Abstract
Background
We explore an innovative approach by transforming patient information leaflet (PILs) into Quick Response (QR) code linked patient information videos (PIVs) in ophthalmology. Our objectives are to assess the subjective utility of a PIV on glaucoma and analyse the use of QR codes as a delivery method.
Methods
A prospective study was conducted in Ninewells Hospital, NHS Tayside. A glaucoma PIV was created and linked to a QR code provided to 130 glaucoma patients. Pre- and post-video questionnaires evaluated the patients’ perception of using a QR code and subjective improvement in their understanding of glaucoma.
Results
Out of 102 responses collected, 55% of patients had no prior experience with QR codes. However, 81% of patients were able to watch the PIV. The average view duration of the video was 3:26, with 82.5% view retention. Statistically significant improvement in glaucoma knowledge was observed across all six areas questioned (p < 0.001) using a 5-point Likert scale. Overall, 70% of patients preferred PIVs over PILs, and 77% acknowledged that PIVs could be a sustainable alternative.
Conclusion
QR codes for delivering PIVs were well-received, with patients finding them easy to use. Our PIV on glaucoma effectively enhanced patients’ understanding of the condition.
Introduction
Effective patient communication and information distribution to enhance understanding of a medical condition has been shown to hold upmost importance as it improves patients’ engagement and compliance with treatment. 1 This is especially relevant in ophthalmology where long-term adherence to treatment is often required, that is, topical treatments in glaucoma. In an ideal scenario, a clinician should deliver patient information during their consultation, aiming to give their patient a complete and personal understanding of their condition. However, retaining information can be challenging for patients in a verbal consultation. And 40–80% of medical information provided by healthcare practitioners is forgotten immediately after a consultation; moreover, almost 50% of the information patients do recall is incorrect. 2 For this reason, spoken information is advised to be supported with written or visual material as it can improve communication with patients. 3 The use of patient information leaflets (PILs) is widely promoted by the General medical council to encourage better patient participation in their healthcare. PILs have proven to be helpful in empowering patients to know more about their conditions and to improve patient experiences overall. 4 The primary medium used for the provision of PILs remains on a paper-based format.
Video-based media are one of the most ubiquitous forms of communication in the modern age and have recently become a prominent platform for disseminating health education and tackling health misinformation since the corona virus pandemic. 5 Some previous studies have examined the use of video intervention for patient education. Rosenthal et al. 6 showed a sustained improved patient knowledge after a PIV intervention and concluded that their video was an economic method of patient education. Similarly, Mednick et al. 7 demonstrated better patient understanding and preference of fundus fluorescein angiography with their narrated white board animation video. One challenge with the use of digital information has been gaining access to this information reliably. Without a suitable link provided by a healthcare professional, patients may fall into the trap of ‘Googling’ a condition and being given waves of unreliable, irrelevant and possibly unsafe information. The recent discussion by Sharara and Radia 8 has shown that Quick Response (QR) codes may be a suitable link to patient information. QR codes are graphic bar-like codes that can be scanned as a personal smart device, offering an easy and a fast link of specific information sources (such as website, PIL or PIV) and can be scanned repeatedly. QR codes are free to generate and can be programmed to be linked to anything online providing the user has internet access.
QR codes are not a new concept and are widely used in healthcare. For instance, they are printed on patient test tubes and biopsy reports to retain records safely in the medical industry, 9 as well as on wristbands for patient's identify. 10 The rise of COVID-19 pandemic further revolutionised the use of QR codes in healthcare sectors. There has been a growing interest in the utilisation of technology in the provision of healthcare services to patients as a strategy for infection control, primarily due to the elimination of printed brochures and other health information in waiting rooms.
