Quality Metrics for Ophthalmic Surgeries: Creating a pathway for a standardized approach

Quality improvement is a continuous process that involves identifying processes or outcomes that are not optimal and implementing changes to make healthcare effective, safe and patient centered. Plan-Do-Study-Act (PDSA) cycle is one of several quality improvement tools to support and improve the activities of quality management and improvement. It involves identification of a problem, collection of data to establish baseline occurrence, development and implementation of a plan to address the problem followed by re-measurement of the frequency to gauge impact. The result of an intervention is used to modify or continue the initial plan and the cycle starts again. The step of identifying a problem can be made easier when standardized metrics are in place for healthcare processes and outcomes. Moreover, metrics enable benchmarking, i.e. comparison of results to institutional or national standards. Currently, gaps that need to be addressed in quality measurement for ophthalmic surgeries include lack of standardized metrics, accessibility to tests for measurement of quality metrics and an electronic health record (EHR) software to record and extract these metrics with ease. The Accreditation Council for Graduate Medical Education (ACGME) requires that a graduate medical education program prepares residents and fellows in the domains of quality improvement and patient safety, with emphasis on providing trainees with data on quality metrics and benchmarks related to their patients.1( ACGME) ACoGME. Common Program Requirements. https://www.acgme.org/globalassets/PFAssets/ProgramRequirements/CPRs_Section-VI_with-Background-and-Intent_2017-01.pdf;Google Scholar An emphasis on quality and safety in ophthalmology is also reflected in the American Board of Ophthalmology’s decision to require a separate patient safety activity for maintenance of certification.2Ophthalmology ABo. Maintaining certification. http://abop.org/maintain-certificationGoogle Scholar There are examples of physician and patient reported quality metrics to monitor the success of ophthalmic procedures. The Merit-based Incentive Payment System (MIPS) is a program administered by the Centers for Medicare and Medicaid Services (CMS) to incentivize quality. MIPS consist of broad metrics for ophthalmic surgeries such as complications after cataract surgery and graft dislocation requiring surgical intervention following endothelial keratoplasty. The International Consortium for Health Outcomes Measurement (ICHOM) has also developed metrics for various ophthalmic surgeries using surveys and modified Delphi technique among their working group members. These have not been employed broadly and a study found significant variation in the type and reporting timeline of postoperative outcome metrics for cataract, cornea, glaucoma, strabismus, and oculoplastic procedures among 8 hospitals that used these metrics.3Michelotti M. de Korne D.F. Weizer J.S. et al.Mapping standard ophthalmic outcome sets to metrics currently reported in eight eye hospitals.BMC Ophthalmol. Dec 29 2017; 17: 269https://doi.org/10.1186/s12886-017-0667-0Crossref PubMed Scopus (15) Google Scholar Patient reported outcome measures (PROMs) recommended by ICHOM for ophthalmology include Catquest-9SF for cataract and Impact of Vision Impairment (IVI) for age-related macular degeneration. There is a paucity of literature on standardized metrics by which we can measure the success of ophthalmic surgeries at physician, institutional and national level. Metrics should consist of outcome and process measures. Outcome measures, such as improvement in visual acuity or development of a complication, are predefined endpoints that reflect the impact of the health care intervention on the health status of patients. Process