E-health in optometry: which clinical services fit the format?

Yes, I would say corona is a part of the reason for the increased focus on e-health today. I know, I should be very careful to say that there are good outcomes of the corona crisis, but there are some interesting changes, and this is one of them.

E-health has been around for many years but with the outbreak of COVID-19, that suddenly got more attention in terms of how we could reach patients and how we could stay open without seeing patients in the stores, physically.

That’s a good question. I haven’t reflected much upon that myself, actually. But if I look back at my history, I started my first job in a software company that went into producing LCD projectors. So already back then I worked closely with software engineers. Later, I have been working with the development of electronic health records and I think since then, I became aware of the potential that software has in optics.

Today, there are several e-health tools that optometrists haven’t started to use yet. One reason for that is that the products are not always fully developed, but there are some new tools that we can pick up and use already today. It’s as easy as downloading apps via the App Store, which you can use in the test room.

Yes. I guess my interest in all the apps started about 15 years ago. I worked in refractive surgery and we included an animation software to visualise what we were talking about with the patients. Things like: what is myopia and hyperopia? how do you correct it with laser? how do you do a refractive lens exchange? and similar. The price was about €4,000 a year per license, and that brought value because suddenly customers and patients started to understand what I was talking about.

After I got this tool, I realised that up until then I had been talking, but only a few patients had probably understood what I was trying to explain about their vision! So, I thought this tool did an excellent job of explaining all the basic things. And after using that tool, I discovered that my conversion rate went up because patients suddenly understood what I was talking about. They were even able to stop the conversation to point at the screen and ask, “what does this mean?”. The quality of the interaction between us improved.

And today, there are many apps to find on App Store like this one – pure educational apps explaining: what is myopia, what is glaucoma, what are contact lenses, and how to put in and take out contact lenses etc. Easy stuff like that which we currently use manual working hours on teaching patients how to do themselves. Instead, optometrists could work more efficiently by presenting an app or an image/video for the patients to look at. I often use my phone to show and tell.

In this article, you’ll find a good overview of the useful apps in optometry.

Yes, exactly. There are good examples of videos teaching how to put contact lenses on/off which are being used in stores or sent to patients with great success.

The way I use apps personally is to show for example the Amsler grid – if I’m in a test room that doesn’t hold an Amsler grid, then that’s no problem since I of course just have it on my phone.

Then there’s also loads of YouTube videos available with very good explanations. Just make sure that you don’t show too complicated stuff and nothing scary! That is why I prefer apps because they are animated. I would never show a patient a video – it’s too scary. Reality can be harsh. So, I soften it up a bit.

Rendia provides good animations to use in optometry and other medical professions. Several of their animations can also be found free of charge on the Internet.

And then there’s also video consultations. I’ve done video consultations myself to test the estimation of the visual acuity over a screen. You use a video conference system and then you flip the screen, making sure that the patient sees the apps or images you want to present. This can be visual acuity charts, Amsler charts, contrast sensitivity, colour vision etc. Working like that, you are able to estimate the visual function. Not completely accurate, but enough for you to pass on the next advice to the patient.

The Confrere video consultation system is a safe and easy tool to use. You can also flip the screen and show your remote patient different on-screen tests.

Oh yes. And this is where I fear that we as a profession are missing out. People are downloading apps, they measure their acuity, and they get advice on what to do next. Especially young patients. These apps, or some of them at least, are developed and sponsored through investment money. They have a very commercial angle and I have seen several apps about vision that do not build on science: the clinical quality just isn’t there. But that does not mean they will disappear from the market!

Some of these advanced eye examination apps can eventually minimise the optometrist’s role as the first point of contact for vision advice. That’s why I see it as our responsibility to make sure these apps are used in a safe way rather than turning our back on them.

This means telling our patients the real pros and cons of using them; “Yes, you can use these functions, but you have to know that there are limitations. Instead, we can use them together in the store or over video to be sure you receive the right advice” etc. I think overall, we need to be much more active in the dialogue with our patients about these trends.

I’m not saying that this market of apps will take over optometrists’ work, even if some try to, but they can weaken our position if we do not pay attention to them. What we will see eventually is, that if you, for example, wake up tomorrow with a red eye and you start to google “red eye” and “what do I do?”, what you then find is some written literature, some advice, and finally you will find the online doctors. The fastest way to get advice will be to connect with those doctors via an app and have a consultation over video.

Some of the online doctors will say: “Okay, with red eye I need to see more details, so you have to see someone.” Often that someone won’t be an optometrist – most likely, it will be an eye doctor. And then our profession might be bypassed again.

