A Pathway-Driven Approach to High-Volume Digital Medical Retina Clinics

✅ Medically reviewed by Dr Sharon Heng

Authors and Affiliations

Ms Bahar Demir, Moorfields Eye Hospital, Medical Retina, 162 City Road, London, EC1V 2PD Email: bahar.demir@nhs.net

Ms Ling Zhi Heng, Moorfields Eye Hospital, Medical Retina, 162 City Road, London, EC1V 2PD Email: ling.heng@nhs.net

The ageing population, increased prevalence of diagnosed diabetes, and the growing availability of treatments have escalated the need for expanded medical retina services within hospital eye care. As highlighted by Lowenstein et al. in their article "Save Our Sight (SOS): A Collective Call-to-Action for Enhanced Retinal Care Across Health Systems in High-Income Countries" .1health systems face an urgent need for sustainable strategies to manage this rising burden. 

In the United Kingdom, the medical retina service at Moorfields Eye Hospital has piloted and developed a pathway-driven model since 2019 1 Approximately 40% of our patients are now safely and effectively managed within this framework. This article introduces the new model as a potential strategy for medical retina services both in the UK and internationally.

Our digital clinic model integrates advanced diagnostic technologies with a multidisciplinary approach, optimizing patient flow and improving workforce capacity. This patient-centred model incorporates healthcare professionals at all levels to ensure high-quality service delivery. 

The model comprises seven distinct, consultant-led pathways: a New Patient Pathway that provides thorough assessments for new patients, ensuring timely care; a Follow-Up Pathway that manages ongoing patient care, ensuring continuity and safety for patients with established conditions; a Stable AMD Pathway focusing on patients with treated exudative age-related macular degeneration (AMD), allowing them to spend less time in the hospital; a Low-Risk Diabetic Retinopathy (DR) Pathway that monitors patients with diabetic retinopathy who have a low risk of progression, reducing unnecessary appointments; a Hydroxychloroquine (HCQ) Screening Pathway ensuring regular screening for long-term HCQ users to detect early retinal toxicity; a Rapid Access (Wet AMD) Pathway that facilitates quick access for patients with suspected wet AMD, expediting diagnosis and treatment; and a Cataract Pathway managing patients with cataracts, ensuring timely surgical interventions when necessary.

Each of these pathways is supported by a team of trained assessors—including consultants, fellows, optometrists, and nurses—who undergo appropriate training for the specific pathway. This stratified model ensures that patients are managed efficiently while maintaining high-quality care. Before full implementation, each pathway underwent a pilot audit to evaluate feasibility, cost-effectiveness, and equipment efficacy. 

Following these audits, pathways were subject to stakeholder reviews and business meetings to assess scalability. This iterative development process ensures that each pathway is robust, safe, and efficient.

The success of our model hinges on the integration of a diverse team of assessors with varying levels of expertise. This tiered system ensures that patient cases are reviewed by the most suitable healthcare professionals, improving service efficiency without compromising patient safety. The digital nature of the model further enhances efficiency by providing seamless access to comprehensive patient data, enabling rapid decision-making and reducing patient journey times.

A key element of our model is its focus on improving the patient experience. Several tools have been developed to enhance communication and convenience for patients. QR codes provide audio information and adjustable reading fonts, improving accessibility. Informational videos offer patients an easy-to-understand overview of their care pathways and what to expect. 

Conveniently located diagnostic hubs near shopping centres and public transport improve patient accessibility and reduce travel times, promoting environmental sustainability. Email and phone clinics provide an additional layer of communication, ensuring that patients can easily reach their healthcare teams. Patient-friendly correspondence, including letters and documents, is specially designed to enhance clarity and understanding of medical information.

Running a high-volume digital service requires stringent protocols and regular audits. Standard Operating Procedures (SOPs) guide the service's day-to-day operations, and audits are conducted routinely to ensure continued efficacy and safety. 

Two key publications demonstrate the model's success: "Outcomes following implementation of a high-volume medical retina virtual clinic utilizing a diagnostic hub during COVID-19" and "Efficacy and Safety Outcomes of a Novel Model to Assess New Medical Retina Referrals in a High-Volume Medical Retina Virtual Clinic" 2,3. An integral part of the model is the failsafe system, which ensures that no patient is lost in the system. 

This system monitors patient appointments, test results, and follow-up care, flagging any patients who may need urgent attention. It serves as a critical safeguard to ensure that patients continue to receive timely and appropriate care.

Our digital clinic model is built with future advancements in mind, including the integration of artificial intelligence (AI). As AI technologies mature, they have the potential to enhance diagnostic accuracy by analysing imaging data for subtle changes in disease progression. AI could assist clinicians in decision-making and streamline patient management, further improving the efficiency and effectiveness of the service.

We present a pioneering strategy for managing high-volume digital medical retina clinics. By combining advanced diagnostic technologies, multidisciplinary care, and streamlined patient flow processes, the model provides a scalable and sustainable solution for managing the growing demand for retinal services. 

This pathway-driven approach, coupled with robust safety measures and a focus on patient experience, ensures that high standards of care are maintained. The future integration of AI technologies offers the potential to enhance the model further, keeping it at the cutting edge of retinal care. As global health systems face increasing pressures, the Moorfields model offers a valuable blueprint for others to adopt and adapt to their specific needs.

References

1. Loewenstein A, Berger A, Daly A, Creuzot-Garcher C, Gale R, Ricci F, Zarranz-Ventura J, Guymer R. Save Our Sight (SOS): A Collective Call-to-Action for Enhanced Retinal Care Across Health Systems in High-Income Countries. Eye. 2023;37(12):3351–3359.

2. Hanumunthadu D, Adan A, Veeramani P, Agorogiannis E, Nicholson L, Heng LZ, Hamilton R. Outcomes following implementation of a high-volume medical retina virtual clinic utilising a diagnostic hub during COVID-19. Eye. 2021;36:627–633.

3. Veeramani P, Martin-Gutierrez MP, Agorogiannis E, Hamilton R, Griggs T, Nicholson L, Heng LZ. Efficacy and Safety Outcomes of a Novel Model to Assess New Medical Retina Referrals in a High-Volume Medical Retina Virtual Clinic. Eye. 2023;38:168–172.