Glaucoma electronic patient record--design, experience and study of high-risk patients

A collaborative care pathway for patients with suspected angle closure glaucoma spectrum disease

BACKGROUND

Currently, no specific collaborative care pathway exists that distinguishes open angle glaucoma from narrow angle or angle closure disease. This study evaluates a newly developed referral and collaborative care pathway specifically for patients with angle closure spectrum disease.

METHODS

The medical records of consecutive patients referred to the Centre for Eye Health for glaucoma assessment were examined, six months before (Pre Suite) and after (Post Suite) the introduction of a novel referral pathway for anterior chamber angle assessment (Angle Suite). Patient demographic and clinical data, the referral letter and practitioner characteristics were extracted.

RESULTS

Angle Suite (n = 77) patients had an appointment much sooner compared to Pre (n = 383) and Post Suite (n = 425) patients (p < 0.0001). Following the introduction of Angle Suites, there was a reduction of incidental angle closure disease found in routine, non-angle closure glaucoma assessment. Onward referral was required by 36.4 per cent of patients referred for suspected angle closure disease, while the rest could be discharged back into the community (13.0 per cent) or reviewed at the Centre for Eye Health (50.6 per cent). Multinomial logistic regression found that the presence of an angle description in the referral letter improved the true positive rate for angle closure disease (p < 0.0001).

CONCLUSIONS

The clinical pathway may reduce the number of incidental angle closure patients and improved the timeliness of appropriate clinical care delivered to a subset of patients who may benefit from prompt medical attention. This pathway provides an opportunity for appropriately staffed and equipped collaborative care clinics to reduce the burden on tertiary level ophthalmic facilities.

A comparative study of glaucoma referrals in Southeast Scotland: effect of the new general ophthalmic service contract, Eyecare integration pilot programme and NICE guidelines

Background

Glaucoma is a progressive disease responsible for the second commonest cause of blindness in the UK. Identifying appropriate patients for hospital care remains an ongoing challenge for all UK hospital glaucoma services. The purpose of our study is to evaluate accuracy and outcome of community optometry referrals before and after implementation of the new general ophthalmic service contract in 2006, the Eyecare Integration Programme pilot in 2008 and the effect of NICE guidelines in glaucoma in 2009, over a 12-year period

Methods

A retrospective case analysis using a glaucoma electronic patient record was performed encompassing two six-year periods, 2000–2006 (Group A), and 2007–2012 (Group B).

Results

One thousand six hundred twenty-two new patients’ records were analysed. Waiting times reduced from 12.3 to 9.4 weeks. Significantly more patients kept first appointment (p = 0.0002) in group B. Glaucoma symptoms were significantly more in group A (p <0.0001) and only three patients lost Snellen’ visual acuity before appointment in group B compared to 12 in group A. Documentation of intraocular pressure was made in 74.1 % of Group A and 75.9 % of Group B, optic disc appearance in 85.4 % of Group A, and 93 % of Group B and visual fields in 84.4 % of Group A and 81.3 % of Group B. Significantly less normal (p < 0,0001), more glaucoma suspects (p < 0.0001), more open angle glaucoma (p = 0.0006) and fewer other conditions (p = 0.0024) were present in group B, compared to group A.

Conclusion

Patients were referred earlier with shorter waiting times for hospital appointments with the new Scottish general ophthalmic service and Eyecare Integration Programme. Additionally there were fewer false positive referrals with more diagnosis of glaucomatous disease. We discuss the benefits of these national screening and referral pathways together with their limitations and further refinements.

Glaucoma-service provision in Scotland: introduction and need for Scottish Intercollegiate Guidelines Network guidelines

Purpose

To describe the pattern of glaucoma-service delivery in Scotland and identify areas for improvement, taking into account Scottish General Ophthalmic Services (GOS) arrangements and the Eye Care Integration project, and to design Scottish Intercollegiate Guidelines Network (SIGN) guidelines to refine the primary and secondary interface of glaucoma care.

Materials and methods

A glaucoma-survey questionnaire was sent to all consultant glaucomatologists in Scotland. The design of SIGN guidelines was based on the results of the questionnaire using SIGN methodology.

Results

Over 90% of Scottish glaucoma care is triaged and delivered within hospital services. Despite GOS referral, information is variable. There are no consistent discharge practices to the community. These results led to defined research questions that were answered, thus formulating the content of the SIGN guidelines. The guideline covers the assessment of patients in primary care, referral criteria to hospital, discharge criteria from hospital to community, and monitoring of patients at risk of glaucoma.

