Using an electronic patient record to establish virtual clinics

East Kent Hospitals University NHS Foundation Trust has five hospitals serving the local population of around 695,000 people. The Trust receives over 200,000 emergency attendances per year.

Situation

East Kent Hospitals University NHS Foundation Trust ophthalmic department realised a significant backlog of follow-up patients had built up and was finding difficulty in accommodating the demand for new patients requiring services. The Trust needed a solution to help increase capacity within the system.

Aspiration

An electronic patient record (EPR) which allowed communication, data input and image and data transfer on multiple devices was required. It needed to be flexible to allow different services to set up virtual clinics.

Solution and impact

The virtual outpatient photographic diabetic review clinic started in 2017 initially at three sites but following its success was expanded to a further two sites. This service reviewed new and follow-up diabetic retinopathy patients without proliferative diabetic retinopathy.

Ten patients were booked per session with five weekly sessions. Clinical data obtained from patients included history, visual acuity, retinal photographic imaging, and optical coherence tomography (OCT) scans. All data was collected in OpenEyes EPR and images viewed on Imagenet, a web-based system for reviewing ophthalmic images.

The grader reviews the results and refers for face-to-face consultation if necessary. Over a two year period 82% of patients remained in the virtual clinic for surveillance, hugely reducing face-to-face appointments.

In July 2019 East Kent started a naevus imaging clinic at two sites. The clinic sees 40 to 60 patients per month with a technician and an ophthalmic science practitioner. Patients are seen within a review period designated by the doctor and receive standardised imaging and reviewing with any urgent cases being fast-tracked to the consultant clinic. Clinics are paperless, using instead the OpenEyes EMR with consultation information all integrated on one system. Appointment duration is now shorter by 27 minutes per patient on average.

The rapid access referral system for wet age-related macular degeneration started in July 2017 with one ophthalmic technician and one reviewer to access images and outcome. All data was uploaded on OpenEyes to allow a paperless, integrated system.

This was to address the large proportion of false positive referrals via this process as it was found that only 17% required treatment when audited over a six month period. 20% of patients were discharged from virtual clinics, 16% were referred to another ophthalmology clinic and 47% were booked into the age-related macular degeneration clinic but did not undergo treatment. This service increased the capacity of the service by 25 new referrals per week and reduced appointment duration for patients.

East Kent started a community glaucoma network in 2014 with primary care optometrists who had undergone some further training providing an enhanced service in 10 optical practices. All clinical data was uploaded onto OpenEyes for virtual consultant review. This allowed stable glaucoma (>500 patients) and ocular hypertensive (>1000 patients) patients to receive care in the community.

Functionality

OpenEyes is a widely-used open source EPR application specifically for ophthalmology. It runs on a web browser so that it can be accessed in multiple locations and on multiple devices. It can be customised to suit local needs and will scale to seamlessly connect primary and secondary eye care.

OpenEyes consolidates patient information including clinical examination results, images, pathology and correspondence, into one easily accessible record. OpenEyes provides fast entry of Systematised Nomenclature of Medicine – Clinical Terms (SNOMED CT-coded) diagnoses and results as well as decision support, outcome analysis and easy-to-interpret summary views of the patient’s care.

Capabilities

• Records clinic visits, assessments, investigations, and ophthalmic procedures
• Instantly review patient history and progression of findings over time
• Consolidates records and scans from multiple sites and ophthalmic instruments
• Generates correspondence with patients and care professionals
• Reports on activity and clinical outcomes in line with national datasets and audits
• Direct integration with ophthalmology imaging equipment
• DICOM (Digital Imaging and Communications in Medicine) integration
• Maintains an integrated, digitised record regardless of where the patient had their episode of care
• Electronic Certificate of Visual Impairment (CVI) forms
• A portal allows optometrists to upload cataract surgery outcome data
• New OpenEyes V3 is able to submit directly to the National Ophthalmology Database (NOD)
  

Scope

• Provide an ophthalmic suitable electronic patient record
• Shared fully-integrated clinical record system for primary care, community care and secondary care
• Images and Visual Fields can be viewed but may show limited information depending on the device One solution will be to use OpenEyes with a non-proprietary software to integrate multiple devices
• Referrals and advice and guidance messaging can be performed on the system
• Runs on a web browser so no carrying of patient records, with merging of multiple patient medical record numbers from different sites and interfacing with the hospital IT systems to retrieve patient demographic data
• Disease progression can be assessed quickly and easily with graphs of progression. Images and scans can be compared over time with a few mouse-clicks, and charts highlight changes in treatment and how these affect outcomes
• Generate audits more easily and all information can easily be reviewed from any location, allowing outcomes reporting, research, and service demand forecasting. Audits in line with national ophthalmic audits and recognised/recommended ophthalmic outcomes
  

Key figures/quotes 

• A survey published in 2017 found 45.3% of UK eye units use an EMR, with 79.1% of those being an ophthalmic specific system. Medisoft was the most-widely reported EMR in use, followed by OpenEyes
• “Complete postoperative feedback (ie data on refraction, visual acuity and intraocular pressure) was available in 97% of these patients compared to 50% of patients reviewed in the hospital.” Sligo University Hospital, Ireland

Find out more

Find out more from the NHS Futures website (account required)

Key contact

Susan Walker, specialist ophthalmic science practitioner, East Kent Hospitals University NHS Foundation Trust

susan.walker21@nhs.net