Consumers’ expectations of healthcare are changing at a rapid pace. Many today want to be involved in decision-making – whether it’s about proactive disease prevention, management or cure.
Now, as ‘digital natives’ increasingly dominate the population, there is a growing expectation that they will have online access to, and control of, all information required to assist in their own healthcare decision-making.
Eye care is leading the way towards a digital health environment but we still have far to go. mivision spoke to sector leaders driving change to find out more.
Technology has been incorporated into the healthcare delivery system for many decades, however a significant shift in demographics, along with increasingly sophisticated yet more affordable technology, means we are now heading towards an era of true ‘digital health’.
Digital health will enable healthcare to be delivered much more ubiquitously, when, where and how patients want it, particularly in primary care
While some believe that digital health simply means the ability for a consumer to book an appointment and for practitioners to share information online, David Rowlands, author of Digital Health Workforce Australasia’s whitepaper What is digital health? And why does it matter,1 says it’s actually much more.
Digital health is not just new jargon for ‘e-health’ or ‘health IT’, instead, it represents “a paradigm shift” with profound implications, he says.1 Digital health “will enable healthcare to be delivered much more ubiquitously, when, where and how patients want it, particularly in primary care. It will enable advances in prevention, early detection and early intervention, and precision health. It will enable citizens to decide how and where their data are assimilated and used … Service providers will be participants as opposed to controllers. Data will be harvested in real time from sources within and beyond traditional health settings.”1
DIGITAL EYE HEALTH
Digital health has certainly captured the imagination of Australia’s eye health sector.
At Optometry Australia (OA), Chief Executive Officer Lyn Brodie says that, like David Rowlands, her organisation sees digital health as a paradigm shift in how we think about and ‘do’ health.
“Our work identifying preferred, plausible futures suggests we are moving into a future where the very way we think about health and healthcare is shifting as we employ digital technologies, data and analysis.
By capturing patient information on a digital platform, we’re able to build in safety nets to support patients as they move from one service provider to another
“There is already significant disruption in how people think about eye health and access eye health care, and this will only escalate with rapidly evolving technology. Many aspects of eye health assessments are already digitised, and some can be accessed through readily available devices like smart phones. There is a lot of development work going on in this space. A future where eye health assessments are integrated into aspects of daily life seems plausible,” said Ms Brodie.
The Australian and New Zealand College of Ophthalmologists (RANZCO) observes that we can expect outcomes to improve as digital health increasingly involves patients in their own care.
“In the short-term, there is potential to provide information directly to patients, personalised to their health conditions in a manner that is understandable to them, and shared with other important members of their personal ‘healthcare team’ – e.g., family. If done well, this has the ability to improve patient adherence to treatment plans and ultimately improve healthcare outcomes for patients – which has already been shown to be an evidence based approach,” said a RANZCO spokesperson.
With digital health comes access to artificial intelligence (AI) which will offer convenience, speed and safety. “RANZCO also acknowledges the potential for AI to allow non-specialists (e.g., optometrists) to perform certain tasks (e.g., monitoring patients) at the level of a specialist, allowing better access to limited healthcare resources.
“Long-term, the potential for digital health to enhance ophthalmology services is particularly exciting. Currently most ophthalmology visits require specialised equipment, which is not available for at home use. As technology evolves, components and equipment gradually reduce in cost. At some point, it is likely that much of the equipment we use in the clinic will be available at a price point that is accessible to patients at home.
“For example, imagine having age-related macular degeneration patients doing optical coherence tomography at home every day, with an AI algorithm analysing the image taken, and automatically booking them in for an injection as needed. Or insights from cloud-connected continuous blood sugar level monitoring informing a diabetic retinopathy patient of their underlying disease state compared to simple point in time blood tests.”
ONLY THE BEGINNING
Dr Kate Taylor, Chief Executive Officer of the e-referral platform Oculo says the early successes of digital eye health is a promising step in the right direction. “Given the widespread use of Oculo, ophthalmology is at the forefront of digital health in Australia. We are demonstrating, with evidence, the difference digital health can make to health outcomes, even within a highly specialised area – both in terms of interdisciplinary clinical care and for nonclinical patient support services.”
When a patient is seen by their optometrist, ophthalmologist or GP, Oculo’s asynchronous telehealth system enables the patient’s images, examination results and referrals to be immediately uploaded to the patient file for permitted practitioners to view. Additionally, Oculo’s synchronous telehealth system can be used to facilitate secure telephone or video consults with practitioners and patients in attendance.
“By capturing patient information on a digital platform, we’re able to build in safety nets to support patients as they move from one service provider to another. We can see if a patient is due to have an eye examination or has a referral pending and if no action is taken, prompts can be sent. Alerts are sent with greater frequency for higher priority patients,” said Dr Taylor.
The public private partnership between KeepSight, Oculo, the Government and and eye care practitioners is another great example of the opportunities that come from digitising eye care and communications.
Each step in this journey must be considered and measurable in order to deliver not only the promised patient outcome, but gain incremental trust with the industry and in particular the individual providers involved
Led by Diabetes Australia, KeepSight provides vital support for people with diabetes who are registered with the service, by sending them reminders to have an eye examination that complement those sent by their optometrist. Additionally, it facilitates the secure exchange of eye examination results by the patient’s eye care practitioner.
