Effect of digital cataract workflow on time and resource efficiencies in cataract surgery: time and motion study

Integration of digital workflow significantly reduced the overall cataract surgery time, variability of overall time, number of data fields recorded, and resource utilization to offer efficiency gain in cataract surgery.

Abstract

Purpose:

To compare time and resource saving with integration of digital cataract workflow to the existing workflow in high-volume cataract surgery clinics.

Setting:

L V Prasad Eye Institute, Hyderabad, India (site 1), and Narayana Nethralaya, Bengaluru, India (site 2).

Design:

Prospective, time and motion.

Methods:

The total time to complete each step (preoperative measurements, surgical planning, and surgical procedures) of the cataract workflow, number of data fields entered, and support staff required for both workflows were recorded. All study measurements were determined first for existing electronic medical record (EMR) cataract workflow followed by digital workflow (integrated data management system with data reviewer, surgical planner, and data transfer to operating room) at both sites.

Results:

A total of 85 (site 1, 44; site 2, 41) cataract workflows were analyzed. The integration of digital workflow into the site's existing EMR workflow reduced the mean time for preoperative measurements by 25.3% (P = .006), surgical planning by 55.1% (P = .008), and surgical procedures by 22.6% (P = .002). The mean ± SD overall time for the surgery was significantly shorter in the digital group (887.3 ± 103.3 vs 1271.3 ± 300.7 seconds; P < .0001). For both sites, the number of data fields recorded and number of support staff needed were significantly lesser for the digital workflow (P < .0001, for both).

Conclusions:

Integration of digital workflow significantly reduced the overall cataract surgery time, variability of overall time, number of data fields recorded, and resource utilization. Complete digitalization has important implications for improving the efficiency and standardization of cataract surgery workflow.

The World Health Organization estimates the global population aged 60 years and older to double and those 80 years and older to triple by 2050.¹ Population-based studies have shown that the incidence of cataracts increases with age ranging from 3.8% to 47.7% in 55 to 64-year-old individuals and from 0.7% to 92.6% among those 80 years and older.^2–5 Owing to the aging population and increased life expectancies, the demand for cataract surgery is rising worldwide.⁶

Over the years, techniques of cataract surgery have evolved; the development of intraocular lens (IOL) in terms of design and material has resulted in better postoperative refractive outcomes.^7,8 Regardless of the advancements in cataract surgical practices and improved safety profiles, surgical planning still involves comprehensive preoperative and intraoperative assessments including patient selection, thorough ocular examination, selection of accurate formulas for IOL power calculation, and postoperative management.^7,9,10 Not all diagnostic instruments used for preoperative measurements have the formula for calculating IOL power included and, hence, may need data transfer to and from various devices.^11,12 For optimal surgical planning, surgeons need to review the preoperative workup in a paper-based format or electronic medical records (EMRs), which are available either on different devices than those used for IOL calculations or through digital data management systems. In short, cataract surgery workflow includes multiple preoperative assessments and manual transcription of these data to cataract surgical planning systems, which can be error-prone and time and resource-consuming, leading to increased costs.

Considering the rising volume of cataract surgeries and an inadequate number of ophthalmologists performing these procedures, improving the efficiency of cataract workflow is of key importance.^6,13,14 This would enable error-free preoperative planning, good visual outcomes, and minimal complications. In this regard, newer technologies have reported a reduction in the time required for surgical planning using online software, better refractive outcomes with computer-assisted toric IOL axis marking, and convenient and efficient toric IOL power calculation and toric IOL implantation using the software-based digital approach.^15–19

To our knowledge, time and resource saving for monofocal, nontoric IOLs at high-volume cataract facilities using a software-based digital cataract workflow compared with a conventional approach are not adequately addressed. Assessing the advantages of a digital cataract workflow irrespective of the existing workflow and the type of IOL implanted can provide insights for simpler and seamless services and improved patient satisfaction specifically at high-volume cataract facilities. Hence, this study compared the time and resource saving in cataract surgery with the integration of ZEISS digital cataract workflow (Carl Zeiss Meditec AG) to the existing cataract workflow in the clinic.

METHODS

Study Design

This is a prospective, time-and-motion, nonclinical study to evaluate time and resource utilization with the integration of ZEISS digital cataract workflow solution to the clinic's existing EMR-based cataract surgery workflow, for patients undergoing routine age-related cataract extraction with monofocal nontoric IOL implantation.

