SummaryCommunity Health Center, Inc., Connecticut's largest federally qualified health center with 13 primary care sites and more than 200 service locations, developed a comprehensive annual visit for patients with diabetes that includes retinal screening enabled by telemedicine technology. Using specially designed retinal imaging equipment, trained medical assistants take digital images and send them electronically for evaluation by Yale Eye Center. Community Health Center, Inc. pays the ophthalmologists a flat fee to provide this service, and these ophthalmologists also offer followup and in-person care as needed to those unable to get such care locally. The program has enhanced access to retinal screenings, reduced costs, and increased patient convenience and satisfaction. These successes have led the Connecticut legislature to authorize a demonstration project under which the State Medicaid program will reimburse for health care delivered via telemedicine (something it has not previously done).Moderate: The evidence consists of pre- and post-implementation comparisons of various metrics, including the proportion of patients with diabetes referred for retinal screening, the proportion receiving such screening, and the costs of screening, along with post-implementation anecdotal reports from patients served by the program.
Developing OrganizationsCommunity Health Center, Inc., Middletown, CT
Date First Implemented2009
Patient PopulationApproximately 65 percent of CHCI's patients receive Medicaid benefits. Twenty percent are uninsured. More than 60 percent of CHCI patients are racial/ethnic minorities.Vulnerable Populations > Impoverished; Insurance Status > Medicaid; Vulnerable Populations > Medically uninsured; Racial minorities
Problem AddressedDiabetic retinopathy—detachment of the retina caused by tiny hemorrhages in the eyes of people with diabetes—is the leading cause of new cases of blindness among adults in the United States, and the incidence of the disease and disease-induced blindness is likely to grow in the future. Minority patients face a higher-than-average risk of diabetic retinopathy and are more likely to become blind because of it. Although regular eye examinations and prompt treatment can prevent retinopathy-induced blindness, many patients do not receive such care, especially the uninsured and those covered by Medicaid. Telemedicine may offer a low-cost, effective way to perform eye examinations on these patients, but few providers offer this service.
- Major, growing cause of blindness, especially among minorities: Nearly one-fourth of patients with diabetes older than 40 years have diabetic retinopathy, and more than 60 percent of those with type 2 diabetes will develop it within 20 years of diagnosis. Recent evidence shows that retinal damage may begin to occur much earlier in the disease's progression than previously thought. As the incidence of diabetes continues to grow, diabetic retinopathy will become even more prevalent.1 The prevalence of retinopathy tends to be higher among blacks and Hispanics than whites, and among those with the condition, minorities face up to twice the risk of becoming blind.2
- Low screening rates, especially in low-income populations: Diabetic retinopathy shows no overt symptoms until irreparable vision damage occurs. However, early detection and treatment can prevent blindness and diminished eye sight, and current guidelines call for all patients with diabetes to receive regular eye examinations to screen for the condition. Nationally, approximately one-half of patients with diabetes receive these examinations. However, in some areas, there are not enough ophthalmologists to serve the growing number of diabetic patients, especially those on Medicaid or without insurance. Screening rates among these populations tend to be much lower.3 In 2009, only approximately 10 percent of Community Health Center, Inc.'s (CHCI's) 3,900 patients with diabetes were up to date on retinal screenings. Staff identified access to specialty care as a major obstacle to increasing these screening rates.
- Unrealized potential of telemedicine: Telemedicine may offer a solution, allowing specialists to evaluate retinal images and accurately diagnose eye disease remotely. However, reimbursement rules, scope of practice, and other regulations present obstacles to full use of this technology, and consequently few providers offer it at this time.
Description of the Innovative ActivityCHCI developed a comprehensive annual visit for patients with diabetes that includes retinal screening enabled by telemedicine technology. Using specially designed retinal imaging equipment, trained medical assistants take digital images and send them electronically for evaluation by ophthalmologists at Yale Eye Center. CHCI pays these ophthalmologists a flat fee for this service, and these specialists also offer followup in-person care as needed to those who cannot receive it locally. Key program elements are detailed below:
- Integration of screening into comprehensive annual visit: CHCI offers patients with diabetes an annual visit that provides a wide range of evidence-based services for diabetes care, including retinal screenings via telemedicine. In addition to the retinal screening, the visit includes nurse-delivered patient education and setting of goals for self-management of the condition, foot examinations, appropriate laboratory tests, and administration of missing vaccinations. CHCI bills Medicaid (or other insurer) for the comprehensive visit, but not for the telemedicine component. Uninsured patients pay a nominal fee for the comprehensive examination, including retinopathy screening.
