Which way now for our heroic public eye clinics?

The district health boards’ (DHBs) follow-up clinic performance figures to August 2019 have been released in response to an Official Information Act (OIA) request¹. They reveal that those waiting both 50% and 100% too long have more than doubled compared with last year’s figures².

A lot of extra work has been done in DHB eye clinics from 2018 through 2019, but sadly it’s been like pouring water into a sinking ship. The true situation is actually worse than these figures suggest because these results do not factor in ‘new patient’ waits, nor the morbidity from denial of care for many common treatable conditions. Patients are still encouraged by the DHBs to go private for stuff like itchy eyes and sagging eyelids as opposed to the alternative of having to put up with their various afflictions. But some 40% of Kiwi superannuants are 98% dependent on National Super, while the next 20% are 70% dependent, so most cannot afford private sector care³.

So, New Zealand public sector doctors are faced with a most uncomfortable choice, between servicing each individual optimally and servicing the needs of the clinic as a whole. Servicing large numbers of people at speed introduces risks, but not servicing much of the workload at all brings the certainty of failure. Managers have been making this choice by simply ‘bouncing’ follow-ups in favour of new patients, which has led to complaints being made to the health and disability commissioner when people then lose sight.

Something has to be done!

We are going into a scenario where the baby boomer generation is missing out. Clearly there has to be a change in work practices to avoid this. Recently, ophthalmologists and nurses have been sharing more of the burden with nurse specialists and optometrists but not without controversy. The Royal Australia New Zealand College of Ophthalmologists (RANZCO) particularly, has been a rejectionist about sharing some procedures, such as laser treatment and intravitreal injections. But even if the entire public stipend for clinical work were given to optometry it would not be enough. Moreover, there is a decision-making bottleneck in clinics staffed by optometrists and nurses who often bring people back to see the doctor for the hard decisions, making clinics even more overburdened. Plus, the personal cost of being in a war zone with management has often led ophthalmologists to disengage from responsibility for the public sector and its woes and concentrate on delivering quality service in the private sector.

So, is there a way through that would work for all the groups participating in eye care in New Zealand?

EHRs: part of the problem and the solution

The crisis in the transition to electronic health records (EHRs) within the DHBs has not helped. Reviewing patients has become an obstacle course. Firstly, there is the patient; that’s the good part. But then there may be up to five different applications running in the background on the doctors’ workstations with separate logins, plus the paper notes which need to be deciphered and written, and dictation on each patient as well. With different computer processes and manila folders stacked everywhere, it’s hard to keep track. In this doctor’s humble opinion, it was actually easier for doctors in the ‘70s and ’80s!

In 2017, I ran a campaign to get images and reports onto Concerto, Orion Health’s physician portal adopted by many of DHBs⁴. I suggested it should be developed into a real EHR system and now, finally, Orion has been allowed to do this at Canterbury DHB, thanks to clinical input from Geoff Duff⁵ and Anthony Bedgood. The new EHR module is called ‘PaperLight’ and this may be the most positive development of 2019 because, if successful, it can be rolled out nationwide at minimal cost.

Among other patient management systems out there, is the one formerly developed by Houston Ophthalmology, now owned by Best Practice Software, which has thousands of users in Australasia, including many private clinics. However, even when BP Software has been purchased by our DHBs, it has often either not been used or not been useable, presenting broken or out-dated templates to the user, which don’t get fixed for whatever reason, although they easily could be.

There is also the UK Medisoft programme, now owned by Heidelberg Engineering. It is state of the art, proven effective in much of the UK and attracting more and more international interest, and could be implemented in all New Zealand DHB clinics for a few million dollars. However, from my investigations, the chance of our Ministry of Health (MOH) buying into it is remote, unfortunately.

Also available to us is the ‘Open Eyes’ product, an open source electronic patient record system designed by clinicians specifically for ophthalmology. It abounds with on-screen forms for the doctor to fill in, which to me makes it an EHR system that’s likely to be more part of the problem than the solution. Systems that insist on inputting structured data for the core narrative miss the point; they just hold things up.

Making a user-friendly EHR shouldn’t be hard at all. Medical stories are like everyday life stories in that they can be naturally parsed into ‘encounters’ and reporting on these then becomes the core of the EHR. It is the succession of our encounters that makes up our personal narratives. A clinic design based on this, can make the walk through the clinic, the talk at the visit, and the ‘squawk’ (in the sense of the ‘report’) into one coherent process. The personal narrative component is more a poem than a story, so is best left as ‘free text’. A mistake many systems make is to try to make the personal narrative into structured data. Harvesting structured data is like making ‘a raid on the inarticulate’, as poet TS Elliot said about using words⁶, and should be an adjunct to the free text narrative. Fortunately, PaperLight appears to acknowledge the importance of recording free text narrative as the core process of the EHR while facilitating the harvesting of structured data into robust data base repositories.