This study was conducted at 2 high-volume cataract surgery sites, namely L V Prasad Eye Institute, Hyderabad, India (site 1), and Narayana Nethralaya, Bengaluru, India (site 2), between July and November 2022. The study parameters were measured consecutively for the workflows—first, for the existing EMR-based workflow. ZEISS digital cataract workflow was then installed at the site followed by the measurement of parameters for the digital workflow. The ZEISS digital cataract workflow facilitates a complete digital workflow from the clinic to the operating room (OR) and consists of (1) FORUM, which allows for digital data transfer to and from various devices connected to the cataract surgery workflow. (2) EQ Workplace, which is the cataract surgical planner to autopopulate IOL power calculation, using state-of-the-art IOL formulas, lens selection, lens ordering, and surgical parameters. The data are then exported digitally to the OR. (3) OPMI with CALLISTO Eye in the OR, which is an image-guided markerless system.

The study was performed in accordance with the tenets of the Declaration of Helsinki. The study protocol was reviewed by the Narayana Nethralaya Institutional Ethics Committee and was deemed exempt from approval, as no protected health information or clinical data were collected.

Sample Size

The number of cataract workflows was estimated based on a minimum of 5 minutes time savings (300 seconds) per workflow after implementing the Zeiss digital cataract workflow and the enrollment ratio of the 2 types of workflows. As both the study sites were high-volume cataract surgery hospitals (>100 preoperative assessment and surgical procedures in a day) with staff skilled in executing the EMR workflow, the enrollment ratio of 1:3 for the existing EMR workflow to the digital workflow was determined. Therefore, a sample size of 21 workflows (existing workflow: 5 and digital workflow: 16) was estimated to achieve a power of 80% and a significance level of 5% (2-sided).

Study Measurements

The total time to complete each step of the workflow such as preoperative measurements, surgical planning (data review, calculation of IOL power, transfer of data to intraoperative devices), and surgical procedures (import and verification of data in OR and surgery) were recorded, using a stopwatch, for the existing EMR cataract workflow and the digital cataract workflow. All study measurements at each site were performed by the same observer. The time recorded was limited to the data entry and duration of measurement at each device/review stage. In addition, the number of data fields entered and support staff required for the workflows were recorded. Any wait time, a challenge with patient mobility, and/or alignment and instructions were not included in the measurements.

Cataract Surgery Workflow Steps

Preoperative Measurements

As part of the standard workflow, both eyes of each patient underwent preoperative measurements and IOL power calculation at both sites. The protocol for preoperative cataract assessment at the sites started with optical biometry using the LENSTAR (Haag-Streit AG) and IOLMaster 700 (Carl Zeiss Meditec AG) devices. Ultrasound contact biometry (Tomey Corp.) and optical coherence tomography (OCT, Optovue, Inc.) were performed at site 1 only when the optical biometry measurements exhibited large variability and/or for patients with dense cataracts. At site 2, all preoperative cataract measurements also included corneal topography (Pentacam) and OCT (Heidelberg Engineering GmbH) measurements. Specular microscopy was performed only if required per the site's protocol (Figure 1). All preoperative data were entered into the patient's EMR as part of the existing workflow at both sites. In the digital workflow group, the data was exported from the measurement devices to FORUM.

Figure 1.

Cataract surgery workflow in the digital and existing groups (A) site 1 and (B) site 2. EMR = electronic medical record; OR = operating room.

Surgical Planning

A monofocal nontoric IOL was planned in all the workflows in the study. In the site's existing EMR workflow, the reference images and data for the IOL power calculation were reviewed by a surgeon, and surgical parameters were determined. The relevant IOL data and surgical parameters were transferred to the OR computer through EMR.

In the digital cataract workflow, the surgical planner software within EQ Workplace was used to determine and review IOL power and surgical parameters as well as the automatic export of the surgical plan to the CALLISTO eye in the OR.

Surgical Procedures

Procedures in the OR included (1) import of the surgical plan, including the IOLMaster reference data; (2) verification of the patient information, IOL power, and surgical parameters; and (3) surgery (removal of the crystalline lens, and IOL implantation). In the site's existing EMR workflow, all the data were exported electronically through EMR to the OR computer and reviewed by the operating surgeon. In the digital cataract workflow group, the data and reference images were available in the CALLISTO eye directly from FORUM and the surgical planner.

