The potential to expedite and ensure support: Electronic Certificate of Vision Impairment (eCVI)
Pilot Project Final Evaluation
DH Funded Project: Voluntary Sector Investment Programme, Innovation, Excellence and Strategic Development Fund
Dr Tammy Boyce for RNIB
May 2017
Contents
Executive Summary 1
1 Introduction 3
1.1 The Certificate of Vision Impairment 3
1.2 Aim 4
1.3 Context 4
1.4 The pilot 5
1.5 Budget 5
1.6 Timeline 6
2 Methodology 7
2.1 Interviews with staff 7
2.2 Patient analysis 8
2.3 Ethics 8
2.4 Project board 8
3 Findings 9
3.1 Patients 9
3.1.1 Phase 1 and 2: Improving choice and control 10
3.1.2 Patients in Phase 2 10
3.2 Health and social care professionals 11
3.3 Comparative eCVI processes – Open Eyes and Medisoft 12
3.3.1 Paper CVIs delaying certification 12
3.3.2 Improving patient care and referrals for support 13
3.3.3 Importance of ECLOs in supporting patients 15
3.4 Changing IT systems: Implementing eCVI in the NHS 16
3.4.1 Information governance 17
3.4.2 Upgrade of IT systems 17
3.4.3 Additional delays 18
3.5 eCVI and hospital systems 18
3.5.1 Making certification systems more reliable and consistent 19
3.5.2 Improving data collection 20
3.5.3 Improving full completion of eCVIs 20
3.5.4 Changing behaviour in reluctant staff 21
3.6 Added value of eCVI 22
3.6.1 Potentially more certifications issued 22
3.6.2 Saving time for ECLOs and social service departments 22
3.6.3 Accessible eCVI 23
3.7 Additional reflections 24
3.7.1 Suggestions to improve the interface 24
3.7.2 Consent 26
3.7.3 ECVI in the home nations 27
4 Conclusions 28
4.1 Project outcomes 28
4.2 Developing new eCVI systems in the future 31
4.3 What can be implemented now? 32
5 References 32
List of Tables
Table 1. Pilot Project Budget 5
Table 2. eCVIs issued 9
Table 3. Participating interviewees 11
Table 4. Delays in paper CVI process (Boyce 2012) 29
Table 5. Anticipated delays in an electronic CVI process 30
List of abbreviations
CVI Certificate of Vision Impairment
ECLOs Eye Clinic Liaison Officers
eCVI Electronic Certificate of Vision Impairment
EMR Electronic Medical Records
RCOphth Royal College of Ophthalmologists
SI Sight impaired (partially sighted)
SSI Severely sight impaired (blind)
Executive Summary
The pilot project analysed whether an electronic certification process is a more reliable and efficient way to help people who are sight impaired/ severely sight impaired to access the support associated with registration. Two electronic Certificate of Vision Impairment (eCVI) systems were tested.
The pilot project examined if eCVI systems:
· Increase patient choice and control over their certification and registration;
· Provide patients with swifter access to advice and information about local support;
· Improve the effectiveness and efficiency of certification and registration processes.
Methodology
The pilot worked with two providers to develop and trial two different eCVI systems.
· Open Eyes, an open source electronic medical record system developed at Moorfields Eye Hospital.
· Medisoft is the biggest supplier of ophthalmology electronic medical records (EMR) systems in the UK. The software was installed in three hospitals.
The pilot used realist evaluation methods to assess the eCVI process in four sites. The approach was qualitative and involved interviews with staff in health and social care and patients.
Findings
41 interviews with health and social care staff were carried out. Over 400 eCVIs were issued in the Open Eyes trial and 77 eCVIs were issued in the Medisoft trial. 165 patients were referred to RNIB, almost all were received during Phase 1. Of the nine patient referrals made during Phase 2, 8 agreed to participate in the evaluation.
Implementing the eCVI system in the three Medisoft pilot sites took much longer than anticipated. The two reasons why implementing the eCVI took so much time were due to information governance and the need to upgrade existing IT systems.
Due to the length of time to implement the eCVI, fewer patients than anticipated were certified in the Medisoft sites. As a result, the evaluation concentrates on interviews with health and social care staff.
