Glaucoma electronic patient record—design, experience and study of high-risk patients

Eye (2005) 19, 956–962 & 2005 Nature Publishing Group All rights reserved 0950-222X/05 $30.00 www.nature.com/eye CLINICAL STUDY 1 Department of Ophthalmology, Ninewells Hospital, Dundee, UK 2 Department of Ophthalmology, Queen Margaret Hospital, Dunfermline, UK Correspondence: R Sanders, Department of Ophthalmology, Queen Margaret Hospital, Whitefield Road, Dunfermline, Fife KY12 0SU, UK Tel: þ 1 383 623623; Fax: þ 1 383 674009. E-mail: roshini.sanders@ faht.scot.nhs.uk Received: 19 November 2004 Accepted in revised form: 6 June 2005 Published online: 29 July 2005 Presentations: Royal College of Ophthalmologists Annual Congress, May 2003 HCMMI Awards for the best use of IT in a clinical sector, London 2002. Competing interests: none declared Glaucoma electronic patient recordFdesign, experience and study of high-risk patients F Imrie1, A Blaikie1, C Cobb2, A Sinclair2, D Wilson2, S Dobson2 and R Sanders2 Abstract Introduction Aim To set-up a glaucoma electronic patient record (GEPR) and study referral details to a new glaucoma service, concentrating on highrisk patients. Method A GEPR was designed using the pre-existing hospital information technology (IT) infrastructure. Referral details of all new patients to the glaucoma service were completely electronically entered and analysed. Results A GEPR was successfully established. A total of 402 referrals were studied. In all, 43% (40) of high-risk clinic patients (IOP429 mmHg, or C/D ratio 40.8 or moderate to advanced visual field defects) had to wait longer than 8 weeks from GP referral to be seen at the glaucoma service. Of these, nine patients lost more than one line of Snellen’s visual acuity attributable to glaucoma. The optometrist failed to document IOP in 17%, fundoscopy in 30%, and visual fields in 45% of all referrals. Conclusions A GEPR can be introduced in an NHS setting without disruption of clinical care and ophthalmic training, and facilitates detailed, accurate and rapid audit. Study of high-risk glaucoma referrals showed inadequate optometric referral details and poor prioritisation of urgent cases. This information is being utilised with the cooperation of local optometrists to refine the pattern of glaucoma referrals. Eye (2005) 19, 956–962. doi:10.1038/sj.eye.6702008; published online 29 July 2005 The government white paper ‘Information for Health’ has mandated the use of level 3 EPRs in all acute hospitals by 2005.1 The Queen Margaret is a new 949 bedded hospital where a uniform information technology (IT) system Oasis was installed throughout the hospital to support both administrative and clinical needs. Oasis is an open and integrated clinical IT system that can operate beyond EPR level 6.2 The hospital is well equipped with computers, has a 14-man IT team, an on call IT officer, a lead physician and close links with Capula Limited, the providers of Oasis. This supportive IT environment enabled us to develop a Glaucoma electronic patient record (GEPR) in 2000. A new consultant led glaucoma service was set-up in 1998 seeing all new referrals with possible glaucoma in addition to providing the regional glaucoma training needs of SpRs. The waiting time for new patients gradually rose from 6 to 24 weeks and within 1 year of the service new referral numbers doubled. Prioritisation of urgent referrals thus became an immediate need. Fraser et al3 have estimated that an incorrect optometric glaucoma referral is over four times more likely to be a late presenter than a comparable patient with appropriate referral. Tuck and Crick4 have shown that 10% of high-risk glaucoma patients had to wait at least 14 weeks for an NHS appointment. This paper describes our experience of design, installation, use, and benefits of a GEPR. As the first of a series of reports made possible by the GEPR we chose to analyse referral details of all patients, concentrating on high-risk patients. Keywords: electronic record; high-risk glaucoma; optometry Glaucoma electronic patient record F Imrie et al 957 Methods Glaucoma electronic patient record The GEPR was designed within Oasis in 2000 by DW, RS, AB, and Capula Limited (a major national and international provider of innovative IT health services) using the Oasis clinical tool sets, a generic system that enabled clinicians to design their own systems using recognised open technologies, Java, and XMEL. The only precedent in the UK at that time for an ophthalmic EPR was the vitreoretinal EPR at Moorfileds Eye Hospital.5 The GEPR was designed to incorporate all information previously recorded in the handwritten glaucoma clinical records but with greater detail and additional optometric referral details. Altogether, the GEPR had 42 stem questions, which defaulted to a range of common preset answers. Rare conditions or findings required free text. The design was such that each section required completion in order to default to the next section. Users were required to complete the GEPR in a standardised manner not possible with the written record. The GEPR generated automatic GP and optician discharge summaries and patient information letters. Although Oasis had its own drawing package developed in Java applets we found this to be as inaccurate as the free drawn images in clinical notes. Therefore, all new patients had stereodisc photographs inserted in their case notes and images stored on our digital photography system accessible using a standard integration package (Oasis interface engine). In addition, the GEPR had detailed accounts of disc parameters that required completion (Figure 1). Anterior segment abnormalities were also photographed and stored in a fashion similar to disc photographs. Special software was required to link Oasis to the Humphrey visual field analyser and this development is currently being investigated. The IT specifications utilised for the GEPR are outlined in Table 1. All patient information was entered at the glaucoma clinic by RS, AS, FI, and AB, each of whom had a unique username. The GEPR had multiple access and required signing off after completion. Once signed off the GEPR could not be electronically amended but was Figure 1 Still of GEPR with details of ophthalmic examination. Eye Glaucoma electronic patient record F Imrie et al 958 Table 1 The IT details of computer soft- and hardware and network requirements for the GEPR Glaucoma clinic computersFDell Optiplex GX270, P4 2.00 Ghz, 512 Mb RAM Operating systemsFWindows 2000/XP Database softwareFOracle Intranet browserFMicrosoft Internet Explorer Version 5.5 NetworkF10 Base T Ethernet Network softwareFWindows 2000/Citrex Metaframe XP available as a shared record for viewing by other hospital staff. There was also an audit trail in place that recorded details of all GEPRs accessed within the hospital and so acted as security for patient information required under the Data Protection Act 1998 and Coldicott Guidelines.6 Hospital policy dictated that a printed paper copy of the (...truncated)