Statistics Analysis

Descriptive analysis was performed to compare time and resource utilization between the 2 workflows. Continuous variables were presented as mean and SD. t Test was used for comparison of the means between the groups, and a P value of less than 0.05 was considered statistically significant.

RESULTS

Across the 2 study sites, time and resource measurements for both the existing EMR workflow and digital cataract workflow were performed for a total of 86 (site 1, 45; site 2, 41) cataract workflows. One of the surgeries at site 1, within the EMR workflow, required a vitrectomy procedure and was excluded from the analysis.

Preoperative Assessments

At each site, the sequence of preoperative testing remained consistent between the existing EMR workflow and digital cataract workflows. Overall, the mean ± SD time required to complete preoperative measurements was significantly shorter in the digital group compared with the site's existing workflow group (333.1 ± 92.3 vs 446.1 ± 153.7 seconds, respectively)—resulting in time saving of 25.3% (P = .006) (Figure 2). The mean preoperative testing time varied between the 2 sites because of the difference in the number of tests performed during the cataract workflow (Table 1).

Figure 2.

Pooled analysis of time measurements and savings at various steps in cataract surgery workflow (N = 85). Time savings (↓ down arrow). $\text{Time}\hspace{0.17em}\text{saving}=\frac{\left(\text{time}\hspace{0.17em}\text{measured}\hspace{0.17em}\text{with}\hspace{0.17em}\text{site}’\mathrm{s}\hspace{0.17em}\text{existing}\hspace{0.17em}\text{workflow}\right)‐\left(\text{time}\hspace{0.17em}\text{measured}\hspace{0.17em}\text{with}\hspace{0.17em}\text{digital}\hspace{0.17em}\text{workflow}\right)}{\text{time}\hspace{0.17em}\text{measured}\hspace{0.17em}\text{with}\hspace{0.17em}\text{site}’\mathrm{s}\hspace{0.17em}\text{existing}\hspace{0.17em}\text{workflow}}\times 100$. Surgical planning includes data review, calculation of IOL power, and transfer of data to intraoperative devices. Surgical procedures include data import and verification in operating room, and surgery. $\text{Overall}\hspace{0.17em}\text{time}=\left(\text{preoperative}\hspace{0.17em}\text{measurements}\right)+\left(\text{surgical}\hspace{0.17em}\text{planning}\right)+\left(\text{surgical}\hspace{0.17em}\text{procedures}\right)$. *P < .05; **P < .0001.

Table 1.

Comparison of time measurements for various steps in cataract surgery workflow at site 1 (N = 44) and site 2 (N = 41)

Workflow steps of interest	Existing workflow group Mean ± SD	Digital workflow group Mean ± SD	P value
Site 1	n = 9	n = 35
Preop measurements (s)	368.7 ± 180.3	282.7 ± 47.4	NS
Surgical planning (s)a	438.4 ± 171.4	165.1 ± 13.5	<.0001
Surgical procedures (s)b	622.2 ± 73.7	476.8 ± 58.8	<.0001
Overall time (s)c	1429.3 ± 264.1	924.6 ± 81.5	<.0001
Site 2	n = 10	n = 31
Preop measurements (s)	515.7 ± 83.3	390.0 ± 97.9	.0015
Surgical planning (s)a	98.4 ± 27.4	61.6 ± 13.1	.0001
Surgical procedures (s)b	514.9 ± 196.3	393.5 ± 59.4	.037
Overall time (s)c	1129.0 ± 267.0	845.2 ± 110.2	.001

NS = not significant; OR = operating room

^aSurgical planning includes data review, IOL power calculation, and export of relevant IOL data to the OR system for surgery

^bSurgical procedures include data import and verification in OR and surgery

^cOverall time = (preoperative measurements) + (surgical planning) + (surgical procedures)

Surgical Planning

The mean ± SD time for surgical planning was significantly shorter with the digital cataract workflow (116.5 ± 53.7 seconds) compared with the conventional workflow (259.5 ± 209.4 seconds; P = .008), resulting in a time saving of 143.0 seconds or 55.1% (Figure 2). The relative difference between the digital cataract workflow and the existing EMR workflow was 273.3 seconds at site 1 and 36.8 seconds at site 2 (Table 1).

Surgical Procedure

In the OR, the complete time for the surgical procedures (data import, verification, and surgery) was reduced by 22.6% using the digital cataract workflow approach (437.7 ± 72.0 vs 565.7 ± 157.2 seconds, respectively; P = .002) compared with the site's existing EMR workflow (Figure 2). The reduction in surgical procedure time with the integration of the digital workflow was similar between the sites (site 1, 23.4% and site 2, 23.6%) (Table 1).

