Overview

A team at the University of Virginia utilized a retina-imaging device for screening coupled with workflows for ophthalmologists to remotely review and manage detected pathology to improve diabetic retinopathy screening.

Organization Name

University of Virginia

Organization Type

• Academic Medical Center

National/Policy Context

• Nationally, diabetic retinopathy is the leading cause of blindness in non-elderly adults. 
• Many patients with diabetes do not undergo the recommended yearly eye exam. 
• Screening can help detect diabetic retinopathy earlier, which can decrease long-term morbidity.

Local/Organizational Context

• At University Medical Associates (UMA), which is a primary care practice within UVA’s health system, many patients with diabetes are uninsured and face significant barriers in accessing regular screening and appointments with ophthalmologists.

Patient Population Served and Payor Information

• The pilot site for this project had a high proportion of uninsured patients with diabetes.

Leadership

• A primary care champion was required for the early success of this project.

Funding

• The project was supported by outside grants and other funding opportunities.

Research + Planning

• Prior to initiation of the project, it was necessary to identify a pilot clinic.

Tools or Products Developed

eConsult technology: Mechanism of exchanging information between providers within the electronic medical record – a digitization of the standard specialist consult. This technology was adapted to be used in this intervention.

Training

• Nurses in primary care settings received training to use the Remidio device, a smartphone attachment with a fundus camera, to image the retina.
• Physicians, including primary care and ophthalmologists, may have received training on the eConsults system in order to properly transmit the retinal images and to view them remotely

Tech Involved

• eConsult/eReferral
• Electronic medical record
• Fundus camera
• Smartphone

Team Members Involved

• Physicians
• RNs

Workflow Steps

• A patient with diabetes enters the clinic.
• A PCP confirms the need for screening, recommends screening for the patient, and obtains consent from the patient for the screening.
• A nurse images the patient’s eyes using the Remidio device. 
• The images are uploaded into the EHR. 
• An eConsult is created within the EHR. 
• The consulted ophthalmologist reviews the images and acts on it accordingly, providing the interpretation back to the PCP. 
  • Certain results may demand that the patient receive a follow-up appointment with an ophthalmologist.

Budget Details

• Costs of purchasing and maintaining the Remidio devices
• Labor costs associated with additional time spent by nurses to screen patients
• Labor costs associated with additional time spent on training for nurses and physicians

Outcomes

• Percent of eligible patients with diabetes who receive annual diabetic retinopathy screening.
• Turnaround time of image review and interpretation.
• Percentage of abnormal findings / patient screened.

Future Outcomes

• The level of acuity that such a system can support may be investigated in the future. 
• In its current form, it is used for screening in a chronic care management setting, but could potentially be adapted for use in acute presentations of ophthalmologic emergencies to emergency departments that do not have 24/7 access to ophthalmology consult.

Benefits

• Potential benefits include greater access to screening for diabetic retinopathy in patients with poor access to care and improved communication between ophthalmologists and PCPs.
• Ideally, this would also lead to better outcomes for patients with diabetes, specifically lower rates of blindness secondary to diabetic retinopathy.

Unique Challenges

• Possible consequences of disrupting complicated clinic workflows in the primary care setting because of the new screening task
• Obtaining the necessary buy-in from nurses and ophthalmologists to make the platform function efficiently
• Ensuring a minimum standard of image quality

Glossary

Remidio Fundus on Phone camera: smartphone-enabled retinal imaging system

Sources

• Dowdell, K., Collins, S., Cotter, K., Dirghangi, A., & Helenius, I. (2019 March). A New Vision for Diabetic Retinopathy: Facilitating Screenings Using Ophthalmology eConsults. Poster session presented at the Society of General Internal Medicine Annual Meeting, Washington, D.C., United States.
• Common Eye Disorders. (2015, September 29). Retrieved from https://www.cdc.gov/visionhealth/basics/ced/index.html
• NM Fundus On Phone (NMFOP). (n.d.). Retrieved from https://www.remidio.us/fop.php