A Successful DR Screening Program, Five Years In

In a positive environment where the entire culture challenges people to go above and beyond, and where those who do accept the challenge are recognized often and enthusiastically, it’s not too hard to keep improving a worthwhile - if imperfect - program. So says Chelsea Revoir, Quality Improvement Coordinator for HealthPoint’s Auburn (WA) clinic. “In a perfect world, our rollout of this extensive program would have come with an official ‘roll-out package,’ openly identifying barriers that we might face, and offering those solutions outright,” Chelsea admits. “It would have been preferable to begin this journey with a designated, permanent screening room, an ample number of certified photographers, and fundamental training on diabetic retinopathy for all staff members. But our staff was pioneering this program. There was no other healthcare organization in the area they could learn from.”

HealthPoint Auburn makes certification as a retinal photographer one step toward promotion to MA2. Today the Auburn Medical Clinic has 13 retinal photographers.

HealthPoint Auburn makes certification as a retinal photographer one step toward promotion to MA2. Today the Auburn Medical Clinic has 13 retinal photographers.

But who gets it perfect from the start, especially when it’s cutting-edge technology and a whole new program and skill set for staff? While HealthPoint Auburn had to learn as they went,  their quality data now show they have, indeed, learned how to manage a successful Diabetic Retinopathy (DR) screening program. And they have lessons learned and innovative approaches to share.

In 2012, when Community Health Plan of Washington (CHPW), a nonprofit organization founded by local community health centers, offered to place portable digital retinal cameras in its member clinics to screen for DR, HealthPoint Auburn Medical clinic volunteered to go first. Five years later, now systematically screening 65% of its 775 diabetic patients each year, and inching toward the CHPW goal of 70%, this clinic has identified barriers, implemented creative solutions and worked out some winning policies and procedures to keep moving the needle forward.

Early Barriers to Success

When they got their digital retinal camera in November 2012, HealthPoint Auburn’s diabetic screening rate was at 28%. Their Health Center Assistant Manager, Yvonne Paschke, was trained and certified as a photographer, a trainer and the on-site administrator of the program. She, in turn, trained the two Lab MAs as photographers. As time went on, more staff were trained; now the clinic has 13 certified photographers and two more in training.

Today at HealthPoint Auburn Medical clinic, the daily photographer schedule requires two certified photographers to rotate as the retinal photographers for the day. Assigned retinal photographers are announced daily at the morning huddle and listed on the daily MA schedule which is sent to all staff. This allows staff to easily identify whom to call when a patient needs screening for diabetic retinopathy.

Another early barrier was placement of the camera, which needs a dark space for optimal performance. It sat in a procedure room or exam room, taking up needed space and necessitating a complicated schedule of the room’s availability. It would often move from place to place - not optimal.

Program leadership also realized that staff and diabetic patients were not always well informed of the importance of the retinal screening.

Got challenges? Meet Chelsea! As the Quality Improvement Coordinator at HealthPoint Auburn, Chelsea Revoir strives to implement quality process improvement workflows in order to enhance up to 30 measures in any given year. She welcomes the opportunity to execute creative, upbeat solutions. When the Wright Center’s DO Residency Program left the HealthPoint Auburn Medical clinic to start a new clinic, several of the photographers transferred to the new start-up clinic. HealthPoint Auburn’s DR screening numbers dropped significantly. Chelsea saw three avenues for recovery: Urge all interested staff  to become certified photographers; educate the staff  on the importance of retinal screening; and get meaningful educational materials into the hands of diabetic patients - all while continuing to identify and resolve related barriers.

Creative solutions

Soon HealthPoint Auburn had a colorful quarter-sheet flyer with images, communicating to diabetic patients the great importance of annual retinal screening – offered in several languages.

A little nook at the end of a hallway on fourth floor was converted into a permanent home for the eye camera and screening process - a place where photographers assigned for DR screening on that day could meet patients and perform the exam. A few of the initial problems were now resolved.

Consistent, ongoing quality improvement

Within three months of that dip in screening rates, when the residency left, the clinic saw its numbers creeping back up. But nothing is perfect, right? Committed to maintain quality, Chelsea performs chart audits and meets one-on-one with the MAs to continuously find areas for improvement. One thing she discovered was that patients were not making their way up to fourth floor where the exam is performed.

As a multi-floor clinic, HealthPoint Auburn needed to create an easier flow for patient movement. Initially, the MA would simply tell the patient to head to the 4th floor for the exam – and also instruct them where to go to complete their blood draw, pick up their prescriptions, etc. When patients focused on the latter, they sometimes left the clinic without completing the DR exam.