Across the four sites all 24 consultants agreed an eCVI would make the current certification process more reliable and accurate. The two participating social services confirmed all eCVIs received were complete and accurate.
The eCVI appears to expedite the certification and registration process by omitting the role of secretaries. In an electronic process the CVI goes directly from the ophthalmologist to the Eye Clinic Liaison Officer (ECLO) or Social Services, no longer requiring secretaries to post the document to social services. In the paper process the Certificate of Vision Impairment (CVI) can take days, weeks or even months to be posted to social services. The eCVI also appears to expedite the process as the eCVI is only permitted to be sent once completed, incomplete eCVIs often delay the final steps in the certification and registration processes.
Completing the eCVI as opposed to a paper CVI does not appear to save ophthalmologists any time in the clinic.
Consultants were more supportive of using verbal consent system in Medisoft compared to the password / photograph system used in Open Eyes.
The pilot project provided further evidence of the delays in the certification and registration processes. The eCVI confirmed the important role ECLOs have in the certification and registration processes.
The eCVI could lead to more eligible patients being offered certification by providing a prompt (nudge) however this requires further analysis.
The eCVI is accessible and allows all staff who are visually impaired (in hospitals and social services) to complete the certification process on their own for the first time. The paper CVI was not accessible for staff who are visually impaired (the revised paper CVI form will be accessible).
Any eCVI system should be flexible and able to be adapted to local contexts.
1 Introduction
The pilot project was funded by the Department of Health’s Innovation, Excellence and Strategic Development Fund. The entire pilot project ran from 2013-2017. This evaluation analyses the second phase of the project which ran from 2016-2017.
The pilot project analysed whether an electronic certification process is a more reliable and efficient way to helping people who are sight impaired/ severely sight impaired (SI, SSI) to access the support associated with registration. The pilot tested two electronic Certificate of Vision Impairment (eCVI) systems, one developed by Open Eyes (at Moorfields hospital) and the other developed by Medisoft.
1.1 The Certificate of Vision Impairment
The Certificate of Vision Impairment (CVI) was introduced in England in September 2005. A CVI is issued by Consultant Ophthalmologists to formally certify a person as either SI (partially sighted) or SSI (blind). Its purpose is to provide a reliable route for someone with sight loss to be brought to the attention of social care.
The CVI is given to the person with the visual impairment and sent (in paper form) to the relevant local Social Services. Upon receipt of the CVI, social services ask each individual if they want to be registered and then provide the support to which they are entitled. Both health and social care are integral to the certification and registration processes.
The Department of Health recommends the certification and registration process should take five days from completion of the paper CVI to it being sent to social services. Problems with the certification and registration process in England have been established. In some instance, CVIs are misplaced, lost or are incomplete and take many months to complete. During this period many patients wait without support (Boyce, 2014).
In an eCVI system the CVI would be part of an electronic medical record (EMR). It would involves ophthalmologists, in conjunction with colleagues who help to complete the CVI (e.g. ECLOs) to complete an online form. Once completed, the eCVI would be emailed to social services.
1.2 Aim
The aim of the evaluation is to provide evidence for future specifications for an eCVI system and, in particular, the evaluation will examine if eCVI systems:
· Improve patient access to information and support and improve patient experience
· Improve effectiveness and efficiency of the certification and registration process and improving referral to social services
· Increase patient choice and control over their certification and registration so they are actively engaged in their own health and social care.
The evaluation will focus on the eCVI system’s benefits to patients and hospital systems and examine what clinicians and professionals find useful in an eCVI system.
1.3 Context
ECLOs are integral to the certification process (Boyce et al. 2014, 2015).
Eye Clinic Liaison Officers (ECLOs) work closely with staff in eye clinics and the sensory team in social services. They provide those recently diagnosed with an eye condition with the practical and emotional support to deal with their sight loss and maintain their independence. One of the main functions of ECLOs is to help clinicians complete the paper CVI. Despite the importance of ECLOs in the certification process only 55% of hospitals in England have an ECLO ([1]). Many ECLOs are part-time thus whilst 55% of hospitals have an ECLO, not all clinics have access to an ECLO.
New CVI.
