THE EYEPACS HANDBOOK TOOLS FOR DIABETIC RETINOPATHY SCREENING PROGRAM SUCCESS MARCH 2009 In Partnership with the California HealthCare Foundation and the UC Berkeley Optometric Eye Center
TABLE OF CONTENTS TABLE OF CONTENTS.....................................................................................................1 I ABOUT THE PROGRAM ...............................................................................................3 About this Handbook .................................................................................................................. 3 Program Description and Goals ..........................................................................................
2 Table of Contents Tips, Tricks and Advanced Training Topics ............................................................................... 55 Patient Spotlights ..................................................................................................................... 56 Responsibilities of Site Administrators ..................................................................................... 57 Overview of Site Administration Objectives .......................................................
3 I About the Program I ABOUT THE PROGRAM About this Handbook In the four years since the start of the EyePACS pilot program, EyePACS staff members, along with clinic administrators and photographers in the program, have learned a great deal about integrating diabetic retinopathy screening (DRS) into the clinic setting.
4 I About the Program “I’m personally committed to this program. They call me ‘The Shadow’ because I follow the providers around and hound them to refer patients for screening. I put post-its on charts, notes on the exam room doors, and posters in the halls. I’ll do whatever it takes – last month one of my patients who is in a wheelchair didn’t know if he could make it to my diabetes education clinic, so I arranged a cab for him to get home safely.” - S.G.
5 I About the Program Program Description and Goals About Diabetic Retinopathy Screening Diabetic retinopathy is the leading cause of blindness among working-age adults in the United States. The National Eye Institute estimates that more than 40 percent of diabetics aged 40 and older have diabetic retinopathy and that 8.2 percent have an advanced, vision-threatening form of the disease. More than 4 million Americans, or 3.4% of the general population, have some form of diabetic retinopathy.
6 I About the Program A Note to CEOs, Operations Directors, and Clinic Managers There are a few key ways that administrators can ensure a successful diabetic retinopathy screening program: 1. Communicate your support for the program at its inception and on an ongoing basis – your buy-in is absolutely essential in motivating the clinic staff. Ask for updates at staff meetings, and promote the clinic's goals, milestones and successes. 2.
7 I About the Program The EyePACS Team The EyePACS team is available to answer questions for photographers and administrators. Please contact us by using the contact information provided below. Jennifer Kaufer, MPA Program Administrator Kimberly Vergez Program Assistant Alma Martinez Program Coordinator, Northern Region Jennifer Muise Program Coordinator, Southern Region Jorge Cuadros, OD, PhD Program Director 510-589-9394 jkaufer@berkeley.
8 I About the Program Expectations of Clinics with Diabetic Retinopathy Cameras Congratulations on your commitment to offering diabetic retinopathy screening services in your clinic! Like you, we are passionate about quality patient care and we want to make this program a success in your clinic. On the grant application you submitted, you indicated that you will be able to meet the annual screening target of 1,000 patient screens.
9 I About the Program Getting Started Checklist Sign and return the MOU with UC Berkeley and the CHCF agreement. Identify a point person to “champion” the diabetic retinopathy screening program in your clinic, and provide contact information to EyePACS. Set up the camera and room. Please ensure that your clinic has met the Minimum Technical Requirements as outlined in the MOU and on page 16 of this handbook. If you don’t have a dedicated room, designate where the camera will be stored.
10 I About the Program Selecting Optimal Camera Operators Most clinics draw on their existing staff – including medical assistants, X-ray techs, diabetic care coordinators, and telemedicine coordinators – to identify and train camera operators. When looking for an ideal candidate to perform retinopathy screenings, here are some of the traits we have found helpful: Strong hand-eye coordination and fine motor skills.
11 I About the Program The First 60 Days: Benchmarks and Milestones The First Month Clinic Site Visit: Administrator and Provider Meetings The EyePACS director and program administrator will schedule a date to visit your clinic and meet with your clinical and administrative staff. Since your clinicians will supply the patients for the program and receive the reports of the retinal exams, their buy-in is absolutely imperative.
12 I About the Program • Responsibilities of on-site EyePACS site administrators: o Adding user accounts o Editing or deleting accounts o Adding sub-sites The Regional Coordinator will guide each trainee through the complete screening process once, using other trainees as test cases.
13 I About the Program Week 2 – Online Questionnaire and Photographer Certification In week 2, photographers can expect to get back comments on all 10 of their test cases and will be asked to go through an online questionnaire intended to ensure that trainees are prepared to address the common issues that arise when performing a retinopathy screening.
14 I About the Program Integrating Screenings into Clinic Workflow The success of any clinical program depends on how well it is integrated into the workflow of the care process. One straightforward way to ensure that this happens is to create a simple set of clinical scenarios and then map out suggestions for a modified workflow, including alerts and reminders for all the people involved with the patient.