measures, such as measuring intraocular pressure on post-endothelial keratoplasty visits, constitute the actions performed by a physician to manage a patient’s condition. There is a need to establish unifying metrics for measuring success across ophthalmic procedures and for different subspecialties to allow for monitoring and implementation of quality improvement plans. Unplanned return to operating room has been used as a quality metric across various surgical specialties. In ophthalmic surgeries, this metric has been used to describe the success of cataract, vitreoretinal, and glaucoma surgeries.4Cardakli N. Friedman D.S. Boland M.V. Unplanned Return to the Operating Room After Trabeculectomy.Am J Ophthalmol. Nov. 2020; 219: 132-140https://doi.org/10.1016/j.ajo.2020.06.016Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 5Menda S.A. Driver T.H. Neiman A.E. Naseri A. Stewart J.M. Return to the operating room after resident-performed cataract surgery.JAMA Ophthalmol. Feb. 2014; 132: 223-224https://doi.org/10.1001/jamaophthalmol.2013.5675Crossref PubMed Scopus (15) Google Scholar, 6Stewart J.M. Estrada M.M. Porco T.C. Incidence of unplanned return to the operating room following vitreoretinal surgery at a public teaching hospital.Curr Eye Res. Aug. 2013; 38: 886-888https://doi.org/10.3109/02713683.2013.780626Crossref PubMed Scopus (4) Google Scholar Likewise, similar to post-surgical infection rates in other surgical sub-specialties, endophthalmitis rates have been reported following various intraocular surgeries and procedures in ophthalmology.7Soliman M.K. Gini G. Kuhn F. et al.International Practice Patterns for the Management of Acute Postsurgical and Postintravitreal Injection Endophthalmitis: European Vitreo-Retinal Society Endophthalmitis Study Report 1.Ophthalmol Retina. Jun 2019; 3: 461-467https://doi.org/10.1016/j.oret.2019.03.009Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar A study by Zafar et al. found that the rates of post-cataract surgery endophthalmitis among Medicare beneficiaries have decreased over the last decade.8Zafar S. Dun C. Srikumaran D. et al.Endophthalmitis rates among medicare beneficiaries undergoing cataract surgery between 2011 and 2019.Ophthalmology. 2022; 129: 250-257Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar They have also identified risk factors for this complication which may help surgeons in counselling their patients and in keeping a closer surveillance on patients at higher risk. Developing consensus on additional metrics would help track their trends and risk factors as well. Given the rarity of certain complications at the physician level e.g., postoperative endophthalmitis, composite complication rates (multiple infrequent complications combined into a single metric) adjusted for the severity of each complication may serve as a valuable quality metric for the purposes of benchmarking. While many ophthalmology departments have Quality and Safety oversight, only four of them i.e. Massachusetts Eye and Ear, Cole Eye Institute at Cleveland Clinic, John A. Moran Eye Center at the University of Utah and Kellogg Eye Center at the University of Michigan have released the metrics publicly. These institutes measure a range of outcomes that are different from each other in most cases. Common measures include rates of zonular dialysis, and endophthalmitis after cataract surgery; and wound leak, suprachoroidal hemorrhage, and infection rates after glaucoma surgery. Table 1 outlines examples of quality metrics for commonly performed ophthalmic surgeries.3Michelotti M. de Korne D.F. Weizer J.S. et al.Mapping standard ophthalmic outcome sets to metrics currently reported in eight eye hospitals.BMC Ophthalmol. Dec 29 2017; 17: 269https://doi.org/10.1186/s12886-017-0667-0Crossref PubMed Scopus (15) Google Scholar,9Weizer J.S. Brosnan T.M. McCallum R.M. Velazquez M.S. Lee P.P. Development of a quality improvement program in a department of ophthalmology.Br J Ophthalmol. Dec. 2013; 97: 1549-1553https://doi.org/10.1136/bjophthalmol-2013-304069Crossref Scopus (3) Google Scholar, 10Boese E.A. Lee P.P. Greenberg G.M. Harrison R.V. Weizer J.S. Implementation of a standardized patient safety checklist in ophthalmic surgery.Journal of Academic Ophthalmology. 