Telehealth reaches the unreachable

Internists, ophthalmologists team up remotely to screen diabetics, and find those with sight-threatening disease.

By Karen Blum, Contributing Editor

Looking over quality metrics three years ago, physicians at Austin Regional Clinic in Texas noticed an alarming pattern among their 15,000 diabetic patients: only half were going for recommended annual retinal eye exams, despite constant reminders to do so during their primary care visits; patients also received mailed letters and messages through the system’s online patient portal.

Studying obstacles to eye appointments, they found patterns typical of the diabetes population at large. Eye exams were off the radar for patients with early diabetes because they weren’t having symptoms, explains internist Anas Daghestani, MD, the practice’s president and director of population health and clinical quality. If “it doesn’t hurt you, it doesn’t bother you,” he says, “so it’s another appointment to make and another copayment.” But the same was true for those with advanced diabetes experiencing complications. “If you’re seeing the kidney doctor and the heart doctor, then it’s also another appointment.”

Physician photography training, Guanajuato, Mexico.
COURTESY JORGE CUADROS, OD, PHD

Wanting to save their patients time, let alone their eye health, Dr. Daghestani and colleagues decided to try in-house diabetic retinal screening. The practice contracted with IRIS (Intelligent Retinal Imaging Systems) to establish a telehealth program, placing fundus cameras in three clinics that treated the most diabetics. Patients could simply walk to another room for their diabetic retinal exam, where trained lab technicians waited to operate the cameras.

The images were then sent electronically to ophthalmologists in a reading center, who returned results, within 24 hours, to the primary care physicians through the clinic’s electronic medical record. In the first three weeks of offering the service, the clinics screened 100 patients, 20% of whom had unexpected pathologies in their eyes. All were referred for ophthalmic care.

“Our physicians are telling us this is one of the best things we’ve done,” Dr. Daghestani says.

IRIS is one example of how primary care-based telehealth imaging programs are successfully reaching out to patients who might not otherwise see an eye-care provider.

A cyber toehold

Telehealth programs are gaining traction, says Jinan Saaddine, MD, MPH, a medical epidemiologist at the CDC’s Division of Diabetes Translation who leads its Vision Health Initiative.

Consider: 24 states now insist that private payers reimburse for telemedicine, of any type. Forty-eight states, through Medicaid, have some type of coverage for telemedicine; the federal Affordable Care Act (ACA) is providing the states with this financing.

As for savings, a PricewaterhouseCoopers analysis showed that telemedicine, on an annual basis, can save 9% — $908 million down to $827 million — on overall diabetes management costs.

But, telemedicine isn’t a cure-all. Adherence — patients heeding the warnings and heading towards a specialist — is far from perfect. Overcoming opposition from ophthalmologists is another issue.

Still, ophthalmologists not involved in telehealth programs might want to reconsider, says retinal surgeon Sunil Gupta, MD, chief medical officer of U.S. Retina, LLC, in Pensacola, Fla., and founder of IRIS. Annual retinal exams are part of the HEDIS (Healthcare Effectiveness Data and Information Set) measure for diabetes as established by the National Committee for Quality Assurance. Medicare Shared Savings programs mandate these exams as well. CMS and other payers are prioritizing access to care and the “triple aim” framework of improving population health and the patient experience while decreasing costs. Payers can increase their Medicare Advantage program STAR ratings if they identify high-risk patients early enough for cost-saving intervention.

Removing false images

The Veterans Administration loves telemedicine. Its fundus imaging program started in 2006.

In the beginning, some people, including ophthalmologists, “were worried that telemedicine would be looked at as completely substituting for face-to-face care, which it really doesn’t — it enhances it,” says Mary Lynch, MD, a professor of ophthalmology at the Atlanta Veterans Affairs Medical Center. “It’s supplemental, and I think people are seeing now that telehealth can really help extend care to people in rural and remote areas.”

“In the past there’s been this belief that ‘I’d rather examine the patient than have someone do a telehealth exam on them’,” Dr. Gupta says. “That’s great — about half of patients are making it to the ophthalmologist’s office. But we’re targeting the other half that the eye-care field is just not seeing.” Telehealth, he says, allows providers to identify “those patients at risk of blindness and bring them” to an ophthalmologist, who otherwise would not be treating them.

