Elsevier

Public Health

Volume 129, Issue 2, February 2015, Pages 117-123
Public Health

Original Research
Improving patient access to prevent sight loss: ophthalmic electronic referrals and communication (Scotland)

https://doi.org/10.1016/j.puhe.2014.10.010Get rights and content

Highlights

  • Electronic referral in ophthalmology offers the opportunity to improve patient care in many ways.

  • A modernized electronic interface has improved referrals between the community and HES.

  • The pilot study showed the system was feasible, fast, safe and reduced outpatient visits.

  • Following regional rollout of the electronic referral, significant improvements were observed.

  • The Eyecare Integration Project aims to create and improve electronic communication in Scotland.

Abstract

Introduction

With the number of people with sight loss predicted to double to four million people in the UK by the year 2050, preventable visual loss is a significant public health issue. Sight loss is associated with an increased risk of falls, accidents and depression and evidence suggests that 50% of sight loss can be avoided. Timely diagnosis is central to the prevention of sight loss. Access to care can be a limiting factor in preventable cases. By improving referrals and access to hospital eye services it is possible to treat and minimise the number of patients with preventable sight loss and the impact this has on wider society.

Clinical pilot study

In 2005, NHS Fife took part in a flagship pilot funded by the Scottish government e-health department to evaluate the feasibility, safety, clinical effectiveness, and cost of electronic referral with images of patients directly from community optometrists to Hospital Eye Service (HES). The pilot study showed that electronic referral was feasible, fast, safe, and obviated the need for outpatient appointments in 128 (37%) patients with a high patient satisfaction.

Centralised ophthalmic electronic referral unit

The results of the pilot study were presented and in May 2007, the electronic referral system was rolled out regionally in southeast Scotland. Referrals were accepted at a single site with vetting by a trained team and appointments were allocated within 48 hours. Following the implementation of electronic referral, waiting times were reduced from a median of 14 to 4 weeks. Significantly fewer new patients were seen (7462 vs 8714 [p < 0.001]). There were also fewer casualties (1984 vs 2671 [p < 0.001]) and ‘did not arrive' (DNA) new patients (503 vs 635 [p < 0.001]).

Eye care integration project (Scotland)

In 2010 the Scottish Government Health Department committed £6.6 million to community and hospital ophthalmic services forming the Eyecare Integration Project in 2011. The main aim of this project was to create electronic communication between community optometry practices and hospital eye departments. Five electronic forms were specifically designed for cataract, glaucoma, macula, paediatric and general ophthalmic disease. A Virtual Private Network was created which enabled optometrists to connect to the Scottish clinical information gateway system and send referrals to hospital and receive referral status feedback. Numerous hurdles have been encountered and overcome in order to deliver this project.

Discussion

An efficient unique system has been described within the NHS whereby the provision of eye care has been modernised by creating a user-friendly electronic interface between the community and HES. This system ensures patients are vetted into the correct specialist clinic and thus will be less likely to go blind from treatable conditions. Urgent conditions will continue to be prioritised and savings made with efficiencies gained can be re-invested towards better overall patient care.

Introduction

With the number of people with sight loss predicted to double to four million people in the UK by the year 2050,1 preventable visual loss is a significant public health issue. This trajectory is linked to increasing lifespan and its association with sight threatening disease. The indirect cost of sight loss was estimated at £4.3 billion in 2008, including reduced employment rates.1 Apart from the cost, sight loss can be associated with other significant adverse health problems such as an increased risk of falls, accidents and depression.2, 3 Evidence suggests that 50% of sight loss can be avoided.1 In the United Kingdom, age related macular degeneration (ARMD) is a leading cause of blindness in adults; where the wet form can be prevented from causing sight loss, especially if treatment is commenced early.4, 5 Timely diagnosis is central to the prevention of sight loss. Access to care can be a limiting factor in preventable cases, sometimes due to challenging initial assessments, complex referral pathways and inequality of access leading to increased waiting times to see an ophthalmologist.6

In the UK a General Ophthalmic Service (GOS) contract exists, that incorporates screening eye tests in addition to refraction and spectacle dispensing. However there are significant differences to the Scottish contract and this paper describes a Scottish wide ophthalmic project that makes full use of the Scottish optometry arrangements.7 This contract remunerates every Scottish optometrist at a much higher rate than anywhere else in the UK to carry out a comprehensive initial ophthalmic assessment to include slit-lamp examination of the anterior segment, contact intraocular pressure check, computerized visual field testing, fundus examination and any other relevant ancillary testing. The contract also remunerates optometrists for repeat tests in an attempt to reduce false positive referrals to hospital. Furthermore, in 2007 central government grants were issued for the purchase of ophthalmic digital cameras by optometry practices. At this time two major goals for the Scottish government were the promotion of community eye care and reduced waiting times for ophthalmic attention. Despite this vision and investment there was a relative barrier between optometrist and ophthalmologist which resulted in pockets of delayed treatment and ultimately compromised visual outcomes for the patients.8 This came from the process of communication by the optometrist through the patient's GP which incurred a significant paper trail delay (see Fig. 1). Additionally paper communication did not allow for the full potential of being able to refer with digital patient images to be realized.

This paper describes the significant Scotland-wide redesign of ophthalmic service delivery since the inception of the NHS in 1948. Initially a clinical pilot study of electronic referral in Fife, (2006) it was rolled out to Southeast Scotland in 2008. This was followed by the Eyecare Integration Project, Scotland in 2011. This project is set to connect all community optometrists electronically to hospital eye services (HES)9 using the Scottish clinical information gateway system (SciG), a Scotland wide electronic system that has connected GPs to hospitals for over 20 years. This national system integrates primary and secondary care systems providing a number of advantageous features, including direct electronic referral of patients from the community to hospital.

Section snippets

Methods

In 2005, prior to the GOS contract, NHS Fife took part in a flagship pilot funded by the Scottish government e-health department to evaluate the feasibility, safety, clinical effectiveness, and cost of electronic referral with images of patients directly from community optometrists to HES. Three optometry practices took part in the pilot study. A new electronic referral form (see Appendix 1) was designed in collaboration with the optometrists and consultant ophthalmologists within the

Methods

The results of the pilot study were presented to three hospitals and in May 2007, the electronic referral system was rolled out regionally in southeast Scotland. All stakeholders (GPs, optometrists and patient representatives) were informed and clinical training and IT support was given. The referral form was altered after feedback to reflect more details on cataracts, ARMD and glaucoma as these constituted the majority of eye referrals. Additionally, attendance at previous HES appointments

Methods

Data from COeRU and other electronic referral systems in Scotland fed into a business case and in 2010 the Scottish Government Health Department committed £6.6 million to community and hospital ophthalmic services forming the Eyecare Integration Project in 2011.13 The main aim of this project was to create electronic communication between community optometry practices and hospital eye departments. This would potentially also reap the previous investments in digital cameras and use the GOS

Discussion

Public health involves the promotion of good health, the prevention of ill health and minimizing the impact of disease. Good visual health underpins overall general health and well-being and significantly impacts on capacity for independent living.14, 15, 16 The electronic referral system offers several advantages in respect to these goals which are described below.

The traditional route for ophthalmic referral into hospitals involves opportunistic community optometry examination of patients

Ethical approval

None required.

Funding

None declared.

Competing interests

None declared.

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