2018; 10: e172-e178Crossref Google Scholar, 11Center JAME. Patient Outcomes and Quality Improvement: Our Commitment to Excellence. https://healthcare.utah.edu/moran/news/physician-consult/2021/quality-improvement-message.phpGoogle Scholar, 12Ear MEa. Quality Outcomes Ophthalmology Report. https://masseyeandear.org/assets/MEE/pdfs/about/2020-Quality-Outcomes-Ophthalmology-Report.pdfGoogle Scholar, 13Institute CE. 2016 Outcomes. February 28, 2023, https://my.clevelandclinic.org/-/scassets/files/org/outcomes/outcomes-eye.ashx?la=enGoogle Scholar, 14Services CfMaM. MIPS Quality Payment Program. https://qpp.cms.gov/mips/overviewGoogle Scholar, 15Hass A.N. Penne R.B. Stefanyszyn M.A. Flanagan J.C. Incidence of Postblepharoplasty Orbital Hemorrhage and Associated Visual Loss.Ophthalmic Plastic & Reconstructive Surgery. 2004; 20: 426-432https://doi.org/10.1097/01.Iop.0000143711.48389.C5Crossref PubMed Scopus (0) Google Scholar, 16Porteous A. Haridas A. Collin J. Verity D. Upper lid ptosis surgery: what is the optimal interval for the postoperative review? A retrospective review of 300 cases.Eye. 2018; 32: 757-762Crossref Scopus (0) Google Scholar Measuring process metrics has prevented complications such as surgery on the wrong patient or side and preventing insertion of wrong intraocular lens.10Boese E.A. Lee P.P. Greenberg G.M. Harrison R.V. Weizer J.S. Implementation of a standardized patient safety checklist in ophthalmic surgery.Journal of Academic Ophthalmology. 2018; 10: e172-e178Crossref Google Scholar Whereas monitoring outcome metrics has helped these institutions in detecting outliers and identifying areas for improvement. For example, monitoring complications resulted in formulation of guidelines for alerting attending physicians of abnormalities on pupillary examination prior to dilation by a technician at the Kellogg Eye Center.9Weizer J.S. Brosnan T.M. McCallum R.M. Velazquez M.S. Lee P.P. Development of a quality improvement program in a department of ophthalmology.Br J Ophthalmol. Dec. 2013; 97: 1549-1553https://doi.org/10.1136/bjophthalmol-2013-304069Crossref Scopus (3) Google Scholar In addition, monitoring cases of wrong intraocular lens insertion led to the development of a safety protocol including an intraocular lens-specific “time-out,” at four institutions across the United States.17Schein O.D. Banta J.T. Chen T.C. Pritzker S. Schachat A.P. Lessons learned: wrong intraocular lens.Ophthalmology. 2012; 119: 2059-2064Abstract Full Text Full Text PDF PubMed Scopus (0) Google ScholarTable 1Examples of Quality Metrics for Ophthalmic SurgeriesProcedureMetric TypeMetric: What is measured?All ProceduresOutcomeUnplanned return to operating room within 90 days 9Weizer J.S. Brosnan T.M. McCallum R.M. Velazquez M.S. Lee P.P. Development of a quality improvement program in a department of ophthalmology.Br J Ophthalmol. Dec. 2013; 97: 1549-1553https://doi.org/10.1136/bjophthalmol-2013-304069Crossref Scopus (3) Google ScholarOutcomeEndophthalmitis within 6 weeks 9Weizer J.S. Brosnan T.M. McCallum R.M. Velazquez M.S. Lee P.P. Development of a quality improvement program in a department of ophthalmology.Br J Ophthalmol. Dec. 2013; 97: 1549-1553https://doi.org/10.1136/bjophthalmol-2013-304069Crossref Scopus (3) Google ScholarProcessPreoperative patient verification 10Boese E.A. Lee P.P. Greenberg G.M. Harrison R.V. Weizer J.S. Implementation of a standardized patient safety checklist in ophthalmic surgery.Journal of Academic Ophthalmology. 