A population-health approach to preventing blindness

Improved access, increased quality, and decreased cost. In short, it's the Triple Aim as defined by the Institute for Healthcare Improvement (IHI) and the goal of forward-thinking health systems nationwide.

It is also the initiative that can leave healthcare executives asking, "how do we actually achieve this?" But when it comes to a growing and significant population – diabetics – and the ability to prevent something as life altering as blindness, the "how" can be easier than most realize.

The diabetic crisis.
Diabetes is the fastest growing disease in America. In fact, it's been predicted that if current disease rates continue, one in three Americans will have diabetes by 2050. Every patient with diabetes is directed to complete an annual diabetic retinal exam every year by the American Diabetes Association, the American Academy of Ophthalmology, and the World Health Organization. Yet, only 40% of patients with diabetes have a documented eye exam each year leaving a huge gap in compliance.

The awareness of the issue is improving. For example, a call for attention to the matter has been made with HealthyPeople2020. This initiative to improve the health of all Americans specifically calls out diabetic retinopathy as a common vision problem that can be detected with an annual eye exam. This awareness is key, as the added challenge with diabetic retinopathy is that retinopathy – unlike the well-known kidney and foot issues that can be caused by diabetes – often has no warning signs. And commonly in healthcare patients don't seek out a physician until something hurts; when there are noticeable lumps and bumps. In many cases, early detection is built around warning signs but diabetic retinopathy is, unfortunately, often asymptomatic.

Achieving the Triple Aim
With increased awareness of the need for these preventative exams comes the need to remove common barriers and ultimately broaden access to this care. The current approach, which focuses on referring diabetic patients to an eye care specialist, still leaves 60 percent of diabetics (approximately 18 million people) unexamined each year. The good news is that new technology and workflows, now available in the primary care setting, can drive exam compliance rates to over 90 percent. Plus, for those patients that have pathology, telemedicine technology allows for the appropriate triage of patients which has been shown to drastically reduce scheduling wait times with local ophthalmologists.

While the technology has come a long way, success still hinges on good process and workflow. This includes enforcing how patients are identified for the exam and ensuring that the results are delivered back to the EMR using discrete, structured data. By leveraging good processes, adoption and engagement will increase leading to higher compliance and improved The Healthcare Effectiveness Data and Information Set (HEDIS) scores. In addition to improving quality outcomes, the financial benefits are equally as impressive. The direct medical cost to treat a patient who has gone blind is estimated at $6,680 per year1, which does not include the societal costs of blindness which are even higher. But by leveraging new technology and great processes, early detection can help eliminate this cost from the health system for 95% of the patients who otherwise will lose their sight.

Healthcare systems across the nation have successfully protected the vision of hundreds of thousands of patients using telemedicine retinal imaging systems provided in the primary care setting. One such health system experiencing success is Harris County, Texas- based Harris Health System, a Federally Qualified Health Center (FQHC) and the first healthcare organization in Harris County designated by the National Committee for Quality Assurance (NCQA) as a Patient Centered Medical Home.

Harris Health took charge of its diabetic population by implementing IRIS (Intelligent Retinal Imaging SystemsTM) within eight of its primary care clinic locations. IRIS is designed to fit into the existing patient workflow and any member of the lay staff can be trained to operate the equipment. Upon capture, images are immediately sent to the web-based grading platform and interpreted by eye care specialists with the, results then sent back - as discrete, structured data – and integrated into the Harris Health EMR.

Within the first 12 months, Harris Health completed diabetic retinal exams on 19,000 patients improving its HEDIS score from 3 to 5 STARS. Of those patients examined, sight threatening disease was found in 1 out of every 8 patients. An additional 8% of the population had suspected glaucoma and 5% with macular edema. Most, if not all, of these patients had no idea they had eye disease until they sat down and received the IRIS exam.

Health systems and physician practices across the country can seize this opportunity and experience similar positive outcomes as Harris Health. With one in three American adults – 86 million people –having prediabetes, the incidence of the disease and the risk of blindness is only going to rise. The opportunity is here and now for health systems to proactively identify services that will enable them to detect blindness early, therefore achieving the Triple Aim of improved quality, increased access, and lower costs.

Here are steps to follow to make a difference in your organization:

• Identify your population of patients with diabetes by PCP by location to determine your need.
• Calculate financial and clinical benefits of a telemedicine solution in primary care, including revenue increases, risk identification, cost savings, patient engagement, clinical outcomes and enhanced population health.
• Seek telemedicine technologies that implement and integrate into practice operations to maximize clinical and business workflows.
• Identify telemedicine providers that score high with patients and providers on factors like ease-of-use, interoperability, FDA approval, support history, and ability to drive outcomes.
• Look for telemedicine technologies supported by clinical evidence as well as case examples and studies that outline opportunities, implementation paths and results.
• Make sure that hospital, health system and practices will receive orientation, training and education. The best telemedicine technologies are supported by online training modules.
• Find a telemedicine service that provides the practice with resources and expertise in marketing and promotion.

Looking Forward
Diabetic retinal exams provided through telemedicine platforms are no substitute for comprehensive, ongoing eye care. However, they remain powerful tools to identify and triage patients with varied types of diabetic eye disease. By implementing diabetic retinal exams in primary care practices, the health system will take a bold and powerful step in the prevention, diagnosis, and treatment of sight threatening disease. Diverse populations, including those with minimal access to eye care, will experience early detection and prevention of blindness. Patients and their family members will experience the benefits of a lifetime of good vision.

We are a country focused on population health management and achieving better care, better health, and lower costs. Let's join together to end preventable blindness, one patient at a time.

About Dr. Gupta:
Dr. Sunil Gupta is the founder and the chief medical officer of IRIS. He is a nationally recognized surgeon who holds multiple diagnostic and pharmaceutical patents. Dr. Gupta is focused on bringing efficiency and Six Sigma inspired systems to healthcare; he is on a mission to end preventable blindness and improve the current practices for diabetic retinal care.

1) http://www.eyeresearch.org/pdf/Vision_and_Blindness_Factsheet.pdf

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