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Service Delivery Innovation Profile

Remote Retinal Screening Facilitates Diagnosis and Treatment of Retinopathy for Poor and/or Uninsured Patients With Diabetes in Rural California

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During a 2-year study at 13 rural primary care clinics, diabetic retinal screening was provided to more than 12,000 patients in California's Central Valley, an area where many residents are poor and uninsured and might not ordinarily have access to this type of specialty care. As of July 2009, there have been 46,000 patient encounters in more than 120 sites. As of September 2011, there have been over 120,000 consults in 194 active clinic sites. The program used a model of service delivery that relied on new user-friendly, open-source software for managing digital retinal images. The pilot resulted in significant increases in screening rates, the identification of retinopathy in one-half of patients, and referrals for followup care for 15 percent of patients.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation data on screening rates from 2 of the 13 clinics, along with post-implementation data from all the clinics on the results of the screenings.
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Developing Organizations

University of California Berkeley
School of Optometryend do

Use By Other Organizations

In addition to the California clinics, EyePACS has been used by many other organizations in Canada, Mexico, and 10 other states in the United States. The Veterans Administration has also been a leader in the use of remote retinal imaging screening.

Date First Implemented

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Patient Population

Race and Ethnicity > Hispanic/latino-latina; Vulnerable Populations > Rural populationsend pp

Problem Addressed

Diabetes is the leading preventable cause of blindness in adults aged 20 to 74 years,1 yet many patients in rural, inner city, or other underserved areas do not receive annual retinopathy screening as recommended.2 Telemedicine offers the opportunity to provide remote screening to these populations, but the high costs and other operational barriers associated with traditional telemedicine systems make the sharing of high-quality digital images impractical, especially in low-resource settings.
  • Blindness a major problem among diabetes patients: Diabetes is the leading cause of new cases of blindness among adults aged 20 to 74 years; diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year.3
  • Retinopathy screenings can prevent blindness, but often do not occur: Evidence indicates that patients without diabetic retinopathy who receive systematic screening have a 95 percent probability of remaining free of sight-threatening retinopathy over the next 5 years4; however, it is estimated that only about one-half of all U.S. diabetic patients receive the recommended annual screening for diabetic retinopathy.5
  • Remote screening through traditional vehicles often not possible, due to quality and cost issues:
    • Problems with using e-mail: Although the cost of e-mail tends to be low, the size of high-quality digital image attachments may be too large to be accepted by many e-mail proprietors, and the images can take a long time to download. In addition, the information can be difficult to track once downloaded, and comments and findings may not be permanently recorded.6 Finally, available imaging processing tools may limit the specificity of ocular images.7
    • Problems with electronic medical records (EMRs) and picture archive communication (PAC) systems: EMRs and PACs have not been used extensively in outpatient settings due to high costs and the proprietary nature of many of these systems. In addition, EMRs and PACs are not universally interoperable, limiting communication between providers who work in different systems, particularly those in small private practices.6

What They Did

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Description of the Innovative Activity

