Modernising Moorfields

Moving eyecare beyond the hospital

In December 2004 I made my first visit to Moorfields Eye Hospital just off the Old Street roundabout at the heart of the City of London. I’d been sent there by a High Street optometrist after what I thought was a routine check up, following a few problems with vision in my left eye. But I emerged with a frightening diagnosis - I had a malignant melanoma behind my eye and that needed urgent treatment .

A month or so later I was spending a week in a lead lined room at the hospital recovering from an operation which had seen a radioactive plaque inserted behind the eye to tame the tumour. Ever since, I have been a regular visitor to Moorfields for further treatment and monitoring of the malignant little bump behind my eye. Just this week I’ve been in for an injection designed to mitigate the glaucoma which is the side-effect of a very successful bout of proton beam therapy in 2019.

Over that period I have seen a remarkable transformation of the hospital’s IT systems and processes. While the standard of care at this, the biggest eye hospital outside China, has always been excellent, a visit to Moorfields was in the early years like a journey back into the technological dark ages.

I’d arrive in a stuffy basement to find around 40 patients had been told to turn up around the same time. We’d each then be sent on a slow journey around the hospital for various tests - a vision check, then off to wait in line at the imaging department for a series of scans, and up three floors to a large room which contained just one ultrasound scanner and its operator. Finally after three hours or more you would get to see a doctor , undoubtedly a world expert in their field, who would again examine your eyes and peer closely at the printout of the ultrasound scan.

What I could not help noticing on my visits was the sheer volume of paper generated and the antiquity of the computer systems. The doctor would spend ages hunting through a vast bulky folder to try to find last year’s scans, while their ancient computer sat slumbering in a corner, apparently unable to contribute much.

But in the last few years, there’s been a radical change. When I turn up at the clinic, there are only half a dozen people waiting. We proceed quickly through the tests, mainly because the various machines involved have been moved into the clinic. And what’s always seemed to be the most important scan, the ultrasound, is now done on a compact machine by the doctor rather than a technician. “I know what I’m looking for,” the consultant explained to me last time. He also went straight to his computer and with a few clicks had hi-resolution images of my last set of scans available.

What’s changed? Well obviously the pandemic has made a difference but it seems that Moorfields managers have also identified the need to modernise and have appointed the people to lead that process. At a recent appointment my consultant told me I must meet the hospital’s new head of IT, a man called Peter Thomas - “he’s brilliant!” he enthused. Knowing how disdainfully many doctors regard managers - and indeed IT - I was intrigued.

But when I met Dr Thomas I understood. The man whose title is actually Chief Clinical Information Officer has a combination of medical and technology qualifications which make him ideally suited for this job. He qualified as a doctor after taking a very circuitous route - an internship at IBM before a Cambridge degree in Natural Sciences and a PhD in computational neuroscience. Only after that did he take a four year graduate entry medical course.

He came to Moorfields in 2017 as a consultant in paediatric opthalmology, but from the start he used his technology background, collaborating on a project to use AI in working out how to correct squints in children. In 2018 he became clinical director for digitalisation while still working as a doctor part of the week, and last year he got the top job, in charge of digital transformation.

Much of the work has involved taking Moorfields’ services out of the hospital and closer to patients, either at local hubs or via remote consultations. This trend dates back some years but has been massively accelerated by the pandemic. Peter Thomas explains how a few years ago he tried to get his fellow consultants interested in doing video consultations but found little take-up - understandably, many felt that a webcam was no substitute for the slit lamp which is their main tool for examining eyes.

Covid changed everything . Suddenly, there was real concern during the first lockdown that patients with dangerous eye conditions just would not turn up to A&E:

“We were really worried that we’d have lots of patients with early symptoms of a retinal detachment - that’s where you get some flashes or floaters in the eye - that could lead to irreversible sight loss over a week if they weren't seen and we were worried they’d stay at home because of Covid and not come to A&E.”

So, very quickly, they set up a drop-in video A&E service. “Within a couple of minutes,” Dr Thomas explained, “you're speaking to a virtual receptionist who takes your details on the system and about five minutes later, you'll be speaking to a doctor.”

