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By Richard B. Prince, MD, FACS Southampton, Pennsylvania
If the pressures of declining reimbursements have you wondering
how you'll cope, take heart. The answer is on its way, part
of which may be in the form of the Internet. While most of
us use this technological marvel just for fun now, in just
a few years, we'll be using it as a highly effective cost-saving
tool that will allow us to deliver higher quality care more
economically than ever before. Read on for a preview of some
of the areas where I think the information highway will impart
the "technological edge" so critical to the future
of practices planning for growth and success well into the
Millennium.
Where We Are Now
An increasing number of ophthalmologists
are already turning to the Internet as an alternative communications
tool. For starters, communication by e-mail fits nicely into
our hectic lifestyles. The ability to read and write messages
at any time makes responding more convenient and faster, whether
replying to your neighbor down the street or a colleague across
the globe. Many ophthalmologists are involved in on-line discussion
groups covering a panoply of ophthalmic topics. These discussion
groups occur through e-mail via listservs. One of the most
popular listservs, maintained by the University of Buffalo
and called OPHTHAL
enables participants to post discussions in a variety of sub-specialty
topics each day which are then shared and read by the thousands
of ophthalmologists around the world who subscribe to that
listserv. Groups such as the International Society of On-Line
Ophthalmologists and the Internet
Ophthalmology Society as well as electronic journals such
as the Digital Journal
of Ophthalmology are springing up and making available
many different resources to the web-surfing ophthalmologist.
Some private practices---including mine---are also offering
original information via a "home page" on the World
Wide Web. In addition, most of our specialty medical groups
now offer their own Web sites. Both the American
Academy of Ophthalmology and the American
Society of Cataract and Refractive Surgery, to name just
a few, have impressive Web pages which offer information germane
to laypeople and physicians alike. Since access to any site
on the Internet is possible by anyone, these groups have set
up certain "members only" sections which require
user names and passwords to access certain content. In the
case of the Academy's home page, you're required to register
and obtain a password if you want to access the final program
for the annual meeting. Similarly, if you want the latest
information relevant to HCFA or Medicare, you will need a
username and password at the ASCRS's Web site to gain access.
But while there's definitely been a boom in how we use the
Internet, I don't think we've even scratched the surface yet.
Here are just a few ideas, from marketing to database linkage
to opticianry services, on how I think ophthalmologists may
need to integrate the information highway into their practices.
New Ways to Advertise
If managed care continues to grow, we may rely less and less
on word of mouth referrals to attract new patients. Instead,
the list of participating providers in the patient's health
plan may affect the patient's choice of specialist by default.
Still, I think we'll be able to use the information highway
to market to patients participating in one particular health
plan or network. We'll be able to market to prospective patients
by providing information about us on their health insurance
company's web site. We'll also be able to purchase and create
advertising for placement on computer sites or home pages
frequented by the particular patient demographics we treat.
Because Web advertising should be less expensive and more
directed then traditional modes, we'll be able to create many
different ads, using animated graphics and even audio snippets,
to help inform patients about the specific services we offer.
On your practice home page, your patients will be able to
download newsletters and brochures about your practice, as
well as finding information such as hours of operation, emergency
numbers, policies, and physician CVs. Conversely, patients
will be able to upload requests for further information to
your practice. Based on my own initial experience, I've found
the development and maintenance cost of a Web site is small
when compared to the added public exposure possible. The costs
will continue to decline while the exposure potential will
continue to rise.
Streamlined Scheduling
By using the Internet combined with automated phone systems,
known as telephony, we'll be able to streamline the appointment
process for our staffs and patients. Patients will be able
to connect via the Internet to a menu and choose their own
appointment times. This will help free up our staffs for other
office duties, while reducing the time patients need to be
kept on hold. In addition, we'll be able to do authorizations
for routine check-ups, referrals for networked specialty care,
and confirmation of capitation participation using the Internet
and computer networks. Eventually, patients may even carry
pocket-size computers, called Personal Digital Assistants,
which will be encoded with capitation information and authorizations
for specialty referrals by the primary care physician. When
this technology becomes available, our staffs will no longer
have to track down insurance information, another big time
savings. We'll also be able to automatically notify the patient's
pocket computer to remind him of an appointment 72 hours in
advance. Although certain patients still won't show, confirmation
telephone calls will no longer be necessary.
Easy Access to Patient Records
The benefits of computerized patient records within an office
today are innumerable, but I think the Internet will add another
exciting dimension. We will be able to access charts from
remote locations, and we'll be able to transfer information
and photos, saved as files, to colleagues or subspecialists
when a second opinion is needed. And think about how much
simpler and error-free it will be to send a patient's new
refraction directly to your optical shop or finishing lab
downtown. Similarly, we'll be able to order, renew and change
prescriptions for medications by tapping a few keys on our
examining-room computers. The information will be transmitted
directly to the patient's participating pharmacy. We can also
expect that medical correspondence and transcription services
will be cheaper, more efficient, and faster when tied into
the information highway. All correspondence will become a
part of the computerized medical record. Scanners will incorporate
data from printed paper sources into the medical record. Copies
of medical reports to employers, lawyers, and patients will
be effortless. Even the school nurse will know who's had an
eye exam and who needs one---all through the World Wide Web
of the Internet
Database Management
Another benefit will be the availability of on-line database
management. At the forefront of this effort is a company founded
by Kansas City refractive surgeon Dan Durrie. Recently renamed
"Data.Site", this company already provides basic
on-line outcome analysis for some refractive surgery centers
in the United States. Imagine being able to send pre-op corneal
topography to a refractive surgical database, and within minutes,
receiving a suggested surgical plan in return. Similar examples
may exist for contact lens fitting, ordering, and dispensing.