The program was piloted in 13 primary care safety net clinics in rural areas of California's Central Valley and has now been made available to any diabetes clinics in California. The region where the program was piloted has many low-income and/or uninsured diabetes patients who lack a regular source of care. The innovators trained local staff to use new Web-based, user-friendly, open-source software for capturing and sending high-resolution digital ocular images. The system has been integrated into the clinical workflow in these rural clinics, where clinicians use it as follows:
  • Patient recruitment: Clinicians (often medical assistants) recommend remote retinopathy screening to those patients with diabetes who are due for a screening during the clinic visit.
  • Creating and loading the ocular image: For patients who are interested in the screening, the clinician photographs the patient's eyes using a high-resolution retinal imaging camera. Typical images are of the anterior eye and retinal fundus. The clinician can access the Eye Picture Archive Communication System (EyePACS) through any computer with Internet access, and then download the images from the camera to the computer. Images can also be downloaded from other diagnostic instruments (e.g., a visual field test, topography) or an EMR.
  • Preparing the case for review: The clinician creates a patient case in the Web browser, with key facts entered into free-text fields; to protect privacy, only nonidentifying patient information is included. A separate field (known as the "clinical question" field) allows the local clinician to highlight key topics or issues for consideration by the reviewing physician. Thumbnail links to full-size digital images are included on the case presentation page. The compressed image of the data is uploaded to the system server. Once the images and text have been uploaded, an e-mail is sent informing the reviewer that a case has been posted to the system for review. Cases can be marked for public viewing by all system users or marked "private" to allow access only by an authorized viewer. Interesting or unusual cases may be added to the "eye gallery," a collection of cases for general reference.
  • Specialist review: Specialists at University of California Berkeley (UC Berkeley) read the digital images and provide diagnoses. After the specialist reviews the case and responds, an e-mail is automatically sent back to the initiating clinician noting that a response has been posted.
  • Postreview followup, referral, and patient education: Once the review comes back, those patients who are identified as having retinopathy are contacted and referred for appropriate followup care. The primary care clinicians also use the retinal images and the specialist's review to educate patients and engage them in the self-management of their diabetes, including appropriate steps to prevent deterioration in the health of their eyes.
  • Certification: Formal certification and quality assurance programs have been instituted for retinal photographers and retinal consultants. In addition, certification program for primary care providers and diabetes educators has been created to allow site clinicians to use retinal images for their own assessment of patients' microvascular status and also for patient education.

Context of the Innovation

The innovator recognized the critical need to provide better eye care access to the hundreds of thousands of uninsured farm workers in California. He saw how computer technology and optometry could converge to help patients who were struggling with the traditional health care system. He targeted the Central Valley because Latinos, along with Asians and African Americans, are predisposed to retinopathy—a sight-threatening disease related to diabetes—and glaucoma. This interest fit well with the goals of the California Health Care Foundation, an independent, philanthropic organization committed to improving the delivery and financing of health care to California citizens.

Did It Work?

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A pilot study in 13 primary care, safety net clinics found that the system increased the rate of retinopathy screening in diabetes patients, leading to the diagnosis of some level of retinopathy in one-half of screened patient, and the referral of 15 percent of patients (two-thirds of whom faced sight-threatening conditions) for followup specialty care. Based on the success of this pilot, the program is being expanded significantly to serve low-income, uninsured individuals with diabetes throughout California. As of July 2009, the EyePACS program has recorded more than 46,000 patient encounters at more than 120 sites. As of September 2011, there have been over 120,000 consults at 194 active clinic sites.
  • Increased screening rates: During the pilot test, the system was used to screen more than 12,000 patients. Two of the 13 clinics could quantify their pre-implementation screening rate, and both of these reported significant increases in screening (from 7 to 26 percent of all diabetes patients in one clinic, and from 25 to 100 percent of diabetes patients in the other). Although the remaining clinics could not quantify their pre-implementation screening rate, anecdotal reports from these clinics suggest significantly improved screening as well.
  • Increased detection of retinopathy and referrals to needed care: One-half of screened patients were diagnosed with some level of retinopathy, with approximately 15 percent requiring referrals (two-thirds for sight-threatening retinopathy and one-third for other eye conditions). Of the patients referred for sight-threatening retinopathy, approximately 25 percent had never had an eye examination, suggesting that these patients would have fallen through the cracks in the absence of the system.
  • Success leads to significant program expansion: In the fall of 2007, the California Health Care Foundation approved the spending of $1.8 million to expand the project for use in roughly 100 safety net and rural clinics across California that serve approximately 100,000 patients. Approximately 50 cameras were provided to clinics that could screen a minimum of 1,000 patients annually. Forty-three other clinics acquired their own cameras to participate in the EyePACS program.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation data on screening rates from 2 of the 13 clinics, along with post-implementation data from all the clinics on the results of the screenings.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Getting support from clinic administrators: California Health Care Foundation and representatives from UC Berkeley introduced the program to clinic administrators to educate them on the purpose of the initiative and obtain their support.
  • Initial funding of pilot: The foundation provided funding to purchase 13 cameras and to pay specialists at UC Berkeley to interpret the digital images and provide a diagnosis during a 2-year pilot test.
  • System setup: Staff members from UC Berkeley set up the cameras and the software system at the participating clinics.
  • Certification and training: Staff members from UC Berkeley led a 1-day program in which medical assistants and/or primary care physicians at each of the clinic sites were trained to use the camera; the session included 2 hours of hands-on training and 6 hours of practice.

