FormalPara Key Summary Points

Why carry out this study?

Patient perceptions and experiences are vital in shaping healthcare models.

The perceived 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.

We aim to study how patients feel about using a web-based screening tool to determine whether it is a viable method for assessing visual acuity and visual functions in the community.

What was learned from this study?

Most patients thought that a web-based screening tool would be useful for monitoring their visual function and were confident in and receptive to its use.

Technical difficulties in using any new application or technology, especially in older patients, would remain a challenge.

Results show 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 consultations.

The study has limitations in the lack of data on the socioeconomic status and educational levels of the patients and the exclusion of non-English-speaking participants. Also, participants were surveyed on a single proprietary app. These factors are crucial, as they can significantly affect a patient’s access to and proficiency with digital applications.

Digital Features

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.

Introduction

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.

Methods

Study Design

A cross-sectional questionnaire-based survey was conducted before and after patients used the PocDoc application.

Participants

A total of 440 patients were recruited from general and specialist eye clinics from March 2022 to October 2023. The inclusion criteria were (1) patients who attended outpatient ophthalmological services from March 2022 to October 2023, and (2) patients who could self-administer and understand the questionnaire, or if unable to for reasons such as poor vision or language barrier, had an accompanying person to assist. The exclusion criteria were (1) patients who did not agree to participate in the study, and (2) patients who could not understand English and had no accompanying persons or family members who could understand English.

App Description

The PocDoc application is a comprehensive platform for eye examinations. It includes visual acuity tests (Snellen test, Landolt C test, Tail the Dog test, and tumbling E test), color vision test, visual field using microperimetry, contrast sensitivity test, Amsler grid test, and red desaturation test, as well as detailed guidelines for users to perform these tests with precision (see Supplementary Video File 1). The PocDoc app is compatible across a range of devices, including laptops, personal computers (PCs), and mobile devices such as iPhones, iPads, and Android tablets and smartphones. The operational details and instructions for use of the application have been comprehensively documented elsewhere [3].

Setting

The survey was split into two parts: a pre-test and a post-test questionnaire. The patients first completed the pre-test survey, followed by using the PocDoc application, and then completed the post-test survey. The pre-test survey involved a six-item self-administered questionnaire (Supplementary Materials Appendix 1A), and the post-test survey involved a 10-item self-administered questionnaire (Supplementary Materials Appendix 1B). The questionnaires were designed to elicit patients’ perceptions and experiences regarding the use of digital applications to assess visual acuity and visual function. A total of 440 patients performed the pre-test questionnaire. After using the purpose-built web-based PocDoc application, a total of 387 completed the post-test questionnaire. With six eye tests, PocDoc evaluates different aspects of visual function, including visual acuity, and can be administered on mobile phones, tablets, or desktops [3]. However, for this study, all patients accessed the app on a Galaxy Tab S6 Lite smartphone (model SM-P615, resolution 1200 × 2000 pixels). Both the pre- and post-test questionnaires were conducted in English, and patients who were able to understand English were allowed to self-administer and complete the survey form. In cases where patients could not understand English, an accompanying person or family member could help to translate the questionnaire into the language that the patient spoke (e.g., Hindi, Tamil, Mandarin, Malay).

Data Analysis

The survey was conducted using a five-point Likert scale. On analysis of responses to the questionnaire, ‘‘agree’’ and ‘‘strongly agree’’ were considered positive responses while ‘‘disagree’’ and ‘‘strongly disagree’’ were regarded as negative responses to the questions. A univariate analysis was conducted to calculate the frequency of each response to individual questions. Then, in order to assess the impact of test complexity and the quantity of tests administered, we stratified the patients into distinct groups based on the type and combination of tests they underwent. Group 1 (simple test) comprised patients who were exclusively subjected to the visual acuity test. Group 2 (complex test) included those patients who underwent only the visual field test. Lastly, Group 3 (multiple tests) consisted of patients who received multiple tests during a single visit, encompassing a combination of the aforementioned tests. This grouping strategy was designed to isolate and analyze the effects of different testing protocols on patient outcomes. To analyze the data distribution, we initially applied the Shapiro–Wilk test. Finding non-normal distribution, we then utilized the Mann–Whitney U test for group comparisons. We used a one-way analysis of variance (ANOVA) test for comparison between age groups. A p value of less than 0.05 was considered statistically significant.