A fairly easy solution was to make use of a special small waiting area near the lab. This helped reduce the number of patients sitting in the lobby, waiting, and/or leaving the clinic without having their retinal screening. As the lab MAs came out to get patients, they easily identified the DR screening patients and shepherded them to the screening room.

Eventually staff noticed that, once again, some patients were failing to make it to that special waiting area, so Chelsea whipped out some hot pink card stock and came up with another simple solution: She created a most visible little card for DR screening patients to carry with them in the clinic. The card reminded them where to go for their screening, but its easily identifiable appearance alerted all staff to help this particular patient find that particular waiting area. Another bump in the road smoothed out.

Everyone knows that remembering to refer every patient for every preventive screening every day, all the time, can be a huge challenge. While performing her chart audits, Chelsea noticed that physicians and MAs sometimes forgot to check on their diabetic patients’ retinal screening status. Knowing that visual cues are extremely helpful, little yellow chicks that soon perched vibrantly above each monitor – they couldn’t be ignored. The message below reminded staff to “CHICK to see if the patient is due for an eye exam!”

Not all of Chelsea’s great ideas have been wildly effective. Patients complained that retinal screenings were available only on weekdays, for example, so HealthPoint offered Saturday screenings for a few months. It was not a success; on average only three patients took advantage of the alternative screening opportunity.

Covering all the bases - daily

Still, Chelsea was ready for the next challenge, embracing every opportunity to implement an easy, reliable solution to keep the DR screening program running smoothly. She reviews all the reports from EyePACS daily, tracking follow-up for patients with abnormal exams while also keeping an eye on the quality of the retinal images as noted on the report. If she sees a trend toward “poor” retinal images for a particular photographer, Chelsea works with the Medical Assistant Supervisor, Keri Stephenson, to ensure the photographer receives another training session from the designated retinal iCam trainer, Jay Fernandez (MA2).

HealthPoint Auburn holds its photographers to high standards and creates fail safes to ensure they are performing at optimal capacity.  But things can still go wrong. “Our camera might go down,” Chelsea said. “When that happens, we have workflows in place to ensure our diabetic patients are still referred to the ophthalmologist for their retinal screenings.”

Chelsea Revoir, Quality Improvement Coordinator, and Jay Fernandez, MA, Lead Photographer

Chelsea Revoir, Quality Improvement Coordinator, and Jay Fernandez, MA, Lead Photographer

Jay Fernandez, who has been with the retinal screening program since its inception, is now the photographer trainer and on-site administrator. He said, “I’m very proud of the partnership HealthPoint has with EyePACS to provide the Diabetic Retinopathy screening program together. As the main trainer, I have had the opportunity to train over 20 photographers through the past 5 years. We’ve seen significant growth in our productivity since we acquired the diabetic retinal camera. I love the fact that the patient can have an office visit and retinal exam on the same day here at HealthPoint. Patients are grateful that we relieve a lot of stress about possibly having to go elsewhere for further exams.”

Planning for future success

Chelsea added, “We inspire all MAs to become certified photographers. It’s a good challenge that moves them forward professionally, and the HealthPoint culture encourages employees to step up and accept new challenges. We make it a point to acknowledge and congratulate every retinal photographer newly certified by EyePACS.”

Today, HealthPoint Auburn Medical clinic ranks among the top ten most productive EyePACS screening programs in the nation. All creative solutions aside, another factor keeps HealthPoint driving toward success: Community Health Plan of Washington offers monetary incentives to its members who reach some fairly demanding goals. “We are proud of our partnership with HealthPoint and the success they have experienced through Community Health Plan of Washington’s Diabetic Retinal Care and training program,” says Victor Collymore, M.D., Chief Medical Officer of CHPW. “We have seen a continual increase in diabetic eye exams across the network in locations with a retinal camera since introducing the program in 2012.”

Asked how he feels about the DR screening program now, five years down the road, HealthPoint CEO Thomas Trompeter said, “We are really happy to make this service available to our patients. It is a major improvement in the quality of care that we provide. We can make a very important service more accessible and convenient for our patients, many of whom would probably not get this service if we weren’t providing it. This also helps us save money in our healthcare system, but most importantly we reduce the potential for the pain and misery caused by retinopathy.”

