Monitoring ophthalmic conditions with bring your own device (BYOD) smartphone photography

Moorfields Eye Hospital oculoplastic department receives around 9,500 new referrals and around 22,000 outpatient attendances each year.

Around a quarter of these patients are those with eyelid lesions.

These lesions may need urgent diagnostic biopsies or routine surgical excisions. These have to be performed in a clinic and require quality clinical photographs.

Situation

Periocular lesions should be photographed during each clinic visit to document the presence or absence of any suspicious features. This helps to monitor for change that could indicate malignancy.

Photographs are ideal because they capture detail and accurately show findings from the examination.

At the hospital, a trained medical photographer in the medical imaging department usually takes the photos using a designated slit lamp camera.

Due to the limited number of appointments, patients have not been able to have regular photos taken.

Clinicians have to rely on illustrations to document appearance and compare clinical progress. This lacks detail and results in medical errors.

A visit to the medical imaging department takes around 43 minutes. This interrupts clinic flow and causes delays that have negative effects on patient experience.

It's also difficult for patients to navigate new environments when they have a visual impairment. It would be best to reduce their movement around the hospital where possible.

Since the COVID-19 pandemic, it's become important to reduce patient movement, face-to-face contact and time within the hospital. This helps to reduce the risk of viral transmission.

Aspiration

The team wanted to use BYOD techniques to:

• introduce routine secure ophthalmic smartphone photography within the clinic setting
• reduce patient movement within the hospital
• replace illustrations with safer clinical documentation and monitoring

Solution and impact

The oculoplastic and medical imaging departments worked together to introduce a routine clinical BYOD photography service. This was a low cost solution to:

• improve documentation standards in order to monitor eye conditions regularly and safely
• refine patient flow through the clinic to improve efficiency and patient experience
• reduce patient movement through the hospital and contact points in response to COVID-19

The oculoplastic team purchased 2 iPhones and installed the Pando app. Both phones were registered to a dedicated oculoplastic imaging NHS.net account.

They were able to:

• take the photographs within the Pando app
• rename the images with the patient’s hospital number
• export them to the NHS.net email accounts

The team also purchased 2 Quikvue magnification lens attachments and a Celestron NexYZ universal mount. These were used to attach the smartphones to the slit lamp biomicroscopes. This helped to produce high quality photographs.

The healthcare assistants in the oculoplastic clinic were trained to use the Quikvue lens and Pando app to capture external lesions at the start of the clinic.

The examining doctor performed any clinical presentations that required slit lamp mounted photography.

All ocular photographs that were taken were then placed between photos of the patient’s identification label. The photograph itself was renamed to include date, time and hospital number before being sent to the associated NHS.net inbox.

A dedicated member of the medical imaging team checked the email inboxes twice a week and uploaded the images to the patient's records in the hospital image database.

This solution replaces freehand sketches.

As more patients get photographed in the clinic, the database of images to compare their clinical progress with will increase."

The BYOD aspect makes this solution scalable and can be replicated in any department with limited cost. It supports the increasing move to virtual and asynchronous models of care.

Functionality

The Pando app is as easy to use as other messaging apps, but built for healthcare. It has:

• simple and effective image capture
• image sharing with other Pando users and exporting to NHS.net
• secure instant communication
• a smart directory
• a free ‘ask advice’ feature ask specialist teams for advice and guidance
• an ‘unavailable’ status toggle button to help clinicians handle work-life balance as needed

Quikvue can be attached to most smartphones and has:

• a 15 times magnification lens
• white LED light with 2 brightness levels to illuminate the ocular structures
• blue light for fluorescein staining
• the ability to photograph anterior segment structures, including those within the anterior chamber

Celestron NexYZ can be used to attach any smartphone to any slit lamp eyepiece.

Capabilities

Pando app can be used on devices owned by the Trust. It’s an intuitive communication tool made for health and social care professionals.

It’s an approved supplier on the NHSX Clinical Communications Framework and can be found in the NHS Apps library. It’s also available to download on the Google Play Store and Apple App Store.