Another option is that the online doctors treat the patients themselves; “Here are some antibiotics. Don’t worry. Call me in two days if it’s still an issue.” But again, it should be the optometrists who are the first point of contact. That’s also one of the reasons why we decided to adopt video consultations in the company I work for today – Specsavers. And I think this area will develop, or at least it should. But that never happens if the optical industry doesn’t embrace it and start thinking about how the younger patients will behave when they have an eye problem; will they call their family optometrist, or do they turn to google? And where do they then end up…at optometrists, online doctors, or ophthalmologists?

Yes, definitely. And this was where my interest in e-health really started – with the electronic health records. That’s an e-health tool as well. Defined by the World Health Organisation, an e-health tool is any electronic tool or method that healthcare workers use when they deliver a healthcare service. That’s a very broad definition, making electronic records a definite e-health tool in that context.

We also see that the subterm, mHealth, is on the rise, which points towards the use of mobile technology in healthcare.

The purpose of the WHO Global Strategy on Digital Health 2020-2026 is to promote healthy lives and wellbeing for everyone, everywhere, at all ages, which you can read more about here.

But back to the electronic health records – and here the masters are radiologists. They merge the images with notations to grade their findings. To have clinical data and images in the same software system is the way to go for many other medical professions since there are more and more devices that build on objective ways of measuring human functions – or malfunctions. For us, this is typically OCT, fundus images and other ways of imaging the eye including slit-lamp photo and video. These objective measurements should be collected in one place. It increases safety when you know you have the right images from the right person into the same system as your medical notes.

Right now, in optometry, we often use at least 2 and maybe up to 4-5 systems, because there is usually one electronic support system linked to every device, and that is not sustainable. You lose efficiency, you lose safety, and you also lose patient attention. Every electronic tool I’ve put in front of me is taking my focus away from the patient. We need to make sure they get a good experience, so the screen time needs to be as short as possible. We need to have systems where we can integrate all the examinations and all the images into one system or at least the different systems need to talk with each other.

Yes, spot on! That would make it possible to deliver integrated care between these professions in a good way.

Several nations’ health systems are trying to put all medical information into one system to make sure they are easily available for the patient and caregiver. This idea traces back to the ’40s, when George Orwell wrote his book “1984”. The point is that there are not only benefits about these things, but it will happen eventually no matter what.

A good example of getting close to this goal of “one system” is Finland, where they have Kanta; the public archive for medical information. Today, optometrists in Finland are obligated to send information to Kanta by law to make sure all relevant information is gathered in one place. Not only better care but also better health statistics will be the outcome of this.

Another huge benefit of one common electronic health record system is that it helps get the diagnoses right. Behind every diagnose there’s a certain pattern of clinical data. At least, in theory, it shouldn’t be very complicated to steer your thoughts on a direction toward the correct diagnose. What I’m talking about is automated clinical decision support – not artificial intelligence – just basic support in what you need to think of. For example, the eye pressure; if the pressure is more than 3 millimetres difference between the eyes, what should the optometrist then think of? Automated decision support like that in health record systems is something that I think will be introduced to optometry very soon.

In Norway where I work, we have a very good public electronic e-health system referring platform which all GP’s, hospitals, dentists, and other health professions are connected to. That referral system is then integrated into several medical file systems to make communication fast, easy and safe.

Optometry can also link into that system, but no one is doing it yet. Within that system, you have access to about 50-60 different software and apps that might help in the caregiving. Most of them are targeted towards GP’s.

Worth noticing is that there is one company in that pool that offers second opinion support to optometrists via a team of ophthalmologists. Optometrists can ask questions to ophthalmologists about cases they are in doubt of by sending in data and images.

I, however, really think that optometrists should send more referrals to GP’s instead of ophthalmologists because often we can take quite a workload off the GP’s shoulders. That will also generate referrals back to us over time. But this is only possible if you are inside a referral platform. Otherwise, you are left with having to write letters while the GP’s and ophthalmologists have been online for 5-10 years already – at least that’s how it is in Norway. Sorry to say but to continue to communicate with the outside healthcare system via letters is not sustainable in the long term. It is old-fashioned and we cannot expect that health systems adapt to us. Today, this acts as a barrier to our profession. So, if we want to be part of the healthcare system, we need to be able to send electronic referrals.

In the next 2-5 years, it’s critical to be inside those platforms and seek to collaborate with ophthalmologists and GP’s to deliver the best, most coherent healthcare journey for all patients.

The e-health services will and are already affecting how we work in the test room – both in good and bad ways. E-health solutions should only be implemented if they deliver a benefit for the patient. There have been some e-health attempts – actually quite a few – that complicates how we work rather than help.

