One Camera + Full Commitment = Success!

In many ways the Cowlitz Family Health Center (CFHC) Longview, Washington, story is like so many other stories of EyePACS partner clinics striving to save their diabetic patients from blindness and vision impairment: seven sites and only one camera; no eye care specialist on staff; a diabetic population equal to 12% of its total adult patient population; a chance to get the first camera at no cost, thanks to Community Health Plan of Washington, and then only the dream of a second or third camera.

The CFHC story has a different ending, though, with some strong, identifiable themes running through it. Here is a health center with one camera and one MA-photographer serving 7 sites -- and consistently screening more than 75% of all diabetic patients’ retinas annually or biannually.* Under the direction of Dian Cooper, CEO, this health center has become what the EyePACS staff likes to call a “top performer.” So what are their secrets?

Well, the secrets are not terribly unusual or colorful. They bespeak committed program leadership, savvy use of the EHR, internal accountability, and big-picture orientation. To hear Dr. Gerry Melgar, Medical Director since 2006, tell it, they just keep at it and celebrate their successes and look for logical ways to achieve better outcomes. “When we got the camera in 2013 and started doing in-house screening in January 2014,” Dr. Melgar explained, “everyone was enthusiastic. Our screening rates immediately improved – for three months. Then it wasn’t so exciting anymore, and our rates started to fall again.”

Like most other health centers, CFHC collects quality performance outcomes data and reports it back to the providers and on up to the highest echelons of leadership, AND they take that data seriously. Dr. Melgar is determined to squeeze every bit of support he can from his Epic EHR. An OCHIN** member and leader, Dr. Melgar has collaborated with OCHIN to create reporting systems that bring all the key data points together, allowing his staff to quickly determine which diabetes patients are due for retinal screening, alerting his providers and their support staff to the need for today’s patient referrals, and allowing EyePACS readers to have the reports directly interface with the OCHIN Epic EHR for easy viewing by the ordering providers.

For its part, OCHIN focuses much of its work on integrating technology platforms with community partners and with the technologies used by their member clinics, such as the EyePACS digital retinal camera. Abby Sears, OCHIN CEO and President, explains “OCHIN firmly believes in the value of truly integrated care and supports the efficient flow of patient information to the providers that need it, where they need it. Not only is this more efficient for clinic staff, it’s better for patient care. Cowlitz Family Health Center under Dian’s leadership has been a great partner with us in this area, and their outcomes demonstrate both the importance and the potential of integrated data.”

Great work with the EHR aside, though, perhaps Dr. Melgar’s real secret weapon is Jodi Davis, the MA who runs the program. “I started here as an MA in 2010 in a traditional MA role, and I really enjoyed my work,” Jodi said. “I liked direct patient service. But after I became a certified EyePACS photographer, suddenly I saw how far-reaching this type of patient service could be. I have learned that, if I am diligent in using the EHR to find the patients in need of their DR screening and I reach out to them to make an appointment, I really can drive up the rate of screening for our total diabetic population.”

Every few weeks Jodi packs up her Optovue camera in its original carton, carefully protecting it with the padding the staff has hung onto since 2013. She sets the camera in its box right back on the adjustable table and wheels it out to her car. The two pieces of equipment ride in her backseat to another CFHC site where screening appointments have been set up in advance.

Jodi packs the camera to travel to yet another Cowlitz Family Health Center site.

Jodi packs the camera to travel to yet another Cowlitz Family Health Center site.

Setting up those advance appointments is critical to success, of course. A master calendar records the DR screening dates for all clinics, and the staff at each site is expected to help fill those appointments appropriately through patient outreach. Each clinic can easily find the list of patients due for DR screening in the Epic system. “We also send batch letters through the EHR,” explained CIO Janice Emery. “The reminder gives them the option to have the procedure done in our clinic or through referral to a local eye care specialist. We do not have a preference for who does the screening.” The staff explained that most patients who choose to go to an outside provider have third-party insurance. “The Medicaid patients and those uninsured come to us,” they said.

That brings up the question: Do you charge your patients a fee for the EyePACS DR screening? “We do,” said Jodi Davis. “The current rate is about $42, but the sliding fee scale lowers that for many patients.” And she explained that the warm hand-off in the main Longview clinic is still a popular way to refer a patient for DR screening. That site, incidentally, which is home to the camera most of the time, provides a separate room specifically for DR screening.

