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Video: evidence-based approach to digital medicine at Moorfields Eye Hospital

Dr Peter Thomas, CCIO and Director of Digital Medicine at Moorfields Eye Hospital, joined us at HTN Now to discuss Moorfields’ approach to digital medicine and their experience so far. Peter is also the Clinical Lead (Digital) of the National Eyecare Programme.

Peter opened his session by sharing the intention to focus on hard evidence: what evidence Moorfields used to decide on their digital approach and how they evidenced that the approach was working.

He began by highlighting the importance of getting clinical informaticians involved. When he took over as Chief Clinical Information Officer at Moorfields last year, the main question was how clinical informatics should be structured: “what should I put in place… to develop this group of leaders who can make sure that when we do something [with technology], it’s successful?”

Moorfields conducted a consultation process with digital leaders from other trusts and organisations, resulting in five hours of structured interviews and 32 in-depth survey responses from which to learn from. The responses provided Peter with data to guide his own approach.

Although respondents broadly agreed that their organisations had a good track record for implementing IT systems to support clinical care, Peter noticed that those with an IT background tended to report a better performance than those with a clinical background did. This split in opinion suggested that the people who were designing the systems had more confidence in the system’s abilities than those who were actually using it in their jobs. “While we’ve had all this work around clinical informatics to try and ensure that clinicians are heard and involved in clinical IT, we still find that the lived experience of clinical IT in hospitals for users is significantly different to the opinion of those who are implementing the systems.”

Quotes from surveys and interviews provided Peter with further guidance; a clinician reported that “sharper focus on clinical safety” is needed by IT systems, whilst an IT professional mentioned that their time was eaten up by clinicians “asking for things that they don’t understand.” Peter noted that this was a recurring theme within the survey responses, and provided focus to explore the process of understanding the problem and what a good solution might look like, before clinicians approach their IT colleagues for help.

Other key findings from the research found that 28 percent of respondents were not confident that they knew the make-up of their own CxIO team, and that only one respondent agreed that their organisation would be able to deploy new technology at scale without additional resourcing or significant re-organisation. Themes from the research suggested that clinical informaticians are not well-sourced or well-supported, their profile and stature in hospitals in terms of influence, and core activities like digital clinical safety require development.

As a result of these findings, Moorfields came up with the concept of the department of digital medicine. “A little bit like an IT department, but for clinical informatics,” explained Peter, “with the idea being that we centralised it and structured it. We could formalise its relationships to other parts of the organisation.”

“It clearly gives a name and voice to the speciality… which brings with it, I suspect, more representation at a high level,” one respondent said when asked for feedback, whilst another commented, “I liked the professionalisation… it brings home to people that digital is as important as the stethoscope, the eyes and mouth and other stuff just like that, that’s a new tool of delivering care, and it’s good to have a specialist department.”

The research led to three recommendations for Moorfields to act upon; to establish and resource a department of digital medicine; the department should have specific responsibility for digital clinical safety; a digital council should be established to connect all clinical services; and a user-centred approach should be developed, including patients in the process.

Moorfields moved forward with their recommendations in spring/summer 2021; key individuals were appointed in November and the work is now divided across six workstreams, each with identified owners who work on a shared management programme.

With the project ongoing, Peter said that they are working on gathering hard evidence of impact, but he shared some examples of the progress of the professionalisation in clinical informatics. Where Moorfields previously had one Clinical Safety Officer, they now have four; one Fellow at the Faculty of Clinical Informatics has become six. They also run weekly collaboration sessions “which bring together the core digital medicine team as well as other interested people from the organisation”, ensuring strong levels of communication.

Moorfields’ approach to video consultations

“I’m going to talk about the evidence that the department of digital medicine has been generating to support across the range of other services,” Peter said. “Video consultations are an interesting one to start with, because the context is that they were absolutely not established in ophthalmology prior to COVID. There was no evidence base to support use-cases or to demonstrate clinical safety.” He added that there were “generally very low expectations of success [for video consultations] in ophthalmology”, explaining that this is due to the fact that ophthalmology is very dependent on magnified examination on the eye.