15 I About the Program Alert and reminder systems can help to make the new workflow consistent: • Patient Check-In, Records and Charts: Every patient with diabetes should be receiving an annual retinal exam, so the date of their last screening should be noted on their charts. Some clinics provide the check-in staff with pre-printed Post-It reminder notes saying “Reminder for Diabetic Retinopathy Screening” so that the physician or provider who sees the patient remembers to make that referral.
16 I About the Program Minimum Technical Requirements The following is a list of requirements for community clinics to participate in the UC Berkeley EyePACS diabetic retinopathy screening program. 1. Fast Internet connectivity. At least 128 KB/second speed; allow upload of image files to trusted site on the Internet; and allow SSL at 128-bit encryption in Web browser. 2. Telephone access in the imaging room.
17 I About the Program Space and Facilities Requirements In an ideal world, every clinic could dedicate a private exam room to diabetic retinopathy screening. However, the vast majority of clinics do not have the space for this, and many have found creative solutions that enable them to perform effective screenings despite tight space constraints. Here are the minimum space requirements for a screening location: • Space for two chairs and the equipment. Minimum 5’x5’.
18 I About the Program The External Evaluation Process As part of the Diabetic Retinopathy Screening Initiative, the California HealthCare Foundation has identified five broad areas of questions to evaluate the success of the program in each site. The external program evaluation is being conducted by an independent third party to ensure that it is impartial and complete. Results will be used to guide policy development and program improvements. Below are the five areas to be evaluated: EVALUATION TOPIC 1.
19 II For Camera Operators (Pullout section) II FOR CAMERA OPERATORS (PULLOUT SECTION) Camera Diagrams and Settings Diagram of the Canon Fundus CR‐DGi 1. Focus Knob 2. Monitor 3. Setting Switches 4. Power Lamp 5. Shutter Button 6. Joystick 7. Height Adjusting Dial 8. View Switching Button 9. Fixation Target Button 10. Platform Locking Knob 11. Correction Sleeve 13. Infrared Ray Knob 14. Lamp Knob 15. Power Switch 16. Fuses 17. Power Connector 18. Forehead Rest 19. Height Adjustment Mark 20.
20 II For Camera Operators (Pullout section) Diagram of the Canon Rebel 1. Menu Button 2. White Balance Button/Down Button 3. Drive Mode Button 4. ISO Button/Up Button 5. Metering Button/Left Button 6. Shutter Speed Dial 7. Power On/Off 8.
21 II For Camera Operators (Pullout section) Canon Rebel Screen: 6. Quality 7. Exposure Composition 8. ISO Setting 9. Lens Focus 10. Drive Mode 1. Shutter Speed 2. Shot Setting 3. White Balance 4. Metering 5.
22 II For Camera Operators (Pullout section) Talking to Patients about the Screening General Suggestions Communicating with patients during the screening process is an important – and sometimes challenging – part of diabetic retinopathy screening. • Before you begin the screening: o Explain what diabetic retinopathy is (see below for more information) and how the patient might be affected. The National Eye Institute offers a free flip chart photographers can use.
23 II For Camera Operators (Pullout section) Common Patient Questions What are the Stages of Diabetic Retinopathy? Diabetic retinopathy has four stages: 1. Mild Nonproliferative Diabetic Retinopathy. At this earliest stage, microaneurysms occur. They are small areas of balloon-like swelling in the retina's tiny blood vessels. 2. Moderate Nonproliferative Diabetic Retinopathy. As the disease progresses, some blood vessels that nourish the retina are blocked. 3.
24 II For Camera Operators (Pullout section) Normal vision Same scene viewed by a person with diabetic retinopathy Who is at risk for diabetic retinopathy? All people with diabetes – both type 1 and type 2 – are at risk. The longer someone has diabetes, the more likely he or she will get diabetic retinopathy. Between 40 to 45 percent of Americans diagnosed with diabetes have some stage of diabetic retinopathy.
25 II For Camera Operators (Pullout section) The Diabetes Control and Complications Trial (DCCT) showed that better control of blood sugar levels slows the onset and progression of retinopathy. The people with diabetes who kept their blood sugar levels as close to normal as possible also had much less kidney and nerve disease. Better control also reduces the need for sight-saving laser surgery.
26 II For Camera Operators (Pullout section) How to Perform a Diabetic Retinopathy Screening Overview of the Photography Process The overall objective for EyePACS photographers is to achieve the best readable images possible, in a timely manner, to best serve patients. For each patient, there are four pictures taken of each eye, thus totaling eight pictures altogether. Each eye includes one exterior picture and three interior pictures.
