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Service innovation in glaucoma management: usinga web-based electronic patient record to facilitatevirtual specialist supervision of a shared careglaucoma programme

Heathcote R Wright,1 Jeremy P Diamond2

1Centre for Eye ResearchAustralia, Royal Victorian Eye &Ear Hospital, East Melbourne,Victoria, Australia2Bristol Eye Hospital, Bristol,UK

Correspondence toDr Heathcote R Wright, Centrefor Eye Research Australia,Royal Victorian Eye & EarHospital, Peter Howson WingLevel 1, 32 Gisborne Street,East Melbourne, VIC 3002,Australia; [email protected]

Received 4 June 2014Revised 12 September 2014Accepted 13 September 2014

To cite:Wright HR,Diamond JP.Br JOphthalmolPublishedOnline First: [please includeDay Month Year]doi:10.1136/bjophthalmol-

2014-305588

ABSTRACTAim To assess the importance of specialist supervisionin a new model of glaucoma service delivery.Methods An optometrist supported by threetechnicians managed each glaucoma clinic. Patientsunderwent testing and clinical examination before theoptometrist triaged them into one ofve groups:normal, stable, low risk, unstableand high risk.Patient data were uploaded to an electronic medicalrecord to facilitate virtual review by a glaucoma

specialist.Results 24 257 glaucoma reviews at three glaucomaclinics during a 31-month period were analysed.The clinic optometrists and glaucoma specialists hadsubstantial agreement (0.69). 13 patients wereidentied to be high risk by the glaucoma specialist thathad not been identied as such by the optometrist.Glaucoma specialists amended 13% of the optometristsinterim decisions resulting in an overall reduction inreview appointments by 2.4%.Conclusions Employing technicians and optometriststo triage glaucoma patients into groups dened by riskof blindness allows higher risk patients to be directed toa glaucoma specialist. Virtual review allows the

glaucoma specialist to remain in overall control whilereducing the risk that patients are treated or followed-upunnecessarily. Demand for glaucoma appointments canbe reduced allowing scarce medical resources to bedirected to patients most in need.

INTRODUCTIONThe United Kingdom Hospital Eye Service (HES) isresponsible for diagnosing and managing glaucomaincluding ocular hypertension and glaucoma-suspects. Due to an ageing population, earlierdetection of cases and new referral recommenda-

tions from the National Institute for Health andCare Excellence,1 there has been a dramaticincrease in the number of patients requiring review.This is a pattern that will further increase as thepopulation ages. There are about 1.2 million glau-coma patients in England who require approxi-mately 2.4 million review appointments perannum.2 An additional 500 000 patients are likelyto be brought into the system within the next fewyears ( JM Sparrow, personal communication,2011).

HES glaucoma departments are struggling toreview glaucoma patients at their planned interval,as demonstrated by an alert from the National

Patient Safety Association, suggesting that patients

have come to harm because their glaucoma reviewappointments were delayed.3 In an attempt to copewith the increasing workload, several HES glau-coma departments have outsourced review of theirpatients to community optometrists.4 Appropriatelytrained optometrists have previously been shown tosafely assess glaucoma patients.57 Three potentialconcerns with such a system are: (1) failure to iden-tify at-risk patients who require urgent attentionfor life or sight threatening complications, (2) over-

treatment of patients who do not have glaucomaand (3) there is anecdotal evidence that optome-trists may have a more conservative approach toreview appointments; which could result in overser-vicing of patients and an increase in demand on analready stretched service. We look at the role of glau-coma specialist virtual-supervision of community-based optometrists.

In summer 2007, the Bristol Eye Hospital (BEH)invited a private company (Newmedica) to review abacklog of 4000 glaucoma patients who wereoverdue for their review appointment (by up to2 years). Newmedica provided optometrists, techni-cians, equipment and support infrastructure.

Patients were recruited from the general follow-uppool and were not cherry-picked to excludecomplex patients. All clinical data including history,examination ndings, visual elds and colour opticdisc images were uploaded to a web-based elec-tronic patient record (EPR) (EMMA, New MedicalSystems, London, UK). The clinic was initially runwithin the BEH precinct but was subsequentlyre-engineered to run from a mobile unit sited inthe community. The clinic continued to functionafter the initial 4000 patients were seen and add-itional clinics were established in other centresincluding Nuneaton and Kingston.