2018; 10: e172-e178Crossref Google ScholarProcessPreoperative surgery site marked10Boese E.A. Lee P.P. Greenberg G.M. Harrison R.V. Weizer J.S. Implementation of a standardized patient safety checklist in ophthalmic surgery.Journal of Academic Ophthalmology. 2018; 10: e172-e178Crossref Google ScholarPhacoemulsificationOutcomePosterior capsular rupture and/ or vitreous loss during surgery 9Weizer J.S. Brosnan T.M. McCallum R.M. Velazquez M.S. Lee P.P. Development of a quality improvement program in a department of ophthalmology.Br J Ophthalmol. Dec. 2013; 97: 1549-1553https://doi.org/10.1136/bjophthalmol-2013-304069Crossref Scopus (3) Google Scholar,11Center JAME. Patient Outcomes and Quality Improvement: Our Commitment to Excellence. https://healthcare.utah.edu/moran/news/physician-consult/2021/quality-improvement-message.phpGoogle Scholar, 12Ear MEa. Quality Outcomes Ophthalmology Report. https://masseyeandear.org/assets/MEE/pdfs/about/2020-Quality-Outcomes-Ophthalmology-Report.pdfGoogle Scholar, 13Institute CE. 2016 Outcomes. February 28, 2023, https://my.clevelandclinic.org/-/scassets/files/org/outcomes/outcomes-eye.ashx?la=enGoogle ScholarOutcomeDescemet's detachment during surgery 12Ear MEa. Quality Outcomes Ophthalmology Report. https://masseyeandear.org/assets/MEE/pdfs/about/2020-Quality-Outcomes-Ophthalmology-Report.pdfGoogle ScholarOutcomeDropped nucleus during surgery 9Weizer J.S. Brosnan T.M. McCallum R.M. Velazquez M.S. Lee P.P. Development of a quality improvement program in a department of ophthalmology.Br J Ophthalmol. Dec. 2013; 97: 1549-1553https://doi.org/10.1136/bjophthalmol-2013-304069Crossref Scopus (3) Google ScholarOutcomeUnexpected zonular dialysis during surgery 9Weizer J.S. Brosnan T.M. McCallum R.M. Velazquez M.S. Lee P.P. Development of a quality improvement program in a department of ophthalmology.Br J Ophthalmol. Dec. 2013; 97: 1549-1553https://doi.org/10.1136/bjophthalmol-2013-304069Crossref Scopus (3) Google Scholar,11Center JAME. Patient Outcomes and Quality Improvement: Our Commitment to Excellence. https://healthcare.utah.edu/moran/news/physician-consult/2021/quality-improvement-message.phpGoogle Scholar, 12Ear MEa. Quality Outcomes Ophthalmology Report. https://masseyeandear.org/assets/MEE/pdfs/about/2020-Quality-Outcomes-Ophthalmology-Report.pdfGoogle Scholar, 13Institute CE. 2016 Outcomes. February 28, 2023, https://my.clevelandclinic.org/-/scassets/files/org/outcomes/outcomes-eye.ashx?la=enGoogle ScholarOutcomeIris damage during surgery 9Weizer J.S. Brosnan T.M. McCallum R.M. Velazquez M.S. Lee P.P. Development of a quality improvement program in a department of ophthalmology.Br J Ophthalmol. Dec. 2013; 97: 1549-1553https://doi.org/10.1136/bjophthalmol-2013-304069Crossref Scopus (3) Google Scholar,13Institute CE. 2016 Outcomes. February 28, 2023, https://my.clevelandclinic.org/-/scassets/files/org/outcomes/outcomes-eye.ashx?la=enGoogle ScholarOutcomeWrong intraocular lens implantation during surgery 9Weizer J.S. Brosnan T.M. McCallum R.M. Velazquez M.S. Lee P.P. Development of a quality improvement program in a department of ophthalmology.Br J Ophthalmol. Dec. 2013; 97: 1549-1553https://doi.org/10.1136/bjophthalmol-2013-304069Crossref Scopus (3) Google ScholarProcessConfirmation of correct intraocular lens for correct patient from surgeon as part of surgical timeout and prior to opening the intraocular lens 10Boese E.A. Lee P.P. Greenberg G.M. Harrison R.V. Weizer J.S. Implementation of a standardized patient safety checklist in ophthalmic surgery.Journal of Academic Ophthalmology. 