Учебники / Computer-Aided Otorhinolaryngology-Head and Neck Surgery Citardi 2002

come increasingly commonplace as a preoperative educational tool and a surgical planning tool. The World Wide Web has become an increasingly important forum for communication and education.

As computer technology has caught up with the needs and dreams of surgeons, increasingly it is finding significant applications in the operating room. Continuing technological advances—some anticipated, others not—will undoubtedly lead to continued improvements in facial plastic surgical care. As we become increasingly reliant on computer technology, it is critical that we understand its potential and also its potential pitfalls, such as medicolegal issues. Understanding the rapidly occurring developments in computer technology may allow facial plastic surgeons to prepare for the office and operating room of the future. In this chapter, we discuss the current and potential future status of computer technology in facial plastic surgery.

20.2PLASTIC SURGICAL OFFICE SOFTWARE

Office software has become so integrated into physician practices that it is often overlooked in discussions of computers in otolaryngology and facial plastic surgery. Zupko and Toth provide an overview of important considerations in the selection of a computer system that meets the specific practice needs of the facial plastic surgeon [1]. They point out the importance of having an organized approach, especially when one considers that there are approximately 1000 practice management systems available nationwide. Zupko and Toth describe what they perceive to be the facial plastic surgeon’s specific practice needs: namely, a need for niche marketing strategies; a need to track patient relationships from the first telephone call, to the appointment, to surgery, and postoperatively; a need to track skin care product use and sales; a need to track in-office OR inventory; financial control given the cash nature of cosmetic surgery; and computer imaging. They emphasize the need for an integrated system that incorporates all of these factors.

Hodnett described important guidelines for the facial plastic surgery practice seeking new office software [2]. He felt that office software must have the following features: it must be Windows based (Microsoft Corporation, Bellevue, WA), it must be Y2K compliant, and it must be able to integrate easily with present and future programs. In addition, Hodnett proposed that the software should easily customize materials (such as forms) for the patient, that it should decrease the need for the patient to ask questions before and after surgery, and that it should simplify the tasks of the office staff. The author felt that an office software program should be able to track patient information, including demographical information (such as the geographic origin of patients) and practice parameters (such as the percentage of patients who seek consultation and ultimately proceed to surgery). A knowledgeable sales force with immediate techni-

cal and customer support was also deemed vital. The software should have comprehensive database capabilities to accommodate the critical need for comprehensive reports in practice management. Lastly, the author emphasized that the software company should provide a copy of the software in the office on floppy disk or CD-ROM, because the practice could be stranded if the computer’s hard drive fails.

Quatela et al. [3] reviewed important considerations in plastic surgical office software. They pointed out a number of important practical considerations, including the need for an adequate network server, the ability of the system to quickly compile and analyze reports, electronic scheduling and mailing, and electronic billing link to insurance companies. They noted that the Health Care Financing Administration indicated that by 2002 insurance companies and state providers will only accept electronic claims [3,4].

20.3DIGITAL PHOTOGRAPHY, COMPUTER IMAGING, AND PHOTOARCHIVING

Photographic images in facial plastic surgery play a critical role in photodocumentation, patient education, preoperative planning, and self-education [5–8]. Consistent, uniform, high-quality photography allows the best opportunity for critical self-assessment and self-education by surgeons. Uniform photographs are essential for legal documentation of surgical events and outcomes. Furthermore, an increasingly sophisticated patient population often asks to see photographic examples of a surgeon’s work, providing an added incentive for the surgeon to produce high-quality, uniform, professional images that reflect the surgeon’s attention to detail. However, perusal of most medical journals suggests widespread and significant persisting deficiencies in photographic quality.

Equipment, lighting and background, film selection, and a standardized photographic technique are critical aspects of achieving satisfactory images (Figure 20.1, Table 20.1). Multiple reports discuss the essential elements of professional photography for facial plastic surgery [5–8]. Digital cameras are becoming increasingly less expensive and offer increasingly better quality; they also have significant advantages with regard to ease of image storage and retrieval [6]. Miller et al. compared a number of currently available digital cameras [8].

