Implementation and Acceptance of Teleophthalmology Program for Retinal Screening in Clinical Setting

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Implementation and Acceptance of
Teleophthalmology Program for Retinal Screening
in Clinical Settings
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Authors

• Robb Wilson, MA1
• Andrew Eller, MD1,2
• Russell Silowash, BS1
• Leslie Anthony, MA2
• 1University of Pittsburgh, Pittsburgh, PA
• 2University of Pittsburgh Medical Center,
  Pittsburgh, PA

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Collaborators

• University of Pittsburgh, Department of
  Biomedical Informatics
• University of Pittsburgh Medical Center (UPMC)
  Integrated Medical Information Technology System
  (IMITS)
• University of Pittsburgh, Diabetes Institute
• UPMC Eye Center

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Funding/Disclaimer

• This work was supported by funding from the U.S.
  Air Force administered by the U.S. Army Medical
  Research Acquisition Activity, Fort Detrick,
  Maryland (Award No. W81XWH-04-2-0030 and Contract
  No. DAMD 17-0302-0017).
• The content of the information does not imply
  U.S. Air Force or Government endorsement of
  factual accuracy or opinion.

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Background

• UPMC has developed a process for packaging and
  transporting digital images.
• The IMITS program customized this process for
  retinal images to overcome challenges of
  providing adequate screening and diagnostic
  services for people at risk for diabetic
  retinopathy.
• The Diabetes Institute used the IMITS customized
  software to implement an effective/functional
  screening program for diabetic retinopathy using
  single-field non-mydriatic digital fundus
  photography.

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Diabetes

• There are 20.8 million children and adults in the
  United States, or 7 of the population, who have
  diabetes.
• Nearly one-third or 6.2 million are unaware that
  they have the disease.
• It is estimated that if the present trend
  continues, one in three Americans born in 2000
  will develop diabetes in their lifetime.

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Diabetic Retinopathy

• Complications of diabetes results in 12,000 to
  24,000 new cases of blindness each year.
• In the 20 -74 year age-group, it is the leading
  cause of blindness.
• Laser therapy, when applied in a timely manner,
  can help prevent blindness from diabetic
  retinopathy
• Early detection is essential.

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Diabetic Retinopathy

• Diabetic Retinopathy may affect vision by
  two different mechanisms. 1) Tiny blood vessels
  grow on the surface of the retina. When they
  break, hemorrhaging occurs which can obscure
  vision. These vessels can also turn to scar
  tissue, and produce a detachment.
• 2) Blood vessels in the retina (macula) may
  leak serum, leading to retinal swelling, and
  blurred or distorted vision.
• Photo courtesy of the National Eye Institute.

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Evaluation Objectives

• Evaluate innovative approach to diabetic retinal
  screening.
• Assess real-world application of the
  teleophthalmology technology in community and
  clinical settings.
• Apply lessons learned from each phase of
  implementation to improve the technology and
  workflow model.

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Observational Settings

• Center for Diabetes and Endocrinology, Falk
  Clinic at UPMC Presbyterian Hospital
• General Internal Medicine Clinic at UPMC
  Montefiore Hospital
• Community Health Fairs and Symposiums

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Subject Demographics
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Subject Demographics
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Grading Follow-up Recommendations

• Within six weeks proliferative retinopathy
• Three months severe non-proliferative
  retinopathy
• Six months moderate non-proliferative
  retinopathy
• One year no or mild non-proliferative
  retinopathy

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Imaging Results
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Result Letter
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Clinics

• Falk Clinic
• - Imaging began February 2006
• - Imaging temporarily stopped
• January 2007
• General Internal Medicine
• - Imaging began November 2005

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Clinic Camera

• Falk Clinic

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General Internal Medicine

• 100-150 patients attend clinic on a typical day.
• 75-100 are given an electronic tablet.
• 4924 patients with any type of diabetes.
• 247 patients imaged from November 2005 through
  March 2007.
• 5 of the patients with diabetes.

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Methods of Interventions In Clinics

• Breakfast meetings
• Signage
• Focus groups
• Research question

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Signage
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Focus Groups

• Increase signage.
• Physicians need/not need to write
  order/recommendation?
• Patients often in hurry.
• Staff/physicians forget to offer to patients.
• Staff handle/not handle consent forms?
• Staff willing to help with study.
• Physicians need more information.

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Response to Question

• 635 patients with diabetes given the electronic
  question from September 2006 through March 2007.
• 196 responded YES to question.
• 97 responded MAYBE to question.
• 46 positive response to question.
• 195 patients imaged since electronic question was
  activated.

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Interventions Over Time
Focus Groups and Research Questions (9/06)
Breakfast Meetings (2/06)
Increased Signage (5/06)
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Summary

• 653 subjects with diabetes were successfully
  consented, registered, imaged and had their eye
  photos graded. - 337 community sites
• - 316 clinical sites.
• Mean time for subjects to be registered, imaged
  and have eye photos graded was 001313.
• 52 of the subjects reported that their last eye
  exam was Greater than 12 Months or Never
• 89 of our sample were instructed to follow-up
  with their eye doctor within one year. Six (1.08
  ) were asked to see their eye doctor within 6
  weeks.

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Conclusions

• Eyes do not need to be dilated to produce a
  gradable retinal image.
• Quality retinal screening can be done in a
  clinical setting.
• Communication with clinical staff is essential.
• Providing patient results to the clinical staff
  is a plus.
• Healthcare professionals can supply a valuable
  service to the patient with diabetes.

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Website

• http//www.dbmi.pitt.edu/news.htmlarchive