However, there are limited studies that evaluated patients’ utilisation of QR codes, their preferences or the efficacy and proficiency of QR codes in delivering electronic patient information. To our knowledge, most studies to date examine the efficacy of digital healthcare services in enhancing clinical outcomes without focusing on patient engagement in its specificity. We take the innovative and sustainable approach of transforming and digitalising PILs into QR code-linked patient information videos (PIVs) in ophthalmology. This is the first published real-world assessment of the use of QR code in accessing a PIV in ophthalmology. Our study aims to (1) assess the patients’ utility for our PIV on glaucoma and (2) analyse the use of QR code as a mode of delivery.
Methods
This prospective study was conducted at a tertiary hospital ophthalmology department in the United Kingdom. Ethical Caldicott approval was awarded by information governance in the local hospital trust. Locally an in-house glaucoma patient information video was produced by the NHS Tayside glaucoma firm which includes ophthalmology consultants, an ophthalmology registrar, an optometrist and a specialist nurse. This video is 4 min and 10 s long. This video was made to cover key information for glaucoma patients similar to and based on the RCOphth glaucoma PIL. The script was peer reviewed by the glaucoma team. The spoken information in the PIV was delivered by the NHS Tayside glaucoma firm. The PIV can now be freely viewed publicly on YouTube on https://www.youtube.com/watch?v = Mu-m3IIBBaY or via the QR code (Figure 1).
PIV QR code. QR: Quick Response; PIV: patient information videos.
Between August and September 2022, all patients attending the glaucoma clinic were invited to participate with a total of 130 questionnaires sent out. All patient participation were completely voluntary, and informed consent of participants were obtained by ophthalmology registrar or consultant running the glaucoma clinic. Patients who refuse to be part of the study were excluded. No further supports were given. All patients were given a paper questionnaire which consisted of four parts: addressing patients’ demographics, pre-video statements, QR code access to the video and post-video statements. The questionnaire explored patients’ utility in accessing a QR code, whether their understanding of glaucoma improved subjectively and patients’ views on delivering healthcare information in video form. Each statement in the pre- and post-video section had 5-stage Likert scale responses graded from 1 (strongly disagree) to 5 (strongly agree). Other question types involved multiple choice and white space for further comments. Questionnaires were then returned in prepaid envelope directed to the local ophthalmology department.
During the study's duration, the video remained private. Only patients who received the QR code were exclusively able to watch the PIV. Participants did not require a YouTube account to access the video with the private link. While having an account allowed them to like or subscribe, we did not collect this data as part of the study's scope.
In our study, we utilised “YouTube Analytics” to analyse the objective data regarding the video such as: total views, total watch time, audience retention and timeline specific retention analysis. These data were then correlate to participant response in our questionnaire including total number of video viewing and if video was shown to anyone else to enable us to correlate view counts beyond the number of participants.
Statistical analysis
The statistical analysis was conducted using SPSS software (version 22.0, IBM Corp.) Descriptive statistics were used to summarise the baseline characteristics of the cohort. Patient’s age was described using the median and interquartile range (IQR) and then grouped into categories (<60 or ≥ 60). The relationships between patient demographics and prior experience with QR code as well as ability to watch the video out were investigated using logistic regression. Associations between pre- and post-video patients’ perspective were analysed using Chi-squared test. A p value <0.05 was considered statistically significant.
Results
A total of 102 respondents completed the questionnaire, and a 78% response rate was achieved. The median age was 72 (IQR 67–79) and 66% (67/102) of patients were female. Out of 102 participants, 77% of our patient cohort consisted of follow-up patients with 22% of patients reported attending the glaucoma clinic for the first time.
Fifty-five percent (56/102) of patients reported no prior experience with a QR code. Nevertheless, 81% (83/102) were able to watch the video (Figures 2 and 3). The frequency of video replay varied between 1 and 2 times for 72% of patients (73/102) with 39% reporting they showed the video to family or friends. A total of 155 view times was reported by YouTube analytics. Barriers to watching the video are illustrated in Figure 4, with the most common reason being due to technical challenges such as not owning a smart phone (11/18, 61%). One participant did not comment on why they could not access the QR code (1/18, 6%).
Have you used a QR code before? QR: Quick Response.
Did you manage to watch the video?