2018; 10: e172-e178Crossref Google ScholarPenetrating KeratoplastyOutcomeSuprachoroidal hemorrhage during surgery 13Institute CE. 2016 Outcomes. February 28, 2023, https://my.clevelandclinic.org/-/scassets/files/org/outcomes/outcomes-eye.ashx?la=enGoogle ScholarOutcomePrimary graft failure (failure of graft to clear within 8 weeks following surgery) 13Institute CE. 2016 Outcomes. February 28, 2023, https://my.clevelandclinic.org/-/scassets/files/org/outcomes/outcomes-eye.ashx?la=enGoogle ScholarEndothelial KeratoplastyOutcomeAcute pupillary block on postoperative day 1 9Weizer J.S. Brosnan T.M. McCallum R.M. Velazquez M.S. Lee P.P. Development of a quality improvement program in a department of ophthalmology.Br J Ophthalmol. Dec. 2013; 97: 1549-1553https://doi.org/10.1136/bjophthalmol-2013-304069Crossref Scopus (3) Google ScholarOutcomeGraft detachment requiring rebubble within 2 weeks 9Weizer J.S. Brosnan T.M. McCallum R.M. Velazquez M.S. Lee P.P. Development of a quality improvement program in a department of ophthalmology.Br J Ophthalmol. Dec. 2013; 97: 1549-1553https://doi.org/10.1136/bjophthalmol-2013-304069Crossref Scopus (3) Google Scholar,13Institute CE. 2016 Outcomes. February 28, 2023, https://my.clevelandclinic.org/-/scassets/files/org/outcomes/outcomes-eye.ashx?la=enGoogle Scholar,14Services CfMaM. MIPS Quality Payment Program. https://qpp.cms.gov/mips/overviewGoogle ScholarOutcomePrimary graft failure within 8 weeks 13Institute CE. 2016 Outcomes. February 28, 2023, https://my.clevelandclinic.org/-/scassets/files/org/outcomes/outcomes-eye.ashx?la=enGoogle ScholarTrabeculectomy or Tube shuntOutcomeSuprachoroidal hemorrhage within 90 days 9Weizer J.S. Brosnan T.M. McCallum R.M. Velazquez M.S. Lee P.P. Development of a quality improvement program in a department of ophthalmology.Br J Ophthalmol. Dec. 2013; 97: 1549-1553https://doi.org/10.1136/bjophthalmol-2013-304069Crossref Scopus (3) Google Scholar,12Ear MEa. Quality Outcomes Ophthalmology Report. https://masseyeandear.org/assets/MEE/pdfs/about/2020-Quality-Outcomes-Ophthalmology-Report.pdfGoogle Scholar,13Institute CE. 2016 Outcomes. February 28, 2023, https://my.clevelandclinic.org/-/scassets/files/org/outcomes/outcomes-eye.ashx?la=enGoogle ScholarOutcomeBlebitis within 90 days 9Weizer J.S. Brosnan T.M. McCallum R.M. Velazquez M.S. Lee P.P. Development of a quality improvement program in a department of ophthalmology.Br J Ophthalmol. Dec. 2013; 97: 1549-1553https://doi.org/10.1136/bjophthalmol-2013-304069Crossref Scopus (3) Google Scholar,13Institute CE. 2016 Outcomes. February 28, 2023, https://my.clevelandclinic.org/-/scassets/files/org/outcomes/outcomes-eye.ashx?la=enGoogle ScholarOutcomeHypotony with maculopathy or choroidal detachment within 90 days 9Weizer J.S. Brosnan T.M. McCallum R.M. Velazquez M.S. Lee P.P. Development of a quality improvement program in a department of ophthalmology.Br J Ophthalmol. Dec. 2013; 97: 1549-1553https://doi.org/10.1136/bjophthalmol-2013-304069Crossref Scopus (3) Google Scholar,13Institute CE. 2016 Outcomes. February 28, 2023, https://my.clevelandclinic.org/-/scassets/files/org/outcomes/outcomes-eye.ashx?la=enGoogle ScholarAdult Primary Rhegmatogenous Retinal Detachment and Macular Hole SurgeryOutcomeFinal retinal reattachment rate at 3-6 months for primary rhegmatogenous retinal detachment surgery 3Michelotti M. de Korne D.F. Weizer J.S. et al.Mapping standard ophthalmic outcome sets to metrics currently reported in eight eye hospitals.BMC Ophthalmol. Dec 29 2017; 17: 269https://doi.org/10.1186/s12886-017-0667-0Crossref PubMed Scopus (15) Google Scholar,12Ear MEa. Quality Outcomes Ophthalmology Report. https://masseyeandear.org/assets/MEE/pdfs/about/2020-Quality-Outcomes-Ophthalmology-Report.pdfGoogle Scholar,13Institute CE. 2016 Outcomes. February 28, 2023, https://my.clevelandclinic.org/-/scassets/files/org/outcomes/outcomes-eye.ashx?la=enGoogle ScholarOutcomeSingle surgery retinal reattachment rate at 3-6 months for macular hole surgery12Ear MEa. Quality Outcomes Ophthalmology Report. https://masseyeandear.org/assets/MEE/pdfs/about/2020-Quality-Outcomes-Ophthalmology-Report.pdfGoogle Scholar,13Institute CE. 2016 