Google Achieves Healthcare Breakthrough Using EyePACS Retinal Images

Question: Can a computer using “deep learning” (a new type of artificial intelligence) be successfully applied to medical imaging? In other words, can a computer, given enough “practice” examples, learn to detect diabetic retinal disease as well as a board-certified medical specialist? More specifically, is it possible for a computer to create its own algorithm that will allow it to examine images of human retinas and correctly diagnose diabetic retinopathy (DR) or macular edema?

Answer: Google has just announced that “an algorithm based on deep learning had high sensitivity and specificity for detecting referable diabetic retinopathy.” The study was published in the Journal of the American Medical Association (JAMA) on December 1, 2016.

So, why is this announcement so important to primary care? Because, according to Google’s announcement, “automated grading of diabetic retinopathy has potential benefits such as increasing efficiency and coverage of screening programs; reducing barriers to access; and improving patient outcomes by providing early detection.” Those three benefits resonate loudly in the healthcare safety net, where access to care and screening is a challenge, and achieving better patient outcomes in chronic disease management is always high on the list of priorities in any primary care setting.

The study was led by Lily Peng, MD, PhD, of Google Research, Inc., using retinal images provided by EyePACS as well as sources in France and India. EyePACS (which stands for Eye Picture Archive Communication System) places digital cameras in primary care clinics to image the retinas of diabetic patients and then upload the images to “the cloud” where they are read by certified specialists who render an opinion and recommendation within 24 hours.

Thousands of competing algorithms for detecting diabetic retinopathy were developed through a Kaggle data science competition funded by the California Health Care Foundation, using EyePACS images, developed by over 600 teams from around the world in early 2015. Encouraged by that successful project, Dr. Peng and her colleagues used 128,000 retinal images from EyePACS and Messidor, a French retinal image database, to train a new neural network optimized for image classification. Images were graded three to seven times for diabetic retinopathy, diabetic macular edema, and image gradability by a panel of 54 US licensed ophthalmologists and ophthalmology senior residents between May and December 2015. The resultant algorithm was then validated using EyePACS-1 and Messidor-2 data sets, both graded by at least seven US board-certified ophthalmologists.

The EyePACS-1 data set consisted of nearly 10,000 retinal images. The prevalence of referable diabetic retinopathy (RDR), defined as “moderate and worse diabetic retinopathy, referable diabetic macular edema, or both,” was eight percent of fully gradable images. The Messidor-2 data set had 1,700 images from 874 patients. The prevalence of RDR was 15 percent of fully gradable images. “Use of the algorithm achieved high sensitivities (97.5 percent [EyePACS-1] and 96 percent [Messidor-2]) and specificities (93 percent and 94 percent, respectively) for detecting referable diabetic retinopathy,” according to Google’s announcement.

In the JAMA article, the authors explain, “These results demonstrate that deep learning neural networks can be trained, using large data sets and without having to specify lesion-based features, to identify diabetic retinopathy or diabetic macular edema in retinal fundus images with high sensitivity and high specificity. This automated system for the detection of diabetic retinopathy offers several advantages, including consistency of interpretation (because a machine will make the same prediction on a specific image every time), high sensitivity and specificity, and near instantaneous reporting of results.”

The authors observe that “further research is necessary to determine the feasibility of applying this algorithm in the clinical setting and to determine whether use of the algorithm could lead to improved care and outcomes compared with current ophthalmologic assessment.”

Why is such a breakthrough significant, and what will it mean for diabetes patients? According to Jorge Cuadros, OD, PhD, CEO of EyePACS, 415 million people worldwide have diabetes, and of those, about 15% are at increased risk for vision loss and blindness due to diabetic retinopathy. DR is the leading cause of blindness among working age adults in most developed countries, yet 90% of vision impairment is avoidable through early detection by retinal screening and appropriate treatment.

“The problem,” Dr. Cuadros explained, “is that DR often presents no symptoms until the disease has progressed beyond the point of effective treatment. Regular screening of all diabetic patients is important to detect DR before it’s too late.” Cuadros added that, even with screening and detection, patient adherence to referral recommendations is often the next roadblock to timely treatment. This algorithm will raise an instantaneous red flag while the patient is still in the clinic, and will hopefully activate that patient to take charge of their eye care and prevent disease progression and blindness.”

Direct application of this algorithm in the primary care setting is still off in the future, of course. But now that the first question has been answered (Yes, deep learning can be successfully applied to medical imaging of the human retina) the next step will be to test the hypothesis that immediate feedback to generate concerned intervention by a trusted provider will activate diabetic patients to follow through on sight-saving recommendations. “Our ultimate goal is to actually prevent vision loss and blindness, not just to check the box that says we conducted a retinal exam on our diabetic patients” Cuadros explained.