Ethical Considerations

The study was conducted in accordance with the tenets of the Declaration of Helsinki. Institutional review board (IRB) approval was obtained from the National Healthcare Group Domain Specific Review Board (NHG-DSRB Ref. 2020/00384). Informed consent was obtained from all the study participants by the research staff. All survey responses from the participants were anonymous, and no identifiable data were collected.

Results

Patient Demographics

A total of 440 pre-test and 387 post-test questionnaires were completed. The mean age of the participants was 54 years (standard deviation [SD] ±20.1). The youngest patient was 6 years and the oldest patient was 89 years of age; 256 patients were male (%) and 184 were female (%). The majority of the participants, 335 in total, were Chinese (%), while 53 Indian (%), 25 Malay (%), and 26 other races (%) made up the rest of the participants. A total of 269 participants tested had ocular pathology in both eyes (%), while 52 only had ocular pathology in their right eye (%), and 41 had pathology in their left eye (%); 78 patients tested had no ocular pathology. Patients came from a wide range of occupations, including business and office jobs, computer and mathematical work, and healthcare and architectural roles. A large number (n = 147, 33.40%), however, did not declare their occupation, and the next largest group comprised those who were not working or were retired (n = 70, 15.90%) (Table 1).

Table 1 Demographics of included patients
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Perceptions of the Application (PocDoc) Before Using it

A total of 440 pre-test survey results were collected. A total of 382 (86.8%) participants felt that a remote eye monitoring application would be useful (50.2% strongly agree, 36.6% agree). In addition, 312 (70.9%) participants thought that they would use a remote eye monitoring application such as PocDoc frequently (25% strongly agree, 45.9% agree). Only a small proportion of participants, 72 (16.4%), thought that the idea of a remote eye monitoring application was unnecessarily complex (3.4% strongly agree, 13.0% agree).

Slightly more than half, 243 (55.2%) participants, thought that the application sounded easy to use (20.0% strongly agree, 35.2% agree). Additionally, most participants—319 (72.5%)—thought that most people would learn to use an application such as PocDoc very quickly (22.1% strongly agree, 50.45% agree). However, 152 (34.5%) participants thought that they would initially need the support of a technical person to utilize the application (14.6% strongly agree, 20.0% agree) (Fig. 1).

Fig. 1
figure 1

Graphical illustration depicting patients’ perceptions of the PocDoc digital application before using it. The responses from the survey participants for all six questions were graded based on a Likert scale

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Perceptions of and Experiences with the Application (PocDoc) After Using It

A total of 387 (88%) participants who had taken the pre-test survey also completed the post-test survey. Of these, 245 (63.3%) participants still thought that they would use PocDoc or a similar application frequently. A total of 99 (20.4%) participants felt that a tool like PocDoc would be too complex to use. In total, 307 (79.3%) participants thought that the application was easy to use; 141 (36.5%) of them thought they would still need technical support, while 348 (89.9%) felt that they would learn to use the application quickly. Additionally, 299 (77.3%) found the various functions well integrated, and 250 (64.6%) felt very confident using PocDoc. Only 39 (10%) thought there was too much inconsistency in PocDoc; 71 participants (18.3%) found it cumbersome to use, while 125 (32.3%) participants felt they needed to learn more before starting to use PocDoc (Fig. 2).