At the end of January 2021, 3,638 optometrists had signed up to KeepSight and 2,857 had registered patients since the program launched in late 2018. Although there were delays in on-boarding during COVID-19, KeepSight expects to have 200,000 people with diabetes registered to the site by the end of June 2021.
Specsavers, one of the early supporters of Oculo, saw more than 17,000 people with diabetes, who were registered with KeepSight, return for an eye health check in the second half of 2020. “Since KeepSight has been implemented, recall rates have already increased to 34% for people with diabetes,” said Specsavers Professional Services Manager Naomi Barber.
With 1.1 million patients from Australia and New Zealand now registered on Oculo, the platform is providing a similar service to people registered with Glaucoma Australia and Macular Disease Foundation Australia.
While it all sounds brilliant, Dr Taylor says a true digital health platform can do even more.
“The public sector is where we are really seeing delays in treatment due to an ageing population and more recently, the impact of delayed appointments due to COVID-19.
“A real challenge in overcoming this is the current disconnect between private, optometry and public eye care. By leveraging technology, we could improve the information available for triage and monitoring and better use the capabilities in the community to support the public sector. Doing so will reduce costs, take the pressure off waiting lists, and ultimately ensure those with the most urgent need to see a specialist are seen first,” Dr Taylor said.
For this to happen, however, requires a funding model linking private and public providers.
DATA COLLECTION AT THE HEART
One of the most impressive features of Oculo has been its capacity to capture and enable the exchange of patient data, including imaging and referrals, in real time between practitioners.
This is integral to effecting a successful digital health environment and to improving patient outcomes.
Peter Larsen, formerly Specsavers Optometry Director Australia and New Zealand (ANZ), was integral to the development of Oculo and the establishment of the KeepSight Registry. He also initiated an entirely new model of care within the Specsavers Group, centred around clinical informatics, which is increasingly acknowledged for driving improved health outcomes.
Now the Honorary Principal Investigator of the Health Services Unit at Centre for Eye Research Australia (CERA), Mr Larsen’s new role is focussed on examining how innovative technologies, telemedicine and better coordination between different parts of the eye care sector could increase access to screening services, early treatment and prevent avoidable blindness.
He says evidence-based data is essential to positively change eye health outcomes globally. Importantly, this requires eye health professionals, whether working independently or in corporate structures, to collectively gather, share, analyse and benchmark data. This is something a digital platform like Oculo can help facilitate.
Clinicians have a window of opportunity, right now, to… advocate for… improvements
“The standard global operating model of optical retailing assumes eye health outcomes are consistently delivered by the ‘professionally independent’ workforce,” Mr Larsen said. “This established belief has been held without any ability for businesses and individuals to quantify and understand the actual health measures resulting.
“It should not be a surprise that stubborn eye health problems like 50% undiagnosed glaucoma persist, and that organised medicine, with a culture of big outcome led data, struggles with any coordinated collaborative action proposed by optometry.”
Having led the transformation of Specsavers in building new data insights and ways of working, Mr Larsen recognises that “it can be culturally challenging for an established model to firstly understand the deficits in customer care, and then proactively respond to make incremental improvements”.
He believes that until recently, the sector did not understand the importance of benchmarking individuals on referral rates, or gathering data to quantify the impact on glaucoma diagnosis of optical coherence tomography in pre-tests.
Doing so across Specsavers has driven self-directed training and professional development for optometrists and is now leading to improved health outcomes for patients.
While smaller practitioners do not typically have the resources to collect and analyse data in the same way, OA is now working to collect and share de-identified data from its members as part of its 2040 strategy.
“We are in the early phases of an exciting project that is seeking to establish a national data set for optometry and to support practices to assess patient data with an eye to how it can be mined to improve effectiveness of clinical systems and approaches,” said Ms Brodie.
“By collecting data from optometry practices and using it in a systematic way we can work with our sector to gain a deeper understanding of patient needs and identify the health care systems required to meet them not just now, but in the future.”
Sharing evidence-based data on patient health outcomes will help, as Specsavers has shown, to ensure funding is protected and will demonstrate a methodology to redefine how the collaboration of allied health providers can benefit society.
INTEGRATED PATIENT DATA
On a broader level, Australia’s My Health Record (MHR), now under scheduled review, was the first step towards the collection and sharing of health data, however it currently does not include allied health services like optometry. Additionally, the uptake of MHR was not as strong as anticipated, with many consumers opting out before it went live.
Peter Larsen said trust has been the main issue.
“We are all confronted by the way big population data has been leveraged for commercial gains and so are naturally averse to the thought of any consolidation of health metrics,” Mr Larsen said.
“Evidence of the poor take up of MHR from the medical workforce is clear.
“The program needs to resolve the privacy concerns and more clearly demonstrate the benefits. In terms of eye health, we know as an industry, how it could evolve, connect, and benefit patients. However for successful engagement we need all providers to strongly believe in the benefits of the MHR now, and we need seamless connectivity that makes it easy to integrate data from disparate sources.
