Telehealth Extends Diabetic Retinopathy Screening Across California
The nonprofit University of California-Berkeley Digital Health program has grown to offer diabetic retinopathy screening services to more than 100 health systems throughout California. During a recent webinar hosted by the California Telehealth Resource Center, leaders of the program described how telehealth has allowed them to provide services statewide.
“We basically help FQHCs and other healthcare institutions in California reduce diabetic blindness,” explained Mark Sherstinsky, O.D., M.P.H., clinic outreach specialist and assistant clinical professor. “We have about 230 sites that are operating. These are essentially sites that have retinal cameras that are screening patients with diabetes. We cover everywhere from north of Yreka in the north to Calexico in the South. Basically, were clustered the Bay Area and LA County, Orange County and Riverside and along the Route 99 corridor. Most of programs that we work with are FQHCs and rural health clinics, but we also work with a number of Indian Health System hospitals and public health departments, as well as insurers who are trying to incentivize their clinics to raise the compliance and raise the quality of care of screening their patients with diabetes.”
Diabetes is the No. 1 cause of blindness in working age adults. That has actually increased significantly in prevalence over the last 15 or 20 years. “What that means in safety net clinics is that if you have 12 patients with diabetes in a room, statistically speaking, one of those patients will have sight-threatening retinopathy,” Sherstinsky explained. That means in the next one to five years, they will go blind without any kind of treatment. “The reason for our existence is that with timely detection, that diabetic retinopathy is treatable. We can stop the progression of vision loss if we catch that patient early. So that's where we come in — to help you stop that vision loss and decrease the incidence of diabetic blindness.”
The recommendation by the American Diabetes Association is for these patients to get an annual eye exam. Especially in safety net settings, patients have a much higher risk of sight-threatening retinopathy.
As an alternative, the ADA recommends retinal photography as a screening tool. “The reality on the ground, especially in FQHCs, is that it is very hard to get a patient to a live eye care provider, and even if you can get the patient to a live eye care provider, it's very hard to get a feedback loop from that eye care provider that gives you a report,” Sherstinsky said. “So one alternative that is sanctioned by the ADA is to use retinal photography. That's a validated assessment tool. In places where you just can't get that patient to be seen live by a care provider, it has been the supplement to getting compliance for retinal screening programs in the last 15 years for a lot of FQHCs.”
The UC team works with a store-and-forward telehealth platform vendor called EyePACS, which operates in 43 states and abroad. “It's secure and encrypted,” Sherstinsky said. The FQHC staff uploads images of the patient from the point of care, it's stored and forwarded to an eye care consultant and it's graded.
He noted that EyePACS is a level three-approved screening program. “There are multiple other retinal screening programs out there and most of them are not level three,” he said. “All that means is that they're less accurate. If you use a level one or two program in your clinic, you will send more patients who don't need to be referred out for referral. And you will also miss patients that have sight-threatening retinopathy and risk of blindness. You'll have a lot of false negatives, and you'll have a lot of false positives.”
Once trained and certified, photographers in the clinics screen live diabetic patients and the images are uploaded into EyePACS and usually within 24 hours, and sometimes within a few hours, the UC team is able to grade and make an assessment and recommendations. “The report gets sent electronically and if there's an interface with your EMR, it gets populated in the EMR,” Sherstinsky said. “A handy report is generated that has the ICD-10 codes, and it's a digitally signed report. We can also customize it to include any other billing codes.”
He pointed to several partners who had implemented the telehealth program and were able to raise their screening compliance by about 35 to 45 percentage points. “We can significantly move the needle with the telehealth program,” Sherstinsky added.
“All the indicators are that diabetic retinopathy screening using telehealth is a major solution to the public health problem of low diabetic retinal screening rates,” he said.
Harry Green, O.D., Ph.D., chief of telehealth and associate clinical professor, noted that one of the biggest challenges that they’ve had in providing these services has been to establish a financial model that works well. They have had to keep their service fees really low and come up with some creative ways to maintain a sustainable financial model. “A lot of that was because the billing guidance really wasn't there for a very long time, and even now, it is somewhat ambiguous,” he said. “With the pandemic, however, there's been a significant push to expand telehealth services in general.”