Barriers to watching PIV. PIV: patient information videos.
The 5-point Likert scale used to grade patient's understanding of glaucoma pre- and post-video is summarised in Table 1. There was a statistically significant improvement in subjective glaucoma knowledge in all six areas questioned (p < 0.001). Figures 5 and 6 illustrate the shift in patient grading from pre- to post-video.
Pre-video patients’ perspective questionnaire.
Post-video patients’ perspective questionnaire.
Patient's understanding of glaucoma pre- and post-video.
QR: Quick Response.
Overall, 58/83 (70%) of patient agreed or strongly agreed that they are more likely to watch a patient information video than read a paper leaflet. Sixty-four out of 83 (77%) acknowledged patient videos may be a sustainable alternative to paper leaflets. Positive written feedback has also been collected in the white space of the questionnaire for further comments.
A statistically significant negative association was found between age and prior experience with QR code (p = 0.05). However, no statistically significant correlation was found between age and ability to watch the video (p = 0.58). Similarly, there were no statistically significance differences in improvement of understanding of glaucoma between new patients with first clinic appointment and patients who had previous clinic visits (p = 0.10).
YouTube video analytics showed that our PIV achieved a total view time of 8.9 h. The average view duration of the video was 3.26 (4:10 total) with a view retention of 82.5%. Timeline retention analysis showed an increase in viewer retention at two sections of the PIV (this implies that this part of the video was rewatched). There was an increase of viewer retention of 3% (76–79%) in the section giving information about driving and explaining the Driver and vehicle licensing agency (DVLA) rules. There was also a small increase of retention of 2% (78–80%) in the section giving a patient ‘lived experience’ example of glaucomatous visual field progression.
Discussion
This study serves as a formal evaluation of patient experience with using QR code technology to access a novel PIV in ophthalmology. To the authors knowledge this is the first of its kind in the literature to assess the use of QR codes to deliver a PIVs in ophthalmology. Our PIV has shown to be a patient education tool by improving a patient's comprehension of glaucoma. This resonates with findings from previous research by Rosenthal et al. 6 and Mednick et al. 7
Various medium exist for delivering healthcare information for patient education, encompassing paper leaflets, posters, videos and internet-based applications. Overall, 70% of patients in our study reported their preference of PIVs over PILs. This has been similarly shown in previous studies indicating greater patient satisfaction with the video education compared to brochures received during a clinic visit.11,12
Our study presents data from a population aged between 32 and 90. No statistically significant correlation was found between age and ability to watch the video (p = 0.58). As a matter of fact, the oldest respondent that reported the ability to use the QR code was aged 89. Most current literatures claim that age has been suggested as a potential limiting factor hindering the use of technology for healthcare. 13 Nevertheless, our study reported statistic which encourage further exploration on older generations accessibility and adaptability to digital healthcare. Less than half of our patient cohort had prior experience use of QR code, despite this the vast majority managed to gain access to the PIV via the QR code given. This data supports the ease of use of QR codes and can be easily learnt without prior experience. The COVID-19 pandemic has revolutionised the use of QR codes across all industries. It has been adopted into the healthcare sector, particularly for providing patients with digital information. 14 This has factored into making QR codes more familiar and acceptable as an alternative to PILs.
Our PIV on glaucoma had a viewer retention is 82.5% with repeated views from patients suggesting good engagement. The total watch time in for our study was 8.9 h. Using innovative technology such as PIV can help improve patient understanding and consequently, reduce the time needed for patient education during their follow-up clinic visit. 15 Previous studies have reported that PIVs have shown to reduce physical consultation time while maintaining patient comprehension and satisfaction in ophthalmology cataract consent 16 and in otolaryngology for rhinology surgery. 17 Our questionnaire received positive written feedback regarding the visual explanation using a patient ‘lived experience’ visual field loss progression associated with glaucoma. This was also supported by the increase in viewer retention on video analytics by 2% in that section of the PIV. The asymptomatic, progressive nature of glaucoma is a common gap in patients’ knowledge that can lead to poor compliance. 18 This shows the power of a simple visual explanation. There are potential benefits of improved compliance from our PIV but go beyond the scope of this pilot study.
