What are the experiences of teleophthalmology in optometric referral pathways? A qualitative interview study with patients and clinicians

Efficiencies of teleophthalmology

All welcomed teleophthalmology due to its ability to improve patient and clinician experiences. There is regional variation in referral pathways depending on the specific condition; GPs typically process routine referrals for SRC. However, it was reported that GPs were not always suited to create referrals due to their limited skillset in specialist eyecare. Patients often described GPs as the unnecessary ‘middleman’. Patients reported being keen to be referred directly by their optometrist and felt this would reduce their waiting time to hear back from HES if referrals were processed directly.

If the optician can do the referral directly rather than you know, the optician telling me you’ll need to go and see your GP who will refer you (…) I would be more comfortable because they (optometrist) know what they’re doing whereas the GP is just saying you are alright then, if your optician told you that, then I’ll send you. (Patient 11)

In the HERMES study, optometrists used teleophthalmology to refer patients to HES, enabling a quicker referral process direct to triaging ophthalmologists. They shared that teleophthalmology could improve patient satisfaction and help relieve hospital capacity pressures by reducing unnecessary hospital visits.

I think the whole teleophthalmology thing will improve patient satisfaction and it makes life a lot easier, less patients, elderly patients having to find transport to the hospital, and being dilated once in the optometry practice and then being dilated again, back at the hospital and patient transport having to be arranged, so overall good, big saving of cost and finance and less crowded waiting rooms at the hospital. (Optometrist 18)

Ophthalmologists shared that the teleophthalmology platform introduced uniformity to the referral process by requiring the same data fields to be completed for each patient, which was easy for the referring optometrist. This enabled referrals to be triaged and reviewed more quickly: referral decisions could be made promptly, and the appropriate triaging decision could be made regarding the indication and the urgency for a hospital visit.

It’s more informative because, as you know, the platform has the questions with the tick box, um, on the optician findings which (is) not always involved in a classic referral proforma. And obviously, it has the imaging as well, which helps us to make a decision very quickly. (Ophthalmologist 1)

As mentioned, the key benefit of the teleophthalmology platform is the ability to review and triage patient referrals without them having to attend a face-to-face appointment. All participants recognised and shared the advantage of saving time and resources by using teleophthalmology.

Teleophthalmology enables feedback

Some patients reported that they were happy for teleophthalmology to be used to assess their referrals as they would not want to attend HES if not required. Still, they expected feedback to explain the reason for not being seen for a face-to-face appointment. This was not always provided. Some patients reported dissatisfaction with their referral experience due to the lack of communication. This was also shared in the context of not receiving feedback promptly. Patients expected to hear about their referral decision more promptly through the teleophthalmology process, which increased concerns over their eye health when this expectation was not satisfied. In these cases, patients wanted to be seen or told directly and promptly why an appointment was not required and not to be kept waiting in uncertainty. Teleophthalmology can overcome this expectation discrepancy through accurate information presentation and timely and clear feedback.

If the patients were to get a letter or some form of communication from the hospital or the specialist to reassure them that your case has been looked at and this is what has been concluded, I think that would be enough to put somebody’s mind at ease. (Patient 10)

Optometrists stated that one of the significant benefits of teleophthalmology was the ability to receive feedback from ophthalmologists. Optometrists reported that when patients were referred to HES in the absence of teleophthalmology, patients would often return to them seeking more information and advice about their care; therefore, it was important for optometrists to be involved in the referral pathway and remain informed of their patients’ management plans. Optometrists shared that many patients were not a reliable source of information about their eye health/treatment, which could affect future care or monitoring they provided.

Once we refer the patient, we don’t actually know then what is happening thereafter, unless we chase the patient or, our patients are quite loyal, so they would, we would see them a year later, we will say or remember, we referred you last time, what happened? (…) So, it’s actually we’re basing it off what the patient is then telling us, so we are actually getting like the second story through the patient rather than the actual clinical information. (Optometrist 12)

By receiving feedback, optometrists can also verify whether their referrals were appropriate and audit themselves to improve the quality of their referrals.

Because if we keep referring something that we think is urgent, but (the) ophthalmologist tells us this is not urgent, and if you learn by that, that’s going to help you, you see. Right now, there’s no feedback (…). But if I got feedback from the ophthalmologist that saw the patient and I will know for next time when I see that similar sort of situation that well, actually this isn’t urgent. (Optometrist 10)

Having a system where the community-based clinic is connected to the HES was also seen as a great benefit for ophthalmologists. They welcomed being able to provide feedback to the referring optometrists, especially to enable the sharing of referral decisions directly and concurred with the need to provide feedback on the referral quality to improve future referrals. It was suggested that the teleophthalmology system should send referral replies to the referring optometrist, patient, and GP so all are informed of the outcome.

Concerns about teleophthalmology

There were some concerns about using technology to manage patient referrals. Some patients still wanted the reassurance of seeing a clinician rather than having their referral decision and notification completed remotely. Seeing someone face to face provided the holistic care some patients reported wanting and addressed their worries and anxieties.

I think (if) you don’t get a chance to see the patient yourself, there is something about looking at data visually transactionally, that is fine, but there is also something about talking to the patients about how they’re feeling and how they’re coping with things. (Patient 10)

Optometrists were mainly concerned with the practicalities of implementing a new system into their workflow. This included concerns over training to use the equipment, the reliability of network connectivity, and equipment costs that some smaller practices may not be able to bear, as well as remuneration for their time for taking on additional roles. Some also reported that completing a referral on the teleophthalmology platform took time.

The barriers would be cost, because this is all based on the information that is being sent from an OCT device, yeah, as part of the process of referral, it’s not just from a letter, so when it comes to having the equipment, that’s an immediate barrier. And having the right remuneration for the equipment. (Optometrist 2)

Ophthalmologists also shared these concerns; however, they were positive towards the ability of teleophthalmology, enabling them to use their time more efficiently.