27 II For Camera Operators (Pullout section) Anatomy of the Retina The EyePACS Handbook: Tools for Program Success
28 II For Camera Operators (Pullout section) Camera Preparation 1. The retinal screening camera has two components: a fundus camera and a Canon Rebel Digital Camera. The fundus camera sits on top of an adjustable table stand. The camera should be placed so that the lens is pointed in the direction opposite of the up and down button found on the table stand. The digital camera and the table stand should each be plugged in to a wall outlet. The fundus camera can be plugged into the outlet on the table stand.
29 II For Camera Operators (Pullout section) target inner circle. Note: The screen on the fundus camera will appear out of focus until step 4, when you press the View Switching Button. 3. If the pupil is split, as seen in the image below, move camera platform toward patient or yourself until the split is corrected and there is no split (see below). 4. Press the View Switching Button (#8 on camera diagram on page 19) to increase the size of the onscreen image of the eye.
30 II For Camera Operators (Pullout section) Internal Photos Preparation: 1. Position patient’s head onto Chin Rest (#21 on camera diagram on page 19) and Forehead Brace (#18 on camera diagram on page 19). For the internal photos, the patient’s forehead should rest against the Forehead Brace. You will need to ask the patient to move forward. 2. Push in the Correction Sleeve (#11 on camera diagram on page 19) completely.
31 II For Camera Operators (Pullout section) 4. Press View Switching Button (#8 on camera diagram on page 19) to view the retina. You will see an image of the patient’s retina on the screen of the fundus camera. 5. Line up the red bars in the center of the screen. If you are having trouble seeing the red bars, ask the patient to look straight ahead and identify the red bars (if possible).
32 II For Camera Operators (Pullout section) 2. Position the circular target onto the center of the pupil. To do so, move target up or down using the Height Adjusting Dial (#7 on camera diagram on page 19); move target left or right using the Joystick (#6 on camera diagram on page 19). The three white lights (in the form of a triangle) should be within the pupil and target inner circle. 3.
33 II For Camera Operators (Pullout section) Joystick up and down. Note: Be careful of the patient’s proximity to the camera so that you don’t bump the nose! 8. Press the Fixation Target Button (#9 on camera diagram on page 19) to the LEFT three times. You will see a white square on the screen of the fundus camera (appears green in image above) shifting as you move the Fixation Target Button. 9. Readjust the two dots.
34 II For Camera Operators (Pullout section) THIRD SET (FIELD 3 OF RIGHT AND LEFT EYE): 1. Always capture images of the patient’s right eye first. Move the camera platform to the left to capture images of the patient’s right eye. 2. Position the circular target onto the center of the pupil. To do so, move target up or down using the Height Adjusting Dial (#7 on camera diagram on page 19); move target left or right using the Joystick (#6 on camera diagram on page 19).
35 II For Camera Operators (Pullout section) 7. Look at the image of the patient’s eye on the screen of the fundus camera and find the two dots. Line up the two dots in the correct position, as pictured below in the “Focused and Ready” image. To do so, move target up or down using the Height Adjusting Dial (#7 on camera diagram on page 19); move target left or right using the Joystick (#6 on camera diagram on page 19).
36 II For Camera Operators (Pullout section) Joystick. The optic nerve (if visible) will appear in the far right of the retina for this image. 14. Take the photo by pressing the Shutter Button (#5 on camera diagram on page 19).
37 II For Camera Operators (Pullout section) Images of the Right Eye External: Fundus Reflex Correction Sleeve (#11 in camera diagram on page 19) on the right side of the camera is pulled out completely; head is positioned 1 inch from Forehead Rest (#18 in camera diagram on page 19); iris detail should be focused by using the Focus Knob (#1 in camera diagram on page 19); eye should take up 2/3 of the screen as pictured.
38 II For Camera Operators (Pullout section) Images of the Left Eye External: Fundus Reflex Correction Sleeve (#11 in camera diagram on page 19) on the right side of the camera is pulled out completely; head is positioned 1 inch from Forehead Rest (#18 in camera diagram on page 19); iris detail should be focused by using the Focus Knob (#1 in camera diagram on page 19); eye should take up 2/3 of the screen as pictured.
39 II For Camera Operators (Pullout section) Helpful Hints Flash Illumination: If the photo is too light or too dark, adjust the flash illumination on the fundus camera. This is done by pressing the Setting Switches (#3 in camera diagram on page 19). Press the +/‐ buttons to increase or decrease illumination. For lighter skinned patients or patients with big pupils, a lower flash illumination is required. For darker skinned patients or patients with smaller pupils, a higher flash illumination is required.
40 II For Camera Operators (Pullout section) Pupil Dilation Protocol Policy: Patients will undergo pharmacological pupillary dilation with one drop per eye of 1% tropicamide solution when retinal images are of insufficient quality for interpretation and no risk factors exist for complications from pupillary dilation.
