Care close to home

OT  investigates the impact of an award-winning project that has halved referrals into the hospital eye service by using technology to connect ophthalmologists and optometrists

Moorfields professionals
Will Amlot

When Dawn Sim joined Moorfields Eye Hospital, an acquaintance tried to convince her of the benefits of the private sector.

For some clinicians, working long hours within an overburdened NHS might have made this an inviting prospect. But this was not the case for Ms Sim.

“I remember saying, ‘I can’t. I have things to do.’ I wanted to fix things that have been the bane of my life for a decade. Now I feel I am finally in a position where I can,” she shared.

As a consultant ophthalmic surgeon and head of telemedicine at Moorfields, Ms Sim has led a remote referral project that has seen an increase in the number of cases managed by optometrists within the community rather than being referred to secondary care.

The remote referral system has been used in the management of around 300 patients across two Croydon and four Hampshire optical practices.

The initiative’s potential was recognised with the Telehealth Award at the 2019 Health Business Awards.

How it works

As part of the community optometry pilot, optometrists enter details into a system when they see a patient who they want to refer to secondary care.

The technology prompts relevant follow-up questions after the initial information is entered.

“It is a decision tree. For example, if the patient has glaucoma in the family a few more questions will be asked,” Ms Sim explained.

The optometrist then takes a scan of the patient’s eye and the data is automatically uploaded to a platform for a Moorfields specialist to review.

Optometrists have the ability to ask questions within the system.

“They might ask, ‘I think this is X – do you agree?’ It is a dynamic, two-way conversation,” Ms Sim shared.

She highlighted that the enhanced ability for optometrists to collaborate with ophthalmologists opens up the potential of continual education throughout the working day.

Ms Sim shared with OT that she dislikes the phrase ‘inappropriate referrals’ because a referral is simply an indication that the referrer had a question.

“On the recipient end, to say that a referral is inappropriate is very arrogant. I think the way in which referrals are made and handled is inappropriate in our current digital age.

The focus needs to be on communication and education,” she emphasised.

The impact

The pilot within community optometry has resulted in the number of cases that would be referred reducing by 50%.

Within the hospital eye service, more than 2000 patients with stable eye disease have been seen using the same technology.

The pathway’s efficiency is obvious; not just in terms of cost efficiency but also access to care for those who require treatment. It is a no-brainer

Dawn Sim, consultant ophthalmic surgeon and head of telemedicine at Moorfields

A technician takes the history and scans before this information is passed on to a specialist clinician for review.

“In the beginning, 30% had to come back to a face-to-face clinic but now our technicians are able to gather information required and less than 10% are seen in clinic with 90% remaining in these stable diagnostic imaging clinics,” Ms Sim shared.

She highlighted that the NHS is becoming increasingly open to technological solutions. “What is exciting is that the appetite for change is finally reaching the decision makers within the NHS. Traditionally healthcare has been very risk-adverse but times are moving on,” she shared. 

The NHS Long Term plan highlights that in 10 years’ time it is expected that models of care will look markedly different, with the NHS offering a ‘digital first’ option for most patients.

Taking this into account, Ms Sim believes that technology similar to the remote referral system will be integral to healthcare pathways going forward.

“The pathway’s efficiency is obvious; not just in terms of cost efficiency but also access to care for those who require treatment. It is a no-brainer,” she emphasised.

New opportunities

Head of optometry at Moorfields, Sarah Canning, highlighted that teleophthalmology has “huge potential” to be embedded into most eye health patient pathways.

She shared that the technology can be used to expand screening programmes as well as enhancing referrals and diagnostics.

There are also implications for the ongoing surveillance of patient groups with chronic conditions, Ms Canning shared. 

What everyone really wants to be doing is focusing on the patients who are most in need of our help

Peter Thomas, consultant paediatric ophthalmologist and director of digital innovation at Moorfields

“The benefits will be more timely diagnoses and subsequent interventions, which will improve patient care and ultimately reduce the risk of vision loss for many patients,” she said.

Ms Canning emphasised that teleophthalmology has the potential to build trust between primary care optometrists and hospital teams by facilitating greater feedback and closer working partnerships.

“As a profession we need to make sure we’re fully on board with telehealth as it brings fantastic opportunities to maximise the potential of optometrists as well as other eye care professionals, to ensure that patients have access to the best possible care,” she observed.

Healthcare at home

Consultant paediatric ophthalmologist, Peter Thomas, is Moorfields’ director of digital innovation.

He highlighted that Moorfields has recently launched technology at the London hospital’s accident and emergency department that allows clinicians to seek expert advice by attaching an adaptor to a smartphone during a patient examination.

“It is as if the doctor at home is looking down the slit lamp,” Mr Thomas highlighted.

“Already, in the first few days of the pilot we have been able to get three patients with unusual conditions receiving instant senior advice overnight,” he said.

Moorfields is also completing early research into the potential for home-based monitoring of patients with conditions such as wet age-related macular degeneration.

As a profession we need to make sure we’re fully on board with telehealth as it brings fantastic opportunities to maximise the potential of optometrists

Sarah Canning, head of optometry at Moorfields

He shared his view that home monitoring technology may be implemented within five years.

“It would be disappointing if we weren’t able to meet that timeline,” he added.

Mr Thomas highlighted that the ultimate goal is to provide the same quality of care that would traditionally be offered in hospital. However, this care would be more responsive and closer to home, with less need to attend hospital for repeat visits.

“I would hope that there are a lot of encounters where the patient has to go no further than their local optometrist with Moorfields then able to provide ophthalmology expertise without the patient needing to come in to hospital,” Mr Thomas shared.

Like Ms Sim, Mr Thomas sees opportunities for enhanced efficiency through the use of telemedicine.

“There is a lot of cost involved with bringing a patient into hospital. If we can use telemedicine to let us manage conditions at home or in the community that frees up resources within the hospital,” he observed.

As well as benefiting patients, this model of care has advantages for clinicians, Mr Thomas emphasised.

“What everyone really wants to be doing is focusing on the patients who are most in need of our help,” he said.

“If we can use technology to create smoother pathways that are less intensive for the patients who are well-controlled, then it will let clinicians practise at the top of their license,” Mr Thomas shared.

Mr Thomas does not believe that teleophthalmology will or should replace all in-person interactions between patients and clinicians.

“Part of being a doctor or an optometrist isn’t just the skills and the knowledge to make a diagnosis but also how you support a patient,” Mr Thomas elaborated.

However, Mr Thomas observed that if less time is spent completing high-volume, repetitive tasks, clinicians will have more time for patients with complex needs.

“This technology can help to free resources and space in brick and mortar locations to offer more services that patients will really benefit from. We will be able to offer all of the value-added services rather than spending so much time on the bread and butter services that could be delivered out of hospital,” Mr Thomas concluded.