We Take the EyePACS System to Eurasia

Diabetes and diabetic retinopathy do not abide by man-made boundaries. According to the World Health Organization, the number of individuals with diabetes around the world has quadrupled in the past 35 years. Prevalence is increasing worldwide, particularly in low- and middle-income countries. As everyone in the EyePACS community knows well, one devastating consequence of diabetes is diabetic retinopathy (DR), which now accounts for 2.6% of all blindness in the world. While our major focus has been screening for DR across the United States, EyePACS has, throughout its 15-year history, taken its telemedicine solution to countries across the globe, including Mexico, Guyana, Djibouti, Colombia, and now Armenia.

Most recently, in October 2016, EyePACS joined a medical mission to provide immediate and sustainable healthcare improvements to the beautiful country of Armenia. Before we detail the mission and our part in it, we’d like to tell you something about this country, so little known to most Americans. Formerly a Soviet republic, Armenia is an ancient country in the South Caucasus region of Eurasia. It shares borders with Turkey and Georgia and just barely meets Iran to the far south.

Armenia is a democratic nation-state, mostly mountainous, with few forests. The country has developed a modern industrial sector; Intel recently agreed to open a research center there. Over the past decade Armenia has made vast improvements to health services and healthcare accessibility, including an “open enrollment” program which allows Armenians to choose their healthcare service provider.

Our purpose in joining this medical mission was, of course, to bring a telemedicine solution to a country struggling to screen its diabetic population for DR and thus lower the rate of preventable blindness. The project was planned and developed through the joint effort of Sante Health, (a group in Central California with more than 1200 physicians and nurse practitioners in partnership with hospitals, labs, x-ray facilities, and outpatient caregivers), and the Armenian Consul in Fresno, California, Berj Apkarian. Together they arranged to bring surgeons, internists, gynecologist, neurologists, neonatologists and other healthcare professionals to offer their knowledge, materials and skills to the Armenian healthcare system. The country’s Health Ministry fully supported these efforts and welcomed us.

Thanks to the support of Dr. Kuldip Thusu, PhD, a respected philanthropist and CEO of Alta Family Health Clinic in Dinuba, California, as well as owner of Universal Biopharma Research Institute, EyePACS was able to establish multiple diabetic retinopathy screening sites in hospitals in three locations in Armenia: Yerevan (the capital city), Gyumri and Stepanakert (which lies in the autonomous region of Artsakh). We placed four digital retinal cameras in Armenian health facilities, at no cost to the providers or patients, and trained staff to operate them. We demonstrated the EyePACS system, which will now provide a telemedicine solution to better control their DR rate through early detection.

According to Pablo Cuadros, EyePACS Program Coordinator, “In spite of their turbulent history, the Armenian people impressed us with their resilience and good natured hospitality. From our first day in Yerevan, their gratitude and willingness to participate in our mission significantly enhanced the amount of sustainable care we were able to provide. We were honored to interact with brilliant ophthalmologists who caught on to the EyePACS system very quickly and were enthusiastic about this new technology to improve patient care. They were also eager to express other needs that the mission might fulfill in the future.”

This futuristic approach demonstrates the benefit of working with professionals who are constantly looking for new ways to collaborate. Dr. Thusu and EyePACS look forward to communicating with our new friends on the other side of the world to see what additional services we can provide.

Levon Altunyan, center, Armenian Minister of Health, poses in the Health Ministry office with the organizers and participants of the U.S. mission, including EyePACS representatives and other health care specialists.

Levon Altunyan, center, Armenian Minister of Health, poses in the Health Ministry office with the organizers and participants of the U.S. mission, including EyePACS representatives and other health care specialists.

EyePACS Program Coordinator Pablo Cuadros, right, poses with Levon Altunyan, Armenia’s Minister of Health, on the left, and Dr. Ali Fayad of Sante Health, organizer of the healthcare mission to Armenia.

EyePACS Program Coordinator Pablo Cuadros, right, poses with Levon Altunyan, Armenia’s Minister of Health, on the left, and Dr. Ali Fayad of Sante Health, organizer of the healthcare mission to Armenia.

In Stepanakert, Dr. Thusu gets a real-life demonstration of the Optovue portable camera and the EyePACS system as Pablo Cuadros of EyePACS images the retinas of the son of one of the mission’s Armenian hosts. The boy had complained about pain and redness in his eye and was prescribed medication that did not provide a solution. After examining the eye, the team decided to take him to Yerevan for further diagnosis and treatment. 

