5 things we need to jump-start LVC

Kaizen — Japanese for improvement or change for the best — must become the norm to revive refractive surgery.

By Brian R. Will, MD

Over the past two decades, laser vision correction and refractive procedures have successfully delivered clear natural vision solutions for millions of patients. Unprecedented industry advances in technologies, including wavefront diagnostic systems, eye-tracking technology and femtosecond laser systems, have made laser vision correction (LVC) significantly safer and more predictable than ever.

Despite these medical advancements, growth in refractive procedures has been anemic. We frequently use the Great Recession of 2008 to explain this phenomenon, but other industries that depend on discretionary consumer spending have recovered and thrived. So what do we need to jump-start refractive surgery? Here, I outline what needs to happen to bring refractive surgery back.

WHAT’S HOLDING US BACK

Disregard for evidence-based medicine

The primary factor adversely affecting refractive surgery is an inability to provide consistently excellent results across patients and refractive centers. This stems from our profession’s apparent disregard for the widespread adoption of evidence-based medicine — although ophthalmology is far from alone among medical disciplines in resisting EBM — and an unwillingness to define clear standards of care that a relentless pursuit of perfection drives.

Our collective oath to “first do no harm” appears to be neutered by the notion that “freedom of expression” somehow validates an industry represented by a literal smorgasbord of technologies ranging from the obsolete to the state-of-the-art. However, we must recognize that, as a group, the public will never perceive our profession to be better than the weakest surgeons among us.

To convince consumers our products are safe, effective and of value, we must be prepared to optimize every outcome. That goal is attainable only if we markedly change the way that we capture, analyze and use outcomes data and perform those tasks on a scale we have not previously considered.

We are data challenged

But our ability to rapidly capture and learn from the vast amount of outcomes data our profession captures is limited. Despite all the advances in technology, we have essentially ignored opportunities to create datasets that define benchmarks and create reproducible algorithms that allow all surgeons to consistently replicate the best results.

So our patients believe refractive surgery is a crapshoot that requires them to navigate a morass of Internet hype in the hope they find the “most experienced” surgeon who uses “leading technology” — whatever that is. If they fail, they could end up on the evening news under the banner of “blinded by the light”.

This minefield of information and disinformation that a medically unsophisticated public must navigate wreaks havoc on consumer confidence in our services and consistently telegraphs a message of “buyer beware”.

If we are serious about changing how consumers perceive refractive surgery, we must face serious management information system failures that are rampant in our profession. Apple and its iPhone may provide a lesson we can learn from.

Lessons from Apple

When Apple introduced the iPhone, plenty of reliable cellular phone devices were already on the market. The fact the iPhone instantly simplified and enhanced its users’ lives drove its incredible success. Moreover, the iPhone provided a consistent consumer experience that promoted user loyalty and cult-like brand evangelism.

So now we have to focus on consistently providing LVC consumers with excellent experiences with visual results that simplify their lives and create value. This is more than having a comfortable office with soft music and a pleasant staff. It’s about creating an excellent experience that delivers a consistently positive visual result that enhances patients’ lifestyles and helps them attain personal goals.

Yet, LVC providers are also in critical need of solutions that simplify their practices and their employees’ tasks, create consistently excellent results, grow their market and provide a satisfied user experience.

We must find solutions to the profound inadequacies in our profession’s management information systems. Advances in computer connectivity and database management have opened a path toward improving consistency and outcomes. Here are five things we need to jump-start our refractive surgery practices.

1 Embrace evidence-based medicine (EBM) and best-practice benchmarking.

EBM involves applying population-based vision outcomes data to the individual patient. Currently, LVC essentially relies exclusively on the limited experience of individual physicians to make decisions about treatment options for any given patient, often based on “seat-of-the-pants” clinical judgment and limited outcomes analytics.

This approach is unacceptable when dealing with human vision. This is particularly egregious in a medical field in which a plethora of easily quantifiable metrics are available and information is so readily managed.

LVC surgeons rapidly find themselves unable to cope with the influx of massive amounts of data regarding patient care. We cannot use paper records and Excel spreadsheet to analyze upwards of 27 Zernike coefficients, Q-values and localized corneal power. We need information technology that captures complex vision metrics automatically, integrates this data into a comprehensive relational database and provides us with real-time outcomes analytics.

