“Patients were so relieved to actually get hold of someone to speak to”

In the conversation OT asked them to unpick what role virtual consultations have played in their practice, how they have captured and used patient feedback to inform their work, and what artificial intelligence (AI) could mean for the profession in 2021 and beyond.

The only experience of telemedicine most optometrists are likely to have had pre-2020 was when seeing diabetic screening patients, Joanne Tutt, a senior optometrist and clinical lead of Birmingham-based The Eye Collective, said – but observed that this changed with the pandemic.

“Over the last 12 months, we have been taking part in the COVID-19 Urgent Eyecare Service (CUES), and this has meant we have been triaging and offering remote consultations for patients,” Tutt explained. 

“It has been quite challenging. One early learning was that it was easier to do a telephone consultation with the patient rather than a video call.”

Using the example of a patient with red eye, Tutt said she would ask them to send a photo, and then would arrange a follow-up call.

“This gives me, as a clinician, time to assess the data and information that the patient is sending. I would then call back having reviewed the data. This approach worked better than using a video platform such as Zoom or WhatsApp – we found that patients would get a bit distracted by the phone, plus they would expect an immediate answer on a video call.”

Tutt added that she was “seeing a lot of patients” who were not existing customers with the group of practices, which meant that she had no access to their information. “You are doing a history and symptoms check as well.”

We found some patients would say that they had not used their phone to take photographs before

David Brett Williams, optometrist, clinical lead and JVP of Specsavers Luton, agreed with the limitations of video for triage. “Photos tend to be far more effective, and far more diagnostically significant, than using video, which is low resolution.”

Williams told OT that his practice sticks to a script, and requests a photo beforehand from the patient, which includes instructions on how to take selfies.

“We found some patients would say that they had not used their phone to take photographs before – so we realised that patient education from us was required.”

Williams added that the triage software platform has been adapted and finessed over time, explaining: “As we found hiccups – things that we missed – we developed more dropdown boxes and prompts to help staff enhance the accuracy of their record keeping.”

The appreciation of patients

Asked about the response of patients to virtual consultations, both panellists agreed the reception had been extremely positive.

“Patients like the fact you are there at the end of the telephone, that they can send photographs, and you can message them back with different questions,” Tutt said. “A lot of people are used to using their smartphones and generally most were comfortable and pleased to have expert advice to hand.”

Tutt noted that it had been “difficult to begin with getting patients to take selfies,” but highlighted a key early learning through triage was “to ask for the photo to be able to find out what the problems are, and then call back.”

Using practice staff to triage patients as the practices opened back up to routine care has also played an important role, Tutt said. “Receptionists field initial calls, and if a clinical issue is flagged, an optometrist can carry out a follow-up to find out the specifics of the issue – that way we then have a better idea of what we are dealing with if that patient needs to come into practice.”

And for Tutt, the whole practice team can get involved in the triage process. “As a company we decided remote consultations are really here to stay. We created a training video for all staff on how to communicate better with patients over the telephone, including a crib sheet of what to ask. The CUES pathway we use is also really good – it has dropdown menus and boxes where you can capture data.”

The scale and speed of the profession’s shift to telemedicine has been startling, Tutt told the group. “You think back to a year ago, and it feels like we have been doing virtual clinics for so much longer.”

This observation was echoed by Williams, who explained with a smile that he had “underestimated” the level of interest from patients and allied health professionals for the 0800-number virtual consultation service he offers via a contract with four clinical commissioning groups (see boxout below).

“We had to get the service up and running at speed. When outpatient appointments were stopped and GPs stopped seeing patients in person, demand rose. In particular, we saw that patients from A&E were being discharged if they were coming in with eye injuries including foreign bodies. They simply were not seen – and were told to call our 0800 number,” he explained.

The appreciation of patients for virtual consultations was palpable, Tutt and Williams explained.

“With the optimism of the vaccines on offer today, it is hard to recall how gloomy it was back at the start of the pandemic in March 2020,” Williams said. “When we spoke to patients, who felt at times like they were being bounced between services, we found that they were so relieved to actually get hold of someone to speak to. As an optometrist, it makes the long hours and the difficulty all worthwhile.”

Both panellists also pointed to an experience in the last year that has been “massively professionally rewarding,” observing that during the pandemic the clinical skills of the profession has been tested in new ways.

Williams shared a story about an older patient with shingles who had been isolating and had been classified as low priority.

“An A&E nurse called me about the case, and from photos of his affected eye it was one of the worst cases I had seen. I was able offer clinical advice, which the nurse took without the need to get the patient into ophthalmology. Before COVID-19, there would have been so many hoops to jump through; now this patient was able to be treated and make a recovery without significant corneal scarring. It is a moment I will remember for the rest of my career.”

For Tutt, it is “through necessity” that ophthalmologists have had to give optometry more leeway in how the profession interacts and treats patients. “Optometrists are more confident, and in turn this has given ophthalmologists more belief in our ability. And patients are simply pleased that there is help out there.”