Although CFHC has worked with OCHIN to add a function to the “health maintenance” section that alerts providers and MAs directly when DR screening is due, the clinic also has standing orders, per Dr. Melgar, to make the referral in any case. Jodi or one of the other two EyePACS certified retinal photographers can order the procedure if the primary care provider is unavailable to do so.  And once the EyePACS certified reader, who reads the images remotely, submits the report directly to Epic, the automatic alert is turned off so staff and patients do not waste their time deliberating about the need for a screening until the next one is due.

Dr. Melgar explained that, once the clinic got its DR screening rates up to 50%-60%, the rate was hard to sustain. “Patient outreach was the critical piece,” he explained. “That’s one of the most important ingredients Jodi has brought to this program. Not only is she our first full-time EyePACS photographer – and she has a great work ethic – but she willingly and enthusiastically contacts patients and encourages them to be screened.”

So, is the secret to success the fact that the portable camera and adjustable table fit in the backseat, or is it the smiling face and cheerful, can-do spirit of one Medical Assistant?

So, is the secret to success the fact that the portable camera and adjustable table fit in the backseat, or is it the smiling face and cheerful, can-do spirit of one Medical Assistant?

Asked what motivates her to pore through reports and make phone call after phone call, day in and day out, Jodi said, “I enjoy what I do now because I can see that I make a difference. I enjoy all kinds of patient care, and I still help patients, but now I see the big picture. I take pride in my work and want to see the program succeed,” she explained, “but I also think about my own future. By helping the patients get the care they need, I support the program. And by making the program succeed, I improve my own career down the road.”

She said that motivation to look through the reports daily is a big part of her success. “I keep trying if I have failed to reach a patient,” she said. The Epic EHR filters patients due for DR screening that still have no referral. Then Jodi searches the chart of each one to see whether that patient has an upcoming appointment scheduled. If not, she calls or sends a letter. “I know when the camera will be in their clinic,” she explained, “and I forward the information to all concerned parties.”

If Jodi Davis is the heroine of this story, surely Dr. Gerry Melgar deserves huge credit for being the kind of hands-on Medical Director willing to make processes work smoothly. “Part of our success is to look at the entire workflow and try to address barriers,” he said. “For example, ordering the photography can be a problem if Jodi has to find the provider. That’s why we established standing orders. Since Jodi took over the program we’ve identified some issues in explaining risks and benefits to the diabetic patient. Now we use a script in talking with patients. And we look for eye issues that will preclude good images, like cataracts. We give our staff the right screening questions to ask.”

“We also want to ensure patients understand the limitations of this screening – it’s not a complete ophthalmological exam.” Dr. Melgar, who was the health center’s CMO when the program was launched, added, “The only part I’m not involved with is how photographers are actually getting certified. I personally wrote the report in OCHIN Epic, and it’s a dynamic report that actively looks for patients overdue for screening. We wanted to ensure Jodi had the tools she needed to make it a successful program. Integration into our Epic system is really important. And the other big piece,” he continued, “is that we added a report for each provider. They see their screening rates each quarter. It’s only one of about 20 quality measures that we report to our leadership, but it’s as important as the others

In light of how well things are going for CFHC with its one retinal camera, it’s probably not a coincidence that right next to Dr. Melgar’s office sits the Chief Information Officer, Janice Emery. Together the two ensure every part of their EHR is functioning smoothly and they are getting the best efficiencies from the system. That means Janice also keeps the EyePACS portal up to date. She acts as the liaison between EyePACS and OCHIN, sometimes sending out order numbers to determine why the systems are not communicating on certain patients. Between the two of them, this duo tries not to let anything fall through the cracks.

As we stated at the outset: committed program leadership, savvy use of the EHR, internal accountability, and big-picture orientation. Cowlitz Family Health Center seems to have found the secrets to success.  

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* EyePACS recommends annual retinal screening for all diabetic patients unless previous tests have indicated a shorter interval is required.

** OCHIN is one of the largest health information and innovation networks in the country. A non-profit organization focused on serving the safety net, OCHIN provides health information technology, research, and professional services to hundreds of healthcare organizations located in every state in the nation.

