pay their bills. Monitoring insurance receivables is important because offices often process claims internally and collect directly from insurers, health maintenance organizations (HMOs), and preferred provider organizations (PPOs). Programs can rebill the insurer automatically after a specified number of days or produce a list of patients whose insurance payment is overdue.
With growing complexity of ophthalmic practice, flexibility and a comprehensive reach are important to evolving utility of reporting functions. Many practices track monthly department or employee productivity, optical inventory, popular frames or contact lens models, patient return of goods, or service complaints. Another advantage of computerized management reports is that they can be easily changed if new or different information is needed or new categories of services are added. If the information is in the computer, it can be easily accessed without having to manually go repeatedly through all of the medical records.
Electronic health records
In an attempt to promote improved patient care, reduce medical errors, and promote exchange of information between physicians, Congress in 2009 developed an incentive program to encourage physicians to computerize their medical records. The program led to widespread adoption of EHRs and electronic prescribing of medications, although it has not led to significant reduction of cost of medical care, nor has it been convincingly shown to significantly improve the quality of patient care as of yet.
Advantages of computerizing the medical record include consistency and organization, better legibility, facilitated ICD-10 diagnostic code selection, no lost or misplaced hard-copy records, and less paper and clutter around the office.
Computerized medical records also make it possible to automate clinical data analysis either for trend assessment for conditions, such as pressure management in glaucoma, or for broader research projects across an entire patient base. When all medical records have been stored on computers, finding and correlating disease entities and even critiquing quality and uniformity of care given become manageable tasks. The adoption of ICD-10, which significantly increases diagnosis specificity, should also aid in the process of clinical data analysis.
Once patient information has been entered into the medical record, consultation letters can be easily generated and sent electronically to referring physicians. The EHR can also then be used to give patients a copy of their medical record, which will help patients better understand their underlying disease and its treatment.
The resultant database becomes a rich tool for appropriate educational marketing of new medical developments or surgical techniques to any specified patient group because these are easily extracted from the whole database by software analysis of all entered medical records. In addition, research reports can be printed that inform the physician of opportunities to collaborate with pharmaceutical and contact lens companies to the potential benefit of patients who are eligible for studies or research projects. The IRIS Registry, developed by the American Academy of Ophthalmology (AAO), was designed to analyze clinical data from many disparate practices to help understand practice patterns and disease outcomes, hopefully leading to improved patient care.
The advent of EHRs and cloud-based resources, although powerful additions to the healthcare field, have also opened additional vulnerabilities and avenues for compromise of health records. Leaving a computer workstation unlocked can now compromise not only a single patient’s information, but the entire record of any previous or current patient of the organization. Inappropriate or insecure use of computer resources with Internet access can allow cybercriminals to infect computers and access the entire database of records, compromising it or even disrupting normal healthcare operations. Such attacks on healthcare organizations are becoming increasingly common, and it is critical for all members of the healthcare team to be vigilant for ways that information security could be compromised.
Computer-controlled ophthalmic equipment
Lensometry, the measurement of the optical parameters of eyeglasses or contacts, can be done automatically. In general, an automated lensometer quickly averages many measurements of the deviation of instrument light beams passing through a measured lens. Multiple calculations are done by an internal microprocessor to give the final accurate reading of sphere, cylindrical power and axis, and prism of the lens. With increased sophistication, such devices can map the optics of a progressive lens, detecting aberrations or alignment errors.
Small computers inside automated refractors control the placement of the infrared sensing beam that maintains correct placement of the light source. The computers then carefully analyze the readings and an initial determination of the patient’s refractive status is ready within a few seconds.
Keratometry is the measurement of the shape of the cornea in two meridians, usually orthogonal. A number of instruments calculate this information automatically using microprocessors. Often this function is incorporated into autorefractors and optical biometry.
Visual field analyzers
Automated visual field analysis is computer-controlled. The order and size of visual stimuli presented, the timing, and even the monitoring of patient eye movement are controlled by the perimeter’s computer. Results of periodic testing are computer-analyzed and compared with databases of normal patients and with previous results of the same patient (see Ch. 27 ). Such longitudinal study of visual field results allows the ophthalmologist to detect small differences in test results and identify any disease progression. Perimetric test results are generally stored for retrieval and subsequent analysis.
