Cohort 2 Topol Digital Fellow

Ophthalmologist and Digital Health Fellow, Moorfields Eye Hospital NHS Foundation Trust

Bring your own device (BYOD) – ophthalmic services game changer

From hand-written descriptions and freehand sketches that potential build in medical errors, or prohibitively expense slit lamp image technology, pilots show how an easy to use, low-cost, speedy smart phone image, with secure sharing, requiring limited training and infrastructure requirements is transforming eye care for patients and ophthalmic services with the potential to go global… and the Topol Digital Fellowship experience has also changed things for Caroline.

The challenge

Eyes are examined using a slit-lamp biomicroscope that allows clinicians to see detail down to a cellular level but examination findings are documented using written descriptions and freehand sketches. These are not only a major source of medical error, but also key detail is lost for subsequent clinicians to monitor clinical progress. Imaging technology for retinal conditions affecting the front of the eye are prohibitively expensive and therefore not available in most clinical settings.

Ophthalmology is the busiest outpatient specialty at around 10% of all out-patient appointments. The number of patients has almost doubled in the last 10 years and is set to increase exponentially, with new treatments on the horizon and the extent of chronic conditions requiring life-long monitoring.

Patients rarely see the same clinician twice, and each clinician has to decipher from sketches and descriptions, whether the condition is improving, stable or worsening. The routine secure collection of clinical photographs mean clinicians can see changes over time and make more confident decisions.

Working closely with the Department of Digital Medicine, Caroline helped set up a series of pilot studies at Moorfields Eye Hospital NHS Foundation Trust, London, with a bring your own device (BYOD) solution using smartphones to securely take high-resolution ophthalmic photographs. And the results are impressive.

The benefits

A pilot proved that 98% of images were good enough quality for consultants to make management decisions for patients based on the imagery alone. 

For patients the pilot has demonstrated dramatic time saving and reduction in delays to treatment. Patients with potentially cancerous eyelid lesions attend the one-stop biopsy clinic where they are examined, photographed, and either monitored, or have the lesion removed and biopsied. Previously, this required visiting a formal imaging suite with the whole process taking around 43 minutes causing delays to treatment in 6% of cases. Clinical safety concerns were also raised if patients needed to visit multiple sites for photography facilities. The pilot saw healthcare assistants securely take BYOD photographs of the eyelid lesions within the clinic taking only 23 seconds per photograph. 

Patient feedback demonstrated that they thought it was important for their condition to be documented and monitored using photographs, 76% preferred the new service to attending the imaging suite. As a result of the outcomes of the pilot, BYOD photography is now the standard clinical pathway in these clinics. And the benefits are spreading wider with conversations underway with teams in six units spanning four counties, to explore BYOD imaging solutions in their Trusts. 

Another pilot as part of the Topol Digital Fellowship was through glaucoma diagnostic clinics with the aim of reducing backlogs and burden on consultant-led clinics. Patients attend these clinics for a short appointment to undergo a series of tests which are reviewed later by specialist consultants. In the pilot, technicians in the diagnostic clinics took BYOD photographs of low-risk glaucoma patients with consultants reviewing the images remotely alongside other tests with the results showing the images were extremely clear at 94%. The images also resulted in nearly a quarter of cases with a changed management outcome, allowing early intervention in 15%, identifying cataract in 4% and supporting community discharge in 5% of cases.

The clinician and patient benefits haven’t stopped there as other ophthalmic sub-specialties, including ocular oncology (cancer) and sclerites teams are now setting up their own BYOD photography services due to the benefits in time-efficiency and accurate clinical monitoring demonstrated. 

The secure sharing of images has also created benefits outside ophthalmic clinics with remote decision making in emergency care. Caroline ran a BYOD photography pilot in Moorfields 24-hour walk-in emergency eye service after more than nine in ten doctors said they would feel more confident with out-of-hours remote decision-making if they could share patient photographs. During the pilot, the on-site junior clinicians securely shared ophthalmic photographs when phoning senior clinicians for advice on patient management resulting in a third of patients saved a repeat attendance in hours. One patient also avoided an invasive procedure, when the photograph excluded a sight-threatening infection. In a follow-up clinician survey, 82% felt photographs clarified the patient presentation. This has also had the added benefit of creating informal teaching and knowledge sharing with 82% feeling photographs provided informal teaching opportunities. The benefits have also spread further than Moorfields Eye Hospital with two regional hospitals approaching the team for advice and training on securely sharing BYOD photographs to support their non-resident emergency ophthalmic care services. 

The hardware innovation has seen a massive potential cost reduction from more than £25,000 for a traditional slit lamp SLR camera to a smart phone and a £115 magnification attachment and now a personal smart phone with a built-in optical zoom lens. The software solution is still going through improvements with a first iteration using the secure NHS and information governance-approved application exporting via an email account then to a patient record to photography direct into patient records using a secure BYOD-WIFI network. And there’s been a drop from a 23 mouse-click process to just 10 clicks also removing the problem of unidentifiable images and the requirement for lots of staff members. 

Caroline also looked beyond costs, efficiency and ophthalmic clinician and patient benefits to understand that staff engagement is a key factor when identifying potential barriers to introducing new innovations and scaling up a solution. 

Caroline adds: “This innovation solution can be scaled anywhere in the world due to low cost and the ubiquity of smartphones. I’ve been told this could be a game-changer which I’m particularly proud of. There will come a time where we will not believe we relied on sketches.” 

How has the Topol Digital Fellowship helped you?

Caroline gained confidence and leadership skills. “I learned about barriers and enablers to innovation and met a network of like-minded people,” she said, “I have accepted that I will not be able to achieve change alone and need to build a team with a variety of skills to do so.” 

The opportunity has also shaped her career as she’s currently spending her time half and half clinical and as a Digital Fellow, is about to start a postgraduate diploma with plans for a data analyst apprenticeship and coding courses for medics. “I feel I have found my niche, I can now use digital solutions to address clinical frustrations, meaning I’m a happier doctor. I realised I am tenacious and am prepared to see projects through even when the barriers seem unsurmountable,” she adds. 

What would you say to NHS or Social Care staff thinking about doing the Topol Digital Fellowship?

“Do it. It is a fantastic opportunity and opens so many new avenues to help shape your career.”

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Caroline Kilduff

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Moorfields Eye Hospital NHS Foundation Trust

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