Outcomes. February 28, 2023, https://my.clevelandclinic.org/-/scassets/files/org/outcomes/outcomes-eye.ashx?la=enGoogle ScholarStrabismus SurgeryOutcomeGlobe penetration during surgery 9Weizer J.S. Brosnan T.M. McCallum R.M. Velazquez M.S. Lee P.P. Development of a quality improvement program in a department of ophthalmology.Br J Ophthalmol. Dec. 2013; 97: 1549-1553https://doi.org/10.1136/bjophthalmol-2013-304069Crossref Scopus (3) Google Scholar,12Ear MEa. Quality Outcomes Ophthalmology Report. https://masseyeandear.org/assets/MEE/pdfs/about/2020-Quality-Outcomes-Ophthalmology-Report.pdfGoogle ScholarOutcomeDiplopia in primary position at 6 months 3Michelotti M. de Korne D.F. Weizer J.S. et al.Mapping standard ophthalmic outcome sets to metrics currently reported in eight eye hospitals.BMC Ophthalmol. Dec 29 2017; 17: 269https://doi.org/10.1186/s12886-017-0667-0Crossref PubMed Scopus (15) Google Scholar,12Ear MEa. Quality Outcomes Ophthalmology Report. https://masseyeandear.org/assets/MEE/pdfs/about/2020-Quality-Outcomes-Ophthalmology-Report.pdfGoogle Scholar,13Institute CE. 2016 Outcomes. February 28, 2023, https://my.clevelandclinic.org/-/scassets/files/org/outcomes/outcomes-eye.ashx?la=enGoogle ScholarPtosis SurgeryOutcomeOrbital hemorrhage with vision loss within 1 day of surgery15Hass A.N. Penne R.B. Stefanyszyn M.A. Flanagan J.C. Incidence of Postblepharoplasty Orbital Hemorrhage and Associated Visual Loss.Ophthalmic Plastic & Reconstructive Surgery. 2004; 20: 426-432https://doi.org/10.1097/01.Iop.0000143711.48389.C5Crossref PubMed Scopus (0) Google ScholarOutcomeOver correction of ptosis at 4 weeks16Porteous A. Haridas A. Collin J. Verity D. Upper lid ptosis surgery: what is the optimal interval for the postoperative review? A retrospective review of 300 cases.Eye. 2018; 32: 757-762Crossref Scopus (0) Google Scholar Open table in a new tab It is important to protect ophthalmologists reporting these metrics. Efforts should be made to improve systems instead of penalizing individuals to encourage transparent reporting without fear or fervor. Moreover, patient risk factors and complexity of a surgeon’s practice should be considered while benchmarking since some patients may be at a higher risk of certain complications. International classification of diseases (ICD) codes can be used to identify the indication for surgery as well as systemic and ophthalmic comorbidities. Composite indices such as the Charlson Comorbidity Index which is a commonly used measure of mortality risk and disease burden can be used for systemic diseases.18Charlson M.E. Pompei P. Ales K. MacKenzie R. Charlson comorbidity index.J Chronic Dis. 1987; 40: 373-383Abstract Full Text PDF PubMed Scopus (36622) Google Scholar Considering systemic comorbidities would be helpful since certain conditions may predispose patients to develop specific complications such as infectious complications in patients with diabetes. EHR can help in automated collection of ICD codes. EHR may also facilitate the collection of PROMs using automated patient questionnaires at appropriate intervals following different ophthalmic procedures. While intra-institutional benchmarking may be valuable, with the expansion of clinical registries and increasing use of Big Data in ophthalmology, national standards to compare quality across physicians and institutions are essential for quality and safety. Registries can be used to create benchmarks for all ophthalmic surgeries using the existing data on patient outcomes. American Academy of Ophthalmology’s (AAO) Intelligent Research in Sight (IRIS®) registry is the largest clinical data repository for Ophthalmology.19Chiang MF, Sommer A, Rich WL, Lum F, Parke DW, 2nd. The 2016 American Academy of Ophthalmology IRIS(®) Registry (Intelligent Research in Sight) Database: Characteristics and Methods. Ophthalmology. Aug 