Photographic storage may be more cost-effective and efficient with digital systems. Ease of storage and image retrieval are important considerations. A busy plastic surgical practice may accumulate as many as 2 million images over a 30year surgical practice [5]. Storage of such a large volume of traditional 35 mm slides requires a significant amount of space, in contrast to a similar number of digital images.

Patients seeking cosmetic surgery now often expect preoperative imaging. Improvements in hardware and software have allowed great increases in speed

FIGURE 20.1 Diagrammatic photographic setup. The patient is seated in front of the photographic background on a chair with a back support. The chair rotates so that patient positioning may be optimized. The camera may be mounted on a mobile tripod, or it may be hand-held by the photographer. The camera is connected to synchronized lights; a ‘‘kicker’’ light overhead and behind the patient is optional.

and accuracy in patient imaging. This can facilitate doctor-patient communication and has the potential to help provide realistic patient expectations. Indeed, Papel and Jiannetto report that a literature search (through 1998) revealed no lawsuits directly involving computer imaging [9]. They suggest that conservative utilization of computer imaging by the facial plastic surgeon may actually reduce liability and promote communication.

Typically, a patient presenting to the plastic surgeon will undergo preoperative photography. Either at the time of the initial visit (or at a later visit), the plastic surgeon or a staff member will review the proposed changes in the patient’s physical appearance on the patient’s computerized image. It must be carefully explained to the patient that this exercise is nothing more than another form of communication. In this way, digital photography helps ensure that both the surgeon and the patient share similar surgical goals. Indeed, computer imaging, when accompanied by appropriate explanation, provides the opportunity for improved patient-doctor communication.

The surgeon or staff member should explain to the patient that computerbased morphing cannot take into account certain unpredictable factors that are a part of the practice of surgery. The patient is ‘‘analog’’ and not ‘‘digital;’’ so the results of an actual surgery can in no way be predicted or represented in advance by a computer ‘‘simulation.’’ The imaging is simply a way for both the patient and doctor to share an image of the surgical goal. Of course, this process can be a reassuring exercise for both the patient and the surgeon. Patients typically

understand this simple concept; some surgeons incorporate provisions that address this disclosure into a consent form.

Papel and Jiannetto also noted recent technological advances that have significantly enhanced the value of computer imaging in the facial plastic surgery practice [9]. Miniaturization, portability, increased speed, and decreased cost have made computer imaging more accessible (Figure 20.2). Indeed, while Koch and Chavez estimated that 10% of cosmetic surgeons owned computer imaging systems in 1998 [10], it has been projected that up to 45% of cosmetic surgeons will own them by 2001 [11]. The imaging process may facilitate presurgical planning and clarification of the surgeon’s own thought processes. Various ‘‘expert system modules,’’ such as the Gunter Rhinoplasty Module (Mirror Imaging Systems), may aid the surgeon in selecting an effective technique for a particular deformity. These algorithms reflect a database that summarizes the approach of a particular expert or the consensus approach of a panel of experts in a variety of clinical situations [9,12]. These systems may be most useful for resident surgeons and novice surgeons.

Chand conducted a survey of 50 facial plastic and reconstructive surgeons in the United States and Canada [13]. In this group, 61% of the 44 respondents reported that they use computer imaging in their practice, but most respondents use the technology for ‘‘selected’’ patients only. Interestingly, there was no correlation between years in practice and the use of a computer-based system.

20.4COMPUTERS IN SLIDE PRODUCTION AND PRESENTATIONS

Computer software for presentations have transformed traditional slide presentations into an elaborate multimedia events [14]. The production of slides is no

20.2 Patient presenting for rhinoplasty (A) who requested pre-operative computer imaging simulation (B). The imaging was done on a laptop personal computer using an inexpensive software program. The photographic slide was scanned into the computer using a ScanJet ADF with Slide Adapter (Hewlett-Packard, Palo Alto, CA). The image was then altered using SuperGoo morphing software (ScanSoft, Peabody, MA). Transfer of the image into the computer via the slide scanner and then into Kai’s SuperGoo degrades the image quality somewhat. This degradation in image quality may be disadvantageous, especially when compared against dedicated high resolution digital cameras, which directly acquire the digital image. However, the senior author prefers the slight fuzziness of the computer simulation image. The fuzzy image seems to reinforce the point that the computer morphing is simply a helpful communication tool regarding the goals of surgery, and that it is not designed in any way to suggest a guaranteed or exact result. The postoperative result shown for this patient (C).