Ocular images from four different patients with four different aspects of diabetic retinopathy.
COURTESY MARY LYNCH, MD, ATLANTA VETERANS AFFAIRS MEDICAL CENTER

Many an ophthalmologist now shares Dr. Gupta’s viewpoint. IRIS’ clients include health systems, academic groups and physician offices, in 18 states. In some cases, ophthalmology practices have brought the service into their networks, Dr. Gupta says. “[Telehealth] is an opportunity for [practice] managers and operating physicians to think about another referral source,” he says. “This is a tool to align vertically with the primary care system.”

Discussing numbers, confronting barriers

Twenty-nine million people in this country have diabetes, one in four of whom is unaware of their condition, according to 2014 CDC statistics.¹ About a quarter of them have diabetic retinopathy (DR), Dr. Saaddine says.

Helping to prevent the preventable

A primary care group learns that to detect diabetic retinopathies early, making the detection process convenient is vital.

By Anas Daghestani, MD

Diabetic retinopathy threatens the vision of more than 5 million U.S. adults over age 40. The leading cause of blindness in this country, diabetic retinopathy can affect anyone diagnosed with type 1 or type 2 diabetes, so blindness is a real possibility for millions of Americans. While diabetic retinopathy is highly treatable if caught early, data suggest fewer than half of diabetics keep up with the recommended annual eye screening.

Our primary care group has seen similar lackluster screening numbers among our diabetic patients. Despite years of proactive efforts — using electronic medical record alerts, mailing letters, making phone calls and delivering nagging in-person reminders — we barely moved the needle from a 45% compliance rate.

Figure. Tractional retinal detachment
INTELLIGENT RETINAL IMAGING SYSTEMS™

Several hurdles kept our patients from fulfilling their important preventive screening. Mostly, the obstacles fell under the heading of inconvenience.

Our staff members wanted to change this dynamic and convince patients to get screened. It was only because of advancements in technology that we found a way to achieve it.

Reinforcing connections via telemedicine

While my medical group offers various specialty care for patients in addition to primary care, we do not have eye specialists on staff. Using telemedicine removed this hurdle to our plan.

In August, three of our 21 clinics, which are located throughout central Texas, were embedded with new retinal screening telemedicine technology. Some 15,000 patients with diabetes are treated in these three clinics.

These patients can now be screened, using the specialized cameras, following their regularly scheduled physician or lab visit. An image of the patient’s retina is captured and then sent seamlessly and securely to a team of local retinal specialists, with whom we have contracted indirectly through IRIS. If a screening detects deterioration in the retina, the patient is recommended to follow up with his or her ophthalmologist to review options.

In this way, technology is influencing our patients to maintain a relationship with their existing eye specialist or establish one, if one already doesn’t exist.

Why convenience resonates

The inconvenience of keeping yet another medical appointment is a key reason our patients choose to skip the annual eye screening. Depending on the stage of their diabetes, patients could see several specialists already, not counting their twice yearly visits, or more, with their primary care physician. These patients do not feel an eye screening is a priority.

Another factor: the disease has few early warning symptoms until it’s too late to treat, often when the onset of blindness is near. With no symptoms, patients are less worried about their risk.

Embedding the screening in the primary care or lab visit also offers advantages of the monetary kind. An eye physician appointment might fall under the patients’ vision coverage, which has cost implications. A screening in a primary care clinic falls under general medical coverage.

Excuses like ‘I don’t have time for another appointment’; ‘I’m too young to worry about eye disease’; or ‘I don’t have vision insurance’; are no longer valid. Our diabetes patients who have not yet had their annual screening will get one, which better ensures that patients see an ophthalmologist at the right time.

Positive results means vision saved

By making it easy for patients to get screened, we are helping to prevent the preventable. Of than 29 million people diagnosed with diabetes, 40% to 45% are expected to have a stage of diabetic retinopathy. There is no indication that the incidence of diabetes in the United States will fall anytime soon. Finding unique solutions is the only way to avert “blindness disease”.