The optometrist assessing the patient categorisedthem according to a ve-step glaucoma manage-ment algorithm. The algorithm was designed afterconsultation between three senior glaucoma consul-tants to differentiate between patients with glau-coma of varying degrees of severity (gure 1):1. Normal, with no evidence of glaucoma (to be

discharged).2. Stable, glaucoma with a low risk of lifetime

blindness (to be reviewed in 12 months).3. Low risk, stable glaucoma with a moderate

risk of lifetime blindness (to be reviewed6 months).

4. Unstable glaucoma (requiring prompt evalu-

ation by a glaucoma specialist within 6 weeks).

Wright HR,et al.Br J Ophthalmol2014;0:15. doi:10.1136/bjophthalmol-2014-305588 1

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5. High-risk glaucoma (requiring urgent assessment by a glau-coma specialist within 24 h).

The clinical information was uploaded to a web-based EPR.Within 1 week of the clinic appointment, a glaucoma specialistwould perform a virtual review by accessing the EPR over the

internet. Patients were advised that the interim outcome mightchange after a glaucoma specialist reviewed their clinical data.

After reviewing all the clinical data, the specialist would eitherconrm the optometristsinterim outcome or change it if clinic-ally indicated (Figure 2).

Virtual review represents a new model of care in which opto-metrists manage patients within the community and receiveonline supervision from glaucoma specialists. We assessed thecorrelation between optometrist and glaucoma specialist todetermine whether this extra level of review is required. Duringdevelopment of the model, it was argued that glaucoma special-ist supervision would be important in two main areas. (1)Safety: by identifying high-risk patients who might be missed by

the optometrist. (2) Ef

ciency: by re-evaluating the diagnosticcategory of a patient and decreasing the number of unnecessaryreview appointments generated. We evaluated data collectedover a 31-month period to determine if this was indeed thecase.

MATERIALS AND METHODSWe collected data from 1 September 2010 to 28 March 2013from Bristol, Nuneaton and Kingston. For all visits to themobile clinic optometrist during this period, the categoryassigned by the optometrist and that assigned by the glaucomaspecialist in the virtual review clinic were entered into SPSSV.21. Ophthalmologists were aware of the category assigned bythe optometrist when they made their decision. Mobile clinical

units would generally see about 20 patients in a half-day

session. Ophthalmologists review electronic records at a rate ofapproximately 1520 per hour.

Kappa coefcient was used to measure inter-observer agree-ment between the category assigned by the optometrist and thatassigned by the glaucoma specialist. All patients who were con-sidered high risk were assessed to determine if there was a

safety issue with optometrists missing potential sight threateningcases. Finally, we compared the number of visits generated byoptometrists grading as opposed to the number of visits gener-ated by glaucoma specialist grading. This was an audit of a pro-gramme that is currently delivering routine patient care. Noidentiable patient data were collected; therefore, ethicsapproval was not required.

RESULTSData were analysed for all patients seen in clinics in Bristol,Nuneaton and Kingston during the study period. A total of24 257 patient assessments were performed. The category

assigned by the optometrist and that assigned by the glaucomaspecialist are shown in table 1. The kappa statistic for inter-observer agreement was 0.69. There was agreement on 19 542(87%) of occasions and disagreement on 4715 (13%) ofoccasions.

The virtual review process identied 13 patients who weredeemed high risk by the glaucoma specialist but not by theoptometrist; 5 of these patients had been categorised as low riskby the optometrist.

Glaucoma specialists tended to classify patients into lessurgent categories reducing the number of review appointmentsrequired. Overall, 378 patients who were thought to have glau-coma by the optometrist were said to be normal by the glau-coma specialist and discharged from the system. In all, 3084

patients were classied into less severe categories by the

Figure 1 Five-step glaucoma management algorithm.

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specialist and 1631 were classied into a more urgent category.The more conservative categorisation created by the glaucomaspecialist reduced the number of additional visits that may havebeen required by 1248 or 2.4% of the total number of visits(table 2).