The overall time (diagnostic, surgical planning, and OR time) for the surgery was significantly shorter in the digital cataract workflow group (887.3 ± 103.3 vs 1271.3 ± 300.7 seconds, respectively; P < .0001), resulting in a time saving of 30.2% with the digital cataract workflow compared with the site's existing EMR workflow (Figure 2). The overall time spent on cataract surgery was decreased by 504.7 seconds at site 1 and by 283.8 seconds at site 2 with the digital cataract workflow compared with the site's existing EMR workflow (Table 1). In addition, there was almost a 3-fold reduction in the SD for the overall time, indicating a consistent workflow time with the integration of the digital cataract workflow.

Data Entry and Resources

The number of data entry fields recorded for the existing EMR workflow was 32.0 ± 4.7 (site 1) and 28.3 ± 3.0 (site 2), which was significantly reduced to 16.0 (site 1, 50.0% reduction) and 16.1 ± 2.4 (site 2, reduction by 43.2%) (P < .0001, for both) with the digital cataract workflow. The number of data entry fields was similar at both sites for the digital cataract workflow (Figure 3).

Figure 3.

Comparison of data acquisition and resource utilization between the cataract surgery workflow groups at (A) site 1 (N = 44) and (B) site 2 (N = 41). Time savings (↓ down arrow). $\text{Time}\hspace{0.17em}\text{saving}=\frac{\left(\text{time}\hspace{0.17em}\text{measured}\hspace{0.17em}\text{with}\hspace{0.17em}\text{site}’\mathrm{s}\hspace{0.17em}\text{existing}\hspace{0.17em}\text{workflow}\right)‐\left(\text{time}\hspace{0.17em}\text{measured}\hspace{0.17em}\text{with}\hspace{0.17em}\text{digital}\hspace{0.17em}\text{workflow}\right)}{\text{time}\hspace{0.17em}\text{measured}\hspace{0.17em}\text{with}\hspace{0.17em}\text{site}’\mathrm{s}\hspace{0.17em}\text{existing}\hspace{0.17em}\text{workflow}}\times 100$. *P < .0001.

The number of support staff for the digital cataract workflow was significantly reduced by 30.9% at site 1 and 26.4% at site 2 compared with the existing EMR workflow (P < .0001, for both; Figure 3).

DISCUSSION

This time-and-motion study was conducted to investigate the time and resource saving with the use of ZEISS digital cataract workflow compared with the site's existing EMR cataract workflow for routine age-related cataract extraction and monofocal nontoric IOL implantation. Time-and-motion studies evaluate healthcare delivery practices and especially transform existing processes or implement new systems to improve efficiency and reduce costs.²⁰ To our knowledge, this is the first study to assess the possibility of reducing the time and resources with the integration of ZEISS digital cataract workflow to the existing workflow at high-volume cataract facilities. In this study, disparities were noted in the overall time savings between both facilities. Compared with the site's existing EMR workflow, the time for preoperative measurements, surgical planning (data review, IOL power calculation, and transfer of data to intraoperative devices), and surgical procedures (import and verification of data in OR and surgery) were significantly shorter in the digital cataract workflow group, resulting in a statistically significant reduction in the overall time for the cataract workflow. In addition, the digital cataract workflow significantly decreased the number of fields recorded and support staff needed.

The cataract surgery practice patterns (including preoperative ocular diagnostics) across institutions and regions influence the time and efficiency gains achieved.^21,22 In this study, the differences noted in terms of time saving, decreased data field entries, and the number of resources used between the 2 study sites suggest that the efficiency gains achieved with the integration of a digital workflow are particularly pronounced in the current setup and likely to be greater where manual steps and/or paper-based workflows are prevalent. Efficient preoperative assessments, surgical planning, and managing patient data are equally important in the cataract surgery workflow. Faster preoperative assessments with the ZEISS digital cataract workflow observed in this study are in line with previously published reports on the digital approach vs the manual approach.^17,18 A swept-source OCT biometer demonstrated faster measurement times, reduced the need for ultrasound biometry, and reported additional benefits of integration with other devices.^14,23

