Contexts of Care Paper: Modules One and Two
Yale School of Nursing
October 9, 2011
Part One: Memo to Veronica Nieva, PhD
I write to you regarding the innovation profile, “Remote Retinal Screening Facilitates Diagnosis and Treatment of Retinopathy for Poor and/or Uninsured Patients With Diabetes in Rural California,” which describes the Eye Picture Archive Communication System (EyePACS) developed by the University of California Berkeley School of Optometry. Implemented in 2005, this practice innovation has an evidence rating of “moderate” based on pre- and post-implementation data on screening for retinopathy.
My interest in this innovation stems from my experiences as an advanced practice nursing student. I am currently pursuing an MSN at Yale School of Nursing in the Family Nurse Practitioner track with additional coursework in the diabetes specialty. Outside of class, I coach strength and conditioning classes, and as a future primary care provider, I hope to promote fitness and physical activity as cornerstones of wellness for my patients. I expect that over my career I will see many patients with diabetes, and preventing blindness and other complications of diabetes will be crucial to helping these patients maintain active lives. Prior to nursing school, I worked as a backpacking guide in Alaska, and I hope to return to a very rural practice setting after I graduate this Spring. For this reason, I took particular interest in this “Remote Retinal Screening” innovation, which expands the screening services for diabetic patients that can be provided by rural primary care offices.
Even in an urban, diabetes-specific practice setting, I have observed the need for patient alternatives to ophthalmology appointments. One of my clinical sites is a hospital-based diabetes center, where I conduct routine chronic care visits for patients with diabetes. While this diabetes center provides education, nutritional consultations, and even an on-site gym, patients are still referred out for retinopathy screening. Although the American Diabetes Association (ADA) recommends annual ophthalmic or optometric examination, many of the patients I see have not had their eyes examined within the past year. At a prior clinical site of mine, a private suburban family practice, patients with diabetes frequently reported that they had not seen an eye doctor in years, citing insurance or co-pay concerns, as well as time and travel constraints. In rural areas, where ophthalmologists are scarce, compliance with standards of diabetic eye care may be even more difficult.
As I examine my patients' eyes with an ophthalmoscope, I remind patients that ophthalmoscopy is no substitute for a dilated retinal exam. However, retinal photography may provide a solution to the challenge of diabetic retinopathy screening, offering improvement over direct ophthlamoscopy: while opthalmoscopy alone detects only 65% of patients with sight-threatening retinopathy, compared with a detection rate of over 88% for mydriatic (dilated) retinal photography (Tubbs, Safeek, & Mayo, 2004). While the ADA cautions that retinal photography should not replace an initial, comprehensive eye exam for diabetic patients, remote retinal screening may be a practical option for ongoing, annual retinopathy screening in primary care practices.
Remote retinal screening would pose challenges in terms of cost, technical capacity, and personnel. The greatest cost would be funding for the cameras, which can be quite expensive (around $20,000, though they are becoming cheaper). Appropriate computers and Internet connectivity would be required to transmit that images for interpretation. Medical assistants or other clinical staff members could conduct the screening photography; these additional duties might necessitate the hiring of more staff at certain practices. Clinics interested in implementing telemedicine-based retinopathy screening could approach and contract with an existing screening program, such as the University of California Berkeley School of Optometry's EyePACS program, who could train staff and interpret images. Alternatively, a clinic or network of practices could start a similar program based on the EyePACS innovation. To replicate a program like the EyePACS program, it would be necessary to identify and collaborate with a regional optometry or ophthalmology center where retinal images could be sent for interpretation.
For example, another successful example of telemedicine-based retinopathy screening in a primary care practice comes from the Vine Hill Community Clinic, a nurse-run clinic in urban Nashville, Tennessee. This clinic's screening program, which has been described by Taylor and colleagues (2007), utilized one retinal imaging camera and one laptop, which clinic staff used to send images to the Vanderbilt Ophthalmic Imaging Center reading center at the Vanderbilt Eye Institute for interpretation. Like the California clinics described in the EyePACS innovation, Vine Hill Community Clinic dramatically improved their rates of retinopathy screening, going from a pre-implementation rate of 23% to a post-implementation rate of 59% of patients with diabetes with documented retinopathy screenings. One difference worth noting between Vine Hill and EyePACS protocols has to do with retinal dilation: instillation of mydriatic drops was standard practice at Vine Hill Community Clinic, but EyePACS protocol suggests pupil dilation only in the event that images are unsatisfactory. Whether or not a clinic wants to make dilation part of their retinopathy screening is a significant decision, as dilation may improve image quality while reducing patient convenience and tolerability.
A similar practice innovation to EyePACS, also on the AHRQ Innovation Exchange, is Diabetes TeleCare, profiled in “Telemedicine-Based Diabetes Management Program Focusing on Education and Eye Exams Improves Self-Management Capabilities and Outcomes For Low-Income Rural Patients.” This program combined monthly diabetes education sessions, conducted through two-way teleconferencing, with telemedicine retinopathy screenings. Clinicians at a community health center obtained images with a retinal camera, then faxed those images to the Wilmer Eye Institute at Johns Hopkins University for interpretation. While the education piece was an asset to this practice innovation, I questioned the use of fax for transmission of images, as Internet transmission would seem to offer higher resolution images for interpretation.
In sum, I was impressed by the EyePACS innovation and would consider implementing such a program in my future practice. Diabetic retinopathy is a serious complication of diabetes but it can be prevented with early detection; this makes it imperative for primary care practices to ensure that patients with diabetes are up-to-date with retinopathy screening. The success of remote retinal screening has been demonstrated in rural California and South Carolina as well as in urban Tennessee. I believe remote retinal screening could be a practical innovation for many primary care practices looking to improve their care of patients with diabetes.
Part One: Memo to Veronica Nieva, PhD
American Diabetes Association. (2011). Executive summary: standards of medical care in diabetes—2011. Retrieved from http://care.diabetesjournals.org/content/34/Supplement_1/S4.full.pdf.
Agency for Healthcare Research and Quality. (2011). Remote retinal screening facilitates diagnosis and treatment of retinopathy for poor and/or uninsured patients with diabetes in rural California. Retrieved from http://innovations.ahrq.gov/node/5536.
Agency for Healthcare Research and Quality. (2011). Telemedicine-based diabetes management program focusing on education and eye exams improves self-management capabilities and outcomes for low-income rural patients. Retrieved from http://innovations.ahrq.gov/node/5536.
Taylor, C. R., Merin, L. M., Salunga, A. M., Hepworth, J. T., Crutcher, T. D., O'Day, D. M., & Pilon, B. A. (2007). Improving diabetic retinopathy screening ratios using telemedicine-based digital retinal imaging technology. Diabetes Care, 30 (3), 574-578.
Tubbs CG, Safeek A, Mayo HG, et al. (2004). Do routine eye exams reduce occurrence of blindness from type 2 diabetes? Journal of Family Practice, 53 (9), 732-4.