Moorfields set up a virtual A&E within 36 hours of lockdown, providing a drop-in consultation service to connect patients to ophthalmologists; a virtual receptionist checked patients in and distributed them to the correct destination, with peak usage seeing around 800 patients a week. It has been sustained and scaled for continued use. “You can speak to one of our ophthalmologists straight away just by going to our website and clicking on the button,” Peter said. “We’ve extended [opening hours] into the evenings and have longer hours on the weekend. That’s a service that’s not available anywhere else in the world… similar to a 111 service, except it’s supported by video. And rather than speaking to a generic clinician, you speak to an absolute specialist.”

Peter discussed how the urgent set-up of the virtual A&E in the first lockdown led to Moorfields quickly collecting “low-powered” evidence; in the first 12 days, they picked up 16 patients with warning signs of retinal detachment, helping to ensure early treatment for those individuals.

“We rapidly moved on to getting high-powered evidence,” Peter said. “We were conscious that we were probably going to get a lot of push-back to the work we’re doing with video consults, with people asking, ‘is it safe’. While it was accepted that we would have to take this approach during COVID, we were conscious that as soon as the lockdowns eased, clinical safety considerations would start to be used in order to reduce that video service.”

Describing how they undertook and published a study of 855 adults to compare incidence of actual and potential harm between in-person and video consultation in A&E, Peter went on to share the results: there was no incident of actual harm as a result of video consultation. Additionally, 78.6 percent of patients who presented to virtual A&E did not require a hospital visit.

Annualised data based on the first year of usage presents some additional facts on sustainability: through video consultations, Moorfields worked out that the travelling distance saved was “1.8 times to the moon and back” and in terms of time spent travelling, “6.4 years of life” were saved.

When it came to patient satisfaction, the results were positive: “It stayed pretty robustly at around 4.5 out of 5,” Peter said. “So, an extremely popular service that actually out-performed the face-to-face emergency service.”

Peter came back to the importance of evidence, commenting, “We were conscious with digital medicine that we were getting into an area where we didn’t have an evidence base to point to, [to show] what we were doing is safe, what we are doing is effective, efficient, popular. So taking this evidence-based approach to digital medicine, within the first weeks of this service being set up and then in an ongoing way, we measured and transparently reported all of these things.” He added that providing a strong evidence base was seen as key for scaling it in the future. “We’re now in the position where this A&E service hasn’t actually disappeared, where many other video services have. It’s embedded in job plans and we’re now looking at how we can expand it.”

Remote vision monitoring 

Moving on to the topic of remote monitoring, Peter talked about the need for evidence to understand if home vision monitoring is valid and how services can be designed around it to ensure that patients engage with it and reap benefits. “We can use that for a number of different purposes,” Peter said. “An interesting use-case is to be able to keep stable patients at home, and conversely, to detect deterioration for a prompt treatment.” He highlighted that a key opportunity is in Wet Age-Related Macular Degeneration. “The drugs cost of that particular condition alone is ¬£500 million a year for NHS England. That’s not including the costs of out-patient appointments, of having an injection room or an operating theatre in which to do it, and doing all the scans we need to support it. So we wanted to get to a situation where we could start to reduce the burden of managing conditions like this, by measuring vision at home. So if a patient’s vision was stable, we wouldn’t bring them in, but the second their Macular Degeneration started to play up, we want to be getting those patients in straight away.”

Peter described how Moorfields embarked on a series of research projects “in order to get to a point where home vision monitoring can start to replace the gold standard treatment.”

The team at Moorfields used two apps called AllEye and My Vision Tracker. AllEye presents patients with three dots that may or may not be in a line and asks them to detect whether they are aligned or not. My Vision Tracker presents patients with circles and a polygon on screen and asks them to identify the polygon, with the polygon becoming more and more like a circle as time passes, making it harder to tell and testing quality of vision.

