The Digiscope dilated diabetic eye exam story.

In 1996, Maryland Healthcare (MHC) was formed as a merger of nine community primary care practices in suburban Washington, D.C. MHC affiliated with Georgetown University as a strategic and capital partner.

In an effort to meet the founding mission of providing the highest quality, evidence-based medicine, MHC established, staffed and funded a quality committee. One of the earliest activities of the quality committee was to define a calendar of quarterly outcome measures for audit and feedback. The compensation plan included a portion that was linked to the performance on selected audit topics.

The strongest early initiative coming from the quality committee was the diabetes outcome improvement program. Initial data demonstrated that the levels of compliance with the diabetes indicators of Hgb A-1-c, LDL cholesterols, blood pressure control, foot exams and dilated eye exams were not nearly as good as the group anticipated and were far below the recommended levels of compliance.

The quality committee recommended that a diabetes education and treatment program be established to improve these outcomes. Recommendations that were adopted included the introduction of certified diabetes educators (CDEs) and the development of an American Diabetes Association recognized diabetes education program.

Two certified diabetes educators were brought into the group and the process for achieving ADA recognition began. The backbone of this program was a diabetes registry and tracking system for continuous monitoring of patients, interventions and outcomes. This system was used to provide regular feedback to clinicians on their diabetes indicators.

Over the subsequent two years, through the efforts of the quality committee and the CDEs, the group was able to significantly lower the aggregate A-1 from 9 percent to 6.8 percent.

In a similar fashion the indicators for foot exams, LDL cholesterol, and blood pressure control all improved. The improvements resulted from the hands-on efforts of the CDEs in individual and group counseling sessions with patients, the education of the clinicians on the importance of meeting measurement goals, frequent feedback on individual performance and ranking relative to peers, and the small financial incentives that were linked to the quality initiatives.

All of the quality indicators improved with this approach with the exception of compliance with the standard for annual dilated eye exams. This indicator was given as much attention in education programs and monitored as closely as any other parameter. However, despite continued feedback and educational efforts, the compliance measured by the group and by external audits (managed care insurance companies) remained unacceptably low, below 40 percent.

Lack of control

Several factors were determined to be responsible for the poor performance in dilated eye exams. The most important factor differentiating this from all other parameters was the lack of direct control by the primary care physician over the completion of this exam.

For the measured parameters of A-1-c and LDL cholesterols, the clinicians generated the lab slip and had a high degree of compliance with the patient having the test done on the day the request was made. For the blood pressure and foot examinations, the clinician was able to accomplish and document these at the time of the visit.

Obtaining a dilated eye exam consistent with the standards set by the ADA (1) required the clinician to refer the patient to an ophthalmologist. In order to be compliant under audit standards required the patient to schedule appointment with an ophthalmologist, go to the ophthalmologist's office to have an examination, have the ophthalmologist generate a report, have the report transmitted from the ophthalmologist to the primary care physician and, finally, have the report placed in the patient's clinical record.

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These steps presented many barriers to success under the existing system. In the local health care community there is a shortage of ophthalmologists (13 ophthalmologists covering a population of 650,000 = 2:100,000). The national average for ophthalmologists is 5.6: 100,000.

The relative lack of resources produced long delays from the time of request for an appointment to the actual appointment date. This delay was even longer for procedures that were deemed to be routine screening rather than acute treatment. Appointments that are farther in the future are more likely to be missed by patients.

Approximately 30 percent of the patients in the area are covered under HMO managed care plans. Many of these plans require referrals that have expiration dates that exceeded the availability of appointments. Some patients did not renew their referrals and missed their scheduled appointments.

A further factor contributing to lack of documented eye exams occurred in patients who had seen the ophthalmologist but in whom a report regarding the outcome of the visit was not found in the patient's clinical record.

The DigiScope arrives

In 2001 at a meeting of the regional quality improvement organization, MHC was introduced to a new technology (the DigiScope) that had promise to improve the dilated eye exam compliance. With this technology, dilated eye exams could be done in the primary care office at the time of the patient's regular visit. The images were sent via the Internet to the Wilmer Eye Institute of Johns Hopkins University, read by specialists and a report sent back to the primary care physician within 24 hours.

This technological solution overcame the issues of referrals and delay in scheduling and put the ability to meet the standards directly and immediately back under the control of the primary care physician.

In 2002 Maryland Healthcare adopted this technology. The group made the availability of the exams known to patients and providers. Staff was trained to administer the examinations. A workflow process was established that fit well into existing patterns.

Over the next year, the compliance with dilated eye exams improved consistently. In 2004, MHC was given the award for the highest level of compliance in the region on dilated eye exams by the Delmarva foundation, the regional Medicare QIO for the District of Columbia and Maryland. The group again received this award in 2005. The change in compliance in the dilated eye exam parameter was dramatic.

Shift in the paradigm

In the paradigm that existed prior to the Digiscope, there was virtually 100 percent reliance on external referrals to ophthalmologists for the performance of the required annual dilated eye exam for patients with diabetes.

This paradigm presented several very difficult hurdles that inhibited compliance with the recommendations for quality. The introduction of this technology put the ability and responsibility for achieving compliance with the primary care providers. The paradigm has shifted, allowing primary care to use technology to achieve a previously unobtainable goal.

Besides the obvious satisfaction that occurs from finding successful solutions to difficult problems, there is also a measurable impact on the improvement in health that occurs when compliance with dilated eye exams reaches nearly 100 percent. It is estimated that nationwide there is only a 50 percent compliance with this examination. This means that a large number of patients with diabetes go at risk for preventable loss of vision from diabetic retinopathy.

Currently 6 percent of the patients evaluated require urgent referral to ophthalmologists for evaluation and treatment of previously unrecognized diabetic retinopathy. Without this technology, half of these patients could have gone without detection of serious diabetic eye conditions that could lead to serious visual loss

As early adopters of this technology, MHC had the opportunity to develop a business relationship with the provider of this service (EyeTel Imaging, Inc.) that provided a cash flow to the practice that more than offset the limited expense of supplies and staffing.

The practice rents the digital camera and accompanying hardware and software from EyeTel Imaging, Inc. EyeTel provides the interpretations, owns the equipment, does the majority of the billing and provides the office with a fair market value rate for each study performed.

Howard Haft, MD, MMM, CPE is president of Maryland Healthcare and Maryland Foundation for Quality Health. He can be reached at 301-705-7870 or [e-mail]

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By Howard M. Haft MD, MMM, CPE

Dilated Eye Exam Compliance Rates

2001    38%*
2002-3  78%**
2003-4  84%**

* Audited insurance claims data
** Medicare claims data

Note: Table made from bar graph.