The Temple Health Experience
Temple Health is an academic medical center in North Philadelphia. It has a faculty practice plan, which includes the ophthalmology department as well as some primary care departments. It also contains a non-academic primary care practice, as well as having affiliation agreements with more than a dozen primary care and FQHC practices.
Temple Health serves the community of North Philadelphia in one of the poorest zip codes in America. Philadelphia is the poorest large city in America. 50% of our patients have Medicaid. 1/3 have income below the poverty line, and half of them are below the deep poverty line. The screening program is designed to bring eye services to the primary care offices that serve the North Philadelphia community.
Temple Ophthalmology screens for eye disease by camera in both primary care and ophthalmology office settings, in person at our free outreach clinic at the City of Philadelphia’s Health Center #5, and via cameras at multiple locations throughout the Temple Health network of primary care offices. We employ 1.5 full-time equivalents (FTEs) whose sole responsibility is this screening project. One FTE is our screening program lead, who is an ophthalmic technician. He has his own schedule of screening photographs in our ophthalmology offices, trains all the photographers in the primary care offices, installs and monitors the AI software program, and helps coordinate follow-up care. The 0.5 FTE is the screening coordinator, who is a Spanish-speaking department administrative assistant who calls all the patients who fail their screening and sets up the appointments in ophthalmology.
The project began with 1 camera purchased by the ophthalmology department and placed in the internal medicine clinic. This was followed by placing 6 cameras purchased by an insurance company in our community primary care practices. During the COVID-19 pandemic, we were able to purchase 12 more cameras using COVID-19 grant money obtained by the Health System and place them in Temple faculty and community-based practices. The ophthalmology department purchased 1 camera, and the FQHC partner purchased 2 additional cameras for use in the FQHC. Finally, the ophthalmology department purchased a robotic camera (Topcon TRC-NW400, La Jolla, CA) to place in one of the community primary care offices. The ophthalmology department received no grant funding for these purchases.
The camera-based screening program has been running since 2016 at about a dozen primary care offices as well as three of our ophthalmology offices.
Temple Health:
AI Screening Program
Goal – The primary goal is to screen for diabetic retinopathy and other eye diseases that occur in patients with diabetes.
Equipment – Canon CR-2 AF (Tustin, CA) non-mydriatic fundus camera with high-speed Wi-Fi internet connection. The cameras were purchased using several different sources of funding, ranging from an insurance company grant, department of ophthalmology funds, COVID-19 funds for the Temple University Health System, and purchases by a primary care office. This is not an exhaustive list of funding sources, but it may serve as a guide for potential funding options.
Screening Exam – We are using Eyenuk’s EyeArt (EyeNuk, Inc., Woodland Hills, CA) and EyeScreen software to perform AI diabetic retinopathy reads. A 1.0 FTE ophthalmic technician installs the cameras and software and provides training for medical assistants (MAs) in the primary care provider (PCP) offices who take the photos in our ophthalmology office screening locations. Initial training for each MA photographer is provided by the ophthalmic technician, and refresher training is provided if there is an issue with photo quality. We strongly encourage 2 to 3 MAs to be trained per office to take photos so that they can take enough to develop and maintain their skills. Some offices have the photos taken as part of the normal workup before seeing the PCP, and other offices have designated the camera as a provider and schedule patients for the camera. There are advantages and disadvantages to both, but we have found that designating the camera a provider is often the more successful strategy, provided photos are taken at least weekly. This is the strategy we are using in our 3 ophthalmology offices.
How Patients Access the Camera – There are 3 main ways to identify patients who need diabetic eye exams. First, you can simply take photos of patients as they come to see their PCP for regularly scheduled exams. Second, because the PCP offices work in a capitated system, they have a list of all the patients with diabetes for each insurance provider seen in that office. They can call those patients and schedule them for a screening. Third, the insurance companies provide a monthly report to the practices of the names of the patients that are cared for in that office who have not had their diabetic eye exam. Some combination of those 3 mechanisms should be able to identify exactly who needs to be screened.
Interpreting the Screening Exam – From 2016 until 2020, an optometrist reviewed the photographs and staged the retinopathy using the International Classification of Diabetic Retinopathy (ICDR) system.3 In October 2020, we switched to Eyenuk’s EyeArt and EyeScreen programs. EyeArt AI is an artificial intelligence program that provides point-of-care diabetic retinopathy results to the patient and clinician. The program indicates patients have referable disease if they have moderate or more severe retinopathy, and/or if there is a suspicion of macular edema. Each day, optometrists (OD) log onto the EyeArt database, where the images are stored, and review the images from the day before for any other eye disease using the EyeScreen program. When a photograph is taken in an outlying office, this is communicated to the screening team in ophthalmology, who then create a retinal screening encounter for the patient in our electronic health record (EHR), Epic. The OD then opens that encounter, orders the screening test, enters results for the test, routes the results to the PCP, sends a message to the ophthalmology screening staff to schedule patients who screen positive, and closes the encounter. If a patient screens negative for any disease other than diabetes, we do not have the OD review the photos for 3 years. The OD enters the EyeArt result into Epic and closes the encounter. We hope that this allows for a balance between screening for other eye diseases and the need to screen patients annually.
