Diabetic retinopathy (DR) is the most common complication among adults with diabetes.¹ And while only about 60% of people with diabetes get their recommended yearly screenings for DR,¹ those who do overwhelm many public and private ophthalmic care practices.

Public health networks like New York’s NYC Health and Hospitals (H+H), however, are stepping up to help improve screening rates and take some of the burden off their eye clinics by creating primary care-based DR screening programs.

“Normally, DR screenings would take place in the eye clinic, but the eye clinics are very busy, very overrun with a patient wait list of about 3 months just to be seen for a screening,” says Michele Rains, telehealth project manager in the H+H Office of Ambulatory Care, who oversees the network’s DR screening program. “It didn’t make sense. Screening rates were pretty low, and we needed a better way to catch those patients, so why not move the location of the screening from the eye clinic into primary care?”

According to Ms. Rains, through April 2022, 38,123 patients with diabetes had been screened; of these, 8,580 (about 23%) demonstrated evidence of retinopathy requiring follow-up care. Almost 17,000 patients were found to have evidence of other conditions such as glaucoma and cataracts in addition to retinopathy.

HOW THE PROGRAM WORKS

Targeted only at patients with diagnosed diabetes or gestational diabetes, the screening program is designed for efficiency and the convenience of both physicians and patients. When a patient arrives for a routine examination with their NYC H+H primary care provider (PCP), an order for a fundus photograph is placed in their EHR.

At the conclusion of the routine exam, the patient is escorted to an adjoining room where the fundus photo is taken. In H+H’s case, a patient care assistant (PCA) uses the iCare Eidon non-mydriatic fundus photo camera. The process adds only about 5 minutes to the patient’s overall time in the office, Ms. Rains says. The images — one color image of each retina — are stored on H+H’s Topcon Harmony picture archiving and communication system (PACS), where they are accessed and read by a network optometrist or ophthalmologist within 3-5 days.

Worrisome findings are documented in the EHR, and the patient is referred to the eye clinic for evaluation. The reading ophthalmologist or optometrist documents in the referral the preferred time to schedule the follow-up appointment based on the severity of the findings. They can also choose which “clinic” the patient needs to be seen in (eg, the retina clinic or other specialist facility).

“Once the reading optometrist or ophthalmologist completes the documentation, that documentation then gets sent back to the PCP in Epic, so they’ll always know what’s happening with their patient,” Ms. Rains says. “It closes that loop of communication so that everyone knows what’s happening with the patient.”

ADDRESSING MULTIPLE ISSUES

Ronni Lieberman, MD, director of ophthalmology at NYC H+H, stresses the program’s positive impact on patients, especially the elderly who face challenges making and keeping appointments with multiple providers.

“It’s difficult for the patients to come in. It’s one more appointment for them,” says Dr. Lieberman. In addition, ophthalmic care providers benefit from being able to concentrate their time and effort on patients with confirmed disease.

The institution overall benefits from improvements in efficiency as well.

“Historically speaking, a lot of our facilities operated as silos and did their own thing. What we’ve been trying to do … is really standardize our workflows and make things much more efficient now that all of H+H is on Epic,” Ms. Rains says.

SCREENING PROGRAM BEST PRACTICES

For public and private health-care systems considering implementing DR screening programs, Ms. Rains says all staff should feel that they are part of the conversation from the beginning.

“Sometimes what happens with larger public health institutions is that communication, which flows from leadership down, doesn’t make it all the way to the frontline staff and there’s pushback or backlash on any new program that is being implemented,” she says.

Along with communication, program leaders must recognize the importance of the role that PCAs and other frontline staff play in ensuring smooth workflows.

“Our clinics would cease to exist without our PCAs,” Ms. Rains says. “They do everything, and now we’re also asking them to take time out of their busy day to take these photos of our patients and make sure that they’re completing the workflow.”

Also, Ms. Rains, who oversees a program that encompasses eight to 10 PCAs at each facility, advises providing staff with ongoing support. “You can’t just train them once and then say, ‘OK, you’re live,’ and send them on their way. I have created extensive training materials that I laminate and put in the room and make sure that there is no question as to what their role is within this program. They also know they can call me or FaceTime me or text me if they have a question.”

Another reason for the NYC H+H program’s success is their technological, end-to-end interoperability.

“The Epic EHR talks to our Eidon camera, which talks to our Topcon PACS, so it’s all automated,” Ms. Rains says. “We also have support not only from the vendors, but also from our IT colleagues to ensure that it is going to work the way that it was built.”

THE FUTURE OF DIABETIC SCREENING

Timothy G. Murray, MD, MBA, founder of Murray Ocular Oncology and Retina in Miami and American Society of Retina Specialists past-president, says telemedicine screening for patients at risk for DR is a unique approach to improve early screening and diagnosis of diabetic eye disease. “This program suggests the utility of telemedicine screening to enhance early referrals for vision-threatening disease outside of the traditional ophthalmologist/optometrist pathway. Enhanced screening and early detection — especially prior to visual symptoms — enables the best vision and anatomic outcomes for patients requiring treatment within the retina specialist’s office.”

Artificial intelligence (AI) is also set to play a role in diabetic screenings. For example, the FDA approved IDx-DR (Digital Diagnostics), an AI-based fundus screening system, is capable of detecting DR requiring referral in adults who have diabetes.

“These unique screening strategies have great potential to enhance diabetic patient care targeted to eliminating diabetic-related vision loss,” Dr. Murray says.

While a DR screening program can improve efficiency in ophthalmology practices, the real beneficiaries are the patients.

“In addition to the multiplicity of problems that you get with diabetes, one of the largest problems is DR, which can lead to blindness and other devastating consequences, even if it’s detected and treated,” says Dr. Lieberman. “The patient’s only chance of doing well is for it to be found early.” OM

REFERENCE

1. American Academy of Ophthalmology. Diabetic Retinopathy PPP 2019. https://bit.ly/3H0GLkc . Accessed June 1, 2022.