Evaluation of Patient Experiences with PocDoc, a Web-Based Eye Screening Tool

This article is published with digital features, including a video as supplementary material, to facilitate understanding of the article. To view digital features for this article, go to https://​doi.​org/​10.​6084/​m9.​figshare.​25488142.

Rising healthcare costs and an aging population place an increasing burden on subsidized government healthcare in tertiary institutes in our society, giving rise to a directed push towards community-based healthcare and personal ownership of health [1]. The growth of web-based applications provides an opportunity for patients to perform higher degrees of self-monitoring using these applications, which can potentially aid in community-based care, triage, and even remote ophthalmological care. Multiple studies have shown that visual acuity testing using web-based applications yields fairly consistent results compared to conventional visual acuity testing [2]. Indeed, the specific application we are studying (the PocDoc application) has been shown in prior studies to yield consistent visual acuity results when used as a screening tool in a rural setting [3].

However, despite their usefulness, potential obstacles to more widespread use of these applications in the community still remain. Challenges to using such applications include patients’ perceptions of their usefulness, the potential learning curve, technical difficulties, ease of use, convenience, and overall patient confidence. Therefore, the viability of web-based applications as accessible and easily operable tools for self-monitoring of patients’ visual acuity and visual function, especially in our aging community, remains to be seen [4].

To explore this problem, this study aimed to evaluate how patients felt about using a web-based screening tool in order to determine whether this is a viable method for assessing visual acuity and function in the community. A survey-based study was performed examining patients’ perceptions of and experiences with the usefulness, expected frequency of use, convenience, complexity, technical difficulty, need for external help to use the application, learning curve, functions of the application, confidence in using the application, and overall popularity of the tool to assess their vision. By understanding how patients feel about using digital eye screening tools, we can better tailor to their needs and potentially optimize our current healthcare model.

Patients’ perceptions and experiences are integral in developing and shaping the direction of healthcare. Our study found that the overall perception of the web-based application tested was positive before and after utilization. Patients thought that such an application would be useful and were generally receptive to using digital tools to assess and monitor their visual acuity and visual function. This was consistent before and after using the application. Concerns from patients included technical difficulties and confidence in using such applications.

Moreover, our study suggests that an increasing number of patients are becoming receptive to mobile and digital self-administered testing. Those who can confidently, frequently, and easily use such applications are likely to benefit most from this healthcare approach. Our findings indicate that this group of patients is sizable. Consequently, a shift towards this healthcare model could significantly enhance community eye screening efforts, promote early detection of diseases or their progression, and potentially alleviate the burden on tertiary healthcare institutions.

So far, numerous studies have been conducted to measure the accuracy and consistency of digital applications for visual assessment, showing consistent results compared to traditional visual acuity testing, which was generally better in patients with good visual acuity. In a systematic review conducted by Claessens et al. in 2021, 17 studies reported on 13 different digital tools focusing on distance visual acuity and showed low mean differences between digital visual acuity assessments and reference charts but lower precision of digital self-assessment [5]. A prior study also evaluated the use of PocDoc’s web-based visual acuity screening total versus conventional visual acuity testing among an Indian rural population and found that it had only slightly worse visual acuity scores than conventional testing, which was more pronounced for worse visual acuity scores [3].

Smartphone applications in ophthalmology are becoming increasingly widespread in our society, and it is important to determine not only their accuracy but also the societal acceptance and willingness to use such applications [6]. A quantitative analysis by Aruljyothi et al. in 2021 found that as of March 2020, a total of 131 apps dedicated to eye care were identified, with the majority of applications (32%) designed for visual acuity screening [7]. However, despite this, there is a clear need for some degree of professional medical involvement and evidence-based principles to be adopted in this emerging area [8]. Various studies have found that digital eye charts can be used as a standard of care for assessing visual acuity, and they offer a wide range of optotypes for different testing purposes [9‐11].

Our study presents new data on patient perceptions and experiences to elucidate societal acceptance on the use of such applications. Current healthcare models in our local society are still largely based on traditional visual acuity testing, where patients physically undergo testing in a clinic or hospital setting. These new data show that patients are willing to explore digital self-monitoring as an alternative to traditional methods and that they perceive such a method to be convenient and relatively easy to learn and use.

In a systematic review of home-based screening tools for amblyopia, Sii et al. found that such tools could be advantageous, especially during a pandemic situation, where screening may stall. These tools may also be a suitable option for low- and middle-income countries. However, as the parents or lay screeners must take the initiative to utilize these resources, there is a need to educate the public on the importance of performing home screening and the various options available [12].

