Let’s Focus on the Clinic’s Blind Spots

 Kathryn E. Bouskill, RAND Corporation, lead researcher and author

Kathryn E. Bouskill, RAND Corporation, lead researcher and author

“Despite noteworthy progress in detecting diabetic retinopathy and access to DR screening, telemedical screening adds additional burdens to medical staff that should be addressed to strengthen the potential of such platforms.” So concludes a recent study by EyePACS at three unnamed Federally Qualified Health Centers in California. Citing “additional burdens to medical staff” that leave “frontline staff in the uncomfortable position of having to witness inequality and resource constraints without the ability to systematically address them,” the study investigates “workarounds” within the clinics and their impact on staff and patients. (The Cambridge Dictionary defines “workaround” as “a way of dealing with a problem or making something work despite the problem, without completely solving it.)

Researchers found that Medical Assistants, who are primarily tasked with implementing the telemedicine DR screening program, take the “squeeze approach” to fit in extra tasks. They tend to come up with innovative practices to ensure that screenings and appropriate follow-through occur, “working in ways for which a technology, power structure, or knowledge system are not designed.” EyePACS found these workarounds helped complete necessary tasks, but they also created “benevolent dissonance... an overstepping of boundaries and disruption of proscribed workflows, not to be self-serving, but rather to provide care for this population with complex medical needs.”

And workarounds were discovered not just in the primary care clinics; ophthalmologists were also found to have created workarounds to address the steady flood of diabetes patients with vision-threatening diabetic retinopathy (VTDR). Eye specialists find themselves educating patients about diabetes management in general and stepping beyond workflows in order to see patients whose telemedicine referrals indicate urgency. One doctor even stored various retinal images on his personal cell phone so he could show patients the development of retinopathy and the value of treatment. A positive upshot of this discovery of physician workarounds is the recognition of the need to include ophthalmologists in designing the communication strategies and materials on proper diabetes management.

What is the solution to this inveterate demand for workarounds that can negatively impact clinic staff and sometimes even negatively impact patients? “Ideally, the implementation of telemedical screening platforms would begin with a participatory, iterative, co-design framework that takes into account staff needs and functions at the front line in order to understand and optimize new workflows,” the report concludes. “This work can be time-consuming up front and potentially be seen as burdensome to staff who must both participate in the co-design, as well as allow for the presence of researchers in the clinic.”

We urge all clinics who have implemented the EyePACS system to read the full article here. Please contact EyePACS if you have (a) Designed and implemented such a “participatory, iterative, co-design framework” to optimize new workflows for your telemedicine program, or (b) You have created and tested useful solutions that preclude the need for some workarounds.