- Telemedicine-based retinal screening: During the comprehensive visit, patients receive a complete retinal screening examination, with digital images taken in the clinic and interpretation occurring by ophthalmologists elsewhere in the state.
- Digital imaging: Specially trained medical assistants at the health center take digital images of the retina using a nonmydriatic fundus camera.
- Transmission via secure server: These images and relevant clinical information are transmitted to the Yale Eye Center via EyePACS®, a secure Web-based store and forward picture archiving and communication system developed in 2001 and first implemented by the University of California at Berkeley's Optometric Eye Center in 2003.
- Remote interpretation by ophthalmologists: Retinal specialists at Yale Eye Center access the files, evaluate the images, make a diagnosis, and develop recommendations for any needed treatment or followup. The specialty consultation is completed in EyePACS® and retrieved by CHCI primary care providers within 48 to 72 hours. CHCI pays the ophthalmologists a flat fee for this service.
- Followup care as needed: CHCI primary care providers refer patients in need of in-person followup care to a local ophthalmologist. If one is not available, the Yale Eye Center sees the patient. To date, only approximately 13 percent of those screened have required followup care from an ophthalmologist.
- Plans for more targeted outreach: Going forward, CHCI plans to conduct more targeted outreach to those at greater risk of diabetic retinopathy, with the goal of ensuring they come in for their annual screening. Based on a multivariate analysis of multiple demographic and clinical variables, CHCI has identified certain patient characteristics that increase the risk, including having had diabetes for a long time (as measured by number of years since diagnosis), the presence of kidney disease, use of insulin, and higher hemoglobin A1C levels.2CHCI prioritizes patients for retinal screening through clinical decision support processes based on these findings.
References/Related ArticlesLi Z, Wu C, Olayiwola JN, et al. Telemedicine-based digital retinal imaging vs standard ophthalmologic evaluation for the assessment of diabetic retinopathy. Conn Med. 2012;76(2):85-90. [PubMed]
Olayiwola JN, Sobieraj D, Kulowski K, et al. Predictors of diabetic retinopathy in a community health center population. Dia Spect. 2011;24(4):218-23. Available at: http://spectrum.diabetesjournals.org/content/24/4/218.abstract.
Olayiwola JN, Sobieraj DM, Kulowski K, et al. Improving diabetic retinopathy screening through a statewide telemedicine program at a large federally qualified health center. J Health Care Poor Underserved. 2011;22(3):804-16. [PubMed]
Contact the InnovatorJ. Nwando Olayiwola, MD, MPH, FAAFP
Chief Medical Officer
Community Health Center, Inc.
635 Main Street
Middletown, CT 06457
Innovator DisclosuresDr. Olayiwola reported having no financial or business/professional relationships relevant to the work described in this profile.
ResultsThe program has enhanced access to retinal screenings, reduced costs, and increased patient convenience and satisfaction. These successes have led the Connecticut legislature to authorize a demonstration project under which Medicaid will reimburse for remote interpretation of ophthalmologic images.
Moderate: The evidence consists of pre- and post-implementation comparisons of various metrics, including the proportion of patients with diabetes referred for retinal screening, the proportion receiving such screening, and the costs of screening, along with post-implementation anecdotal reports from patients served by the program.
- Enhanced access to screening: In 2008 to 2009, primary care providers referred 18 percent of diabetic patients for retinal screening. In 2012, 63 percent of diabetic patients received a referral. Similarly, the percentage of diabetic patients who actually receive the examination has also increased from 10 to 12 percent in 2008 to 2009 to 45 percent in 2012, a level that now approaches the national average. (In addition to implementing this program, CHCI simultaneously developed and strengthened additional quality improvement programs—including ongoing provider and patient education, clinical decision support, performance monitoring, and streamlined referral processes—that have contributed to these outcomes.)
