Kaiser Permanente Southern California's Experience

Kaiser Permanente Southern CA:
Screening Program 

Goal – The primary goal is to perform diabetic retinopathy screening with the additional objective of identifying other posterior segment diseases in patients with diabetes undergoing evaluation.

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Equipment – Non-mydriatic cameras, which are housed in primary care offices. 

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Screening Exam – specially trained staff (typically medical assistants and nurses) acquire pictures. Two 40-degree fundus photographs are taken in each eye: one centered on the macula and one nasal to the optic nerve. Picture quality is significantly improved by utilizing 0.5% tropicamide which has not been found to pose a significant risk of acute angle-closure glaucoma in patients undergoing screening (prior to photographs patients are asked about any past ocular history and dilating drops can be skipped if there is a concern about narrow angles based on history) Images are uploaded into a Picture Archiving and Communication System (PACS) and clinical information forwarded to the EMC for subsequent review and evaluation. Several quality control measures are in place to ensure high performance by the primary care staff acquiring pictures, including a training and evaluation program. The EMC provides feedback on image quality to photographers and medical offices. Additionally, quarterly sessions are held with primary care nursing staff and managers to provide feedback on image acquisition.

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How Patients Access the Camera – Within KP, a logic has been built into the EHR that identifies when patients are due for prescribed diabetic maintenance, such as foot exams, hemoglobin A1c, and diabetic retinopathy screening. When partnering with outside clinics, the outside organization identifies which patients are due for retinopathy assessment, acquires the pictures, loads the pictures into the PACS, and then the EMC reviews the pictures. 

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Interpreting Screening Results – The EMC is a centralized operation supervised by retina specialists who work with administrative staff and certified ophthalmic assistants (COAs)/certified ophthalmic technicians (COTs). The list of patients that needs to be reviewed is first received by COAs/COTs at the EMC who follow a standardized algorithm/check list to prepare the images for resulting with a retina specialist, such as ensuring relevant ophthalmic history is present (i.e., history of eye disease, prior retinal interventions, when patients were last seen, etc.). Online review sessions are held where the retina specialist reviews the images and dictates results and plans to the EMC’s staff. All images are reviewed, and results are signed in the EHR by the retina specialist, with ancillary staff assisting in subsequent coordination of care, such as sending communications to patients and primary care clinicians, as well as ensuring patients receive follow-up appointments. A standardized algorithm is employed when interpreting the photographs. Each eye is categorized by retinopathy severity, presence/absence of macular exudates, and the status of the optic nerve (namely to evaluate for glaucoma concern). Additionally, images are inspected for the presence of non-diabetic retinopathy abnormalities (e.g., glaucoma, nevi, drusen, subretinal hemorrhages, optic nerve edema, retina vein/artery occlusions, retinal detachments).

Creating standardized algorithms and workflows has resulted in greater operational efficiencies at reduced costs and higher quality. 

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Communicating Results to Patients and Clinicians – Within KP, results are immediately available in the EHR for review by other clinicians. Patients receive a notification via email or letter about the results of their testing, when their next retinopathy assessment is due, and if any additional evaluation is necessary. When partnering with outside organizations, different workflows can be employed with results communicated electronically to both primary care clinicians and patients, notifying them of results and the need for any further action. 

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Billing – When working with FQHCs, billing and reimbursement structures are discussed prior to launching pilots. 

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Scheduling Follow-up Care – Patients with no or minimal retinopathy do not require escalation of care and receive a target date for their next annual diabetic retinopathy evaluation. Patients with significant abnormalities are escalated for in clinic evaluation. Patients with moderate-to-severe non-proliferative diabetic retinopathy or proliferative diabetic retinopathy (defined as any neovascularization) are referred for additional evaluation, as are patients with parafoveal macular exudates (to rule out diabetic macular edema). The most common non-diabetic finding requiring additional evaluation is concern for glaucoma suspect. Images with inadequate visualization are also escalated for in-clinic evaluation.

Within KP, patients who require escalation of care are referred to optometry and ophthalmology clinics, depending on the severity of their findings based on pre-defined criteria. Notifications are sent to optometry and ophthalmology clinics informing them of patients that need to be scheduled, along with recommended time frames and additional testing (such as optical coherence tomography). When partnering externally, the EMC will provide the interpretation of the images with recommended follow-up based on previously defined protocols which are co-developed with outside partners, with the external partners arranging for subsequent in-clinic evaluation based on their own network of physicians.

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Measuring Screening Outcomes – We have developed tracking dashboards that monitor the percentage of our diabetic patients who are up-to-date on screening, photographer errors/quality and patients lost to follow-up after an abnormal result, the latter of which is used to ensure continued outreach until patients are seen in the clinic.