A Milestone Reached: A Half-Million Retinal Imaging Encounters

On May 31 2017, EyePACS completed its 500,000th retinal exam, meaning our system has now      imaged the retinas of a half-million diabetic patients! EyePACS, through its partner clinics, has now logged more than three-million images. We feel very fortunate and grateful to work with like-minded clinic leaders and clinicians and all of their co-workers who have enthusiastically adopted this vital service for their patients. Our partner primary care clinics have integrated this nontraditional service into their workflow in order to fight one of the most devastating effects of chronic disease.

We have learned so much over the years from our primary care colleagues:

1.  We learned that while timely treatment is very effective in preventing vision loss from diabetes, blindness continues to occur when eye treatment is not initiated in a timely fashion. 

Our development efforts here at EyePACS are now focused on enhancing the connections between primary care and specialty eye care in order to address factors that impede the road to treatment. Please stay tuned as we roll out new programs to improve patient education, referral workflows, and treatment follow up. In order to enhance this effort, we hope our partner clinics will let us know what new features and changes from EyePACS would help them better serve their patients.

2. We learned the importance of having solidly validated technology and processes. With the rush to bring new smaller and cheaper retinal imaging devices to the market place, it’s important to remember that retinal screening is only as effective as the quality of retinal images that can be obtained. At EyePACS, therefore, we are committed to using only those devices that can truly detect the many fine lesions that must be seen in order to manage your patients' retinas at all stages of their disease.

3. While EyePACS has evolved over the years, we know this is just the beginning.  Health care is changing dramatically. We have had several wonderful opportunities to participate in the study of cutting edge technology such as using artificial intelligence and deep machine learning to automate the evaluation of retinal images. As health care continues to change, though, what will not change is our focus on safety net clinics and our partnership with primary care.

Thanks again for your support!

The EyePACS Team

EyePACS One of Top Ten Telehealth Solution Providers

Recently EyePACS was selected from among 300 nominees as one of the nation’s top ten telehealth solution providers for 2017. The honor was bestowed by Healthcare Tech Outlook Magazine, an annual special-edition publication that identifies telemedicine services “which require minimal upfront investment to their clinical repertoire” and “will play a pivotal role in providing cost-effective, higher value care.” The editors state that they are seeking solutions that “have exhibited comprehensive know-how and in-depth expertise.”

It is, indeed, an honor to be listed among some very innovative and fascinating telehealth solutions that are helping to use technology to deliver care in a wide range of healthcare scenarios. According to Healthcare Tech Outlook, their evaluation team and selection panel skim through hundreds of solution providers in the marketplace to shortlist the final 10 that are at the forefront of tackling technological challenges in this space. “In the process of selecting the 10 Most Promising Telemedicine Solution Providers 2017,” a spokesman said, “we analyzed the company’s offerings, core competency, news/press releases, client testimonials, milestones and other recognition… we have a full-fledged market research team which actively tracks all the solutions available in the marketplace. Round the year, they keep collating information from market reports, industry news, social media, surveys with potential buyers, and industry events.”

Capping that ongoing review, the publishers begin to solicit nominations from subscribers and online visitors three months before the special edition is to be published. An evaluation team carefully reviews those nominations, which numbered 300 this year, and also conducts independent research to shortlist about 50 top solution providers. A “distinguished panel” of CEOs, CIOs, VCs, and analysts, including the Healthcare Tech Outlook editorial board, selects the final “10 Most Promising Telemedicine Solution Providers 2017.”

Among the other telemedicine solutions featured in addition to EyePACS are: Analyze Health, integrating lab testing into telehealth ecosystems; Avedis, streamlining documentation and data collection; Corticare, a neurotelemetry company providing brain monitoring services; Great Lakes Neuro Technologies, pioneering innovation for patients with movement disorders;  Health Navigator, developing digital decision-support tools and clinical vocabularies; InnovaTel Telepsychiatry; Intellivisit, using artificial intelligence to connect people to care; Teledoc, providing on-demand care using a wide range of personal electronic devices; and WorldCare International, offering expert medical second opinions via hospital partnerships.  

Read about all top-ten providers here. Find the EyePACS article, featuring comments by EyePACS Director Dr. Jorge Cuadros, on page 24.

