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.”

Large-scale DR Screening Success Using EyePACS in Primary Care

The largest publicly operated county safety net public health system in the United States recently reported in JAMA Internal Medicine a reduction in median wait time to screening for diabetic retinopathy (DR) from 158 days to 17 days (an 89% reduction in wait time), and an increase in the rate of screening for patients diagnosed with diabetes from 57% to 69% (a 16.3% increase in screening rate). How was this accomplished? Through teleretinal diabetic retinopathy screening (TDRS) in 15 primary care clinics using the EyePACS system. By moving the DR screening into the primary care setting, more than 14,000 visits to specialty eye care practitioners  were eliminated, an important feature in a health care system with limited specialty care resources.

The study, conducted by the Los Angeles County Department of Health Services (LAC DHS) from September 1, 2013, to December 31, 2015, was reported by Dr. Lauren P. Daskivich and her associates at the LA County Health Department, UCLA, and Charles Drew University.   The Los Angeles County safety net serves more than 800,000 patients annually (64,000+ with diabetes), most of whom are underinsured or uninsured. Noting that only 60% of patients with diabetes in the US receive recommended annual eye examinations – that rate dropping to less than 25% in the safety net – the authors conclude that, “Teleretinal DR screening is well suited to solve the problems of the safety net because it increases access by screening through primary care rather than specialty care, improves efficiency by moving patients with normal retinal photographs out of the queue for appointments with specialty care professionals, and reduces wait times for those with treatable disease.”

“We implemented a TDRS program throughout 15 of the largest LAC DHS–operated primary care clinics. Our first clinic began screening in September 2013, followed by rolling expansion to all LAC DHS comprehensive health center primary care clinics, medical center primary care clinics, and multispecialty ambulatory care center primary care clinics by March 2015.” Fifty-eight existing certified medical assistants and licensed vocational nurses were trained and certified as fundus photographers; they uploaded patient images to the EyePACS system. DHS created a retinal photography clinic for which patients were scheduled in advance by their primary care professional or a care manager. “This method best uses the photographers’ time because they often perform other services,” the authors explain. Protocol also allowed for walk-in, same-day screenings.

“We mandate that photographers upload a minimum number of cases monthly to maintain certification, thereby maximizing the quality of the images. Image quality is also graded by our readers, and photographers who do not meet adequacy requirements in any three-month period undergo retraining.” Ten primary certified image readers, optometrists employed by the LAC DHS, read the screening photographs. Referrals for abnormal results were submitted via eConsult, a web-based referral system for specialty care, allowing for submission of screening results and scheduling of follow-up as needed. Based on screening results, patients were triaged into optometry or ophthalmology clinics.

“A key to the sustainability of our program is the integration of DR screening into primary care practices, treating it as a diagnostic test to establish a need for referral to specialty eye care. By eliminating the need for a separate visit to a specialist, we are able to increase the number of patients screened for DR without increasing demand on specialty care, which is critical in a system in which more than 3000 people are currently waiting for eye care appointments.” The report notes that this system also allows for better use of patients’ limited resources such as transportation and time off work.

The authors point out that the “education of all critical stakeholders and support of hospital, clinic, and health system leadership are essential… Eye care professionals fear that TDRS programs will decrease referrals for in-clinic visits. However, eye care professionals need to understand that improved rates of screening for DR and triage actually result in increased detection of patients with significant disease and therefore increased referrals of patients needing higher-level care.”

The conclusion? “With standardization and oversight, primary care–based teleretinal DR screening programs have the potential to maximize access and efficiency in the safety net, where the need for such programs is most critical. Our paradigm for implementation is a model for other urban safety net populations where the need for such programs is arguably the greatest.” The authors note, however, that, “although our TDRS program substantially reduced wait times to screening and improved rates of screening, more information is needed to demonstrate that patients who need treatment are actually receiving this care in an expedited fashion.”

Read the full report, with data tables and citations, here.

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.