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Large studies using claims data have demonstrated considerable regional differences in practice and in the quality of eye care in the United States and worldwide. For example, Stein and colleagues showed a large difference in the use of laser trabeculoplasty between ophthalmologists and optometrists in Oklahoma. Were these high usage rates standards of care, or did they represent overusage, particularly when compared to other treatments? An analysis of the Medicare database revealed that some ophthalmologists had large Medicare expenditures when compared with those of the average ophthalmologist. This big data analysis,among others, prompted investigators to discover fraud in our health care system. Big data can also be used to evaluate how individual ophthalmologists compare to their peers for an outcome 43 of interest, such as the proportion of patients who need to return to the operating room after cataract surgery. If an ophthalmologist has a higher complication rate than that of his or her peers, this information may prompt that ophthalmologist to begin a quality improvement project to lower their patient complication rate via education and further training. Big data offer clinicians many opportunities to measure and improve eye care, particularly when accompanied by an organizing framework to understand the data and develop improvement activities (see the following sections). A useful measurement system may include quality indicators. For example, one question ophthalmologists commonly face is whether they have dilated a diabetic patient’s eyes at least once every 2 years. How might one validate that a dilated eye examination was performed? One cumbersome validation method would be to video record ophthalmologists while they perform patient examinations and then review that recording to confirm the completion of the dilated eye examination. Other validation options may include (1) written documentation indicating that dilating drops were placed in the eye; (2) notations in the medical record indicating that a peripheral dilated eye examination was performed, such as noting whether it was normal or abnormal; and (3) a diagram or drawing of the retina periphery. All of these would be valid measures.