Resources Used and Skills Needed

  • Staffing: The program requires no incremental staff, although staff must have a general facility with computers.
  • Costs: Each camera cost approximately $20,000 each (although costs could decline to $2,000 to $3,000 over the next 5 years). Other potential costs include providing Internet access to clinic sites and running the 1-day training program.
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Funding Sources

University of California Berkeley; California Healthcare Foundation; California Telemedicine and eHealth Center
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Adoption Considerations

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Getting Started with This Innovation

  • Ensure adequate funding for the cameras, which are currently quite expensive (although costs should decline over time).
  • Before getting started, ensure that the software will be able to link with existing EMR and diabetes registry (if any).
  • Convince clinic administrators and physicians to participate by highlighting the quality of care benefits of retinopathy screening.

Sustaining This Innovation

  • This innovation is easier to sustain if third-party reimbursement from insurance companies is available.
  • Develop a network of providers to serve those screened patients who need followup care. For remote retinal imaging to have a meaningful impact, patients in need of followup eye care must have access to it. Many low-income and/or uninsured patients in underserved areas may not have ready access to specialty eye care.

Use By Other Organizations

In addition to the California clinics, EyePACS has been used by many other organizations in Canada, Mexico, and 10 other states in the United States. The Veterans Administration has also been a leader in the use of remote retinal imaging screening.

Additional Considerations

  • Organizational barriers (e.g., administrative buy-in and clinician willingness to absorb additional duties) are much more problematic than technological barriers.
  • Remote retinal imaging is only one way to bring specialty eye care into the rural primary care setting; thanks to their experiences with this project, the participating providers are beginning to think about strategies for preventing blindness from glaucoma, macular degeneration, and a host of other eye problems that typically are addressed only in the ophthalmologist’s office.
  • Screening for sight-threatening diabetic eye disease is a primary care task. EyePACS has begun to train and certify primary care providers to interpret retinal images for the purpose of more immediate and effective triage of their own patients.

More Information

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Contact the Innovator

Jorge Cuadros, OD, PhD
University of California
Optometric Eye Center
Berkeley, CA 94720

Innovator Disclosures

Dr. Cuadros has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile

References/Related Articles

Cuadros J, Sim I. EyePACS: an open source clinical communication system for eye care. Proceedings of the 11th Congress on Medical Informatics; Sept. 2004. pp. 207-12.

Cavellerano J, Bursell S-E, Aiello LM. Validated telemedicine for diabetic retinopathy. Retinal Physician. 2001 Oct;56-73.

Cuadros J, Bresnick G. EyePACS: an adaptable telemedicine system for diabetic retinopathy screening. J Diabetes Sci Technol. 2009;3(3):509-16. [PubMed]

Resources for Diabetic Retinopathy Screening with EyePACS Web site. Also, includes EyePACS Handbook. Available at:


1 American Diabetes Association. Diabetes statistics. Available at:
2 Fong DS, Aiello L, Gardner TW, et al. Diabetic retinopathy. Diabetes Care. 2003;26:S99-102. [PubMed] Available at:
3 National Diabetes Information Clearinghouse. National Diabetes Statistics, for the most recent statistics visit:
4 Tubbs CG, Safeek A, Mayo HG, et al. Clinical inquiries. Do routine eye exams reduce occurrence of blindness from type 2 diabetes? J Fam Pract. 2004;53(9):732-4. [PubMed] Available at:
5 Taylor CR, Merin LM, Salunga AM, et al. Improving diabetic retinopathy screening ratios using telemedicine-based digital retinal imaging technology: the Vine Hill study. Diabetes Care. 2007;30(3):574-8. [PubMed] Available at:
6 Cuadros J, Sim I. EyePACS: an open source clinical communication system for eye care. Stud Health Technol Inform; 2004; 107(Pt1): 207-11. [PubMed]
7 Low Complexity, Adaptable, Image-Capable Inter-Clinician Communication. EyePACS [doctoral thesis]. Available at:
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: May 26, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 30, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: July 17, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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