Los Angeles County Department of Health Services' Experience
The Los Angeles County Department of Health Services (LAC DHS) operates the second largest municipal health system in the United States, serving more than 600,000 primarily disadvantaged and uninsured patients annually. In 2013, LAC DHS launched a teleretinal diabetic retinopathy screening (TDRS) program to expand access to vision screening across its network of primary care clinics. The program screens more than 20,000 patients annually for diabetic retinopathy (DR) and other eye diseases using mydriatic fundus photography reviewed remotely by certified optometrist graders. Since implementation, the program has increased DR screening rates by 16.3%, reduced wait times for in-office visits by 89.2%, and eliminated over 150,000 unnecessary eye clinic visits for patients with no or mild disease. Additionally, it has identified other referable eye disease in more than 17,500 patients.
Los Angeles County:
Screening Program
Goal – The primary goal of the LAC DHS teleretinal diabetic retinopathy screening program is to prevent vision loss from diabetic retinopathy by increasing screening rates among patients with diabetes and improving the efficiency of referrals to eye care specialists. The program also aims to reduce unnecessary in-office visits, expedite care for patients with disease requiring treatment, and establish sustainable workflows for ongoing screening within primary care.
Equipment – To improve access to DR screening, we implemented a TDRS program across 17 of the largest LAC DHS–operated primary care clinics using Canon CR-2 and Topcon NW8 or NW400 cameras. Our first clinic began screening in September 2013, followed by rolling expansion to all LAC DHS comprehensive health center primary care clinics, medical center primary care clinics, and multispecialty ambulatory care center primary care clinics by March 2015. Currently, 55 certified medical assistants and licensed vocational nurses are trained and certified as fundus photographers. We trained existing certified medical assistants to use the cameras in primary care settings and to upload these digital images via our web-based screening software (EyePACS software; EyePACS LLC). To ensure efficiency while maintaining workflow integrity, we train up to three medical assistants per camera, providing for two primary photographers and one backup.
Screening Exam – We created a retinal photography clinic for which patients are scheduled in advance by their primary care professional, patient care medical home (PCMH) staff, or a care manager. This method best uses the photographers’ time because they often provide other services, and it also allows us to give patients advance notice of dilation. However, capacity for walk-in appointments was also built in for same-day screening. All patients are given an educational brochure regarding what to expect during the screening process, either in advance or when presenting to the clinic. Patients are identified as in need of screening by their individual PCP or PCMH in advance of or during their primary care visit, and LAC DHS facilities also run reports, using coding and EHR data that flag all patients with diabetes that have not had an eye exam in 12 months. These reports can be used for facility-based outreach and scheduling into TDRS clinics.
After measuring visual acuity and dilation, photographers are trained to obtain fundus images according to a three-standard-field protocol, with images centered on the fovea, optic disc, and temporal to the macula, as well as one external eye image. We use a single-drop dilation protocol with tropicamide ophthalmic solution, 1% or 0.5% (approximately 10 minutes to dilation) for all patients unless good-quality photographs can be obtained without dilation, the patient declines, or the patient had a previous adverse reaction to dilation. Depending on the clinic, fundus cameras are in a separate room or in the shared exam space, and as patients are dilated, room lighting seldom affects photo quality. Photographers are required to upload a minimum number of cases monthly to maintain certification, thereby ensuring the highest quality of images. Image quality is also graded by our readers, and photographers who do not meet adequacy requirements in any three-month period undergo retraining by the full-time program coordinator.
How Patients Access the Camera – Patients are identified as in need of screening by their individual PCP or PCMH in advance of or during their primary care visit, and LAC DHS facilities also run reports, using coding and EHR data that flag all patients with diabetes who have not had an eye exam in 12 months. These reports can be used for facility-based outreach and scheduling into TDRS clinics.
Interpreting Screening Results – Ten optometrists currently employed by the LAC DHS and certified as image readers read the screening photographs as part of the DHSwide teleretinal reading center using a standardized, validated protocol including grade of DR, recommended timing, location, and type of clinic (optometry vs. ophthalmology) for follow-up, and feedback on the quality of the images. Findings consistent with other ocular pathology, including glaucoma, cataract, and age-related macular degeneration, are also identified and referred according to standardized referral guidelines. Typical turnaround time for review is 48 hours. Quality assurance audits and overreads are performed by LAC DHS ophthalmologists, while supervisory and adjudicating reads are also performed on cases flagged by the primary reader owing to questions regarding pathologic findings. Readers adhere to protocols governing the timing and location of referrals to eye care specialists based on the severity of eye disease and the urgency of need for treatment. These protocols were informed by nationally developed preferred practice guidelines for the care of patients with diabetic eye disease and were endorsed by a working group of ophthalmology and primary care representatives from across LAC DHS institutions.
Communicating Results to Patients and Clinicians – Results of the teleretinal screenings and follow-up recommendations are electronically transmitted to PCPs, either through an EHR interface for those internal to LAC DHS or a data-sharing interface for those without access to the EHR. Patients can also review the screening results at any time through the patient-facing EHR portal.
Billing – LAC DHS participates in managed care Medi-Cal (or Medicaid) plans as well as in fee-for-service Medi-Cal. TDRS visits are coded using CPT code 92228.
Scheduling Follow-up Care – TDRS photographers review the retinal screening results and place initial follow-up referrals for abnormal results via eConsult, a webbased referral system for specialty care, which allows for submission of screening results and subsequent scheduling of follow-up into eye clinics across the LAC DHS. eConsults are placed by the photographers requesting follow-up appointments based on the specific recommendations made in the screening results, and schedulers contact the patients with appointment information (i.e., location, time, etc). PCPs and PCMH staff also receive the screening results via the aforementioned methods and can follow up on the status of the referrals. Based on the results of screening, patients may be triaged for monitoring and/or treatment.