- Lower costs:The total cost of a telemedicine-based examination averages roughly $50 per patient, compared to $77.80 for a traditional in-person examination, yielding a net savings of roughly $28 per patient.3
- Higher patient satisfaction: Anecdotal reports from patients show that they prefer to be screened via telemedicine rather than in person at an ophthalmologist's office. Factors driving this preference include greater familiarity with the facility and staff, fewer transportation issues (since all CHCI sites are easily accessible via bus), the ability to get all needed services done in one visit (not just the eye examination), and the availability of interpreter services at the clinic. In addition, CHCI uses a sliding fee scale for uninsured patients for most services and charges them a nominal flat fee for the comprehensive diabetic examination with retinal screening. Some patients have indicated they are more likely to get future examinations because they are easier to obtain via telemedicine.
- Legislative authorization of reimbursement: As a result of the positive impact of this program (including but not limited to the enhanced access and the documented cost savings), the Connecticut legislature passed a bill in 2012 authorizing a demonstration project in which Medicaid will reimburse for health care services delivered via telemedicine technology. As of May 2013, this project had not yet been funded.
Context of the InnovationFounded in 1972, CHCI is the largest federally qualified health center in Connecticut, operating more than 200 service locations and 13 primary care sites throughout the state. CHCI serves more than 130,000 patients, roughly 60 percent of whom are covered by Medicaid and one-fourth of whom are uninsured. Nearly all CHCI patients live below the Federal poverty level, and nearly two-thirds (65 percent) are racial or ethnic minorities. CHCI operates within the state's health care system, which is built around town-based (rather than county-based) public health departments. As a result, services tend to be highly concentrated in some areas but largely unavailable in others. This disparity tends to be worse for specialist care, making it difficult for some residents (especially those on Medicaid or without insurance) to access such care.
The impetus for this program began in 2006, when CHCI switched to electronic health records and began using the resulting information to track quality and identify opportunities for improvement. As part of this effort, CHCI leaders discovered in 2009 that only approximately 1 in 10 patients with diabetes was up-to-date on retinal screenings. CHCI leaders looked at various potential strategies to improve screening rates, including bringing specialists to primary care sites and providing patients with transportation to the ophthalmologist's office. Neither solution could easily be scaled to serve CHCI’s 200 service locations and 13 primary care sites. As a result, the leaders decided to investigate the potential of telemedicine to allow patients to be screened at CHCI sites.
Planning and Development Process
Key steps included the following:
- Choosing telemedicine system: CHCI staff evaluated various systems and ultimately chose EyePACS®, developed by Drs. Jorge Cuadros and Wyatt Tellis in 2001 and first implemented by University of California Berkeley Optometric Eye Center in 2003.
- Choosing ophthalmology partner: The initial plan called for University of California Berkeley–based ophthalmologists to interpret the images, but they were not licensed to practice medicine in Connecticut. Instead, CHCI decided to partner with Yale Eye Center in New Haven, which offered the added benefit of being within driving distance and hence could serve patients in need of followup care unable to access it locally.
- Negotiating terms with partner: CHCI negotiated directly with Yale Eye Center to pay a flat fee per patient for remote interpretation of the images. Yale Eye Center agreed to supply results within 48 to 72 hours and to provide any necessary followup care for patients who could not find in-person care closer to home.
- Forming multidisciplinary team to develop protocols: CHCI's Chief Medical Officer, Dr. Olayiwola, led a multidisciplinary team that included staff from medicine, information technology, practice operations, nursing, and risk management. Over a 10- to 12-month period, this team developed protocols, policies, and templates for the program, including those related to training the medical assistants and to timeliness of care. In performing this work, the team was cognizant of the need to set up data collection and analysis systems that would allow for evaluation of the program's impact, with the goal of proving to policymakers that telemedicine can enhance access and save money as compared to traditional in-person screening.
- Training and credentialing of medical assistants and nurses: Using the EyePACS®-recommended training procedures, CHCI trains its own medical assistants internally. Training consists of 2 to 3 days of didactic, practical, and technical training by the program manager or an experienced medical assistant. Medical assistants who successfully complete test cases and an online examination receive credentials from EyePACS® as a certified camera operator. CHCI also trained nurses to provide the comprehensive nursing visit, including special instruction on delivering patient education and assisting patients with setting self-management goals.