“I believe the answer is to remain modest with any planned evolvement. Each step in this journey must be considered and measurable in order to deliver not only the promised patient outcome, but gain incremental trust with the industry and in particular the individual providers involved. We have some immediate pieces of the inevitable puzzle that practitioners can partake in – Oculo, for example is the dominant electronic communication solution for optometry with over 60% market share in ANZ. This is unheard of anywhere in the world.
RANZCO also believes in the potential for MHR to improve health outcomes.
“While today’s implementation of the MHR is lacking, this is a deliberate staged roll out – which is a great model to follow, starting with the core essentials from a systems perspective, then moving out to add features.
“Starting with the basics of data collation, and targeting primary care providers, they now have the ability to add various elements following national priorities – e.g. allergies, pathology, radiology etc.
“The Government is also building the MHR in a manner that has the capability to engage with new technologies as they arise. Of course, there is a limit to this adaptability given that nobody knows what the technology environment will look like in 10 years. As such, the best possibility is to build the system architecture in a manner that allows it to be well positioned for change later.”
MONEY AND EFFORT
Ultimately, a successful digital health environment is patient-led and facilitated by technology that seamlessly connects them with data, providers, funders, and research with a transparent purpose of driving optimum patient outcomes.
To get there though, Mr Larsen says, a concerted effort is required by all parties – Federal and State Government, representative organisations and private companies.
“Funding needs to evolve to incentivise patient centric outcomes. Any opportunity to connect and share clinical data should be encouraged through either policy and or funding. The multiple avenues of Federal, State and Insurance funding with the matrix of allocated responsibilities needs to be aligned with the common problems. Inevitably, with greater connectivity and a targeted focus on key topics, the population data should guide an evolvement of policy.”
RANZCO believes there are two obstacles to funding. “When we look specifically at hospitals, and traditional healthcare providers, the adoption (of technology) has been relatively slow. There are likely a few contributing factors. A large portion of healthcare expenditure is based on fee for service or activity based payments, with outcomes often overlooked – as such the financial incentives do not necessarily match the altruistic aims of these organisations.”
“Value based care models tend to have a higher adoption of new technologies through a fiscal need to deliver improved care, which may be achieved through novel methods.”
Additionally RANZCO points out that Australia represents a relatively small portion of the global healthcare market, making us less appealing for technology providers.
“Digital health providers may choose to focus on larger, more sustainable markets initially before moving to smaller markets such as Australia. Government incentives for evidence based solutions may facilitate further availability of solutions.”
WILL EYE HEALTH TAKE THE OPPORTUNITY?
Having experienced many new ways of doing business and accessing services, such as telehealth during the pandemic, David Rowlands now ponders the question, “Will policy-makers, funders, planners, service providers and health professionals be prepared to make enduring changes? Or will the health system spring back into its previous, pre-COVID, comfortable for some, and familiar shape? If it is the latter, then a crisis will have been wasted.
“Some telehealth funding has been extended, which is a positive sign. However, so much more is needed for sustainable digital health, at scale. Consumers have increasingly made their preferences and expectations clear over the last decade. Like clinicians, they want outcomes that matter to them, positive experiences, and good service. Many of them also want digital-first. Clinicians have a window of opportunity, right now, to make and advocate for substantive improvements. Where do you and your practice stand? Will you lead the way?”
- Rowlands, David What is digital health? And why does it matter. 2 December 2019. Digital Health Workforce Academy and Health Informatics Society of Australia. www. hisa.org.au/wp-content/uploads/2019/12/What_is_Digital_ Health.pdf%3Fx97063.
- Optometry Australia COVID-19 Member Survey, May 2020)
COVID-19 lockdowns forced the use of smartphones for telemedicine in many disciplines for the first time. In eye care, their use for capturing and sharing images, and delivering consultations within the mainstream community is now increasingly recognised.
“Smartphones and other sensors are relentlessly closing in on medical-grade measurement, and advances in machine learning (ML) and AI based image recognition and generation linked to precision robotics are opening a wide spectrum of possibility for machine augmentation,” says David Rowlands.
“Real-time self-monitoring of ocular conditions via digital apps can enable timely intervention. Images from smartphone apps are already close to comparable to those from clinic cameras, and AI-based medical devices to screen for and monitor diabetic retinopathy have already been approved for use in Australia and overseas. And there is emerging evidence that ML / AI algorithms can now out-detect humans for referable diabetic retinopathy. Even though specialists being outperformed by machines at scale is still some way off, the day is definitely coming – as radiologists know.”
Ms Brodie said, “Telehealth is now much more broadly accepted by consumers, providers and policy makers, as a legitimate way to provide care”.
“While our research indicates that only 13% of optometry practices offer telehealth2, the COVID-19 experience has made apparent the opportunities, and we believe telehealth can be used to supplement face-to-face care for patients unable to readily attend appointments in-person. OA will shortly release a guideline to support the effective provision of teleoptometry and is beginning the lengthy process of seeking a new MBS item to support teleoptometry.”
RANZCO also sees the potential. “Given that there is enough volume of patients requesting/requiring telemedicine, this makes it a feasible model to continue in certain settings.