Conclusion

With increasing age and limitations to hospital resources, refining glaucoma pathways between primary and secondary care has become a necessity. Scotland has unique eye care arrangements with both the GOS and Eye Care Integration project. It is hoped that implementation of SIGN guidelines will identify glaucoma at the earliest opportunity and reduce the rate of false-positive referrals to hospital.

Improving 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, 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.

Ophthalmology and information technology in tuzla canton health care system

Purpose:

To analyze organization of ophthalmology health care in Tuzla canton and use of information technologies(IT).

Introduction:

IT in ophthalmology is the technology required for the data processing and other information important for patient and essential for building an electronic health record(EHR). IT in ophthalmology should include the study, science, and solution sets for all aspects of data, information and knowledge management in health information processing.

Material and methods:

We have analyzed organization of ophthalmology health care in Tuzla canton. Data relevant for this research were acquired from annual reports of Tuzla Canton health ministry. All institutions and ambulances were visited and all health care professionals interviewed. A questionnaire was made which included questions for health care professionals about knowledge and use of computers, internet and information technology.

Results:

Ophthalmology health care in Tuzla canton has paper based medical record. There is no information system with any possibility to exchange data electronically. None of the medical devices is directly connected to the Internet and all data are typed, printed and delivered directly to the patient. All interviewed health care professionals agree that implementation of IT and EHR would contribute and improve work quality.

Conclusion:

Computer use and easy information access will make a qualitative difference in eye-care delivery in Tuzla canton. Implementation phase will be difficult because it will likely impact present style of practice. Strategy for implementation of IT in medicine in general must be made at the country level.

Using electronic referral with digital imaging between primary and secondary ophthalmic services: a long term prospective analysis of regional service redesign

PURPOSE

Demands on publicly funded ophthalmic services worldwide continue to increase with new treatments, waiting time targets, working time limits, and restricted budgets. These highlight the necessity to develop innovative ways of utilising existing capacity more effectively.

METHOD

A new regional, fully electronic ophthalmic-referral service with digital imaging was trialled using existing information-technology (IT) infrastructure. Following successful pilot study, the service was rolled out regionally. Service delivery data was prospectively collated for all the attendances in the year prior to (2006) and the year following (2008) introduction.

RESULTS

Comparing 2006 against 2008, median waiting times reduced (14 vs 4 weeks), and fewer new patients were observed (8714 vs 7462 P<0.0001), with 1359 referrals receiving electronic diagnosis (e-diagnosis). New patient did not arrive (635 vs 503 P<0.0001) and emergencies also reduced (2671 v 1984 P<0.0001).

DISCUSSION

Novel use of existing IT infrastructure improves communication between primary and secondary care. This promotes more effective use of limited outpatient capacity by retaining patients with non-progressive, asymptomatic pathology in the community, whilst fast-tracking patients with sight-threatening disease. Resultant significant, sustained improvements in regional service delivery point to a simple model that could easily be adopted by other providers of universal healthcare globally.

Impact of direct electronic optometric referral with ocular imaging to a hospital eye service

AIMS

A study to assess the feasibility, safety, and clinical effectiveness of electronic referral--with and without images--of patients directly from optometrists in primary care to the hospital eye service (HES) in contrast to the traditional paper-based referral, through the general practitioner (GP).

METHODS

Three optometry practices sent consecutive referrals with images through the NHS Net to the HES. The standard General Ophthalmic Service form was electronically redesigned with additional information on patient choice for advice, appointment, or surgery. All paper referrals to the HES from the same three optometry practices before the study period were analysed (control group A) as were all paper referrals from the remaining optometrists in Fife (control group B).

RESULTS

A total of 346 electronic referrals were received over 18 months. 218 (63%) were classified as requiring and 128 (37%) as not requiring a HES appointment. The latter were subsequently examined with unexpected pathology found in three cases (glaucoma, macular pigment epithelial detachment, and possible peripheral retinal tear). In both groups, the major pathologies reported were macular degeneration, cataract, glaucoma, diabetic retinopathy, and abnormal retinal appearances. A total of 17 (15%) patients in group A and 26 (8.4%) patients in group B were classified as not requiring HES appointment. These control groups indicate that approximately 10-15% of paper referrals are not seen in the HES. To summarise, therefore, 63% of people referred by the optometrist directly using electronic referral (with or without images) were given a HES appointment compared to 85% of people referred through the traditional paper method (without images) through their GP.

CONCLUSION

Electronic referral with images to the HES is safe, speedy, efficient, and clinically accurate given some limitations and avoids unnecessary consultation in 37% of referrals.