The MoH position

The Ministry of Health's (MoH's) policy now says that New Zealand DHBs may use any EHR they like, provided they incorporate Snomed coded ‘reference sets’ of clinical concepts. Snomed is the international medical coding system to which the MoH has a commitment. Each reference set is unique to its medical speciality⁷. The Christchurch ophthalmology department, led by Rebecca Stack, has been delegated the task of evolving such a list for ophthalmology and others, including myself, have submitted examples of Snomed-coded ophthalmological concepts.

It’s clear the MoH wants to monitor care using these ‘reference sets’ as a currency. The question then becomes ‘what’s on the list’, or more exactly and importantly, ‘who controls it’? But maybe nobody should. Snomed often has more than one way of saying the same thing. Furthermore, ‘current usage’ changes in time, concepts are introduced and others retired. The list can never be complete because our subject is open ended and we don’t need a formal process to allow this to happen. It is more Darwinian to let the concepts used become a currency by virtue of their being used alone.

So, hopefully we can use the EHR of our choice with a shared but open and evolving ophthalmology reference set as a currency. We will still need an access process and governance for the resultant data repositories, but that’s a national project. We can get on and use Snomed-coded terms as reference sets immediately and then change them when we want or need to. So, there’s really no excuse for delay.

The way ahead

A restructuring and opening up of roles together with an effective EHR system could help us get on top of the workload in the public sector and provide hope to our struggling eye clinics and their heroic but traumatised workers. Regarding the former, pioneering work with nurse-led eye clinics at Moorfields may be showing the way ahead. They say, ‘the future of ophthalmology is really about who is best placed to deliver the care, rather than saying, ‘a doctor needs to do this, an optometrist needs to do this and a nurse needs to do this’⁸.

We too, in New Zealand must redefine our customary boundaries and pull together for the common cause or my generation and the one coming up behind me is not going to get the care we need. RANZCO CEO David Evans said we must play about our part in creating a sustainable future⁹, but the current model of eye health care within the New Zealand public sector is neither sustainable nor sustained.

We must rethink the big picture.

References

Overall waiting numbers have increased from 63,700 in 2017 to 73,500 in 2018 and 98,211 in August 2019. The numbers waiting longer than recommended were 22736 in 2017, decreased to 13700 in 2018, but increased again to 18,634 in 2019. Those waiting more than 50% too long, increased from 2337 in 2018 to 6224 in August 2019, while those waiting more than 100% too long increased from about 1000 in 2018 to 2345 in 2019. OIS response 9417 DHBEye Clinic FU wait times..
2018 figures taken from the Radio NZ article: ‘Delayed eye appointments leave thousands unsure of retaining vision’ at www.rnz.co.nz/news/national/378774/delayed-eye-appointments-leave-thousands-unsure-of-retaining-vision
2018 ‘household-incomes-in-new-zealand-report’ p184 - www.msd.govt.nz/about-msd-and-our-work/publications-resources/monitoring/household-incomes/household-incomes-1982-to-2018.html
‘Tackling the Frustrations’ by Mike Mair, NZ Optics -www.eyeonoptics.co.nz/articles/archive/tackling-frustrations/
Geoff Duff the Instigator: “roll out the instigator because there’s something in the air, we got to get together sooner or later because the revolution’s here, and you know it’s right!” www.youtube.com/watch?v=k8zmkzshUvE
From TS Elliot “…And so each venture Is a new beginning, a raid on the inarticulate, with shabby equipment always deteriorating…” East Coker.
The cardiology reference set for the MOH. A similar list is now sought for ophthalmology. www.health.govt.nz/publication/hiso-100552-snomed-ct-reference-set-cardiology-consultation-document
From, Sharing the load safely, published in Feb 2020’s NZ Optics
Eye2Eye 2019, p8: ‘There is no doubt that many around the world including our members have grave concerns for the sustainability of the planet….but through careful thinking and some actions we can play a part in creating a sustainable future

Retiring consultant ophthalmologist, Dr Mike Mair is an early adopter of EHR and a passionate believer in technology and improved processes to better serve the needs of both patients and the eye health community in New Zealand. He has no commercial interest in any companies mentioned in this article.