By Erica Swegler, M.D.

Eight months ago, I remember sighing as I reviewed a diabetic patient’s chart prior to entering the room. It was noted on my diabetic flow sheet that the patient had not obtained a dilated diabetic eye exam in the past three years. This was despite my urgings on all interval exams, despite the fact that there would be no co-pay for that ophthalmologic visit, and despite the fact that no referral was needed.

Seemingly, all of the barriers to care had been removed for the patient. I also reflected that a few days earlier, I had received a report from a local health plan on several HEDIS measures and my patient population rate of obtaining those measures within my office. I was at a commended level, above national and regional averages on everything except diabetic eye exams, where I was at 56 percent compliance.

In fact, barriers to care still existed. The patient still had to take additional time off work and be able to have transportation to visit the ophthalmologist.

One of the great frustrations of being a family physician is having a patient present with a serious problem that could have been successfully treated if identified early. If you have diabetic patients in your practice — a high probability in Texas with 7.7 percent of the population over 18 diagnosed with the disease — you have had to deal with those insurance reports reflecting your compliance with HEDIS performance measures relating to comprehensive diabetes care, as I did. While family physicians treat diabetes quite well, like other primary care physicians, they have almost always fallen short on the criteria for annual eye screenings for diabetic retinal disease. The difficulty with the measure is that until now, it could not be done in our offices at the time of an office visit. Therefore, nationally, only 48.8 percent of diabetic patients receive their annual eye exam. The statistics are even worse in Texas, where only 39.4 percent receive the exam.

Diabetic retinopathy is an abnormal eye condition caused by diabetes which weakens the blood vessels surrounding the retina. When it is untreated or undetected, it leads to blindness. Individuals diagnosed with type I diabetes for 20 years or more will develop retinopathy, and over 60 percent of type 2 diabetic patients will develop retinopathy.

Vision loss from diabetic retinopathy is largely preventable and treatable! Note that there is a direct relationship between HgA1C control and diabetic retinopathy.

Thus, because of its implications for the patient’s ability to be self-sufficient, the eye exam is a critical part of quality care for our diabetic patients. Now, validated technology exists which allows me to perform a dilated retinal exam in my office without on-site ophthalmologic supervision. Table 1 shows a list of companies that offer new methodologies for conducting retinal exams during office visits. The difference between the technologies is illustrated in Table 2.

Entering patient and insurance information into the machine takes 10 minutes or less. Eventually, in the age of computer interopera-bility, it is hoped the machine could be populated with data directly from an office’s billing software.

Since January of this year, I have added a digital fundus camera to the services I offer in my office. The equipment (plus upkeep and maintenance) is the vendor’s. I had an initial payment and now pay a monthly fee. It is easy to use with minimal training required for staff. After a single drop of 0.5% tropicamide (1/10 the strength of what an ophthalmologist would use and associated with virtually zero-percent risk of angle closure glaucoma) for dilation, the procedure takes less than 10 minutes of clinical staff time. The computer captures the images and they are then transmitted via the Internet to the vendor’s image-reading center where they are evaluated by trained readers under the supervision of a retinal specialist, a concept analogous to cytopathologists reading pap smears with a pathologist’s oversight. A report is sent back to my office within 48 hours with an evaluation and recommendation for a re-exam in 12 months if no pathology is found, a referral to an ophthalmologist for moderate nonproliferative diabetic retinopathy (NPDR) or an urgent referral to an ophthalmologist for severe NPDR or vision threatening pathology.

The experience in my office has been nothing but positive. Even with only three exam rooms to work with, flow of patients is rarely impeded. Doing a diabetic retinal exam has virtually the same impact on flow as doing an EKG. As part of my office’s standard operating procedure, when a diabetic patient either arrives or is roomed, we offer the exam to patients. Many readily agree to the exam as it saves them the hassle of taking time off from work to make another appointment with another physician. Dilation drops are put into the patient’s eyes soon after they arrive so the effect can begin while they’re sitting in the waiting area, prior to their encounter with the physician — this is viewed by patients as an effective use of their time. It takes no extra time for me directly.

Depending on patient flow and physician availability, the digital fundus exam can be performed prior to the patient encounter with the physician or immediately after the physician encounter. Patients can also review their photos, which many find fascinating.

I am assured that my patients have received an important screening test so my ability to reach higher levels of HEDIS criteria will be met. There are currently offices using this technology that have brought the office baseline rate of diabetic eye exams from 40 percent to 86 percent in three years.

The procedure is billed to the insurance company for all insurers except Medicare by the vendor, I am then reimbursed a set fee per exam plus I receive some ancillary revenue for my practice. Recently, the fee paid to me has increased to $40 for each exam. The procedure produces a small net profit but more importantly, my patients are more assured of receiving an important screening test for their disease every year. I have the satisfaction of knowing that I am helping reduce the risk of vision loss through the early detection of diabetic retinopathy in appropriate patients. Of course, patients who need to be followed by an ophthalmologist for cataracts or glaucoma or who have been known to have diabetic retinopathy (with or without prior laser surgery) are not candidates for screening with this technology. The technology will also not evaluate for glaucoma or cataracts, which do occur with increasing frequency in diabetic patients. Nor would I want to disrupt a long-standing relationship that a patient has with an ophthalmologist. However, I am pleased with my ability to extend care to patients who often do not get the recommended care. I am firmly convinced that my HEDIS rate will increase overall to greater than or equal 85 percent, which is considered excellent care by at least one local health plan. I truly consider this service to be a win-win for my patient and myself.