In our case, technology now connects our patients to local ophthalmologists who are helping us save the vision of our patients. That’s something to be proud of. OM

Dr. Daghestani is Internist and Director of Population Health and Clinical Quality at Austin Regional Clinic in Austin, Texas.

REFERENCES

1. “The State of Vision, Aging, and Public Health in America”. Centers for Disease Control and Prevention Vision Health Initiative Web Site: http://www.cdc.gov/visionhealth/pdf/vision_brief.pdf

2. Lee SJ, Sicari C, Harper CA, Livingston PM, McCarty CA, Taylor HR, Keeffe JE; Examination compliance and screening for diabetic retinopathy: a 2-year follow-up study; Clinical and Experimental Ophthalmology. 2000. 28:149-152.

3. “National Diabetes Statistics Report, 2014”. Centers for Disease Control and Prevention. http://templatelab.com/national-diabetes-report-2014/

While diabetes rates have somewhat leveled off in recent years,² projection rates for DR are still worrisome, she says: By 2030, 11 million people will have DR, and by 2050, 14.5 million will have vision-threatening DR. Incidence of diabetes continues to climb in subgroups including African-Americans, Hispanics and those with a high school education or less.

“In general, about 50% of people with diagnosed diabetes are not really getting the recommended eye care,” Dr. Saaddine says, in part because of barriers such as cost, lack of transportation or lack of access to eye-care providers.

Offering telehealth exams could increase screening compliance over time, according to a recent study.³ Diabetic patients were randomly assigned to receive either traditional surveillance by an eye-care professional or telehealth screening in a primary care clinic for two years. Those in the telemedicine group were about twice as likely to be screened for DR.

“Our data showed that the primary care provider’s office is a point of care in which telemedicine works,” says lead study author Steven Mansberger, MD, MPH, vice chair and director of glaucoma services at Legacy Devers Eye Institute in Portland, Ore. Eye-care providers seeing these patients applaud telemedicine, because, through referrals, “they’re really seeing the patients who need their care.”

Like those at the VA. The Veterans Health Administration operates one of the most prominent telehealth programs, and offers the service through nearly every VA hospital. About 90% of the VA’s diabetics are routinely getting their retinas looked at according to HEDIS criteria, Dr. Lynch says. Her center alone reads retinal scans from about 6,000 veterans a year, who receive screenings through nine primary care community clinics in the state; in most cases, licensed practical nurses operate the fundus cameras.

“Some of the clinics are quite far — 100 miles away,” she says. “It allows us to … provide a very basic service to patients who have a hard time coming all the way into the city.”

About 75% of patients don’t have anything wrong, Dr. Lynch says. “But 25% of them have something going on they would not know they had. We can take care of them and prevent progressive vision loss. That is a huge benefit.”

A recent study⁴ of nearly 2,000 veterans screened in 2008-2009 found the most common reasons for referral to an eye-care provider were nonmacular DR, nerve-related disease, lens or media opacity, age-related macular degeneration and diabetic macular edema. Fifty-five patients (16.9%) had two or more concurrent problems that put them at high risk for permanent visual loss (glaucoma, DR, diabetic macular edema and AMD). In 90% of cases, the face-to-face exam diagnosis matched that from the screening.

Thanks to the study results, the Atlanta VA this spring placed ophthalmology technicians in community clinics to offer basic vision-care services including glaucoma screening for veterans without diabetes. The program already has screened almost 1,500 veterans, says Dr. Lynch, many of them also “with potentially blinding conditions that they never knew they had.”

Size doesn’t matter

Telehealth programs range in scope and size. Vitreoretinal surgeon Enrique Calderon, MD, was recruited to Charleston Area Medical Center in West Virginia last year, where he started a telehealth-screening program. As of late last year, he has been working with nine rural health care clinics serving some of the state’s poorest residents. “These patients either don’t have the resources to travel to the capital to get an eye-health checkup or live in very remote corners of this state, making it difficult to travel and obtain eye care,” he says. The program is working well, he notes.