California Health Care Foundation Turns 20!

On May 8, 2017, the California Health Care Foundation (CHCF) celebrated twenty years as an organization dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. With this mission in mind, CHCF started the Innovations for the Underserved and Chronic Disease programs.  As part of these programs they provided substantial guidance and support to transform EyePACS into a service that has grown well beyond California. 

In 2005, CHCF funded EyePACS through a grant to UC Berkeley to improve the EyePACS software and develop a network of telemedicine-based diabetic retinopathy screening programs in the California Central Valley. Later that network was expanded  to the entire state. 

Four years later CHCF commissioned a thorough cost-benefit analysis of diabetic retinopathy screening; this analysis was used to pass California Assembly Bill 175, the first telemedicine bill of its kind in the United States. 

Always at the forefront of changes in health care, in 2015 CHCF launched the Diabetic Retinopathy Detection Challenge with EyePACS data and Kaggle, a data science network that conducted the competition to develop artificial intelligence for automatic reading of retinal images.

We thank CHCF for their amazing work, and we remian closely aligned with their efforts to provide innovations for the health and social benefit of all people with a focus on sustainability rather than on profit.  

Dr. Abraham Verghese, keynote speaker for the anniversary celebration, is pictured below. He is a best-selling author who writes about the doctor-patient connection. 

Below, EyePaCS Director Dr. Jorge Caudros poses with four of the fellows from the CHCF Leadership Fellowship, a network of doctors that lead healthcare organizations in California.

El Rio Succeeds by Doing What's Right

Several years ago, Dr. Marisa Rowen, pharmacist and diabetes educator at El Rio Community Health Center in Tucson, who serves as the associate pharmacy director of advanced practice services, was asked to explore options for improving the organization’s rate of diabetic retinopathy screening.  After some research, the decision was made to adopt a telemedicine approach, and the EyePACS DR screening system was chosen for the task.

Marisa Rowen, leading the diabetic retinopathy screening program at El Rio.

Marisa Rowen, leading the diabetic retinopathy screening program at El Rio.

El Rio serves more than 94,000 patients. Some of them have been members of this health center for more than 40 years. This is truly a patient-centered medical home, and it was for the benefit of the patients that Dr. Rowen and her colleagues adopted the EyePACS program. “At least 80% of our patients work two or more jobs,” she explained. “To pay a $40 co-pay is a great burden for some, and to have to make an additional appointment and take off work to be there is almost more than they can manage. Many of our patients also have limited transportation options. So we provide all their services right here, to the greatest extent possible. It was for the patients we added this program.”

Marisa explained that El Rio’s patients trust the health center to make the right choices for them. Adding a DR screening program in-house was not necessarily  what the staff needed, but it was what the patients needed. What was the secret to success? “Everyone in a leadership position here is mission driven – we live and breathe our cultural belief: 'Honor Patients - I always put the patients first.' Our CEO is an experienced nurse. The entire C-Suite bought into the new program. Our CCO sincerely wanted it, and the COO and CFO were completely on board.”

Passing along no cost to the patients, the health center board of directors approved the initial purchase of equipment, even though it was an unbudgeted capital expense. While they are still forming a long-term sustainability strategy, she added, “We went down this road because it was the right thing to do for patient care.” 

El Rio placed cameras in three of its eleven primary care clinics – the three with the highest diabetes rates and largest overall patient populations. In the first 12 months, all three clinics boosted their screening rates by 25-30%. El Pueblo moved from 25% to 50% of diabetic patients screened annually. Congress went from 32% to 65%. And Southwest improved its screening rate from 45% to 76%.

This is phenomenal success in such a short time. So what are the key characteristics of this program that have made it so successful? “Our program is 100% team based and embedded in the diabetes self-management education program executed by pharmacists and medical assistants,” Dr. Rowen explained. The El Rio diabetes self-management education program includes ten advanced practice pharmacists, medical assistants and a pharmacist residency program.

But pharmacists are certainly not the only ones invested in the success of this program. “Our providers, nursing staff and medical support staff are super-engaged,” she said. “Our referral clerks are very familiar with all the local providers, with whom we have long-standing relationships. They make smart referral decisions that really work in the patients’ best interests.”

