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.
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.”
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.
* 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.