longer a time-consuming and expensive process. Digital cameras and digital scanners allow easy input of pictorial information that can dramatically enhance a presentation. New digital projection equipment will support a direct electronic link to the presenter’s PC, increasing the flexibility of presentations, which now can be altered at a moment’s notice. Indeed, it is important to note that dynamic visual aids have a dramatic and measurable effect on audience recall [15]. While the business world has fully adopted these advances, the medical community has been slower to make the transition to these presentation methods.

20.5COMPUTER-BASED LONG-DISTANCE EDUCATION

Meyers summarized the increasing use of the Internet and the World Wide Web for distance education, both of patients and of facial plastic surgeons [16]. He notes a recent report indicating that 22.3 million adults, or nearly 40% of American adults online, used the Internet to seek health-related information [17]. In addition, online journals are proliferating. Several journals offer a website with supplemental materials to the journal. For example, the Archives of Facial Plastic Surgery, an American Medical Association journal and the official publication of the American Academy of Facial Plastic & Reconstructive Surgery and the International Federation of Facial Plastic Surgery Societies, has expanded its content at its web site (http://www.ama-assn.org/facial).

Available electronic textbooks offer immediate, up-to-date information enhanced with audio and video. The first comprehensive textbook of facial plastic and reconstructive surgery is online at http://www.emedicine.com.

Meyers described online chat rooms and discussion groups for facial plastic surgery [16]. FACEnet was established at the University of Colorado Health Sciences Center in 1995 for facial plastic surgeons and has over 250 participants. (For more info about FACEnet, please contact Facenet-request@lists.uchsc.edu). FACEnet members submit questions or cases to colleagues for online advice or consultation.

Several university departments of Otolaryngology–Head and Neck Surgery have posted an online syllabus and grand rounds, including topics in facial plastic and reconstructive surgery. Meyers recommended the website of Baylor College of Medicine as an excellent example (http://www.bcm.tmc.edu/oto) [16].

Online continuing medical education, while still in its infancy, is developing rapidly. Nevertheless, some sites already have extensive offerings, such as America’s Health Network (http://www.ahn.com), the Virtual Lecture Hall (http://www.vlh.com), and others.

Meyers also highlighted several excellent basic science and clinical information websites. He points to the Visible Human Project, a computer-accessible database of over 13,000 images that comprise the National Library of Medicine

Visible Humans. By visiting the National Library of Medicine site (http:// www.nlm.nih.gov/pubs/factsheets/visible human.html), surgeons can study human facial anatomy in a number of formats [16].

Surgical simulators offer enormous potential for teaching complex facial plastic surgery procedures. Meyers reported that the Center for Human Simulation at the University of Colorado has developed simulators for a few selected surgical procedures. These simulators allow surgeons to practice on virtual patients or body parts without the cost and risk of using live patients [16].

20.6THE INTERNET IN FACIAL PLASTIC SURGERY

The Internet offers easy unrestricted access to an incredible volume of information. For this reason it has become a vital tool in the facial plastic surgical practice [18]. The American Academy of Facial Plastic Surgery (AAFPRS), the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS), and the American Rhinologic Society (ARS), as well as other professional organizations, have recognized that the Internet can dramatically help communication among surgeons, members, patients, and the general public. For this reason, many websites, including the AAFPRS site (www.aafprs.org), the AAO-HNS site (www.entnet.org), and the ARS site (www.american-rhinologic.org), offer services to members and nonmembers alike (Figure 20.3). Mendelsohn and Hilger reported that the AAFPRS site received approximately 220,000 hits per month from more than 50,000 visitors in 1999 [19]. At the AAFPRS site, the most commonly visited nonmember areas are the ‘‘Procedures,’’ ‘‘Facial Plastic Surgery Today,’’ and ‘‘Find a Surgeon’’ sections.