Scanning laser ophthalmoscopy
Scanning laser-based ophthalmoscopes (such as optical coherence tomography [OCT]) measure the extent of glaucoma damage where it occurs, at the retinal nerve fiber layer and optic nerve contour. These computer-based technologies complement visual field analysis because retinal nerve fiber layer damage is present up to 6 years before visual field damage. Measurements are compared by computerized algorithm with a normative patient database to provide efficient and objective patient longitudinal analysis. This technology also offers a critical measure for macular health and a powerful tool to direct diagnosis and treatment of diseases such as diabetic macular edema and wet macular degeneration.
Ophthalmic digital imaging
Digital imaging is routinely used in most ophthalmic practices. This can be as simple as a portable digital camera with subsequent storage of images in the computerized medical record or database. More elaborate systems include centralized digital retinal photography or laser-based image scanning that can then be downloaded for contemporaneous viewing along with the patient, or for later review by the physician to any networked workstation in the same or even a distant office. The capability of digital imaging of the cornea and retina includes software manipulation of the image characteristics themselves, as well as the ability to review the image instantly as needed, whether the physician or consultant reviewer is near or far.
Computerized corneal topography
Computerized corneal topography or keratography constitutes a computerized analysis of the topographic reflections of the cornea. Here, computerization allows sophisticated and detailed analysis of topographic data and patterns often too subtle for the unaided eye. Such analysis is used to detect subclinical disease as in screening for keratoconus. Computerized image enhancement allows some models to offer visualization of meibomian gland morphology and tear-film integrity.
Microprocessor-controlled ultrasound equipment is used to determine the length of the eye for intraocular lens calculations. It also can be used to measure reflectance echoes of corneal layers for pachymetry or for intraocular structures, such as tumors, to determine type, size, and location. The original A-scan equipment required the use of an oscilloscope, but today’s computer-controlled equipment takes hundreds of measurements, discards erroneous values, and provides the ophthalmologist with an accurate measurement of globe length. Many such devices have integrated computerization, allowing the calculation of desired intraocular lens powers using programmed formulas to process entered patient data.
Optical coherence biometry
Microprocessor-controlled laser-based diagnostic equipment can be used to determine the axial length of the eye for intraocular lens calculations. This technology offers advantages and disadvantages over ultrasound biometry. Both ultrasound-based and optical coherence–based biometry products generally offer integrated software to calculate intraocular lens powers. They also typically include database software to track outcomes and create surgeon factors intended to enhance future precision and predictability of surgical results.
Wavefront analysis aberrometry
Computer-based wavefront analysis is finding increasing application in ophthalmic practice through laser-assisted in situ keratomileusis (LASIK), IOL advances, and applications in glasses and contacts. These devices analyze light rays that emerge or are reflected from the retina and pass through the optical system of the eye. Light rays are projected into the eye onto the macula. Rays that emerge from a single point in the fovea and pass through the optical system of the eye are analyzed. One such technology uses multiple tiny lenslets located in front of the eye that isolate a narrow beam of light emerging through different parts of the pupil. A digital camera registers the true position of each ray and compares it with the calculated expected position of such a ray for a perfect optical model of the eye without aberrations. This difference enables sophisticated computer-based calculations of the aberrations or distortions of the total true optical system of the individual eye.
Wavefront analysis offers useful information for disease detection and management and selecting surgical parameters, and holds the potential to revolutionize the optical correction of refractive errors.
Classic film-based narrow angle images have been used for decades in imaging the retina. These cameras are now often computerized as well, taking pictures that are digitized and uploaded into databases for review and analysis by the doctor. More recently, technologic advances have allowed for wider fields of view of the fundus, such as ultrawide field laser-based imaging of the retina that may not even require dilation of the patient. These imaging techniques have enabled tremendous advantages in fields, such as diabetic retinopathy where telemedicine programs and, more recently, artificial intelligence algorithms can analyze these images to determine a patient’s risk of vision loss.
