Don't Lose Sight of the Importance of Eye Exams-Using Telehealth in Primary Care Centers to Extend Access to Diabetic Retinopathy (DR) Screening

Kentucky’s citizens have some of the poorest health of any state in the country. According to the 2012 America’s Health Rankings, a study from the United Health Foundation (http://www.americashealthrankings.org/KY/2012), Kentucky’s overall health ranking was 44th in the country. Significant statistics that contribute to that ranking include the rate of Obesity (40th), Diabetes (41st) and smoking (50th). The larger urban populations of Louisville, Lexington and the Northern Kentucky corridor have comparatively healthy populations, closer to the national averages for all these metrics, which leaves a relatively small population in rural Kentucky that has significantly worse health statistics that bring the statewide averages to these dismal levels. One of the most prevalent health problems in Kentucky is Diabetes. According to the 2011 National Diabetes Fact Sheet (http://www.diabetes.org/diabetes-basics/diabetesstatistics/? loc=DropDownDB-stats), 25.8 million Americans have diabetes, and over 27% are undiagnosed. Among all the complications resulting from the disease, including heart disease, stroke, kidney disease, nervous system disease and amputation of extremities, blindness is one of the most devastating. Diabetes is the leading cause of new cases of blindness among adults aged 20-74 years old and in 2005-2008 4.2 million (28.5%) people with diabetes aged 40 and older had diabetic retinopathy, and almost 700,000 (4.4% of those with diabetes) had advanced diabetic retinopathy that could lead to severe vision loss. This project is a partnership between the University of Kentucky and the White House Clinics serving rural central Kentucky and the St. Claire Family Medicine Clinics serving rural eastern Kentucky. Many factors contribute to Kentucky’s health problems, including high rates of unemployment, low per capita personal income (18% lower than national average), low levels of education (high school graduation rates 8% lower than the national average), low primary care physician to population ratio (32% lower than the national average) and poor lifestyle choices that have been passed along for generations, including high rates of smoking, poor eating habits and lack of exercise. The CDC reports that 90% of adult diabetics consult a health professional for their diabetes while only 61.3% receive annual eye exams which are recommended by the American Diabetes Association. While there is no county-level reporting of the compliance with annual eye exams, the White House Clinic reports that only 48% of their patients are compliant and report that many factors contribute to this non-compliance. Patients must visit two doctors, a generalist for the systemic disease and an eye care specialist for the DR screening and the cost and inconvenience as well as the lack of eye care specialists in rural Kentucky leading to very long wait lists can lead to very poor patient compliance. This project will bring sight-saving diabetic retinopathy screening to the patient’s primary care physician’s office where they already travel for their diabetes care. Patients who already have a relationship with an eye specialist will be encouraged to maintain that relationship, but for a population of people who have a high prevalence of diabetes and are often non-compliant with annual eye exams, this service is expected to be well received. This project will utilize The CenterVue DRS fully automated non mydriatic fundus camera system to capture patient images and to transmit those images to the University of Kentucky Department of Ophthalmology for evaluation. Any staff person in the clinic can be trained to use the technology and the results are easily imported into the primary care EMR, supporting the “medical home” concept of patient management by the primary care providers. Objectives 1. Improve compliance with Diabetic patients having annual Diabetic Retinopathy Eye Exams by offering those exams in the primary care center. By extrapolating the simple survey data above that 52% of diagnosed patients have not had their annual eye exam, 100% compliance would yield an additional 2,720 eye exams per year. 2. Gather 100% of retinal screening reports done outside the primary care clinic and import the data into the EMR so patient’s have a true “medical home” where the primary care physicians can better manage the overall health of their patients. 3. Reach out to the community that is not coming to clinic to uncover Diabetes and then make sure they receive eye exams. This will include outreach to community public health departments and two free clinics in the St. Claire catchment area. 4. Refer patients who meet criteria for referral based on the screening results. 5. Survey referred patients to determine how many attend their treatment appointment. Activities/Workplan 1. Set up a Diabetic Retinopathy camera in the six White House Clinics and five St. Claire Family Medical Clinics. 2. Train Clinic staff to use the cameras and transmit the images to UK Ophthalmologists to screen for problems. 3. Train clinic staff to target diabetic patients and ask if they have had an eye exam. If they have not, offer to have the exam done immediately in the clinic. 4. Patients that have been screened in the last year will be encouraged to continue that relationship and to help the clinic staff capture the DR report so it can be integrated into the primary care EMR. 5. Train clinic staff to screen all undiagnosed patients for diabetes and if positive, then offer to provide retinopathy screening in the clinic. 6. Add videoconference technology to each clinic so the UK Department of Ophthalmology can coordinate training of clinic staff and conduct meetings to manage the deployment and operation of the project .