Larrabee and Eggert [20] describe their experience with the World Wide Web. They concluded that the Internet is the medium of the future for physicianpatient communication and that sooner or later every facial plastic surgeon will need a web presence to maintain a viable clinical practice. Approximately 40% of the U.S. adult population accesses the Internet, and this number continues to grow. The Internet is a valuable way to provide information to current and potential patients and to provide general information to the public. Importantly, Larrabee and Eggert emphasized that e-mail interactions with patients and potential patients should be limited until privacy and medicolegal issues are resolved.

Wall and Becker [21] reported on the growing presence of facial plastic surgery sites on the Internet. They noted that a search on the Microsoft Network’s search engine on August 22, 1999, for ‘‘plastic surgery’’ and ‘‘facial plastic surgery’’ identified 39,469 and 5718 sites, respectively. The search parameter ‘‘facelift’’ yielded 12,031 sites, while the search term ‘‘rhinoplasty’’ produced 2923 sites. These numbers reflect an ever-expanding number of people turning to the Internet as a source for medical information. One report noted that 64.2 million

FIGURE 20.3 The American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) home-page. (www.aafprs.org.)

Americans routinely use the Internet for data retrieval [22]. Additional growth in this usage may be anticipated.

Chand conducted a survey of 50 facial plastic and reconstructive surgeons in the United States and Canada [13]. In this survey, 91% of the 44 respondents reported that they maintain an e-mail address, and 64% have a practice web site. Interestingly, 43% of the sites provided ‘‘information only,’’ while the remaining sites permitted users to ask questions that may be answered in a delayed fashion.

Internet-based patient education applications have also been implemented. Murphy has discussed the option of in-office computer for interactive computer programs that serve to make the patient an informed member of the decisionmaking team [23]. This software can improve the doctor-patient interaction and reduce patient anxiety. This approach may be considered a supplement to or even a replacement for standard videotapes, which some physicians use for patient education. Computer-based instruction offers a significant advantage since the

interactive patient education programs are generally thought to yield the highest rate of information retention of any information-delivery system. In order to facilitate their use, these programs may be transitioned to an Internet-based system, which offers the potential for near universal adoption.

Telemedicine, the provision of health care consultation and education using telecommunication networks that communicate information between remote providers and expert mentors offers tremendous opportunities but needs to overcome significant impediments. The widespread availability of the Internet has shifted most telemedicine efforts to this medium, rather than dedicated network facilities. While telemedicine technology may provide easy rapid access to both generalized and specialized medical care (including facial plastic surgical consultation), technical, financial, and legal restrictions must be addressed before telemedicine becomes more widespread in facial plastic surgery [24].

Telemedicine’s initial emphasis had been the provision of general medical services in areas where medical services are limited; however, today, there may be an an even greater need for subspecialty services, since today’s medical system often restricts access to medical and surgical specialists. Sclafani and Romo [24] identified a number of challenges in telemedicine, including the need to (1) define the settings in which telemedicine will benefit patients, (2) balance the benefits of an ‘‘in-person’’ consultation with the theoretical efficiency of a telemedicine encounter, (3) determine the most appropriate type of telemedicine transmission (telephone, high-speed line, or Internet), (4) define the clinical and technical requirements necessary to provide enough information of sufficient detail to make accurate diagnosis and treatment plan, (5) ensure confidentiality of the electronic medical record, and (6) develop a program that accommodates both legal and financial restrictions.

20.7OUTCOMES RESEARCH

In his discussion of outcomes research in facial plastic surgery, Goldberg emphasized that a powerful database is central to any coordinated assessment in health care [25,26]. Computer technology makes possible the efficient and organized accumulation and processing of data to measure the patient experience; this information can then be applied to the analysis and improvement of patient care. This type of quality assurance is as important in facial plastic surgery as in any other medical discipline.

Health-related quality-of-life (HRQOL) questionnaires that focus on aspects of general health can be used in this sort of analysis. The short-form 36 (SF-36) has become popular because of its ease of administration and proven reliability across many diseases. However, to measure factors that relate more specifically to a particular disease process, survey instruments, known as diseasespecific HRQOLs, have been proposed. However, development of these question-