2 Provide critical data feedback to laser manufacturers to drive product improvements and accelerate device approvals.

Presently, no method of systematically accessing and analyzing the vast amounts of data exists. Other than a handful of clinical studies with limited patient enrollment, laser and device manufacturers have little, if any, access to the results their devices actually produce.

We need MIS technology that provides LVC manufacturers with unprecedented access to clinical outcomes, meta-data, information on surgeon errors and biases, surgical device misuse and device operations.

This would enable manufacturers to rapidly modify treatment algorithms, provide surgeon guidance and alter device functionality based upon large pools of data, further drive improvements in patient outcomes, markedly reduce development costs and shorten the duration from new product conception to FDA approval.

3 Develop manufacturer-independent turnkey information technology.

Health providers are adopting EHR at a record pace, but network integration of the sophisticated medical and surgical devices we use in vision-correction surgery has not paralleled this trend due to a variety of complex technical and regulatory issues. These laser and diagnostic systems produce hundreds of critical metrics on each patient that essentially remain untouched and unanalyzed because they are locked into paper reports or static electronic pictures of reports. Worse yet, currently, effectively no laser systems or diagnostic devices used for LVC interface with computer networks.

We need universal software and hardware solutions that can immediately do three things:

• Connect to any computer network or EHR.

• Provide digital formats compatible with any EHR of laser system reports traditionally printed on paper.

• Capture critical health metrics from the reports these devices produce to a secure searchable relational database.

The latter would facilitate clinical research and the development of best-practice benchmarks. These solutions also need to be enterprise grade and provide unbreakable hardware and software security barriers to viruses and malware.

4 Adopt integrated EHR solutions suited to LVC.

Currently, due to unique industry requirements, traditional EHR systems are poorly designed to manage health information for LVC patients. I offer some further ideas besides those I’ve already noted to bring this about.

EHR systems manage data for individual patients, but are not designed to perform research across patient cohorts, nor do they provide data query capabilities that would enable surgeons to perform complex vision research. Moreover, no EHR I know of automatically captures the hundreds of vision metrics associated with each vision correction procedure.

Even if cohort queries were possible, any attempt to perform outcomes analytics with today’s EHR systems would require manual input of an unprecedented amount of clinical data. Except for small limited studies, such a task is practically impossible. To overcome this, EHR systems need to perform all of the following functions quickly and easily:

• Integrate a contact management system that manages conversion of LVC prospects to customers.

• Create a completely paperless patient experience that includes touch-screen technology that begins with patient registration, includes touch-screen signature capture for all medical forms and provides a high-tech, patient-physician interaction at every clinical workstation.

• Integrate internal “chat” tools that facilitate care team communication to provide a superior customer experience.

• Integrate automatic data collection from all commonly used clinical diagnostic tools.

• Integrate patient education materials, instructional video and 3D imaging tools that enhance patient conversions and customer experience by projecting a “high tech” environment.

• Integrate electronic marketing tools and communication systems.

• Integrate web portals for financing into the patient experience.

• Use efficient clinical management software that increases patient throughput.

• Integrate software tools and mobile apps to manage patient referral programs.

• Facilitate social media that uses uniquely designed web tools and USB devices as patient incentives and help to drive viral marketing campaigns.

5 Create marketing and advertising tools that give patients confidence in LVC.

Often in LVC, promotional campaigns are expensive, shotgun and of low yield. This leads to blunt-edged campaigns driven by low price or other low-tech gimmicks that simply have no data to support their validity in truly driving overall industry growth. They can damage the LASIK brand as well as confuse consumers and create cynicism regarding LVC.

We need tools that assure more patients they are going to have a credible, ethical and medically sound experience. Here, again, we can learn from the iPhone, whose success has been driven by a strategy focused upon maintaining brand integrity and consumer confidence.

“Predictive analytics” is one rapidly emerging example of a marketing tool that can boost consumer confidence. It has a track record of substantively improving consumers’ understanding and has identified key metrics that can predict prospective clients within the population. Such methodology, as well as the data troves on consumers they own, has made Google, Facebook, Amazon and Netflix, among others, so incredibly valuable.