Nguyen et al. 19 showed that a high level of anxiety is associated with newly diagnosed long-term conditions and in turn patients would have less information recall when given medical information. Their study encouraged clinicians to continue exploring ways to optimise information provision to patients. This resonates with one patient's comments in the questionnaire, stating ‘I wish this video was available when I was diagnosed with glaucoma 30 years ago, I was so anxious with the diagnosis, but this video explained it all well’. This patient had previously received a PIL and multiple consultations.
The most frequently reported barrier in watching the video was due to technical challenges such as not owning a smart phone. Digital poverty might be the underlying issue here in view of the fact that delivery of healthcare is increasingly incorporating telehealth and electronic strategies. Nevertheless, this may be less of an issue in time and this is echoed by the Office of National Statistics (ONS) report also speculating that smart phone and tablet ownership in the United Kingdom will increase yearly as across all age groups. Conversely, two patients reported that they actively made a choice not to own a smartphone as they were averse to owning any electronic gadget. Although this is a small proportion, one could argue that the healthcare industry is obliged to accommodate for these individuals and therefore PILs cannot be completely replaced by PIVs.
Internet access could also pose to be an issue for QR code utility. The ways in which the internet is accessed varies with age. In 2018 the ONS explored the UK digital divide. And 77% of adults in Great Britain reported accessing internet ‘on the go’ (via a smartphone or tablet). However, this declines with age, with 69% of those aged 55 to 64 years and 39% of those over the age of 65 years. 20 The QR code relies on internet access on a smart device and individuals may not have roaming internet access until they get connected to their home Wi-Fi.
The Royal College of Ophthalmologist have acknowledged global environmental issues and encourages their members to offer practical solutions to some of the sustainability issues within ophthalmology. 21 A modest effort towards the target of making the NHS paperless by 2018 was not achieved and the new target has been redefined to reach a ‘core level of digitisation’ by 2024. 22 The model of PIVs as a substitute to paper PILs could be an angle of approach towards this target. The effective distribution of QR codes is open to discussion and needs to be explored further.
There is an initial cost for making a PIV; equipment, electricity, personnel and time. However, this was a small scale study. Like most sustainable options the true benefits are reaped over time. If a PIV is constructed well, it has the potential to be used for years, therefore reducing the average cost of the initial production cost. We also believe that the true sustainability benefit would be achieved on a larger scale. If a PIV could be used by other ophthalmology departments or even on a national level, the initial cost would be minimised further.
A study limitation was that we used a prospective cohort design rather than a randomised controlled clinical trial. In addition, its single centre nature restricts the interpretation of patients’ experience and level of digital poverty in the wider population.
Conclusion
The provision of PIV through QR codes is a novel method to improve patient communication and information distribution in ophthalmology.
Our PIV on glaucoma via a QR code has been proven to be a promising tool in delivering patient information with high patient satisfaction. If implemented on a larger scale, we hope that with further development this will allow a more environmentally and fiscally advantageous method of providing ophthalmic care without compromising on patient-reported outcome measures.
Although we have found QR codes a helpful tool to deliver our PIV it was not accessible for all the patients in our study. As clinicians, we have a role to continually seek sustainable and environmentally friendly options for the future. We can anticipate that there will be a generational shift in digital use which clinicians should parallel. Until then we propose that QR code delivered PIVs are a helpful adjunct to PILs that can be offered to patients as the journey towards a paperless NHS continues.
Footnotes
Acknowledgements
We thank Gillian Somerville and Claire Brown for their help in producing the patient information video. A version of this study was presented as an oral presentation at the Scottish Ophthalmological Club meeting, February 2023.
Author Contribution Statement
SP designed and implemented the study with support from CC and SG. SP and WHO collected the data, performed data analysis and co-wrote the manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