Communicating Results to Patients and Clinicians – For those clinicians within the Temple Health system, we send the results via an Epic communication. For those clinicians not in the Temple Health system, we send the results using Epic to their EHR through a city-wide EHR data sharing network called the Health System Exchange. Each office decides when the patient receives the results of the screening. Most offices provide the patient with the results immediately after they have the photos taken, but some have decided that the patient should not get the results until their next PCP appointment. Our ophthalmology department strongly believes the patient should be given the results of the screening exam at the time the exam is performed, both because we think the patient should know the results and because it eliminates the element of surprise when our office calls the patient to set up an appointment for a failed screening exam, and the patient is unaware they failed.
Billing – The bill is submitted to the insurance company by the ophthalmology department when the test results are entered, and the screening encounter is closed. Billing for AI-assisted diabetic retinopathy screening (CPT 92229) is processed through ophthalmology. We do not bill for the optometry reads.
Scheduling Follow-up Care – If the patient screens positive for any eye disease or has ungradable photos, the OD will notify the screening coordinator. The ophthalmology department employs one person who spends half of their time (0.5 FTE) calling the patients to help them schedule a follow-up exam. This exam could be with Temple Ophthalmology or with their own clinician. Ideally, the PCP office would coordinate follow-up care for failed screenings. However, this is often challenging for PCP offices, and in that case, that role must be assumed by the ophthalmology department running the screening program.
Measuring Screening Outcomes – there are multiple ways to measure the results of the screening. Tracking retinopathy Healthcare Effectiveness Data and Information Set (HEDIS) scores is one way. Internally tracking the follow-up rates from the screenings is another. Measuring the downstream financial impact on the ophthalmology department is a third. We believe all 3 metrics are important and need to be tracked. Because the Health System benefits financially from quality payment program money due to improved HEDIS scores, it is important to ensure that a portion of that bonus money is shared with the faculty practice plan, whose clinicians do the work. In turn, the practice plan must align the PCP bonus incentives with improving the quality scores to help drive patients to the camera. This is a key step in helping the PCPs understand the value of this screening; otherwise, it can seem like yet another unfunded mandate. Temple Health is still working on this piece of the project.
Temple Health:
Medical Student Free Clinic
In addition to our camera-based screening, Temple Ophthalmology has been running a free outreach clinic at the City of Philadelphia’s Health Center #5 since 2011. This clinic was the brainchild of the Temple medical students and their Ophthalmology Special Interest Group (OSIG). We currently have 1 full day of clinic a month, staffed by a Temple ophthalmologist supported by an endowed chair and up to 4 medical students. Because of holidays and the physician’s schedule, there are typically 10 clinic days a year.
Goal – The primary goal is to introduce medical students to ophthalmology, provide eye care in an underserved environment, and reduce the number of diabetic eye exams coming to Temple.
Equipment – The clinic is based in normal medical exam rooms and largely uses donated equipment or equipment borrowed from the department, although some equipment was purchased through the OSIG via the medical school. We have a slit-lamp biomicroscope mounted on a wheeled stand, a phoropter, a lensometer, a trial lens set, both direct and indirect ophthalmoscopy, and a Tonopen.
Screening Exam – Most of the patients are seen for diabetic eye exams or a refraction. There are no screening photos. Patients are seen in a model typically found in an ophthalmology office. Eyeglasses are provided for $15 through a partnership between the Lions Club and the Health Center. Exam results are recorded in the Health Center EHR.
Scheduling – patients are referred to the clinic by their Health Center #5 primary care doctor. About 30 patients are scheduled per day, and the show rate is about 50%. The patients are scheduled by the front desk staff in the health center.
Interpreting Screening Results – Interpretation is done by the ophthalmologist examining the patient.
Communicating Results to Patients and Clinicians – Patients are told the results of their exam at the point of care, just like in a regular ophthalmology office. Results are available to the primary care physician in the EMR.
Billing – This is a free clinic. There is no billing.
Scheduling Follow-up Care – Patients who need routine follow-up, like another diabetic eye exam in a year, will be rescheduled for the free clinic by the front desk staff. Patients who need more specialized follow-up care are referred to Temple Ophthalmology. We work with the Health Center staff to help get a patient enrolled in an insurance plan. Patients unable to get insurance are referred to Temple for the charity care program.
Measuring Screening Outcomes – The Health Center currently provides no feedback on the number of patients seen, their HEDIS score, or how many patients received eyeglasses. While this would be helpful to satisfy the interest of the ophthalmologist who likes to know the impact of the services, the main outcome is the smiles on the faces of the patients and medical students, and knowing that many of the Temple medical students who eventually choose ophthalmology recall their experience at the Health Center as one that helped them to choose the specialty.