41 II For Camera Operators (Pullout section) 2. Explain to patient that one drop will be instilled in each eye to increase pupil size. Blurred vision and light sensitivity may be experienced for two to four hours. Care should be taken when driving or performing other potentially dangerous activities until the effect of the drops goes away. In rare instances the effects may last for two days. 3. The bottle of drops should be discarded if the nozzle appears discolored or contaminated.
42 II For Camera Operators (Pullout section) Uploading Images to EyePACS 1. Remove the compact flash card from the Canon Rebel camera and insert it delicately into the compact flash card reader attached to the USB drive on the computer. 2. Go to https://www.eyepacs.org and login. Select the “Add a Case” tab at the top of the page. 3. Enter patient information. Please be complete and accurate.
43 II For Camera Operators (Pullout section) 4. To upload the images, go to the “Upload” section at the bottom of the web page. Navigate to the images saved on the flash memory card by selecting the Browse” button (identified in the image below “<1”). Select the option to “View Thumbnails” (“<2” below) in the file upload window. Repeat this step until all images are uploaded.
44 II For Camera Operators (Pullout section) 5. Upload all of the right eye images first and then all the left eye images. For example, images 1, 3, 5, and 7 should be uploaded first. After all eight images are added, select “Save Changes” (“<3” above) at the bottom of the web page. Note: Do not click “Save Changes” repeatedly; the upload will take some time to complete depending on the speed of the Internet connection. 6.
45 II For Camera Operators (Pullout section) 7. To prepare for the next patient, you need to delete the images from the flash memory card. To do so, carefully remove the card from the card reader and insert into the Canon Rebel camera. Press the Canon Rebel “Menu” button (#1 on camera diagram on page 4). Select the third tab, identified as , by using the arrow buttons (#5 on camera diagram on Page 4).
46 II For Camera Operators (Pullout section) Screening without the Internet On some occasions it may be necessary to conduct diabetic retinopathy screening without having access to the Internet for uploading cases into the EyePACS system (e.g. If the Internet connection goes down or if the camera is used for a diabetic screening day outside of the clinic). When it is necessary to screen without the Internet, please follow the steps below: 1. Write the patient’s name on a piece of scrap paper.
47 II For Camera Operators (Pullout section) iii. Type in the patient’s name as the folder name. iv. Insert the card reader along with the compact flash card into a USB port on your computer. v. From the Start menu, select My Computer from the drop-down menu.
48 II For Camera Operators (Pullout section) vi. When the My Computer window appears, select the EOS Digital icon (under Devices with Removable Storage). vii.
49 II For Camera Operators (Pullout section) viii. Open this folder and the subsequent folder until you see image files. ix. Select the images by using the SHIFT and the arrow keys on your keyboard. x. Once the desired images are highlighted, select Move the selected items from the menu on the left-side of the window.
50 II For Camera Operators (Pullout section) xi. When the window appears, select the folder with the patient’s name. xii. Next select Move from the list in the Move Items window. (The images can be uploaded from this folder once Internet connectivity is restored.) xiii. Please complete the Diabetic Retinopathy Screening Encounter Form for each patient. The encounter form contains all the necessary fields for each EyePACS case. This form can be found on the following page.
51 II For Camera Operators (Pullout section) DRS Encounter Form The EyePACS Handbook: Tools for Program Success
Diabetic Retinopathy Screening Encounter Form Patient Name/Nombre del Paciente: ______________________________________________________ Date of Birth/Fecha de Nacimiento: _______________________________________________________ Gender/Genero: M F Ethnicity/Pertenencia étnica:___________________________________ Medical Record Number/Numero Medico: __________________________________________________ Coverage Type/Tipo de Seguro: ___________________________________________________________ Last Eye Exam/Ultimo
53 II For Camera Operators (Pullout section) DRS Cheat Sheet The EyePACS Handbook: Tools for Program Success
54 II For Camera Operators (Pullout section) Good Pictures v. Bad Pictures Perfect External Image Not focused photographer needs to increase focus by using the focusing knobs. Perfect right external image- good focus, position of the optic disc, and no evidence of artifacts. Excellent internal image of the second field for the right eye. Excellent right external image of the third field. This image is too dark. The flash illumination needs to be increased.
55 II For Camera Operators (Pullout section) Tips, Tricks and Advanced Training Topics Problem: Aligning the red lines when they cannot be seen from the fundus camera screen. Solutions: • Ask the Patient to look at the red lines and tell you when they are aligned. • Try lowering the lamp light (this will not affect the pictures). • Move the focusing knobs back and forth – sometimes this brings the lines into your plane of view. Problem: Patient cannot see the target light.
