The Casey Eye Institute Experience
The Casey Eye Institute (CEI) is part of the Oregon Health and Science University (OHSU) and has the Oregon Vision & Health Network (OVHN), a donor-funded, volunteer-staffed program that provides vision screening services in community health centers (CHCs), including FQHCs. The mobile eye clinic was started in 2010 to serve over 60 community partners at locations ranging from the state’s most remote corners to Portland’s urban core. When the COVID-19 pandemic hit, the screening capacity shrank by 50% due to modified operations and physical distancing. Therefore, the program expanded to telemedicine in the fall of 2023.
The CEI has built strong and long-lasting collaborative relationships with CHCs. The OVHN team analyzed the Oregon Commission for the Blind registry data and used demographic patterns of blindness in at-risk groups for site selection. By strategic partnership with the CHCs, the program served 38% rural and 72% urban participants, including 40.9% Hispanic, 34.9% non-Hispanic White, 9.9% American Indian or Alaska Native, 3.8% Asian, and 3.6% Black individuals.
Casey Eye Institute: Telemedicine Program
Goal – The overall goal is to screen for the three major eye diseases that contribute to irreversible blindness: diabetic retinopathy, glaucoma, and macular degeneration, and reduce the burden of blindness in the state of Oregon. The telemedicine program aims to expand screening from 40 individuals per site per year to a goal of 500 per site per year among the 50 sites.
Equipment – Telemedicine program: 1) iFusion 80 (Visionix, IL, USA), which combines a fundus camera and iVue OCT, 2) Tonopen, 3) Snellen acuity chart, and near vision card. The equipment is provided by the screening program and stationed at the FQHC.
Screening Exam – Telemedicine program: The CHW identifies and schedules at-risk participants and then performs the screening exam that includes visual acuity, tonometry, and OCT/fundus photos. The information is then transferred via a secure double firewall server to the reading center at CEI. The CHW provides patient education and helps coordinate follow-up care. Two to three CEI technicians (0.8 FTE) travel between CHC sites to perform training and initial image acquisitions.
How Patients Get to the Screening – Telemedicine program: CHWs assess their willingness to receive telehealth care during the primary care appointment and perform tests on that day if possible.
Interpreting the Exam – Telemedicine program: The scanned documents and images are loaded onto the OHSU PACS system (Continuum) via a secure demilitarized zone (DMZ) network. A trained ophthalmic reader from the CEI reading center and/or a CEI ophthalmologist will access the exam and images through Epic Continuum at CEI and document diagnosis and findings using predefined criteria. One criterion is distance visual acuity worse than 20/40. For glaucoma, the criteria are IOP>21mmHg, abnormal OCT, or abnormal fundus photo. An abnormal OCT is defined by the glaucoma structural diagnostic index, a composite score found to have high sensitivity and specificity by combining retinal nerve fiber layer (RNFL), ganglion cell complex (GCC) and optic nerve head (ONH) parameters. An abnormal fundus photo was determined by using a 0.6 vertical cup to disc (VCD) ratio, 0.2 VCD asymmetry, focal or diffuse thinning, or disc hemorrhages.
Communicating Results to Patients and Clinicians – Telemedicine program: A letter is automatically generated with the diagnosis and care recommendation and sent either via fax or via EHR interface to the CHC. The CHW, who is often able to communicate in the patient’s language, will call the participants to make referral appointments. The primary care clinicians at the CHC also have access to the diagnosis via the local EHR system through CareEverywhere.
Billing – Philanthropy provided funding to purchase the equipment for the mobile health unit ($350,000), OCT machine, FTE/travel expenses for the technicians, FTE for the CEI Outreach coordinator who functions much like a PAS specialist, and
administrative/facilities support for the telehealth site. The clinical workflow currently performs no billing, but the program is actively developing cost recovery and billing plans for the telehealth component. Future phases will likely include reimbursement through teleophthalmology CPT codes.
Scheduling Follow-up Care – For those who screen positive, the CHW manages referrals to local private clinicians, educates patients about their eye health findings, and helps with insurance coverage. A hybrid model is underway to incorporate the mobile clinic on-site every 3-4 months to provide follow-up care for those not able to receive care anywhere else.