The service really took off and at its height was dealing with 200 patients a day. “50% didn’t need to come in and could be treated remotely, 28% were referred direct to a specialist clinic, and only 22% were urgent enough to be told to come in to Moorfields A&E or their local A&E.”

The doctors liked it too. It meant that a number of them who were shielding at home could carry on working. And this innovation has survived the end of the lockdowns -between 50 and 100 people a day are still using the service. The key, says Dr Thomas, has been getting a mix of remote and in-person work written into consultants’ job plans. One doctor now even works from a home abroad for his online shifts.

Well before the pandemic, the idea of getting patients seen at local hubs rather than coming into Moorfields was taking hold. This means that for follow-up visits, patients get all their tests done by a technician at the hub, with the results reviewed at the hospital by the doctor, who can then decide on next steps. “You can get most of the information you need to treat a patient who's already got a diagnosis, simply by doing scans and asking them a set series of questions.”

One such hub was opened in a disused shop in the Brent Cross Shopping Centre: “Places like that have great transport links. Hospitals are really expensive places to run, the high street has plenty of empty real estate.”

So Moorfields is distributing its services in new ways, getting more bang for its buck from the expertise once locked away on the City Road site. But the biggest challenge is tying everything together with new computer systems and, most important of all, an electronic patient record. Many big hospitals are choosing to invest in Epic, which dominates the American market in patient information systems. But that can cost a huge sum - one Surrey NHS Trust spent over £100m on its system - and as I wrote last month, some aren’t convinced that such behemoths are much good when it comes to allowing the extraction of data for research.

Instead, the hospital is continuing to develop OpenEyes, an open source patient record system started by a Moorfields consultant and taken up by a number of other eye hospitals. “That's a totally different proposition from something like Epic in that it is quite clinically oriented,”says Dr Thomas. “So a lot of it's designed to be quite efficient for the clinician with less of a focus than these big American systems on things like hospital billings.”

Peter Thomas then outlines an innovation in the latest version of OpenEyes which sums up for me how far Moorfields and the wider NHS have come. Only a few years ago my high street optometrist was telling me to take pictures with my phone of a scan she’d done to show my consultant because she wasn’t allowed to send it to him.

Advert at Moorfields for new smartphone eye test app

Now doctors at Moorfields will be able to use a mobile version of OpenEyes on their personal phones to take photos which go straight into electronic patient records. “So if I see a kid with something unusual around the eye, it's possible to take a photograph of that directly in clinic and rather than relying on my dodgy drawing 10 years later, you've actually got an electronic medical record with the photograph on it.”

Smartphones are making a big difference in other areas - 500 macular degeneration patients are using smartphone apps to measure their vision twice a week. But the tidal wave of data from such apps, and the increasing use of AI algorithms to monitor that data, bring their own problems:

“When we have 200,000 automated decisions being made by 10 different AI algorithms, how do we make sure that all the data is going to the right place, that all the processes have been correctly followed, that we're appropriately monitoring the behaviour of the forms of all the systems?”

But those are problems of the future. I asked Peter Thomas how far along the journey to the digital future Moorfields has got. “About midway, “he says."We’re not there yet,” There is still a good deal of paper flowing down the hospital’s corridors and more to be done to integrate a range of IT systems and make all of the processes digital. But as a patient I am hugely grateful for the progress that has been made so far. Much as I admire the Moorfields team, it is great to be spending less time in the hospital when I do visit.

POSTSCRIPT

Oh dear. I wrote most of this post before my latest visit to Moorfields for an eye injection. That little operation - unpleasant but nothing like as bad as anticipated - only took fifteen minutes but it came after a three hour wait, partly elongated by an IT failure. For some reason, the results of the routine vision test with which every appointment begins could not be uploaded to my patient record. In the end, after a lot of toing and froing, it was agreed that they could be recorded on old-fashioned paper and uploaded later. “IT, always a problem,” said the technician doing the test with a smile. “But at least they fix it much quicker than they used to.”

Moorfields’ digital journey continues..