56 II For Camera Operators (Pullout section) Patient Spotlights Sometimes it’s easy to forget that this program really is about avoiding preventable blindness and changing people’s lives. There are countless stories of patients whose eyesight was saved because they were given a routine retinopathy screening through the EyePACS program. Here are some of those stories. • A woman came in for a regular appointment. She had relatively low blood sugar levels and was not experiencing any vision problems.
57 II For Camera Operators (Pullout section) Responsibilities of Site Administrators Overview of Site Administration Objectives The overall objective for EyePACS administrators is to manage the user experience in the clinic, including creating new user accounts and implementing any site changes. Each clinic (site) should contain individual accounts for all photographers, consultants, site clinicians, outside clinicians, and anyone involved in the implementation of the EyePACS program in the clinic setting.
58 II For Camera Operators (Pullout section) Adding New Users 1. On the side menu of the EyePACS website, select Edit Accounts. 2. The EyePACS Administration options will appear. 3. Select Add, Edit or Delete Users. 4. The next screen will display a list of all users in the EyePACS system. Use the Site Filter to select your specific site to which you are adding a new user.
59 II For Camera Operators (Pullout section) 5. Once you have selected your site, only users for that site will appear. In the example below, Sample Site is the selected site. 6. Select Add New User.
60 II For Camera Operators (Pullout section) 7. When the “Add New User” fields appear, enter information into all fields. • Group ‐ generally most users will be Photographers. • Credentialed Consultant ‐ Only checked for those who are credentialed image readers. • Photographer – Select this if user is a Photographer. • Account Active – Select this for new users. This can be unchecked if user is no longer needing access to EyePACS system (i.e., if any employee leaves the clinic).
61 II For Camera Operators (Pullout section) Editing Profile Information 1. On the side menu of the EyePACS website, select Edit Accounts 2. The EyePACS Administration options will appear. 3. Select Add, Edit, or Delete Users. 4. The next screen will display a list of all users in the EyePACS system. Use the Site Filter to select your specific site to which you are adding a new user.
62 II For Camera Operators (Pullout section) 5. Once you have selected your site, only users for that site will appear. In the example below, Sample Site is the selected site.
63 II For Camera Operators (Pullout section) 6. Select the user’s name to edit the account information. Here, you can also change the Role of the user. Roles include the following options: • Consultant • Outside Clinician • Photographer • Site Administrator • Site Clinician 7. Make changes and select Save Changes. 8. The List of Users will be displayed and edits will be saved.
64 II For Camera Operators (Pullout section) Adding Sub‐Sites Sub‐sites are used for organizations that have multiple site locations. Each site should have its own location listed with its own set of users. 1. On the side menu of the EyePACS website, select Edit Accounts. 2. The EyePACS Administration options will appear. 3. Select Add, Edit, or Delete Sites. 4. The complete List of Sites will appear. Scroll to the bottom of the list and click Add New Site. 5. Enter all data for new site. 6.
65 II For Camera Operators (Pullout section) 7. For the Parent Site Name you must select the parent site in this drop down menu. 8. Default Private Selection Value should be left unchecked. 9. Click Save. The List of Sites will appear.
66 II For Camera Operators (Pullout section) DRS Troubleshooting CR-DGi Problem Monitor (#2 in camera diagram on page 19) shows error message. Monitor (#2 in camera diagram on page 19) of camera is black. Camera bed will not move. Fundus camera goes dark/sleep mode. Cannot see ring to focus patient’s pupil and the image is way out of focus. Solution Turn camera off and on using Power Switch (#15 in camera diagram on page 19) Make sure both cameras are turned on. Make sure lens cap is off.
67 II For Camera Operators (Pullout section) Canon Rebel Problem Camera does not flash or take picture. Camera does not flash or take picture AND/OR a photo is showing on the screen of the digital camera. There is an artifact on all images captured. Solution Delete images from the memory card. See instructions for formatting card on Page 20. The camera is in program mode. Press the “playback” button and turn off. Use the camera “blow brush” to clean the front lens of the camera.
68 II For Camera Operators (Pullout section) Importance of Good Data What are good data in terms of EyePACS? Good data are data that help ensure that diabetic retinopathy is an effective method of treatment, support its sustainability in a clinical setting, and inform telemedicine policy.
69 II For Camera Operators (Pullout section) What other data should be reported to the EyePACS team? 1. Patient Stories. For example, a story about someone who would have otherwise gone blind if they had not been screened. 2. Process Stories. Stories about what works when recruiting patients, scheduling screening and tracking referrals, and what does not. 3. Screening Events.