Fig. 2
figure 2

Graphical illustration depicting patients’ perceptions and experience with the PocDoc digital application after using the web-based tool

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Comparison Before and After Using the Application

After using the application, the number of participants who initially thought they would frequently use PocDoc decreased from 70.9 to 63.3%. However, a large number still found it easy to use and a larger percentage of participants felt they would learn to use the application easily, as the percentage of positive responses increased from 72.5 to 79.3%. The perceived need for technical support remained fairly consistent, at 34.5% before using the application and 36.5% after using it. Confidence in using the application increased after using it from 55.2 to 64.6%.

Effect of Age on Patient Perception

We observed significant differences in mean responses among the age groups (1–19, 20–59, and 60 years and older) across most questions, indicating that age significantly influences perceptions and attitudes. Specifically, younger respondents (aged 1–19 years) generally reported higher agreement levels, whereas the oldest age group (60 and older) often showed lower mean scores, suggesting a more critical view. The middle-aged group (20–59 years) displayed moderate perspectives, bridging the views between the younger and older participants. Notably, for questions 5 and 7, the analysis did not reveal significant differences across age groups, suggesting a consensus or shared viewpoint on these topics regardless of age (Fig. 3).

Fig. 3
figure 3

Mean Likert scale responses in the post-test survey stratified by age group. The figure presents the average responses to the Likert scale questions in the post-test survey, categorized into three age groups: 1–19 years, 20–59 years, and 60 years and older. Statistical analysis via one-way ANOVA revealed significant differences in the mean responses among the age groups for all questions, except for questions 5 and 7, indicating that age significantly influenced the responses in the post-test survey across most questions. *Indicates a statistically significant difference with a p value < 0.05. Supplementary Table 1 in the Supplementary Materials contains detailed information about the mean, standard deviation, and standard error for each question

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Effect of Complexity and Number of Tests on Patient Perception

The study included 83 patients undergoing only the visual acuity (VA) test (simple test), 44 patients subjected to only the visual field (VF) test (complex test), and 243 patients who had two or more tests (multiple tests). Detailed information on the tests is provided in Table 2. Notably, there were no significant differences in patient perceptions between the simple and complex test groups. Interestingly, patients who underwent only the complex test reported finding the PocDoc less cumbersome than those who had the simple test. However, a contrast emerged when comparing patients with single versus multiple tests. Those who underwent multiple tests were more likely to agree that the PocDoc is user-friendly, well-integrated, and easy to learn. There were no marked differences in perceptions between patients who underwent a complex test and those with multiple tests. More detailed results are available in Table 3.

Table 2 Breakdown of single and combined diagnostic tests administered
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Table 3 Comparative analysis of patients’ post-test perceptions based on test complexity and quantity
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Discussion

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 [9,10,11].

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.

Limitations

There are several limitations of our study design. One limitation is the absence of data on the socioeconomic status and educational levels of the patients and the exclusion of non-English-speaking participants. These factors are crucial, as they can significantly affect a patient’s access to and proficiency with digital applications. Socioeconomic status and, to a certain extent, English-speaking ability may influence the availability of technology and internet access, essential for using digital health tools. Similarly, educational background can greatly impact a patient’s ability to understand and navigate these applications independently, potentially necessitating additional technical support. This limitation is important, as it suggests that our findings might not fully reflect the experiences of all user demographics, particularly those who might face digital or educational barriers in using health applications.

The second limitation of our study is that the questionnaire only focuses on questions around the specific app. It would have been helpful to obtain more general results about how patients feel about technology and healthcare more broadly and then further discuss the specifics of this app. However, based on the study design, wherein we did not want to introduce heterogeneity in people’s responses about various types of apps, we did not include different types of apps but only one prototype app. This might have introduced bias, but for this pilot project and this prototype, we were able to obtain responses from participants about their perceptions related to this app.

Moreover, although this study exclusively utilized the Samsung Galaxy Tab S6 Lite for patient interactions with PocDoc, limiting generalizability across different devices, this approach ensured uniformity in patient evaluation and enhanced study replicability by controlling for device variability. Future research would benefit from considering these factors to gain a more comprehensive understanding of digital health tool usability across diverse patient populations.

Conclusion

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.