Also, centralized reading centers for stereo disc photographs,
visual fields, and fluoroscein angiograms will enable the
information highway to provide a higher level of excellence
to any provider who wants it while creating a whole new industry---all
the while improving the quality of care.
Simplifying Cataract Surgery
As a cataract surgeon, I'm particularly excited by some of
the ways I think the Internet will streamline the surgical
process. We will be able to access our outpatient surgery
center's Web site to allow for surgical scheduling, IOL ordering,
and payment authorization. Pre-operative medical clearance
and laboratory data will be sent through the information highway
directly to the hospital or surgery center, as well as encoded
on the patient's pocketsize personal computer. I think we
will also see IOL power databanks maintained by the lens manufacturers
which will allow surgeons to do instantaneous and accurate
IOL power calculations using multiple formulas. Plus, we'll
be able to send post-operative acuities to an outcome analysis
provider---a likely requirement of some health care payors---eliminating
additional paperwork.
Easier Continuing Medical Education
We may no longer need to travel far from our practices in
order to participate in continuing medial education. Instead,
we'll "attend" a virtual meeting through video tele-conferencing.
Or, you'll be able to watch it a few months later in the comfort
of your den or office by accessing the archive stored at a
Web site. Through the Internet, we'll be able to access lectures,
presentations, and courses, thereby meeting our CME requirements
with instantaneous accreditation, without substantial cost.
Newer conferences will be designed and developed solely for
the purpose of on-line continuing medical education.
So Long, Printed Word?
Printed journals will decrease in popularity and readership
as the medium is transferred to an electronic digital state.
Subscriptions to certain journals may be custom-tailored to
suit your interests or needs or time. Filters may be available
which block access to articles of low interest while allowing
for perusal of more articles and original research germane
to your selected area(s) of interest. Literature searches
are already more facile and powerful through the databases
made available to us through the Internet.
Better Medical Society Access
With access to the Internet, our national, state, and local
medical societies can more effectively coordinate membership
initiatives, legislative referenda, and educational mandates
through the information highway. They'll easily be able to
lobby for our support simply by e-mailing to their membership
list. In addition, details of funding, lists of clinical trials,
recruitment requirements, and even interim results from government-funded
research and clinical trials will be available to us on the
Internet. Investigators trying to recruit eligible patients
may send an electronic memorandum to every practice in their
geographic areas informing physicians of the study parameters.
The potential exists for an investigator's computer to search
another physician's or network's patient database for eligible
patients.
New Paradigms
As ophthalmology struggles for survival between the older,
fee-based models of practice and the newer, more efficient
paradigms of managed care, the Internet may well help us with
the transition. By incorporating the technological edge of
tomorrow's information highway into our professional and personal
lives, I think we will be rewarded with increased efficiency,
higher tangible and intangible return on our efforts, and
renewed pride in our work. Ophthalmology, no stranger to cutting
edge, high-tech developments, must try to maximize the future
opportunities that the information highway will offer. Then
we'll not only be able to secure the future of our individual
practices, but we'll also help to keep ophthalmology at the
forefront of providing quality eye healthcare.
Dr. Prince, a clinical assistant professor of ophthalmology
at the University
of Pennsylvania's Scheie Eye Institute, maintains a private
practice in Bucks County, Pa. He can be reached via e-mail
at prince@tricountyeye.com or through the World Wide Web at
tricountyeye.com
Sidebar: The Information Highway, Simplified
The Internet began as a project by the Department of Defense
in 1969 and was known as ARAPNET (ARPA stands for Advanced
Research Projects Agency). The network was an experiment in
linking computer networks of both military research contractors
and large universities involved in military research with
the Department of Defense. What was to make this primordial
network resilient was its dynamic rerouting, which enabled
network links to be automatically rerouted in the event of
accidental or purposeful disruption of the computer network.
Theoretically, information transmission on the network was
always available and secure. By the early '70s, the network
had become enormously popular at many larger universities
and had to be split up into two groups: MILNET for military
sites and ARAPNET for non-military sites. Fortunately, through
a technical scheme called Internet Protocol, both networks
remained connected to each other. Next, the National Science
Foundation decided to set up five supercomputer centers for
research use. These were to be linked to the universities
through ARAPNET. For a variety of reasons, this usage of ARAPNET
did not work and forced the NSF to connect its five supercomputer
centers through its own network, NSFNET. By 1990, NSFNET had
become so popular that ARAPNET was shut down. Additionally,
many universities had already developed their own workstations
which ran under the UNIX operating system and actually rivaled
supercomputer power at a fraction of the cost. Soon, their
use outpaced and was more reliable than that of the NSF's
supercomputers.
Today's Internet is an amalgam of all of these networks, although
a unifying network called NREN, for National Research and
Education Network, is now under development. If the Internet
is the information highway, the World Wide Web is the vehicle
through which we'll traverse this expansive resource. The
"Web," as it's commonly called, is the graphic component
of the Internet, and its popularity has grown exponentially
in the past two years. Prior to 1994, most information available
on the Internet was text-based only. At that time, Web traffic
accounted for about 1 percent of the Internet use. In 1996,
there are over 250,000 registered Web sites accounting for
25 percent of Internet use. There are over 25 million "pages"
in existence. According to a new survey by Dun & Bradstreet
Corporation's Nielsen Media Research unit, some 24 million
people in the US and Canada alone are already on the Internet.
That's 11 percent of the North American population. The Web
itself has an impressive 17.6 million users. --- R.B.P.
Reprinted from Review
of Ophthalmology, November 1996.
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