70 II For Camera Operators (Pullout section) Telemedicine Consent Form The EyePACS Handbook: Tools for Program Success
AUTHORIZATION AND CONSENT TO PARTICIPATE IN EyePACS TELEMEDICINE CONSULTATION The purpose of this form is to obtain your consent to participate in EyePACS, a program providing Diabetic Retinopathy Screenings by the use of Telemedicine Consultations. Your doctor, __________has determined that telemedicine consultation may provide you with access to services and expertise not otherwise available.
72 III For Providers III FOR PROVIDERS Importance of Physician Engagement Providers are an essential element of the EyePACS telemedicine program. In most clinics, diabetes patients are referred for screenings by the doctors who see them in the course of their regular diabetes management program.
73 III For Providers Patient Spotlights Sometimes it’s easy to forget that this program really is about avoiding preventable blindness and changing people’s lives. There are countless stories of patients whose eyesight was saved because they were given a routine retinopathy screening through the EyePACS program. Here are some of those stories. • A woman came in for a regular appointment. She had relatively low blood sugar levels and was not experiencing any vision problems.
74 III For Providers Standing Orders Clinics can implement a standing order for all diabetic patients to receive retinopathy screening as part of their clinic visit. Standing orders take the burden off of doctors and can more fully integrate retinopathy screening into the workflow of the clinic, making it easier for patients to get screened and ultimately making the program more successful. Sample Standing Order Policy: 1.
75 III For Providers Communicating Screening Results to Patients & Treatment Options Answers to Common Questions about Screening Results and Treatment What are the Stages of Diabetic Retinopathy? Diabetic retinopathy has four stages: 1. Mild Nonproliferative Diabetic Retinopathy. At this earliest stage, microaneurysms occur. They are small areas of balloon-like swelling in the retina's tiny blood vessels. 2. Moderate Nonproliferative Diabetic Retinopathy.
76 III For Providers If the bleeding is severe, patients may need a surgical procedure called a vitrectomy. During a vitrectomy, blood is removed from the center of the eye. How is macular edema treated? Macular edema is treated with laser surgery. This procedure is called focal laser treatment. A doctor places up to several hundred small laser burns in the areas of retinal leakage surrounding the macula. These burns slow the leakage of fluid and reduce the amount of fluid in the retina.
77 III For Providers A vitrectomy is performed under either local or general anesthesia. The doctor makes a tiny incision in the eye. Next, a small instrument is used to remove the vitreous gel that is clouded with blood. The vitreous gel is replaced with a salt solution. Because the vitreous gel is mostly water, you will notice no change between the salt solution and the original vitreous gel. The patient is usually able to return home after the vitrectomy. Some people stay in the hospital overnight.
78 III For Providers Referrals and Follow-Up Care The EyePACS Referral Tracking Module About 15% of patients who are screened through the EyePACS program get referred to an eye specialist for examination and treatment; however, many of those patients don’t go. The EyePACS system includes an area for tracking patient referrals. If a patient is flagged for referral they will show up on the referral list on the EyePACS website.
79 III For Providers The EyePACS Handbook: Tools for Program Success
80 III For Providers Continuing Medical Education Opportunities EyePACS is working to develop a Continuing Medical Education (CME) program in which providers can earn CME credits. EyePACS will offer easy-to–access, online courses to educate doctors and diabetes case managers about diabetic retinopathy and diabetic retinopathy screening. More information will be provided to clinics as it becomes available.
81 III For Providers Tools to Remind Providers to Suggest Screenings If your clinic does not have a standing order for diabetic patients to get screened, there are a variety of other ways clinics can incorporate retinopathy screening into the regular clinic workflow and remind doctors to order regular screenings for their diabetic patients.
82 III For Providers Diabetes Visit Checklist (Example) Date: PCP: AGE:________ RACE: ________ SEX: ________ BP: ________ PULSE: ________ TEMP: ________ HT: ________ WT: ________ Current medications: Laboratory tests sent: Hb1Ac Lipid profile Micro/Alb Lfts Immunizations updated: Pneumo Flu Tetanus Other Retinopathy Exam: Done within last 12 months Referral to Diabetes education referral: Done within the last 12 months? Foot exam: (“Y” or “N” to indicate findings) Is there a foot ul
83 III For Providers Disease Registry Many clinics are using chronic disease management systems (CDMS) to track and manage patient data. These registries provide detailed tracking information on patients’ chronic diseases, including all the care recommended for their known illnesses, a record of the treatments and tests they have received, and automated reminders for preventive health care needs.
84 III For Providers IT department and EyePACS to configure your IP address and begin the testing phase. During the testing phase, the i2iTracks support team will ensure that the demographic data from i2iTracks is interfacing correctly with EyePACS, and that the case data and results are coming back into i2iTracks from EyePACS. Setup of EyePACS in i2iTracks The majority of the setup of the EyePACS Interface is configured by the i2i Systems Support Department.