El Rio also has University of Arizona public health interns who have enthusiastically joined in the effort. They developed three-minute “lobby talks” about the importance of DR screening and offer that education to waiting patients.

A Pharmacy Intern conducts a "Lobby Talk" to educate patients about diabetic retinopathy while they wait to see their provider.

A Pharmacy Intern conducts a "Lobby Talk" to educate patients about diabetic retinopathy while they wait to see their provider.

The health center originally trained 14 staff members to use the retinal camera, but five of them emerged as the core of the photographer cadre. “Our medical assistants are highly motivated and engaged,” Dr. Rowen said, and committed to the DR screening program for the long term. All five of this core team perform retinal imaging every day; the others help when they can. “Sometimes they feel overwhelmed,” she said, “but they are truly mission-driven. One individual MA performed 663 screens last year in addition to her other MA duties.”

At the Congress site, the camera sits in the suite where advanced practice pharmacists see patients (which makes sense for a pharmacist-driven program). The setup at El Pueblo is not ideal. There the camera has been placed in a treatment room in the adult medicine suite, which does sometimes present a logistical challenge. The team finally came up with a little sign that says “in use” so the photographers can be confident no one will open the door while they’re trying to capture retinal images in a dark space. At the Southwest location, a room was completely remodeled to accommodate the new camera.

Once the images are taken and uploaded to the EyePACS site, Marisa explained, then the magic really begins. “Often our reads come back the same day, and 98% are submitted to us within 24 hours. We actually get patients the results of their screening before they leave their diabetes care appointment in some cases,” she explained. “Sometimes EyePACS reads our images and sends us a report within an hour –before the patient has left the building!”

Although referrals for the recommended screening are routinely generated by the provider staff, diabetes patients at the other El Rio sites do not fare as well as do those at the three sites with digital retinal cameras. Asked to travel to El Pueblo, Congress or Southwest for their annual retinal screening, some of those patients never make the trip and never get screened. Consideration has been given to a mobile camera, traveling from site to site, but Dr. Rowen doesn’t favor that approach. “We’d be imposing our schedule on our patients,” she explained. “It’s best to have the camera here when the patients are able to come in for a primary care appointment.”

The financial situation, as challenging as it has been, has also seen some surprises, Dr. Rowen explained. “One payer, committed to screening for diabetic retinopathy, has actually offered us an agreement to reimburse El Rio for the cost of each EyePACS read for any patient of the plan - that is, an established El Rio patient, referred by the provider during the context of their primary care visit. Understanding that this is a very small step in the right direction for financial sustainability, it does not reflect nor recoup the cost incurred by El Rio to maintain this telemedicine approach to screening for diabetic retinopathy.”

El Rio, like many other FQHCs, is now part of an Accountable Care Organization (ACO). Dr. Rowen also gives credit to their ACO, Arizona Connected Care, for a great deal of support related to advertising and marketing within the ACO and partnering health centers. One of the ACO’s quality measures for 2016 was to increase DR screening. Part of the ACO’s support was to secure funding to intentionally provide standardized sensitivity training to staff, focused on engagement of health center nursing and referral staff to be developed and delivered by the ACO eye champions. The training was to be a meaningful experience that included background facts and information about DR, messaging and talking points when providing care to patients living with diabetes during the course of a routine clinic day, and paper “glasses” the staff could wear to experience vision as someone with diabetic retinopathy might see.

The project included gathering follow-up data about how this experience impacted the staff’s willingness and desire to engage in conversations related to screening for DR. The El Rio staff, surveyed later, rated the training as exceptionally helpful. From that training also came a clever little device that staff now proudly wear. It’s a button clipped onto their name badge lanyards saying “EYE care about diabetes; ask me why.” But they wear it upside down! When a patient mentions that the button is upside down the staff member says, “Thanks for telling me. That’s my cue to talk to you about the importance of having your eyes checked yearly for diabetic retinopathy!”

What’s the future for the El Rio DR screening program? “We’re building a new clinic in southcentral Tucson,” Dr. Rowen said. “Called Cherrybell, it will open in 2018. That clinic, will house some specialty services along with our DO medical students from A.T. Still University and medical residents from the Wright Center. It will have its own ‘EyePACS Program’ room, specially designed for digital retinal screening!”

Looks like more success ahead for folks who “just wanted to do the right thing.”