Presented at Advanced Technologies and Treatment for Diabetes 2013: Two internists and a medtech were trained and certified remotely through EyePACS Reviewer Credentialing Program.
COURTESY JORGE CUADROS, OD, PHD

“We are seeing diabetic retinopathy earlier than we typically would in this patient population; that is good,” Dr. Calderon says. A major strategy for patients with diabetic macular edema, as emphasized in the DRCR Protocol I study, was that patients should not be undertreated in the first year, he says. Through his program, patients whose images aren’t well captured or are too blurry to discern adequate details are referred to a general ophthalmologist, who has outfitted some for glasses and removed cataracts. “So with screening we are seeing the opportunity to identify or suspect other ocular pathologies than just diabetic retinopathy.”

At the grassroots level are imagers like George Hayes. Mr. Hayes screens about 800 patients a year in three primary care clinics in San Diego through a program called Project Dulce, a diabetes care and education program funded by Scripps Health. Hayes isn’t a medical professional — he’s a photographer by training, who took a course at the University of California, Berkeley, to become a certified retinal reader.

Mr. Hayes uses a mobile camera to take photos; he shares results with physicians on-site. If they spot a problem, like they did in a recent patient who came in with 20/100 vision and a pre-retinal bleed, they can immediately e-mail the images to a retinal specialist for an appointment. That patient, says Mr. Hayes, was treated almost immediately.

Along with finding the problem and saving the person’s sight, says Mr. Hayes, Project Dulce kept the patient out of the emergency room because it got the person an appointment quickly. “There wasn’t an additional cost to the system.”

Retinal screenings can be controversial because the standard of care in ophthalmology is a dilated eye exam, Mr. Hayes says. Screening is a good adjunct, he argues, because screening finds those most at risk and then they can get a dilated eye exam. Those less at risk can be “monitored and given [a diabetes] education and understanding of the risks.”

The downside

But getting them to have that dilated eye exam is another story. The most important part of telehealth screening, says Dr. Saaddine, is “to make sure that the patient who has diabetic retinopathy has been referred to eye-care providers and that the patient is followed.”

In that, the programs struggle. Some studies^{5, 6} indicate that while digital retinal imaging improves screening rates, it does not necessarily improve patient compliance in visiting an eye-care provider, says Jorge Cuadros, OD, PhD, director of clinical informatics research at the University of California, Berkeley, Optometric Eye Center. Dr. Cuadros also is president and CEO of EyePacs, LLC, a telehealth service that provides free cameras and training to community health clinics. It services 360 clinic networks (782 sites) in the United States and five other countries.

Image observation comments:
Moderate bilateral cortical cataracts. Right superior pigmented lesion approximately 1500 microns in diameter with irregular borders and uneven pigmentation

In a 2009 study of 288 patients with sight-threatening DR from four EyePacs clinics, only 22% of referred patients received treatment or entered care with a specialist, for reasons including logistics, lack of insurance and belief that treatment wouldn’t help, Dr. Cuadros says.

“It’s a vicious cycle of nonadherence,” he says: a patient with sight-threatening retinopathy may not go for treatment until he has symptoms, by which point it’s too late and laser treatment is unsuccessful, so the person becomes visually impaired or depressed. Then the patient shares those feelings with friends or family so they become leery, too.

The professionals who can most impact the cycle are those close to diabetics: community health workers, diabetes educators, primary care physicians, Dr. Cuadros says. He has been developing training materials and lecturing to family medicine residents and primary care physicians.

In addition, Dr. Mansberger says, some physicians have been wary about instituting the programs because they weren’t sure how adding the screening would fit into an already busy work day. They aren’t rejecting the idea of telemedicine, he says.

“It’s just finding a way to make it like an EKG where the patient’s in the room, you see the patient, the imaging device comes into the room, images them within a couple of minutes and they’re all done … That’s what we’re waiting for.”

Telehealth programs won’t detect every eye disease, he cautions. “But it’s clear this testing saves lots of money for the patient, the provider and the health system.”

The health-care system has few wins, like telehealth, for all involved, says Dr. Gupta. “This is obviously a win for patients, and also a win for primary care doctors because a lot of them are being graded on quality.” OM

Dr. Gupta is CMO of IRIS. Dr. Cuadros is CEO of EyePacs, LLC. The other interviewees reported no relevant financial conflicts of interest.

REFERENCES