Eyesight is one of our most treasured possessions, yet at some point in our life, many of us are likely to encounter an eye problem that needs specialist attention.
Despite this, until recently, optometry was largely paper-based, which could often lead to unwelcome delays in the diagnosis and treatment of sight-threatening conditions.
Nowhere was this the case more than in Scotland, where hospital ophthalmology departments receive 80% of their referrals from around 1,300 community optometrists.
Ophthalmology patients – which represent 15% of all outpatients in Scotland – sometimes had to wait up to 56 weeks for an appointment with a specialist.
“For too long, eye pathology in the community had relied on hand-drawn diagrams, which is backward to say the least in today’s digital age,” says Dr Roshini Sanders, a consultant ophthalmologist at Queen Margaret Hospital in Fife.
“It meant that if your high street optician detected an abnormality, they would send a sketch to your GP. The latter would then attach your medical history and forward it by post to the medical records department of your local hospital.
“It would then be passed to the ophthalmology department, where someone would make a judgement on the most appropriate specialist for your needs – for example, a glaucoma consultant if glaucoma appeared to be the problem.
“To reduce the number of time-consuming steps in this patient journey, we therefore needed a more effective, IT-enabled pathway between optometrists, GPs and hospital specialist services.”
Pilot and funding
To this end, Dr Sanders says a two-year pilot study was initiated in 2005 among 346 patients in Fife. This used NHSmail to electronically refer patients with ophthalmic disease directly from community to hospital by attaching digital images. It showed that 33% could receive an e-diagnosis without the need for hospital visit.
As a result, the service was rolled out to the rest of the region in 2007. Service delivery was then compared by analysing 47,238 patient attendances during the year prior to introducing the electronic system and one year after.
The findings were astounding, says Dr Sanders. “Waiting times crashed from 33 to four weeks.
"In 2008, moreover, 1,359 new referrals received e-diagnosis, while 687 emergency and 128 ‘did not attend’ appointments were avoided – saving 2,178 new appointments totalling £239,580. Better still, all sight-threatening disease was seen within days.”
In 2009, following rigorous canvassing by lead clinicians, optometrists and patients – plus support from Members of the Scottish Parliament and the BBC – the Scottish Executive gave its backing to an official Eyecare Integration Project (EIP) to electronically connect community optometrists to hospital departments.
All systems go
“Our initial focus was to develop an electronic process that would deliver 95% of referrals directly from optometrists to hospital eye services by April 2014,” says Dr Sanders, who was appointed national clinical ophthalmology lead for the project.
“We also aimed to cut the time from referral to treatment, allocate patients to the correct clinic at first hospital visit, reduce unscheduled attendances, and identify patients suitable for community care.”
By September 2010, the business case was proven and the Scottish Executive announced a £6.6m investment over ten years to extend the service right across the country.
“By referring patients electronically using digital images of their eyes, they can now receive a response within seconds,” says Dr Sanders. “As well as spotting blinding conditions early and retaining non-treatable pathology within the community, it helps save costs and shifts the balance of care away from overburdened hospitals.”
Last year, the EIP team successfully condensed 52 existing community to hospital referral forms down to five electronic forms and gained community health index access for optometrists. “We also established five further pilot sites and 14 project teams to implement the changes,” says Dr Sanders. “It means that over 25% of ophthalmology referrals in Scotland are now electronic, with targets set at 50% by next year and 95% by 2014.”
Reduced waiting times
“The benefit to anyone with sight-threatening disease is that they can now be referred instantly by their high street optometrist to an ophthalmology specialist and receive an appointment very quickly, says Dr Sanders.
“Moreover, less serious eye problems can be detected quickly by e-diagnosis and, in many cases, treated without requiring a hospital visit. By the same token, it saves hospitals considerable resource since specialists need only see patients with sight-threatening disease.
The discovery of new sight saving treatments for macular degeneration and other diseases require patients to be treated within two weeks of symptoms. “Thanks to the EIP, waiting times of one to eight weeks are now among the shortest in Europe,” she says.
“As well as enabling 30% of patients who are asymptomatic to be safely managed in the community, e-diagnosis reduces DNA rates by 20-25% and emergency attendances by 25%.
“At the same time, patients are spared unnecessary hospital visits. All of which has resulted in a much more efficient patient service that increases hospital capacity and allows timely appointments for sight-threatening diseases.”
Saving sight – and money
To date, the EIP has reduced the average waiting time between patients visiting their optometrist and receiving a hospital appointment from 15 weeks down to nine.
Nor do optometrists any longer need to refer patients back to their GP for a hospital appointment; the system simultaneously informs GPs to send medical histories electronically using the Scottish clinical information gateway system.
The system, which is now being adopted throughout Scotland, is currently the only one of its kind in the UK. As well as revolutionising the way people are referred to eye clinics, it has already saved the sight of many patients who required immediate treatment.
Not least, once fully rolled out, the service is expected to save a recurrent £7m every year by improving efficiency and reducing unnecessary appointments.