85 III For Providers Click the Browse button to display your list of Procedures/Referrals. Click to highlight the Procedure for the Retinal or Eye Exam, and click OK. Make sure the procedure name appears in the EyePACS Interface Setup screen. Click OK to save your setup. Creating a New EyePACS Case in i2iTracks: To create a new EyePACS case in i2iTracks, follow these steps: 1. Make sure you know the location of where the pictures that you want to attach to the case are stored. 2.
86 III For Providers 7. Upon creating your new case, you are returned to i2iTracks. 8. Based upon how your interface is configured, EyePACS sends regular updates to i2iTracks. In the next upload into i2iTracks, there will be a new pending EyePACS case attached to the patient you just entered. As completed cases are uploaded, the Profile indicator for Retinal or Eye Exam will be automatically updated.
87 III For Providers Viewing EyePACS Cases in i2iTracks: To view EyePACS cases in i2iTracks, follow these steps: 1. Select Patient > Patient Info and select the patient. 2. Click the EyePACS tab under the Tracking tab. 3. The list of the patient’s EyePACS cases will display. This gives you a summary of all of the patient’s cases, and shows the case number, the case date, and the result summary. 4.
88 III For Providers 6. After you log in, the complete consultation report will appear for your review. Reviewing Your Abnormal EyePACS Cases in i2iTracks: i2iTracks will alert you of abnormal EyePACS cases so that these patients are provided with the appropriate follow-up care. A patient ALERT for an abnormal EyePACS result will be attached to the patient’s alert list. The alert will remain attached to the patient until the abnormal case has been marked as reviewed.
89 III For Providers Once a case has been reviewed, click the Flag as Reviewed button. They will be removed from this Abnormal EyePACS cases report and the Alert is removed from their Alert list. Using i2iTracks Patient Search for EyePACS Cases i2iTracks has provided additional Patient Search filters for EyePACS cases. When creating a new search and adding filters, select the EyePACS cases filter.
90 III For Providers The EyePACS Cases Not Mapped to a Patient screen displays. Highlight the case, and select the Map to Patient button. The Map Patient screen displays. i2iTracks will help you try to find the patient by entering the patient’s first and last initial and the year of birth.
91 III For Providers Review the list or alter the selection criteria so you are able to locate the patient. When you find the matching patient, click to highlight the patient and click OK. You are prompted: “Are you sure you want to assign the following EyePACS case”. Review the information shown and double check to verify the proper patient is selected. When you are certain this is the correct patient, click Yes.
92 III For Providers If you cannot locate the patient account and determine that this is not one of your patients, click the Cancel button. You are returned to the EyePACS Cases Not Mapped to a Patient screen. Highlight the patient and click the Remove from List button. When you have completed mapping your cases, click Close at the bottom of the screen.
93 IV PATIENT OUTREACH IV PATIENT OUTREACH Top Three Patient Outreach Opportunities 1. PROVIDERS. The first contact for diabetic patients is their family physician/general physician, diabetes case manager, or health center provider. These providers should receive information, training, and motivational tools to encourage them to refer diabetic patients for retinopathy screening. Opportunity: Conduct seminars for physicians on diabetic eye complications with focus on eye screening and its importance. 2.
94 IV PATIENT OUTREACH Patient Communications Materials Waiting room posters and mailed postcards are an effective way to educate patients about diabetic retinopathy and encourage them to ask their doctors about getting screened. When placed up in clinic exam rooms, they also remind providers to suggest that their patients get screened during their primary care visits. The following materials can be photocopied or used to inform the creation of clinicspecific postcards and posters.
IF YOU ARE DIABETIC Your eyes should be checked once a year for RETINOPATHY. RETINOPATHY SCREENING is available at this clinic. It’s a simple, painless test that takes about 15 minutes and could save your sight.
98 IV PATIENT OUTREACH Friends & Family Outreach Many clinic patients may have diabetic friends or family members who might not know that they need yearly diabetic retinopathy screenings. Word of mouth is an effective way to try to reach these individuals and bring them in to get screened. Posters and informative emails and text messages can be used to educate patients about the risks of diabetic retinopathy and the screening services that the clinic provides.
99 IV PATIENT OUTREACH Sample Text Messages: (The character limit for an SMS text messages is 160 characters.) Diabetics are at risk for retinopathy, an eye condition that can lead to blindness. A simple, painless exam could save your vision – schedule yours today! [Name of Clinic] now offers screening for diabetic retinopathy, a serious eye condition that has no symptoms but can lead to blindness. Call [Clinic phone].