DISCUSSIONHealthcare spending in the UK will fall in real terms over thenext several years and glaucoma specialists will need to providemore care with less money. To achieve this and continue to

deliver high quality care to glaucoma patients, new models of

care will be required. One such model is described herein anduses an internet-based virtual clinic to enable a glaucoma spe-cialist to review all the clinical information and conrm or alterthe interim clinical decision made by the assessing optometrist.We analysed the inter-observer agreement between optometristsand glaucoma specialist to determine if this specialist supervi-sion provided an additional benet to community-based optom-etrist assessment alone. There was substantial agreementbetween each group as represented by a Kappa statistic of 0.69.

Ensuring patient safety is a critical consideration in the devel-

opment of any new model of care. We assessed patient safety by

Figure 2 Examples of visual eld defects which could be classied as stableand low risk.


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determining if any high-risk patients were identied by the glau-coma specialist who had not been identied as high risk by theassessing optometrist. While there were only a small number ofhigh-risk patients missed by the optometrist (13), each of theseclinical situations can potentially result in a missed opportunityto prevent blindness and this is a benet that must not be under-estimated, particularly if public condence in the system is to bemaintained. With any novel health intervention, patient safety isparamount; these data demonstrate that consultant supervisioncatches a relatively large number of patients who were under-diagnosed by the optometrist. In all, 15% of patients diagnosed

as normal by an optometrist were actually found to have

glaucoma (94 of 625) and a similar number (13.5% 691 of5120) of patients who were said to be stable by the optometristwere actually considered to be at higher risk after ophthalmicreview. However, potentially the greatest risk to patient safetywas the 6.5% (838 of 12 892) of patients thought to be low riskby the optometrist who were actually found to be unstable andthus requiring a clinical review within 6 weeks. Delay in thesepatients seeking a prompt face-to-face consultation with a glau-coma specialist could result in delayed treatment and unneces-sary loss of vision.

The purpose of outsourcing is to streamline clinics and maxi-

mise the quality of care that can be delivered within an inelastic

Figure 2 Continued.

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budget. An important part of this involves reviewing patients atintervals appropriate to their risk of blindness. There was anunderstandable tendency among optometrists to be risk-averseand to review patients more frequently than was thought neces-

sary by glaucoma specialists.Table 2shows data pertaining to the total number of annual

review appointments required based upon the assumption thatnormal patients are discharged, that stable patients are seenonce per annum, low-risk patients are seen twice per annumand unstable patients seen four times per annum. It can beseen that the virtual review process reduces the overall numberof patient review appointments per annum.

By identifying this overservicing and reducing the overallnumber of reviews by 2.4%, glaucoma specialists created anadditional cost saving into the programme. A reduction of 2.4%in reviews extrapolated to 2.4 million glaucoma attendancesthroughout England equates to 57 600 fewer glaucoma review

appointments per year and a saving to the National HealthService (NHS) of nearly 3 million (assuming a net additionalcost of about 50 per appointment and including cost of thevirtual review). However, it must be noted that this study doesnot include a costbenet analysis and no comment can bemade about the costbenet of a virtual glaucoma clinic com-pared with traditional inhospital care.

This study has several limitations. It was a retrospective analysisof an operational programme that has been running in the Bristolregion and elsewhere for 6 years and therefore selection ofpatients was not controlled. Data therefore may not be applicable

to other populations. However, it does suggest that virtual clinicsconducted over the internet by glaucoma specialists are an import-ant safety oversight where community optometrists may otherwisebe managing glaucoma patients in isolation. Furthermore, suchvirtual clinics potentially cut the cost of delivering glaucoma carein the community by reducing the number of unnecessary reviewvisits. The model described optimises use of resources by usingtechnicians to collect data and optometrists to triage patientsbefore directing only those patients deemed at-risk of visual loss

to be seen by specialist medical staff within the hospital. We seethis model as an important tool in the delivery of glaucoma carein much the same way that diabetic screening services haveevolved to screen for diabetic retinopathy, allowing only those athigh risk to be referred for specialist consultation within the HES.