Reducing potential errors and more efficient surgical planning have important implications for surgical productivity. A significant time saving for surgical planning (including data review, IOL power calculation, and export of data to intraoperative devices) observed in our study is consistent with the recent report on using software-based surgical planning for toric IOL implantation.^15,19 Automatic import of preoperative information, fewer data field entries, and direct ordering of IOLs with the digital cataract workflow may reduce the risk of data transcription errors and provide a secure data trail during the cataract surgery workflow. This is of great significance in high-volume cataract surgery facilities where mixing of the patient data, wrong lens implant, incorrect lens order, or power calculations is likely.^24–26

Given the high volume of cataract procedures performed worldwide, perioperative settings and arrangements are equally important for improving efficiency and surgical outcomes.²¹ In this regard, the use of a customized surgical pack (vs sourcing the individual surgical items), a software-based digital approach for IOL axis marking and implantation and online software for surgical planning have shown a convenient and more efficient approach for cataract surgeries.^15,19,27 In brief, an overall (diagnostic and surgical) time saving of 6.4 minutes per surgery with the ZEISS digital cataract workflow highlights a more suitable and efficient workflow for high-volume cataract facilities after the integration of the digital platform. In addition, digitalization of the workflow reduced the variability in measurements recorded as denoted by the decreased SD values. This reduction in variability in preoperative testing and surgical procedure could allow better scheduling of patient visits, reduction in wait times, and standardization of workflow procedures. A significant reduction in the number of data fields recorded (46.8%) with the digital cataract workflow corroborates with a previously published study assessing online surgical planning software vs the manual approach.¹⁵ Moreover, the reduction in the number of staff resources per workflow can facilitate effective resource utilization and serve more patients within the clinic.

Given the increasing demands of cataract surgery, healthcare systems are continually working to decrease wait times and standardize this entire workflow, to improve patients' quality of life and satisfaction.²⁸ The total time saved with digitalization can accommodate and treat more patients and thus, lowering wait times, especially in high-volume facilities. Moreover, digital cataract workflow based on the ZEISS FORUM platform can integrate with various DICOM-compatible devices regardless of the manufacturer and allow a streamlined digital workflow solution together with the prevailing cataract infrastructure.²⁹

This study has a few limitations. The differences in the practices followed at the study sites in terms of preoperative ocular measurements and/or the diagnostics performed might influence the time and resource savings achieved. We have not performed a comparison of a digital cataract workflow with a fully manual approach, which can provide more insights in terms of the time and efficiency for high-volume facilities. Manual data entry in healthcare levies high costs in terms of additional time and resources needed to complete processes and rectify errors. The integration of EQ Workplace in a fully manual approach is likely to produce more efficiency gains.³⁰ The reduced number of support staff with the digital cataract workflow suggests efficiency gains; however, it does not account for the varying time each staff member spends on tasks. Given the differences in proficiency and time commitment among staff members, person-hours saved would have been a more accurate metric for assessing workflow improvements. This study did not compare the clinical outcomes of patients, which could suggest the effect of digitalization not only on procedural efficacy but also on visual outcomes and the risk of complications. Notably, previous studies have reported no statistical difference between the manual and digital toric IOL groups for postsurgical refractive and visual outcomes.^17,18 Finally, the completely digital setup of the workflow may raise concerns about costs, delays, and challenges that may occur because of technical requirements at high-volume centers. Hence, health economic models may be needed to evaluate the cost vs efficiency gains to establish the value proposition of digital workflow solutions.

In conclusion, ZEISS digital cataract workflow significantly reduced the overall cataract surgery time, variability in time within each phase of the cataract workflow, number of data fields recorded, and resource utilization compared with the existing workflow. Complete digitalization of the cataract surgery workflow can be useful for improving the efficiency of cataract workflow.

WHAT WAS KNOWN

• Software-based digital approaches have shown a reduction in the overall time needed for cataract surgical planning, a convenient and efficient IOL power calculation, and implantation, thus resulting in improved refractive outcomes.

• To our knowledge, studies comparing the time and resource saving for implantation of monofocal, nontoric IOLs at high-volume cataract facilities using a software-based digital cataract workflow vs the site's existing approach are lacking.

WHAT THIS PAPER ADDS

• Integration of digital workflow significantly reduced the overall cataract surgery time, number of data fields recorded, and resource utilization.

• Time and resource savings achieved with digitalization can facilitate a reduction in wait times and treatment of more patients at high-volume cataract facilities.

• The reduction in the variability in each phase of the cataract workflow offers an opportunity for standardization in the clinic.