Looking at data gathered through an audit of the app, Peter notes how “this begins to identify problems with this approach that are being found all over the world now as remote vision monitoring takes hold… out of the 417 patients we recruited, 159 of them were non-active users. And even of the 258 active users, 86 were non-compliant… that puts us in a tricky situation, that we’re probably hedging a lot of bets on the value of home vision monitoring.”

Moorfields published a lot of papers as a result of their research; next, Peter showed some pages from “Enablers and Barriers to Deployment of Smartphone-Based Home Vision Monitoring in Clinical Practice Settings”, to point out some of the factors involved in patient compliance and app usage, which helped Moorfields see any emerging trends and potential weaknesses of home vision monitoring systems. “Increasing age, for example, was a very important one in determining non-compliance,” he said; another was “the nature and expense of the disease” the individual experienced. “This begins to give us an evidence base to work out which patients we need to target with additional support, and how we can start to build that support package.”

Another interesting stat pulled up by the research is the level of communication desired by patients. “We found a pretty stark distinction, really,” Peter said. “Some of the patients didn’t like that we didn’t tell them how their vision was when they measured it. Other patients only wanted to know if the vision got worse, they didn’t want to be obsessing about small changes. It was about 50/50. It begins to show some of the complexities of how we design these services.”

Using the AllEye app, Moorfields also researched how early detection could be supported through use of at-home monitoring. 245 patients with Macular Degeneration or Diabetic Maculopathy performed 11,592 remote vision tests. 164 alarms were generated where the vision suddenly worsened; of those, 78.5 percent had a measurable worsening of their disease when they attended in-person for testing, with 60 percent achieving the criteria to receive an injection inside their eye to treat it. “Our expectation is, as we start to scale up these studies and get higher-powered data, we will find that these patients who we treat early will need fewer injections overall.”

Using consumer devices for eye examinations

Peter shared his experiences of documenting eye examination via smartphone, sharing how a colleague discovered that he could use his iPhone X to look through the keyhole of his pupil, once he had dilated it with drops. Showing the image taken on the phone, Peter said, “What you’re seeing here is actually a structure at the back of the eye, it’s part of the central nervous system. It’s called the optic disc. It’s where the optic nerve, that goes into the visual part of the brain, plugs into the eye… So we found that we were able to visualise the brain using an iPhone X and eye drops.

“This started to get me interested with other colleagues about what we could potentially do using phones, which all clinicians have, broadly speaking, to start visualising patient diseases, in ways that we haven’t been able to before.” He highlighted the work of Iain Livingstone, National TeleOphthalmogy Lead for Scotland: “He’s been onto this for a while, attaching iPads and smartphones to microscopes in local ophthalmology practices, so they can livestream eye examinations to him in the hospital.”

Moorfields implemented a secure clinical ‘bring your own device’ photography service using low-cost macro lenses which can be attached to smartphones, in order to monitor suspicious lesions on eyelids.¬†Peter said, “When we looked at the clinical suitability of the photos we got, we were over 90 percent in terms of perceived suitability for smartphone photographs making clinical decisions, and very good agreement was found between clinical agreements made on the basis of a smartphone image, and a face-to-face decision. Additionally, the vast majority of patients felt comfortable with the process and agreed that photographs should be taken at every visit.”

Peter rounded up his talk by sharing some research into digital exclusion, “helping us to begin to understand things that we need to work on in order to reduce it.” The broad factors that were highlighted included improving trust via clear communication, supporting people in gaining access to the resources they need in order to take part in digital systems, and providing instruction and guidance to build people’s confidence in using technology. This has led to the creation of virtual pods and private areas for people to attend their video consultation with volunteer support.

“We’ve made significant progress in embedding clinical informatics and transforming services,” Peter concluded, “and this evidence-based approach has really been central in helping us to justify what we’re doing and justify why we’re doing it.”

Many thanks to Peter for his time. You can watch the full session below.