Moreover, in a study by Rono et al. in 2018, teachers tested the vision of children in years 1–8 using a smartphone-based sight test and referral system (comprising Peek Acuity test, sight simulation referral cards, and short message service [SMS] reminders) versus standard care (Snellen’s tumbling E-card and written referral). The digital system increased adherence to hospital referrals for visual impairment assessment compared with the standard approach among school children. Their results highlight the potential of using digital screening technology to improve the uptake of services and provide real-time visibility of health service delivery to help target resources [13].

Other studies have also evaluated the use of digital applications in performing teleophthalmology consults. One such study also evaluated this in a military setting, where access to readily available healthcare may be more limited. Their findings suggest that teleophthalmology mobile phone apps may improve and extend ophthalmic care in combat zones [14].

The results of our study show that similar healthcare models may be initiated in patients who are accepting of using digital healthcare, and the use of an initial survey may help identify suitable and willing participants. Possible avenues to circumvent patients’ feelings of lack of confidence or need for technical help may be to empower community screening by non-medically trained personnel (social workers, charity organizations). This may be an avenue for further exploration.

Additionally, our findings resonate with the broader trend in digital health literacy, where increased exposure to digital tools enhances patient acceptance and perceived usability. This is exemplified in our study, where patients subjected to multiple tests reported greater ease of use and management of the PocDoc device. This correlation between exposure and acceptance demonstrates that familiarity with digital health technologies often leads to improved user experience and greater trust in these tools [15]. Furthermore, patient engagement with multiple digital health tools can lead to increased comfort and confidence in such technologies. This is particularly relevant in today’s healthcare landscape, where digital tools are becoming increasingly integral to patient care and management. The “learning effect” further supports our findings, suggesting that repeated interaction with digital health devices enhances user competency and satisfaction. This is critical in understanding patient adaptation to healthcare technology, especially in contexts where digital tools are novel or complex [16]. Comparing patients’ perceptions before and after using the PocDoc application, it can be observed that the overall perceptions did not change significantly. This could be an indication that participants who were already confident and open to using such applications had their perceptions reinforced through the use of the application, while those who were not confident and were reluctant or did not find such technology helpful had their negative perceptions confirmed after using it. It may have benefited such individuals to be given more time and exposure or supervised training to allow them greater familiarity and thus the possibility of changing their perceptions from negative to positive ones.

Future advancements in digital ophthalmology are poised to significantly broaden the scope and efficacy of eye disease diagnosis and management and its application in the clinic. The incorporation of advanced imaging modalities, such as fundus imaging, into digital platforms is expected to revolutionize the detection and monitoring of retinal pathologies, including conditions like age-related macular degeneration. Additionally, the integration of gamification strategies in digital eye care tools and visual function assessment in clinics using digital tools represents a promising approach to enhance patient engagement and adherence to treatment and monitoring protocols [17]. Furthermore, the development of multifaceted digital platforms capable of executing a comprehensive array of diagnostic tests will be instrumental in detecting a wide spectrum of ocular conditions, ranging from surface issues like dry eye syndrome to complex retinal alterations. Such integrative and patient-centric technologies are anticipated not only to improve diagnostic precision and patient experience but also to facilitate more personalized and accessible eye care solutions across diverse patient demographics. In a review article by Wintergerst et al. in 2020, the authors concluded that smartphone-based fundus imaging has the potential to make fundus examinations and screenings more accessible for patients, particularly in low- and middle-income settings, and therefore aid in tackling the burden of diabetic retinopathy, glaucoma, and retinopathy of prematurity screening [18]. Uchino et al. evaluated the usefulness of a dry eye mobile application for screening dry eye disease (DED) at educational tear events in Japan and concluded that the easy access to DED screening might motivate people to perform quick tests, as the number of subjects diagnosed with DED was relatively high [19]. Identifying suitable patients for these screening and examination programs can benefit patients in the early diagnosis and monitoring of disease progression while reducing screening loads in clinics and hospitals.

Patients' perceptions and experiences are important in developing the best healthcare models possible. Results suggest that the majority of patients appear to be receptive to using a web-based application, making it a viable strategy for use in selected groups of patients. Initial technical support would likely be required when introducing it to the community. Results indicate that the use of web-based screening tools may be a viable strategy for monitoring vision in the community, promoting early diagnosis of eye disease or disease progression, improving clinical triage, and possibly performing remote teleophthalmology consultations.