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 Introduction
1.1 The Certificate of Vision Impairment
1.2 Aim
1.3 Context
1.4 The pilot
1.5 Budget
1.6 Timeline
2 Methodology
2.1 Interviews with staff
2.2 Patient analysis
2.3 Ethics
2.4 Project board
3 Findings
3.1 Patients
3.1.1 Phase 1 and 2: Improving choice and control
3.1.2 Patients in Phase 2
3.2 Health and social care professionals
3.3 Comparative eCVI processes – Open Eyes and Medisoft
3.3.1 Paper CVIs delaying certification
3.3.2 Improving patient care and referrals for support
3.3.3 Importance of ECLOs in supporting patients
3.4 Changing IT systems: Implementing eCVI in the NHS
3.4.1 Information governance
3.4.2 Upgrade of IT systems
3.4.3 Additional delays
3.5 eCVI and hospital systems
3.5.1 Making certification systems more reliable and consistent
3.5.2 Improving data collection
3.5.3 Improving full completion of eCVIs
3.5.4 Changing behaviour in reluctant staff
3.6 Added value of eCVI
3.6.1 Potentially more certifications issued
3.6.2 Saving time for ECLOs and social service departments
3.6.3 Accessible eCVI
3.7 Additional reflections
3.7.1 Suggestions to improve the interface
3.7.2 Consent
3.7.3 ECVI in the home nations
4 Conclusions
4.1 Project outcomes
4.2 Developing new eCVI systems in the future
4.3 What can be implemented now?
5 References
List of Tables
Table 1. Pilot Project Budget
Table 2. eCVIs issued
Table 3. Participating interviewees
Table 4. Delays in paper CVI process (Boyce 2012)
Table 5. Anticipated delays in an electronic CVI process
List of abbreviations
CVICertificate of Vision Impairment
ECLOsEye Clinic Liaison Officers
eCVIElectronic Certificate of Vision Impairment
EMRElectronic Medical Records
RCOphthRoyal College of Ophthalmologists
SISight impaired (partially sighted)
SSISeverely 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 77eCVIs 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 eCVIsoften 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.
1.2Aim
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.
1.3Context
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, TheRoyal 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 abooklet for newly certified patientsto 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.
1.4The pilot
The pilot worked with two providers to develop and trial two different eCVI systems.
- Open Eyes is an open source electronic medical record system developed at Moorfields Eye Hospital.
- Medisoft is the biggest supplier of ophthalmology EMRsystems 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.
1.5Budget
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 spendMedisoft / 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%
1.6Timeline
Phase 1
2013Project 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.
2017Medisoft 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:
- Whether patients have increased patient choice and control over their certification and registration.
- Whether patients have swifter access to advice and information about local support.
- 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. Arealist evaluation approach seeksto 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 sitesbefore 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).
Secretaries are described as (Admin+number).
Social service staff are described as (SS+number).
Medisoft staff are described as (Medisoft+number).
2.2 Patient analysis
The project aimed to receive at least 100 eCVIs from each site. The evaluation aimed to interview 33 patients in each site, one-third of the total eCVIs to be collected in the pilot period.
To provide a small scale comparator group, approximately half of the patients were to be certified by paper. ECLOs at each site would undertake random selection according to agreed criteria developed for each site (e.g. every other patient in certain clinics over three sessions).
After patients were certified by an eCVI they were to be asked by ECLOs / relevant staff for their consent to share contact details with RNIB. Patients who consented to being contacted by RNIB had their contact details forwarded by the ECLO to the Information and Advice Service team at RNIB. Patients were to be contacted by RNIB staff two weeks after they certified in hospital. The phone survey of patients aimed to examine:
- The number (and proportion) of patients consenting to share their contact details with RNIB and receiving follow-up information.
- Patient opinion of receiving information at this point.
- Impact of eCVI on access to advice and information.
2.3 Ethics
Ethics approval was sought in each site.The Research and Development Office in each of the four sites was contacted and after discussion with each, the project was deemed a service evaluation and full ethics approval was deemed unnecessary.
2.4 Project board
A Project Board was created in Phase 1. At the beginning of Phase 2 Board membership was revised and the new Board aimed to providespecific expertise and guidance in the application of the eCVI. The following organisations were represented:
- Royal National Institute of Blind People (RNIB);
- The Department of Health;
- The Royal College of Ophthalmologists;
- Adult Social Care.
3 Findings
3.1 Patients
Over 475 eCVIs were issued during the pilot, the majority from the Open Eyes site. Due to the length of time to implement the eCVI in the Medisoft areas, fewer than anticipated eCVIs were issued (Table 2).
Table 2. eCVIs issued
Site / Live / No. eCVIs issued by 1.5.2017 / NotesOpen Eyes Site / Sept 2016 / Over 400 / - Unclear number eCVIs issued in Phase 1 and Phase 2
- 1 ECLO and CVI team.
Medisoft Site 1 / Feb 2017 / 29 / - Installing took over two months due to information governance.
- 1 ECLO
Medisoft Site 2 / Feb 2017 / 44 / - Installed in December
, training in January but not used until February.
- No ECLO
Medisoft Site 3 / Apr 2017 / 4 / - Installing took over four months due to problems with information governance and IT upgrade.
- 2 ECLOs
All patient referrals in Phase 1 and Phase 2 came from one hospital, the Open Eyes site which has a full-time ECLO and CVI team. In total 165 patients were referred to RNIB. Almost all of the referrals, 156, were received during Phase 1. It is unclear why the ECLO in the Open Eyes hospital stopped referring patients to RNIB.
In Medisoft Site 1 a small number of eCVIs were issued in February but the bulk of eCVIs were issued in March, when the ECLO was on holiday. No eCVIs were referred to RNIB. Medisoft site 2 was going through the process of replacing an ECLO and again, no eCVIs were referred to RNIB. Medisoft site 3 issued all 4 eCVIs during the final week of the project and made no patient referrals to RNIB.
3.1.1 Phase 1 and 2: Improving choice and control
Since the pilot began in 2013 numerous interventions and actions were introduced to improve patient choice and control in the certification and registration processes. These actions, separate from this pilot project, included:
- Publishing the booklet Sight loss: What we needed to know (see:
- Training in certification for newly qualified ophthalmologists
- Detailed online information for all ophthalmologists (
- Detailed online information for patients / client (
- Increasing the number of ECLOs (RNIB’s new strategy is for everyone to have access to an ECLO service by 2019).
3.1.2 Patients in Phase 2
In Phase 2, eight of the nine patients referred to RNIB agreed to participate in the evaluation.