In Stepanakert, Dr. Thusu gets a real-life demonstration of the Optovue portable camera and the EyePACS system as Pablo Cuadros of EyePACS images the retinas of the son of one of the mission’s Armenian hosts. The boy had complained about pain and redness in his eye and was prescribed medication that did not provide a solution. After examining the eye, the team decided to take him to Yerevan for further diagnosis and treatment. 

Kuldip Thusu, PhD, observes a meeting of the Armenian parliament. Dr. Thusu’s confidence in telemedicine was instrumental in bringing the EyePACS solution to Armenia.

Kuldip Thusu, PhD, observes a meeting of the Armenian parliament. Dr. Thusu’s confidence in telemedicine was instrumental in bringing the EyePACS solution to Armenia.

EyePACS CEO Lectures in Bogota, Colombia

University of La Salle in Bogotá, Colombia, is often considered the "Berkeley" of Latin American optometry, with the most advanced graduate program in Latin America. From October 6 through 9, Jorge Cuadros, OD, PhD, was invited to lecture about diabetic retinopathy and technology to an international audience of eye care professionals and provide a workshop for vision science masters students.  Dr. Cuadros reported, "Not only was it a rewarding experience because of the interest and desire of the participants, but it was a lot of fun!" 

As part of an effort to raise the accuracy and consistency of retinal disease triage in primary care, the students were instructed on the well-validated EyePACS Retinal Grading System, developed by EyePACS medical director, George Bresnick, MD, MPA.  The students later examined and triaged patients with diabetes at La Salle's Teleoptometry Clinic.  "The enthusiasm of the Colombian students and eye care providers is encouraging” Cuadros said, " and we look forward to developing new retinal screening programs in Colombia and the rest of Latin America."


Patient Compliance and Satisfaction - Keys to Success

In the final analysis, that’s what it all comes down to. Whatever the services we provide for our diabetic patients, how they perceive the delivery of that service and how (and whether) they make use of it, is really the deal-maker. When we offer our diabetic patients the opportunity to have their retinas screened annually in the interests of detecting signs of retinopathy, the way that service is delivered must satisfy the patients and convince them of its worth if they are going to use it. Otherwise, compliance rates with screening and recommended treatment will not rise, and the incidence of vision impairment from diabetic retinopathy will not decline.

Of course we probably all agree with that statement, but it’s particularly encouraging when a third party tells us we’re on the right track. So we were excited about an article posted on the Healthcare IT News forum sponsored by Athenahealth: Remote eye exams urged to prevent blindness in under-served diabetes populations. The article was authored by Jeff Rowe, a contributing writer for Healthcare IT News and editor of HIMSS Future Care. He previously served as editor of EHRWatch, a tech blog focused on all aspects of electronic health records.

Rowe’s article opens with this encouraging news: “As healthcare providers consider ways of using telehealth technologies to expand specific service lines, recent research suggests it may come in useful for patients at risk for eye disease due to diabetes.” He goes on to cite a survey of older adults by the University of Michigan’s Kellogg Eye Center, which found that “nearly 70% of respondents indicated that telehealth could be more convenient than traditional one-on-one exams with an eye specialist.”

“People were also more willing to do this if they had a lot of other health problems that made it harder for them to get to the doctor,” according to one of the Michigan researchers, Maria Woodward, MD, professor of ophthalmology. Rowe notes that “virtual exams could be particularly helpful in rural areas where eye doctors are in short supply.”

The findings of the Michigan study as reported by Rowe and Athenahealth corroborate our own data from a 2015 survey of our partner clinics in Washington State. Responses came from 44 sites around the state representing 14 community health centers that had been using the EyePACS system for 1-2 years. The staffs were asked about patient satisfaction and compliance with the annual retinal screening program in general, as well as about staff satisfaction and other questions.

Seventy-seven percent of patients were reported to have been “pleased and satisfied” to be given the opportunity for screening with the cloud-based system, while 23% were characterized as “neutral.” Patient response to the telehealth retinal exam procedure itself was similar, as reported by the health centers: 80% were pleased and satisfied with the exam, while 20% had no observable response. Forty percent of participating clinics indicated their patients used the words “quick” and/or “easy” to describe the exam in the primary care visit.

We will continue to measure the effectiveness of the EyePACS telemedicine solution to detect diabetic retinopathy and prevent vision loss from the disease. In the meantime, it’s reinforcing to know that other reputable health organizations are finding similar results in terms of patient engagement and satisfaction.