This is the rst publication on a novel approach to dealingwith the very large number of glaucoma patients that threatento swamp the NHS. We have suggested that virtual supervisionis an appropriate and cost effective part of such a service innov-ation. Ophthalmic supervision of optometrists provides a usefulfeedback loop that can assist the optometrist to develop theirclinical skills. We have preliminary data that suggest an increasein the kappa score over time as optometrists improve their

skills. Further questions need to be addressed in order to maxi-mise cost and resource efciency. Is the ophthalmic supervisionrequired once optometrists reach a certain level? Are optome-trists required or can technicians upload the data for ophthalmicreview? Can we use more modern progression analysis softwareto improve detection of patients who are deteriorating? Can thissystem be transferred to developing regions where there is ashortage of eye care professionals?

Correction notice This article has been corrected since it was published OnlineFirst. A new version of Figure 2 has been used.

Acknowledgements We should like to acknowledge HES managers at Bristol EyeHospital (Kate Liddington and Geoff Underwood), Kingston Hospital (Nicola Hunt)and George Eliot Hospital, Nuneaton (Heather Norgrove) who have facilitated

development of the service.Contributors HRW contributed to the analysis of data and writing of the paper.JPD contributed to collection and analysis of data and writing of paper.

Competing interests JPD is a director of New Medical Systems (Newmedica).

Provenance and peer review Not commissioned; externally peer reviewed.

Open Access This is an Open Access article distributed in accordance with theCreative Commons Attribution Non Commercial (CC BY-NC 4.0) license, whichpermits others to distribute, remix, adapt, build upon this work non-commercially,and license their derivative works on different terms, provided the original work isproperly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

REFERENCES1 NICE: CG85Glaucoma: diagnosis and management of chronic open angle

glaucoma and ocular hypertension. April 2009.2 Kelly S, Rimmer T, Bailey C,et al.New to follow up (N:F) ratios in ophthalmology

outpatient services. Royal College of Ophthalmologists Professional StandardsCommittee V3, 2011.

3 National Patient Safety Agency. Rapid Response Report. Preventing delay to followup for patients with Glaucoma. 2009.

4 Vernon SA, Adair A. Shared care in glaucoma: a national study of secondary carelead schemes in England. Eye 2010;24:2659.

5 Spry PGD, Spencer I, Sparrow JM,et al. The Bristol Shared Care Glaucoma Study:reliability of community optometric and hospital eye service test measures. Br JOphthalmol1999;83:70712.

6 Banes MJ, Culham LE, Bunce C,et al. Agreement between optometrists andophthalmologists on clinical management decisions for patients with glaucoma. Br JOphthalmol2006;90:57985.

7 Azuara-Blanco A, Burr J, Thomas R,et al. The accuracy of accredited glaucomaoptometrists in the diagnosis and treatment recommendation for glaucoma. Br J

Ophthalmol2007;91:163943.

Table 1 Data relating to interim diagnostic category (after thepatients had been classified by the optometrist) and final diagnosticcategory (after the patient data has been re-evaluated by aconsultant in the virtual clinic)

Assigned categories

Count

Glaucoma specialist

TotalNormal Stable Low risk Unstable High risk

Optometrist

Normal 531 49 28 17 0 625

Stable 267 4162 542 149 0 5120

Low risk 90 1303 10 661 833 5 12 892

Unstable 21 66 1334 4067 8 5496

High risk 0 0 0 3 121 124

Total 909 5580 12 565 5069 134 24 257

Table 2 Number of review appointments required per year based

upon one appointment per annum for stablepatients, two

appointments for low-riskpatients and four appointments forunstablepatients

Reviews generated

Optometrist Ophthalmologist

Category Number seen Reviews Number seen Reviews

Normal 625 0 909 0

Stable 5120 5120 5580 5580

Low risk 12 892 25 784 12 565 25 784

Unstable 5496 21 984 5069 20 276

High risk 124 0 134 0

Total reviews 52 888 51 640


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shared care glaucoma programmeto facilitate virtual specialist supervision of ausing a web-based electronic patient recordService innovation in glaucoma management:

Heathcote R Wright and Jeremy P Diamond

published online October 21, 2014Br J Ophthalmol

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References

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