One of the project board members, The Royal College of Ophthalmologists (RCOphth), alongside the Department of Health, initiated a committee to simplify and update the CVI. Another board member involved in the revision of the CVI was brought into the project board to advise and liaise in relation to the new CVI.
Digital by Default agenda.
EMR systems are common in the NHS and Social Care however GPs, hospitals and social services use different systems.
New information for newly certified patients.
Two members of the project board, RNIB and the RCOphth, were part of a committee creating a booklet for newly certified patients to be distributed by consultants and ECLOs in clinics (Sight loss: What we needed to know). During the pilot project the booklet was piloted in one site.
1.4 The pilot
The pilot worked with two providers to develop and trial two different eCVI systems.
1. Open Eyes is an open source electronic medical record system developed at Moorfields Eye Hospital.
2. Medisoft is the biggest supplier of ophthalmology EMR systems in the UK and used in over 65 NHS Trusts. Most of the data in the eCVI is already collected as a routine part of the care process. The software was installed in three hospitals.
The eCVI software was added to the existing electronic recording systems in place at the four hospitals. Both systems use electronic data already stored on existing systems to pre-populate patient details and demographics and avoid duplication of recording.
1.5 Budget
The pilot project budget from the Department of Health was £141,694.
Table 1 shows the majority of the budget was spent on developing the different eCVI software systems.
Table 1. Pilot Project Budget
Expenditure / Percentage of total budget spend /Medisoft / 35%
Open Eyes / 31%
Project management (RNIB) / 18%
Advice line support (RNIB) / 6%
Governance costs / 4%
Evaluation / 4%
Returned to Department of Health / 1%
Travel / 1%
1.6 Timeline
Phase 1
2013 Project application and approval
2014 eCVI system developed and installed in pilot sites. Four sites initially approached. Over 100 patients interviewed.
2015 Phase 1 re-scoped and recommendations made.
The first phase of the project analysed the paper CVI process in three hospitals and found the process was different, even within one hospital the process in different clinics was different. In addition, information governance issues were different.
Phase one consultants were unanimous in the view that pre-population of patient data into the eCVI was critical to its success.
This phase identified two significant issues to be addressed:
· The cultural responses of ophthalmologists moving from paper to IT based system;
· Information governance.
It was concluded that the same system could not be applied across ophthalmology departments and that the eCVI was not ready for roll out to other hospitals. The project was rescoped.
Phase 2
2016 New project approach involving three new pilots and a revised eCVI created by a second EMR supplier.
Revised eCVI in Open Eyes goes live Sept 2016.
Funding for technical development, employed external evaluator.
2017 Medisoft eCVI in Site 1 and 2 goes live in Feb 2017.
Medisoft eCVI in Site 3 goes live in April 2017.
Evaluation and final report submitted.
Between Phase 1 and Phase 2 the project’s scope changed however the project’s aims remained the same.
This evaluation is informed by Phase 1 and focuses on Phase 2.
2 Methodology
The pilot worked to three outcomes outlined in the project proposal:
1. Whether patients have increased patient choice and control over their certification and registration.
2. Whether patients have swifter access to advice and information about local support.
3. Whether the eCVI improves the effectiveness and efficiency of certification and registration processes.
The pilot used realist evaluation methods to assess the eCVI process in four sites. A realist evaluation approach seeks to understand outcomes, how these outcomes are produced and the significance of conditions leading to different outcomes. Realist evaluations aim to understand policies and how to consistently replicate them (Pawson Tilley 1997).
The methodology was qualitative and involved interviews with professional staff and patients.
2.1 Interviews with staff
Telephone interviews were carried out with staff at four sites before and after using the eCVI system (ophthalmologists, optometrists, ECLOs, secretaries, social services staff and providers). Three sites had ECLOs, one site was in the process of hiring an ECLO.
These interviews examined:
· Time taken to complete eCVI;
· Transfer time of eCVI to social services;
· Time to social services first contact.
Based on these interviews the evaluation analysed attitudes, knowledge and understanding of certification and registration processes and the impact of the eCVI on these processes.
Ophthalmologists are described as Oph+number.
Optometrists are described as Opt+number).
ECLOs are described as (ECLO+number).