Emerging and future computerized technologies
It is almost certain that any new technology adopted in ophthalmic practice will be computer-based. Likely it will use computerization and even artificial intelligence to perform tasks more quickly and to compare individual patient results with a database of normal patients, as well as with that patient’s previous results. Increasingly, such applications will use networking and central databases to allow integration of complementary technologies throughout the practice into the EHR. Such integration will, by definition, improve clinical efficiency, data utility, and analysis, while almost certainly promoting improved quality of patient care.
Special ophthalmic applications
Online databases and Internet resources
It is difficult to overestimate the vast effect that Internet resources have had on society in general and on ophthalmic medical practice in particular. Email and messaging are important tools for near-instant communication within the office or around the globe. Such communication can have a powerful effect on patient care and office efficiencies.
Patient engagement is promoted with the use of patient portals. Physicians can exchange information and laboratory results with patients and patients can now readily communicate with their physician using secure messaging. Direct mail allows physicians to coordinate patient care by exchanging sensitive information securely with other physicians.
The Internet itself is seemingly a diffuse, endless resource. Importantly, there are now hundreds of medical databases with an enormous range of information from important primary resources, such as state and federal government, specialty medical societies and journals, commercial researchers, such as the pharmaceutical industry, the National Institutes of Health, the National Library of Medicine, and the Centers for Disease Control and Prevention, to name just a few. Any of these databases can be accessed instantly by computer from the office, from the home office, or while on the move through any Internet connection. The ability for such databases to be kept precisely up to the minute with the latest research makes them powerful resources indeed, lending their power and authority to the latest options in medical care choices.
Health Insurance Portability and Accountability Act and patient privacy
The Health Insurance Portability and Accountability Act (HIPAA) was enacted in 1996 to ensure that employees who changed jobs would not lose their health insurance. However, since that time, the law has been modified so that sensitive patient information is protected from being disclosed without the patient’s consent or knowledge thus giving patients greater control over their medical information.
HIPAA demands that safeguards be implemented to ensure the confidentiality, integrity and availability of protected health information (PHI). In addition, the law places limits on the usage and disclosure of PHI. Finally, the law requires that patients be notified if the privacy or security of their PHI is compromised. The Health and Human Services Office of Civil Rights is responsible for enforcing HIPAA. Any violations of the provisions of the law could result in a fine or even criminal prosecution.
What is PHI? Any individually identifiable health information is considered protected under federal law and cannot be disclosed except under certain instances only as authorized by law without a patient’s permission. Examples of protected health information include:
Information in a patient’s medical record
Discussions about a patient’s medical care
Patient’s billing information
Any information that could be used to link a patient with his or her medical condition, such as a medical record number, a phone number, an address, birthdate, test results or even a license plate number.
Healthcare providers are required to give patients a clear written explanation telling them how the healthcare provider will use their personal information, to whom it may be disclosed, as well as how it will be protected. Information may not be released other than to other healthcare providers who may be involved in the patient’s care without consent. Violating these rules may result in significant financial penalties, as well as federal criminal penalties.
Remember, all healthcare information is private. Be careful not to display any medical information, such as might be found in a chart or a photograph or on a computer screen so that a patient or nonstaff member could read it.
When discussing a patient be mindful of your surroundings so that other patients cannot overhear your discussions.
Do not leave patient information in plain sight
Do not share your login information with other employees.
Do not take files or documents containing PHI out of the clinic or office.
Fax transmittals should always include a cover sheet.
Never leave PHI on a voice mail message.
Call the patient using only phone numbers that have been approved by the patient.
Do not discuss PHI with any family member or friend without the patient’s written consent.
Do not include PHI in an email, whether to a patient or other healthcare provider.
All mobile devices or laptops that contain PHI MUST be protected (encrypted) so if lost or stolen, unauthorized individuals would not have access to any protected health information contained on them.
The incredible effect of computerization on the ophthalmic practice is impossible to overstate. Increasingly, computers are finding their way into every aspect of ophthalmic practice and patient care. Much of medical care involves gathering information, processing selected information, storing data for future reference, and decision-making based on available data. Computer technologies and management resources—available through office-based and networked computers, computerized diagnostic technologies, increasingly sophisticated analysis and tracking software with artificial intelligence, and instant access to a universe of the latest research—define new levels of patient care. With each advance in sophistication facilitated by greater affordability, new horizons in practice efficiencies and enhancements of patient care are opened before us.