It enables secure password protected photography and sending of images via NHS.net without storing any data on the device.

It also allows secure instant messaging, image transfer and patient lists to be shared with individuals or teams.

Pando's free ‘ask advice’ feature means individuals can contact specialist teams for advice and guidance if it’s been enabled.

Quikvue allows high resolution photography of the anterior structures and segments of the eye, including iris and lens. The blue light allows for fluorescein stain photography.

The Celestron NexYZ mount allows clinicians to attach their smartphones to the slit lamp biomicroscope. This means they can take high resolution photographs of the anterior and posterior segments of the eye.

Scope

This solution has unlocked several applications that are being explored at Moorfields Eye Hospital.

The team can take secure, magnified, high-resolution photos of ocular structures using Trust-owned personal devices at the slit lamp. This can be used within optometry, ophthalmology and any departments with access to slit lamps.

The team can take high resolution anterior segment photos using the Quikvue and smartphone without a slit lamp. This can be used when referring or seeking guidance on patients within:

• a medical ward
• general A&E
• primary care
• other specialties

The team have the ability to send ocular photographs and messages through secure instant messaging between clinicians. This is useful for:

• referral refinement
• advice and guidance for non-eye care specialists
• seeking senior opinions out-of-hours
• reducing the number of unscheduled patient visits

The team can document eye presentations and compare photographs to monitor clinical progress for a low cost. The solution can be used in outpatient clinics and theatre sessions, for example, examination under anaesthesia in paediatrics.

High quality photographs at low cost can be used to support virtual clinics and asynchronous models of care.

The solution can be used as a blueprint to be copied, adapted, and scaled in other departments without the need for expensive infrastructure.

Key learning points

• Ensure Pando app on each device is linked to a different email address to avoid photos appearing in the Pando gallery out of order.
• Ensure lead time is taken to order equipment through hospital procurement systems.
• Train staff on clinical photography to ensure high quality patient photographs.
• Train staff to use the equipment and how to troubleshoot issues.
• Empower and use all staff members in the multidisciplinary team to be part of the change.
• Ensure roles and responsibilities are clearly defined when setting up new ways of working.
• Investigate the easiest methods to carry out each step of the process. For example, consider automating the upload process through integration with the Trust's Electronic Patient Records (EPR) where possible.
• Engage with patients to understand their needs and concerns.
• In some units, it’s possible to take photographs on personal devices and add them directly to EPR. This eliminates the need to manually rename, export and upload photographs and any problems associated with these steps.

Key figures

In a survey conducted on patients:

• 100% of patients surveyed felt that photographs should be taken to document their eye condition at every clinic visit and monitor changes in their eye over time
• 56% reported that they would be happy to have their care in virtual clinics if their team could review photographs of their eye condition. 20% were neutral on the subject
• 88% felt that having photographs in the clinic saved them time compared to attending the medical imaging department
• 74% of patients preferred to have their photographs taken in clinic rather than travelling to the medical imaging department. 21% were neutral on the subject

Time motion studies showed that on average, it took:

• 43 minutes to attend a formal medical imaging appointment
• 23 seconds to mount the Quikvue attachment and take a photograph
• 1 minute 21 seconds to mount the smartphone on to slit lamp using the Celestron NexYZ and take a photograph
• 7 seconds to send each photograph to the associated NHS.net account
• 5 to 7 minutes to upload photographs to the hospital document management system

The image quality of the photos were also reviewed and showed that:

• 97% (35 out of 36) of smartphone images taken with the Quikvue lens were graded as ‘good’ for image quality
• only 3% (1 out of 36) of the smartphone images taken with the Quikvue lens were graded ‘poor’ for image quality
• 90% (18 out of 20) of the smartphone images mounted to the slit-lamp were graded as ‘good’ for image quality
• 2 independent oculoplastic consultants were both able to make management decisions using each of of the smartphone images

Find out more

Patient survey (account required)

Key contact

Caroline Kilduff, ST4 and Topol Digital Health Fellow 2021 to 2022

caroline.kilduff1@nhs.net