Williams noted that optometrists involved in virtual consultations see a far wider range of cases than pre-COVID-19, including minor eye conditions service (MECS) schemes, primarily because hospital services are so limited.

“Our optometrists love it. The practice does have to shift up the gears – and our reception team who were taking calls that were once about the costs of lenses are now getting calls about symptoms – and are prioritising which patients might need to come into the practice. Success for us was being systematic and process-driven with these patients,” Williams explained.

New optimism, new pressures

During the pandemic, the use of smartphone adapters and apps for assessments has evolved at pace.

Williams explained in his practice he had explored “a lot of different things,” but added: “Cost is a factor.”

He noted that he had looked at a range of video conferencing apps but concluded that they did not offer the clarity needed.

Both Tutt and Williams highlighted that the simplicity of email offered tangible benefits.

“We may have had email for decades, but it helps immensely,” Williams said. “We use email to share instructional materials, including the Amsler grid for patients that have been diagnosed with AMD. Plus, we can send a copy of any information we have sent to the GP to the patient via email as well.”

Tutt agreed, using the example of how the practice group now proactively emails links to eye condition leaflets, including dry eye syndrome, provided by the AOP to patients. 

Tutt said the group also use email to send a questionnaire to patients to capture their feedback on the service, as well as the performance of the optometry staff.

The experiences shared by Tutt and Williams spoke of a need to marry clinical care and support to patients alongside pastoral and emotional care. How did the practice team find time to manage these dual pressures?

Tutt explained that The Eye Collective “always worked to deliver satisfaction not volume. We offer a 30-minute testing time, and we are seeing fewer patients in the day. We have found that virtual consultations can save time; it means we can use the time more valuably, offering a holistic service, rather than one that is simply all about refractions and specs.”

For Williams, the NHS faced a “tipping point” that he and his colleagues had to respond to – and are continuing to do so. “Our goal, as I saw it, was to reduce the burden on secondary care. Our work allowed the GP to see the patients they really needed to,” he said.

Williams highlighted that capturing patient data plays an important role in cementing the value that optometry is playing, particularly through the triaging of patients, adding that the practice software shows 97% of calls from patients are answered in eight seconds.

While noting her practice group was not on the scale of Williams’, Tutt explained they had found that the data they collected was useful. “We have been looking at who has accessed virtual clinics, how receptive they were to the experience, and how we as a group can look at using remote care more. We are also looking at why some practices have done more CUES than others – for example what is the impact of the age demographic in key areas. Our main contact lens practice is in a city centre, and we are finding that people do not want to travel in – so we are looking at how to offer remote consults as well as offering a physical location where needed.”

What next?

Faced with the opportunities and challenges of COVID-19, the panel was asked about the role of AI – both for improved patient care and for practice management.

Williams concludes “we are on the cusp in practice. This has been pushed by necessity. But having made this ground I do not think we will go backwards. I believe that our triage service will continue to be contracted by the CCGs. The health outcomes and the KPIs are too good to ignore, and what we can achieve is more efficient and safer.”

He added that evolution is needed in AI, pointing to dry eye and AMD as the most readily applied avenues in practice, and adding the caveat: “We have to justify the number of patients that benefit versus the investment needed.”

Tutt concurred, explaining: “AI is going to come, but as optometrists we are not there yet. The tech has not made the leap, but there is so much opportunity, and it is really exciting. By getting patients to use apps, it means we can free-up time in the practice, free-up appointment slots, and it gives us better practice management of the diary.”

For Tutt, the ‘new normal’ is a balance that “uses virtual consults to enable more patient touchpoints. Plus, we don’t need to only think local – we have patients nationally now.”

Williams shared that his dream AI innovation is a tool that “analyses the data we have to create a risk profile for the patient and guide how we manage their care. We have fundus photography for patients going back 10 years, OCT scans going back four years – and I’d love to have a software platform that takes these images and comes up with a prompt for the clinician to say, ‘consider this scenario, watch out for this sign, capture this data, ask this question.”

Tutt agreed, stating: “We have the data, and we have responsibility to do something with it. I want to be able to make clinical decisions more confidently. By doing that, we can manage our patients ourselves before we need to refer them on for specialist treatment because we are on the right track. As an add-on benefit, the patient is also likely to feel less daunted if and when they go into the hospital eye service because of the patient care the optometrist has provided already.”

Looking to future, Tutt concludes that “COVID-19 has pushed us out of our comfort zone as clinicians, and we have stepped up and shown what we can do. There is a need for us to offer more face-to-face appointments, but remote consults are really useful. We must not lose the momentum and get complacent. We have shown ophthalmology what we can do. We need to look for the opportunities, pre-empt them and adapt.”

For Williams the profession has “progressed a lot,” adding: “I always wanted to have a greater role than as a refractionist. COVID-19 will be with us to stay, and we know we will have other issues to face. The impetus is on CCGs and national bodies to commission the services.”