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