Using electronic referral with digital imaging between primary and secondary ophthalmic services: a long term prospective analysis of regional service redesign

Abstract

Purpose: Demands on publicly funded ophthalmic services worldwide continue to increase with new treatments, waiting time targets, working time limits, and restricted budgets. These highlight the necessity to develop innovative ways of utilising existing capacity more effectively.

Method: A new regional, fully electronic ophthalmic-referral service with digital imaging was trialled using existing information-technology (IT) infrastructure. Following successful pilot study, the service was rolled out regionally. Service delivery data was prospectively collated for all the attendances in the year prior to (2006) and the year following (2008) introduction.

Results: Comparing 2006 against 2008, median waiting times reduced (14 vs 4 weeks), and fewer new patients were observed (8714 vs 7462 P<0.0001), with 1359 referrals receiving electronic diagnosis (e-diagnosis). New patient did not arrive (635 vs 503 P<0.0001) and emergencies also reduced (2671 v 1984 P<0.0001).

Discussion: Novel use of existing IT infrastructure improves communication between primary and secondary care. This promotes more effective use of limited outpatient capacity by retaining patients with non-progressive, asymptomatic pathology in the community, whilst fast-tracking patients with sight-threatening disease. Resultant significant, sustained improvements in regional service delivery point to a simple model that could easily be adopted by other providers of universal healthcare globally.

Figure 1

Illustrates differences between the original paper-based referral pathway in 2006, which had a lengthy paper trail, referral delay, and considerable cross referral as patients were arbitrarily allocated to consultants by untrained medical records staff. The new pathway shows the improved electronic referral system with reduction in the number of steps required for final outcome, and illustrates the two way nature of communication between primary and secondary care.

Figure 2

Examples of patients that were electronically referred and diagnosed. The first was a case of pediatric papilloedema that was transferred from an outlying region to a central pediatric unit within 2 h of community examination and electronic referral (upper two fundus photographs). The second was a case of longstanding myopic degeneration in an asymptomatic patient that did not require hospital examination and was discharged to community followup (lower two fundus photographs).