Understanding the LVC consumer is all about data. Paper charts, traditional EMR’s, and fragmented and isolated websites simply do not provide enough data to capitalize on the power of predictive analytics. We need advanced management information solutions to capture every metric ranging from patient age, e-mail ISP provider, mobile phone location, occupation, contact lens history, client motivation for considering LVC, Facebook “likes” to visual acuity, medical history and individual web clicks — multiplied by thousands of patients and contacts.

Each refractive provider has access to enormous amounts of data on patients but ignores them. We need technology tools that collect this data automatically with each new patient encounter so we can modify our predictive models in real time to adapt to consumer sentiment and economic influences, as well as regional and seasonal factors.

Information is the new “oil”, and we have to get off our backsides and start drilling. When it comes to the use of predictive analytics, we are in the coal age.

WHAT MY PRACTICE HAS DONE

Our own customized MIS solution

A few years ago, I decided to change the trajectory of my own practice, thinking success there could serve as a guiding light to point our profession forward and away from what I saw as a world of evidence-based chaos. Rolling up my sleeves, I immersed myself in information technology with the goal of tackling the specific challenges I’ve articulated here. Starting from nothing, we created a customized MIS solution that addresses all the factors I have addressed here.

The results have been overwhelmingly positive. Patients find the interactive consumer interface consistent with their expectations of how a high-tech office experience matches a high-tech procedure. More importantly, by allowing me to analyze hundreds of data points and metrics on each patient in real time, the software and hardware create orders of magnitude that give me more insight into the clinical picture of each eye and impact outcomes in a positive way.

What data analytics gives us

For example, the data analytics software allows me to begin to understand the complex optical interactions between lower-order aberrations such as myopia and higher-order aberrations such as spherical aberration and coma, as well as corneal thickness and corneal diameter. We cannot understand these types of complex interactions from a few hundred eyes in a clinical study. Moreover, with the solution that we have developed, our system, much like the famous Watson of “Jeopardy” fame, continuously learns and tweaks our treatment algorithms.

This type of continuous improvement, often called Kaizen — Japanese for improvement or change for the best — must become the norm in our profession. If we want consistently excellent outcomes, the database technology and data analytics solutions need to incorporate massive amounts of data gathered from every refractive surgeon. From there we can begin to understand the factors that drive excellence as well as those that deter it. To quote Uncle Ben in “Spiderman”: “With great power comes great responsibility.” As a profession, we exercise great power. We must learn to wield that power with greater responsibility. If we do not, we will continue to be judged by our worst results rather than our best.

Going forward, know the ‘real’ competition

Just as the iPhone created a consumer revolution by delivering a consistently excellent customer experience, our profession must do the same when it comes to refractive surgery. If consumers perceive consistently excellent surgical outcomes are the exception rather than the rule, refractive surgery will never attain widespread consumer buy-in. We can only accomplish this endpoint if we are willing to create the tools and methods to give each surgeon the capability to deliver the best surgical results.

We must also stop deluding ourselves that our colleagues are our competition. The real “competition” that holds us back is our collective lack of focus on our profession’s ability to consistently deliver visually excellent outcomes compared to contact lenses and glasses. When consumers believe that is possible, refractive surgery will own vision correction. However, if we persist on a course that consistently delivers an inconsistent product, we are destined to remain a fringe player in vision care.

In 2014, we can no longer hope to succeed in a world where both good and bad news can go viral in a matter of minutes if we are willing to tolerate bad results from any one that portrays themselves as a refractive surgeon. Our industry must take the necessary steps to ensure that every patient outcome is the best it can be. Only then can we expect that what consumers perceive and what is spoken about in public, on television, on the internet, in chat rooms, blogs, Twitter and every instant method of communication known today or invented tomorrow will uniformly speak positively regarding our vision products. We must become serious about changing our industry and solving its MIS challenges today. OM

Brian R. Will, MD, is medical director of Will Vision and Laser Centers with locations in Vancouver, Portland and Salem, Ore., and is an adjunct clinical professor at Loma Linda University School of Medicine, Loma Linda, Calif., and Pacific University in Forest Grove, Ore. His e-mail is drwill@willvision.com. Disclosures: Dr. Will has no relevant conflicts to disclose.