I mean, a lot of electronic software and devices work brilliantly standing next to each other, but as long as they are not integrated, they might not make the job for an optometrist any easier. To have several stand-alone systems can be complicated to work with and actually enhance the risk of doing mistakes. That’s why the way forward is to integrate systems – that way you work safer, faster and you become more knowledgeable at the same time. E-health solutions need to make life easier – not more complex.

For example, if I can send a referral to an ophthalmologist in a system where it’s easy for the ophthalmologist to feed back to me, then they’ll most likely do that. That interaction means I learn more about the patient and can help in a better way.

If we could have an electronic health record system with automated decision making built in, then that system would give me feedback on what I need to test and ask for. If I for example have a case of red eye, then the system should remind me on that I need to check the anterior chamber for inflammatory cells. That would make me a better optometrist which again benefits the patient.

But what already works great today, when it comes to the new e-health tools, are the many educational apps available out there. These can improve how we work in the test room.

Earlier, you also mentioned professionalism, and professionalism can be many things. It doesn’t matter how skilled I am as an optometrist if the interaction between the two of us fails. Clear communication and mutual understanding are important parts of professionalism. We can enhance that quite easily just by using these educational apps. Some of them are free of charge and others you have to pay a small amount for – we’re talking a few euros per month. With those apps, I’m at least able to explain in a much more comprehensible and down-to-earth way. We don’t need to wait around for anyone to help us with that – the apps, videos and animations are already out there, ready to be put into use.

That’s a good question. First of all, communication is not a one-solution-fits-all. The key is person-centred customer care, meaning that you have to adapt your communication and advice about glasses or contact lenses to each individual. Care should never be delivered in a too complex, or advanced way. You need to think of your audience – let’s use you as an example; you’re a young person who probably doesn’t want me to pull out an old piece of a printed paper that has been in the test room for 6-7 years. You would rather see a video or an app, which you can relate to. But a 75-year-old patient might appreciate the printed version. So, it’s all about being dynamic and using the right tools that fit the person sitting in the chair.

I have a story relating to this. So, in the early days of the corona pandemic, we launched a video consultation service, and I used that one for Norway, taking the inbound calls for the first one or two weeks. I was as surprised as anyone when this elderly lady of 78 years’ chose to have a video consultation instead of a call because she had questions about how she should use her glaucoma medication, now that she couldn’t see her eye doctor. And I would never have guessed that a soon 80-year-old wanted to have a video consultation. At that point, I of course expected some technical challenges and so on, but no – everything went smoothly! After that, it became clear to me, that we should not underestimate the public and patients’ will to use new ways of receiving healthcare.

Early in the pandemic, there was a big focus in the eye care industry and the whole medical community on e-health and video consultations being here to stay. And there was a peak in the utilisation of e-health services, but the level has since then declined a bit. That was also expected from the suppliers in the industry. Maybe the biggest shift has been that e-health is now suddenly on the agenda in all administrations – not just in optical chains – but in healthcare in general.

The World Health Organisation has had a clear e-health strategy towards their member countries for years, so it’s no surprise that e-health is growing. Corona probably just speeded up the commercial side of the medical industry to accept the trend.

But no matter how you spin it, change never feels good in the beginning – and it can also go very wrong if you don’t do it right. You can overcomplicate the easiest things. So, I think what the pandemic “hopefully” brought to optometry and other health professions were awareness of how we make ourselves more available to patients – even when they don’t show up in person. Just simple stuff like picking up the phone to check up on our patients, instead of the standard routine with them having to come into one of our stores every time. We can make it more convenient for them and still provide good care.

Looking into the future, we need to focus more on the young generations to make sure that they still visit their optometrists and not just turn to google. That’s where my focus is lying today – to retain the younger audience visiting our optometry stores. It needs to be easy, fast and uncomplicated to use our services.

But nevertheless, e-health still has some drawbacks and limitations. Particularly this article highlights the benefits and risks very well.

Well, I started working as an optometrist back in 1995, but long before then, I had an interest in optics since I was so passionate about astronomy and creating telescopes when I was a child. I was very into the electronic imaging of the sky – an interest I shared with my father. So many nice memories of that!

The driver was always optics. That’s for sure. And actually, it’s quite a funny story because I thought I started an education that only had to do with optics. And then the first day at school I saw; oh, this is a healthcare education! So, right there and then I had to decide, and then I thought, okay, let’s give it a try.

After optometry school, I worked as an optical engineer for a while and later I took a master’s degree in eye diseases. After that, I started to work with ophthalmologists in integrated care models within laser and cataract surgery. Here it became obvious to me that what limits the quality and efficiency of shared care is actually the e-health solutions. I spent about one-third of my day double-typing information from one electronic healthcare system to another: text and scanning printed images from devices that are not connected. And that’s when I became aware of the basic challenges in what limits shared care.