100 V Training & Recognition Programs V TRAINING & RECOGNITION PROGRAMS Training Day: What to Expect When a clinic begins the program, the EyePACS regional coordinator will schedule a day to conduct on-site training with clinic staff that have been selected to function as clinic photographers. Prior to this visit, the clinic must ensure that they meet the Minimum Technical Requirements (located on page 16 of this binder).
101 V Training & Recognition Programs By the end of the day, each photographer will have gone through the process a total of three times and will have three sets of images that count toward the 10 test cases they need to perform in order to become certified. Trainees will be instructed to perform the remaining 7 test screenings within week and upload them to the EyePACS website on their own. They will receive additional feedback and instruction from EyePACS staff via email and through the EyePACS website.
102 V Training & Recognition Programs The Learning Community & Ongoing Support Once a clinic has been set-up with a camera and staff members have been certified as photographers, your regional coordinator, as well as the EyePACS program administrator and program director, are available to answer questions and provide ongoing support to clinics.
103 V Training & Recognition Programs Recognition for Clinic Staff Clinic administrators can promote the EyePACS program and demonstrate a commitment to it by offering simple incentives and recognizing clinic staff members when they reach significant program milestones. Providing incentives for staff members can also motivate them to integrate diabetic retinopathy screening more fully into the workflow of the clinic. • Initial Milestone – the 100th Screening.
104 V Training & Recognition Programs Monthly Clinic Progress Reports Clinics will be given monthly reports detailing their program statistics for each month and for the year to date.
105 VI Streamlining Administration VI STREAMLINING ADMINISTRATION Billing UC Berkeley clinicians will provide three months of interpretations of retinal images (up to 20 per week) at no charge to your clinic beginning on the day that the first photographer is certified. During this time we will work with your administrative staff to develop a strategy for sustainability of the program.
106 VI Streamlining Administration Reimbursement We understand and acknowledge that reimbursement is a critical element of the EyePACS program. To date, reimbursement for DR screening has been limited. Please know that we are working on this issue but given the current budget environment, we expect to encounter delays in finding resolution.
107 VI Streamlining Administration Specialist at distant site Check with individual payers regarding specific instructions Standard Medi-Cal FFS guidelines Only ACGME trained Ophthalmologists qualify Reimbursable services depending on scope of service & setting – 99241 – 99243 (Office Consultation) – 99251 – 99253 (Inpatient Consultation) – 99211 – 99214 (Established Patient Office Visit) – 99231 – 99233 (Subsequent Hospital Care) – Must add “GQ” modifier Medicare Only reimburses for store-and-for
108 VI Streamlining Administration Healthy Way LA (HWLA) FQHC must participate in the Public Private Provider (PPP) program HWLA does not recognize FQHC status PPP clinics are instructed to contract directly with an Optometrist or Ophthalmologist for services PPP bills for both technical & professional components of DRS PPP responsible to pay specialist Contract with specialist must be approved by the Department of Ambulatory Care of the LA County Health Department Source and Disclaimer: The in
109 VII Community Outreach VII COMMUNITY OUTREACH Screening Events Many clinics hold special event clinics for diabetes education. These are a great opportunity to let patients know about the importance of diabetic retinopathy screening, and even perform screenings on the participants that day. Clinics have been able to see up to 60 patients in a day using this “special event” approach.
110 VII Community Outreach Engaging with Partners for Fundraising Community partners can be a great way to reach out to new potential patients, raise awareness of diabetic retinopathy, and create successful fundraising drives and events. Here are some ideas for potential community partners: • Civic Societies and Fraternal Orders: Elks Clubs, Rotary Clubs, Junior Leagues, and other organizations are often willing to help raise money for worthy causes, especially ones that might affect their members.
111 VII Community Outreach Raising Awareness through the Media Clinic Press Release FOR IMMEDIATE RELEASE Local Clinic Launches Screening Program to Prevent Blindness in Diabetic Patients The EyePACS diabetic retinopathy screening program is a groundbreaking application of telemedicine, digitally connecting clinic providers with leading eye doctors to provide low-cost eye care for diabetics.
112 VII Community Outreach could literally have gone blind within a week. The photographer noted the abnormality, called EyePACS to expedite the reading, and referred her to an ophthalmic surgeon to schedule immediate intervention. About EyePACS: The EyePACS program is a partnership with the California HealthCare Foundation and the UC Berkeley Optometric Eye Center. About Clinic: [ADD BLURB ABOUT CLINIC] Contact: Mary Smith, director of public relations Clinic Name 555-555-5555 http://www.clinicwebsite.
113 VII Community Outreach Copy for Clinic Websites [Clinic name] is now offering screening services for diabetic retinopathy! Diabetic retinopathy is the leading cause of blindness among working age adults in the United States. [Clinic name] is now participating in the EyePACS program, which provides low-cost digital screening services to identify retinopathy in diabetic patients.