Resources Used and Skills Needed
- Staff: As noted, specially trained medical assistants perform the examination at each CHCI site, whereas an ophthalmologist at Yale Eye Center interprets the images remotely. No new staff were hired for this program, but existing staff received additional training and certifications to perform the examinations. As noted earlier, members of the multidisciplinary team and CHCI's Chief Medical Officer spent time during the development phase putting together program-related protocols and policies, including the training of the medical assistants and nurses.
- Costs: CHCI initially purchased 1 retinal camera and associated supplies for approximately $20,000, and that unit traveled among multiple sites. Within the first year, CHCI received a grant to cover the cost of a second camera, and in late 2012, the organization purchased three additional cameras at one-half the price of the original equipment. Ongoing operating expenses consist primarily of staff training, transport of the equipment among the different CHCI sites, and fees paid to Yale Eye Center for interpretation.
Funding SourcesCommunity Health Center, Inc., Middletown, CT; Frank Loomis Palmer Fund
CHCI covered the initial investment in the cameras and computer hardware and software. The Frank Loomis Palmer Fund contributed the funds for one camera to extend the program to the New London area of Connecticut. As noted, Medicaid does not currently pay for the remote interpretation of retinal images. However, CHCI bills Medicaid or private insurance for the comprehensive diabetes examination. Uninsured patients pay a nominal fee for the examination. Although there had been movement within Connecticut to pass legislation to allow for reimbursement of telemedicine-based services in 2009, this bill did not make it to the House of Delegates for consideration. As noted, the legislature recently authorized a demonstration project in which Medicaid will pay for such services, but it has not yet been funded.
Tools and Other ResourcesInformation about the EyePACS® system is available at: www.eyepacs.com.
Getting Started with This Innovation
- Design project to document effectiveness: Many public and private insurers do not yet reimburse for healthcare services rendered via telemedicine. Consequently, new programs should be designed to enable the collection and analysis of all data needed to evaluate their impact on access, costs, and other key metrics of importance to public and private stakeholders, including payers and policymakers.
- Start small, then scale up: CHCI started by purchasing a single camera that was shared among sites. Once it became clear that the program produced positive benefits (better access and lower costs), program leaders purchased additional cameras so that the exam could be offered more days per week at each site.
Sustaining This Innovation
- Monitor and report on program impact to help secure reimbursement: CHCI's Chief Medical Officer and other researchers involved in the project have published at least three papers in response to questions that have come up during efforts to secure reimbursement for telemedicine. These papers have reported on the prevalence of diabetic retinopathy in the target patient population, the characteristics of those most at risk for the disease, and the impact of the program on access to and the costs of retinal screenings.
- Prioritize resources based on risk profile: CHCI’s analysis of demographic and clinical variables associated with higher risk of diabetic retinopathy may help organizations with similar demographics prioritize resources and target outreach to patients at highest risk.
- Provide ongoing structural support for the program: To sustain and expand the reach of this program, CHCI has integrated retinal screening and comprehensive diabetes examinations into its metrics for quality improvement. For example, CHCI has added retinal screening to its performance appraisals, which are completed annually for medical providers and as part of the clinical expectations for providers, nurses, and medical assistants. Standardized templates in the EHR reinforce the inclusion of retinal screening and comprehensive diabetes examinations for all patients with the condition. Retinal screening is also one of the metrics on CHCI’s Diabetes Clinical Dashboard, which is updated daily on the organization’s intranet. New providers, nurses, and medical assistants receive training in retinal screening and the comprehensive diabetes examination as part of CHCI’s orientation. This ongoing training and support ensures that the program will continue to reach more patients.
- Maintain good working relationships with partners: CHCI regularly communicates with the Yale Eye Center and EyePACS® staff to share findings and encourage good relations.
- Work with government entities to encourage reimbursement for telemedicine: CHCI has also worked with the Health Resources and Services Administration on a scope change to its health center grant to accommodate services delivered via telemedicine. The organization also continues to work with Connecticut’s Medicaid administrator (Department of Social Services) to recognize and reimburse for telemedicine.
Li Z, Wu C, Olayiwola JN, et al. Telemedicine-based digital retinal imaging vs standard ophthalmologic evaluation for the assessment of diabetic retinopathy. Conn Med. 2012;76(2):85-90. [PubMed]
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Service Delivery Innovation Profile
Original publication: July 17, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: July 17, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.