Discussion
In recent years, virtual consultations have gained popularity, both within the NHS and commercially. A study by GPs in 2019 found that video consultations appeared suitable for simple presentations.3 Patients were more confident using virtual methods if the consultation was a follow-up and if they had received a diagnosis previously.4
Virtual clinics in ophthalmology are not new; in 2018, 50.0% of UK hospital eye service units in NHS Trusts were using glaucoma virtual clinics, with a further 21.4% planning to introduce such a service.5 A recent innovation at MEH has focused on allowing store-and-forward methodologies pioneered in these hospital-based virtual clinics to extend to community optometry data collection.6
Owing to the dependence on in-person examination using slit-lamp biomicroscopy, however, video consultations have traditionally been thought of as a niche technology in ophthalmology. The ongoing COVID-19 outbreak has provided a unique opportunity to challenge these preconceptions. The service described here shows clear application both in supporting social distancing during the current crisis (by dramatically reducing the number of hospital visits) and in managing simple patients at home or signposting to more appropriate services when normality is restored. We have also deployed video consultations to other services and have recently published our initial experience in scheduled oculoplastic clinics7 where we find similar levels of patient satisfaction (92% of patients indicating they would recommend the service to others). It will be important to benchmark video consultations in each clinical domain to determine the most appropriate case mix and management algorithms.
Strengths
The benefits of the emergency video consultation service go beyond the obvious reduction in viral transmission for both staff and patients. Patients spend significantly less time waiting for their consultation and forgo the time usually spent travelling (though some will have to visit the hospital if the clinician feels this is necessary following video consultation). The service allowed staff members with underlying health conditions, pregnant and those who were self-isolating to continue clinical work in a safe environment, reducing the burden on their non-isolating colleagues.
Clear communication established between IT, clinical informatics services, clinicians and senior management was a key facilitator in the rapid pace at which video consultations were implemented and scaled. Robust clinical processes ensured safe and effective running of the service and parallel administrative processes enabled tracking of service use, audit and supported accurate Trust payment.
Digital accessibility of the platform was demonstrated in this study with a wide variation in the age of patients using the platform (0–92 years; paediatric attendees were accompanied by a parent). Very few patients experienced difficulty managing the technological aspect of video consultation though we recognise that the use of such services produces bias due to a self-selecting population. There were, however, a few examples of poor internet connectivity—in these cases, the consultation was converted to a telephone consultation.
Accessibility and public awareness of the service were further enhanced with robust patient signposting on the MEH website and through multiple social media and communication channels. Following COVID-19 lockdown, Moorfields eye casualty attendances reduced from approximately 250 patients per day to an average of 64. Meanwhile, an average of 38 patients were seen daily via video consultation in the first 12 days, increasing to around 150 daily at the time of writing. A typical A&E attendance would earn the trust approximately £180, whereas a video consultation earns £73 at lower overhead costs to the Trust. The advantage of the low cost of video consultation platforms and their ability to support flexible working without utilising hospital estate may make them an attractive option for longer-term service planning. During the COVID-19 crisis, a block contract is in place to cover clinical activity—a favourable arrangement for video consultations. It is currently unclear how video consultations will be funded post-COVID-19 crisis, but anticipated changes in hospital reimbursement systems should support their continued use.
Weaknesses
In a health service built around traditional face-to-face consultations, a move to virtual consultations presents several challenges. During the COVID-19 crisis, the reduction in routine outpatient activity across the trust made adequate staffing available to support a rapidly growing service. Following the resumption of routine services, sufficient staffing will need to be ensured through modification of duty rosters and longer-term job planning.
From a clinical management perspective, a significant challenge was encountered in getting medications to patients who were not physically on-site. Where possible, local GPs were contacted and the prescription sent to the patient’s local pharmacy for collection. There were occasional delays, resulting in multiple consultations with the same patient throughout the day. Following these, liaison with the MEH pharmacy team resulted in the development of a service to post medications to patients. Although most patients utilising the service were London-based, there were calls from other areas in the UK. There will be a need in the future to identify those calling from out-of-area to advise them to contact local eye units.
Naturally, it was made clear to patients that the video consultation is not an examination tool. However, lid and periorbital signs could be assessed to some extent, and several ocular surface and anterior segment (front of the eye) signs could be detected (eg, presence of hypopyon, and bilaterality, type and severity of conjunctival hyperaemia). Crude estimates of visual acuity could also be reached. Those presenting with features of intraocular inflammation, raised intraocular pressure or those with posterior segment symptoms had to be referred in for formal ophthalmic examination. Devices and smartphone-attached optics, for example, could allow a more capable objective examination of a patient’s eye via video consultation in the future. Home vision monitoring apps show promise in allowing a remote and objective assessment of patient vision, either during a video consultation or asynchronously.
Much remains unknown about video consultations in routine teleophthalmology practice Acknowledging this, we have embedded formal monitoring of activity in our video consultation services. Operationally, we have rolled out an internal dashboard to track video consultation activity across all services. Clinically, services are undertaking audits to describe the safety and clinical outcomes of video consultations. In A&E, for example, we are actively monitoring patients with an unplanned return following a video consultation. This work will inform the clinical scenarios within which video consultations are indicated, triggers for clinical escalation and the clinical safety case for the platform. Finally, patient satisfaction is now continuously monitored using surveys presented at the end of a consultation. It will be important to continue these processes as NHS services return to normal. The current COVID-19 lockdown produces a host of potentially confounding variables that could affect video consultation use and suitability, including changes in patient desire to avoid hospital visits; clinicians’ risk assessment; available clinician time for video consultations; availability of in-person services; and the reopening of high street optometry.