2018;125(8):1143-1148. doi:10.1016/j.ophtha.2017.12.001Google Scholar IRIS® serves as the reporting tool for MIPS, and practices have the option to link their EHR directly with the registry, which makes reporting more efficient. AAO has been developing an IRIS® dashboard based on CMS approved quality metrics and benchmarks for ophthalmology. IRIS® dashboard will ideally allow inter-institutional comparison and can also be used to create personalized performance reports for surgeons to help guide their future practice. Furthermore, data from IRIS® can be used to evaluate benchmarks, devise interventions, and monitor subsequent outcomes. For example, a recent study using the IRIS® registry found that patients undergoing immediate sequential bilateral cataract surgery do not have an increased risk of endophthalmitis.20Lacy M. Kung T.-P.H. Owen J.P. et al.Endophthalmitis rate in immediately sequential versus delayed sequential bilateral cataract surgery within the Intelligent Research in Sight (IRIS®) Registry Data.Ophthalmology. 2022; 129: 129-138Abstract Full Text Full Text PDF Scopus (0) Google Scholar Another example of a clinical registry in ophthalmology that can be used to monitor quality outcomes is the Sight Outcomes Research Collaborative (SOURCE™).21Collaborative SOR. SOURCE: Sight Outcomes Research Collaborative. https://www.sourcecollaborative.orgGoogle Scholar SOURCE™, established by the University of Michigan, is a consortium of academic ophthalmology departments sharing de-identified EHR and ocular imaging data with researchers at participating sites. The IRIS® registry houses a large amount of data with over 13,000 clinicians registered to contribute data electronically. IRIS® is also working on integrating imaging and free text data to its database. The SOURCE™ repository comprises of 14 academic institutions that use EPIC EHR, and the data includes imaging metadata and measurements as well as exam elements from medical reports. Using tools such as the Delphi technique, which is a structured method of consensus-building among experts, subspecialty societies may leverage their position as a collective body of national experts to develop consensus and identify important process and outcome metrics for commonly performed procedures. Members of subspecialty societies may write to the society leadership to form a task force comprising of quality improvement leaders from their field to address this important issue. In these processes, societies should take into consideration the ease of extracting data for varying metrics; metrics that can be examined through automated extraction from the EHR are more likely to be adopted. Electronic clinical quality measure (eCQM) standards define data format and structure, and the meanings of codes and terms included in an electronic dataset. Using standardized eCQMs similar to CMS allows not only for the automated extraction of data to a central repository, but also for the automated and consistent calculation of quality metrics, which is crucial for reducing the burden of calculating these metrics as well as for ensuring the results are comparable between practices and institutions.22Center eR. Standards Summary. September 19, 2023, https://ecqi.healthit.gov/standards-summaryGoogle Scholar Of course, the extraction of good data relies on the input of good data. EHRs must be intentionally designed to format medical information in a way that can be easily entered by clinicians and discretely extracted. Subsequently, registries can be used to create benchmarks for these metrics. Given the potential benefits, a standardized set of global as well as subspecialty specific metrics for ophthalmic surgeries, including patient and surgeon reported measures, is needed. Developing consensus on standardized quality metrics is an important milestone needed to advance quality improvement in our field.