Measuring Screening Outcomes – Each year, we review program data to assess our reach demographically and then target community partners accordingly to address gaps in providing care to groups at risk. We also have an annual survey to assess the CHC’s satisfaction to understand the gaps and needs of our community partners. The program partners with the OHSU Oregon Clinical and Translational Research Institute to place calls and surveys to elicit barriers to follow-up for participants who missed their referral appointments. We also plan to perform a cost-effective analysis with the OHSU health economists, as well as a 5-year screening outcome to identify participants’ vision status.
Casey Eye Institute: Traditional Program
Goal – The overall goal is to screen for the three major eye diseases that contribute to irreversible blindness: diabetic retinopathy, glaucoma, and macular degeneration, and reduce the burden of blindness in the state of Oregon. The telemedicine program aims to expand screening from 40 individuals per site per year to a goal of 500 per site per year among the 50 sites.
Equipment – Traditional program: The van has a 33-foot mobile eye clinic equipped with two full eye lanes, with slit-lamp biomicroscopes, and direct and indirect ophthalmoscopes. Instruments that are transferred into the CHC from the eye van during the exam day include: autorefractor, lensometer, visual acuity chart, a phoropter, Tonopens, and a spectacle dispensing station, all donated by private foundations.
Screening Exam – The outreach coordinator (1.0 FTE) recruits volunteers and facilitates partnerships with CHCs to ensure smooth operation during the screening day. The outreach coordinator recruits volunteer physicians, technicians, and medical, graduate, and undergraduate students to examine patients. The OVHN team developed the first vision health training approved by the Oregon Health Authority Office of Equity and Inclusion to train community health workers (CHW) to perform assessments, including visual acuity and risk assessment for glaucoma, macular degeneration, and diabetic retinopathy. On each screening day (usually a Saturday), participants are registered by a CHW, who also performs intake questionnaires. The volunteer eye care staff measure distance and near visual acuity, lensometry, auto and manual refraction, and tonometry. Patients are then dilated and taken to the mobile clinic for a full dilated eye exam by an eye doctor (volunteer ophthalmologist or optometrist from CEI or the community). Participants receive a manifest refraction prescription and spectacle fitting from a tray of sample eyeglasses. Partner agencies facilitate the delivery of eyeglasses free of charge.
How Patients Get to the Screening – To identify high-risk participants, the CHW from the CHC recruits patients by identifying those who experience barriers to care or are high risk for eye diseases. This includes those without an eye exam in the last year, and not under the care of an eye doctor. Risk factors include older age, race, reported vision loss or other eye symptoms, a history of diabetes or eye disease, or a family history of eye diseases. CHW identifies patients before their primary care appointment and calls to recruit patients to come for the traditional program, and calls patients the day before to remind them of the vision screening.
Interpreting Results – The doctor discusses the diagnosis directly with the participant through an interpreter if needed.
Communicating Results to Patients and Clinicians – Telemedicine program: A letter is automatically generated with the diagnosis and care recommendation and sent either via fax or via EHR interface to the CHC. The CHW, who is often able to communicate in the patient’s language, will call the participants to make referral appointments. The primary care clinicians at the CHC also have access to the diagnosis via the local EHR system through CareEverywhere.
Billing – Philanthropy provided funding to purchase the equipment for the mobile health unit ($350,000), OCT machine, FTE/travel expenses for the technicians, FTE for the CEI Outreach coordinator who functions much like a PAS specialist, and
administrative/facilities support for the telehealth site. The clinical workflow currently performs no billing, but the program is actively developing cost recovery and billing plans for the telehealth component. Future phases will likely include reimbursement through teleophthalmology CPT codes.
Scheduling Follow-up Care – For those who screen positive, the CHW manages referrals to local private clinicians, educates patients about their eye health findings, and helps with insurance coverage. A hybrid model is underway to incorporate the mobile clinic on-site every 3-4 months to provide follow-up care for those not able to receive care anywhere else.
Measuring Screening Outcomes – Each year, we review program data to assess our reach demographically and then target community partners accordingly to address gaps in providing care to groups at risk. We also have an annual survey to assess the CHC’s satisfaction to understand the gaps and needs of our community partners. The program partners with the OHSU Oregon Clinical and Translational Research Institute to place calls and surveys to elicit barriers to follow-up for participants who missed their referral appointments. We also plan to perform a cost-effective analysis with the OHSU health economists, as well as a 5-year screening outcome to identify participants’ vision status.