Retinal exam brings diabetic retinopathy screening to primary-care setting

Take-home message: A retinal exam system improves access for patients with diabetes to detect eye disease early and refers them to an eye-care specialist for further evaluation and treatment. 

Reviewed by Yvonne I. Chu, MD, MBA, and Sunil Gupta, MD

It is no secret that a diabetes epidemic exists in the United States. A 2014 report from the Centers for Disease Control and Prevention states that 29.1 million Americans have diabetes-or a lsttle more than 9% of the total U.S. population. Almost one-third of those with diabetes are undiagnosed, according to the report. 

With the possible damaging effects on the eyes, not to mention the rest of the body, it has been a challenge for eye-care professionals (ECPs) to reach those with diabetes for a recommended annual exam. Pensacola, FL-based Intelligent Retinal Imaging Systems (IRIS) is changing that by providing access for diabetic patients to complete their annual retinal exams in the primary-care physician (PCP) office.

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The company’s retinal exam system integrates into the electronic medical record and identifies patients who need the test performed. At the primary-care office, staff uses IRIS to capture images of the patient’s eye, adding about 5 minutes on to an existing appointment. Then, the images are interpreted by an ophthalmologist or retina subspecialist.

Sometimes, the eye specialist interpreting an image is already based in the same local area as the PCP and IRIS helps to bring them together virtually using the IRIS Cloud which stores the retina images, said Jason Crawford, IRIS chief executive officer.

Other times, a larger health-delivery system may incorporate its own eye specialists already within their system to interpret those images, like at the Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami.

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Yet, a third scenario is that physicians who are part of the IRIS Reading Center will interpret the images. These readers are contracted by IRIS and provide the interpretation via the IRIS Reading Center. The Harris Health System, the public safety net for Harris County in Houston, uses this model in collaboration with the Department of Ophthalmology at Baylor College of Medicine and University of Texas-Health.

Patients with suspicious pathology-be it diabetic retinopathy, glaucoma, cataract, or an epiretinal membrane-are guided to follow up with an ophthalmologist or retinal specialist for further care.

“Our system reaches those patients who do not currently seek eye care and encourages them to establish care,” Crawford said. 

The purpose of IRIS is to reach as early as possible the patients with diabetes who would not otherwise go for an annual eye exam, said Sunil Gupta, MD, chief medical officer of IRIS. Dr. Gupta started the company in 2011.

“In some parts of the country, only 30% to 40% have that annual exam,” Dr. Gupta said. “For whatever reason, it doesn’t happen, maybe because they aren’t symptomatic until they have significant vision loss.”

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By reaching these patients earlier, eye problems are usually less severe, and patient care costs are lower, Dr. Gupta said. Better visual outcomes also are more likely.

This is why the idea of implementing IRIS within a PCP’s office seemed to work most effectively, as those with diabetes will make more of an effort to see their primary-care office, Dr. Gupta said.

The ophthalmologist’s role

One point that both Dr. Gupta and Crawford want to make clear is that IRIS is not a system that will take patients away from ophthalmologists. In fact, they say the system actually provides additional patients for eye-care specialists-and it gets the patients to them who have the most acute pathology. One in eight of the patients with diabetes who are examined have sight-threatening disease.

IRIS works with primary-care providers to set up a system for referral to local ECPs. At systems like Harris Health, there’s already a connection with physicians from Baylor College of Medicine and University of Texas.

“Their ophthalmologists and optometrists have been able to take these patients and manage them,” Dr. Gupta said.

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Yvonne I. Chu, MD, MBA, chief of Ophthalmology Service, Ben Taub Hospital, Harris Health System, and associate professor at Baylor College of Medicine, said Harris Health decided to invest in IRIS in 2013 because leaders at the system wanted to do a better job of managing care for those with diabetes.

They purchased eight systems and strategically placed them at different Harris Health Community Clinic locations in the Houston area. They trained technicians, many of whom had zero eye-care experience before, on how to use them system. As the only things needed were Internet access and a small room with dim lights, Dr. Chu said the upfront start-up costs were manageable.

Since purchasing the systems in 2013, more than 58,000 scans have been performed at Harris Health, Dr. Chu said.

“We have developed a customized care plan based on the interpretation results performed in the IRIS Reading Center,” she said.

“Patients with suspected pathology are referred to optometrists for further screening, and those patients with proliferative disease can come directly to our retina specialists for timely care,” Dr. Chu said. “In a system where we have greater demand than resources, we’ve been able to filter out patients who don’t have pathology to create more capacity for those who need timely intervention.”

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The percentage of patients with diabetes who are getting the initial screenings since they have implemented IRIS has dramatically increased, and the system is now starting to look at their outcomes.

Some primary-care offices are now setting up systems where the test is administered at their office, but a local ophthalmologist’s office will call with the results and set up the follow-up eye exam, Crawford said.

The PCP also receives a copy of the results.

Business side and logistics

The IRIS system is now in 25 states. There were 80,000 patients screened with IRIS last year, said Dr. Gupta, and that’s a number that may at least double this year, he believes.

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Insurance coverage has been favorable as this approach saves cost, improves quality outcomes, and documents the patients risk complications.

“After the patient, the insurance payers have the most economic incentives as we are successfully improving access for their members to complete the diabetic retinal exam,” Crawford said. “As our largest payer, the Centers for Medicare and Medicaid Services insures the largest number of patients with diabetes.”

When a practice decides to work with the IRIS system, someone on practice staff, often a medical assistant or even front-desk person, is given a half day of training on how to use the system. Dr. Gupta describes the training and support as high touch.

“We don’t just sell them a box,” he said.

Incorporating use of the imaging system along with everything else a primary-care practice does may take some getting used to at first. It takes some thoughtful workflow among nurses, scheduling staff, and within the electronic medical record systems, Dr. Gupta said.

Primary-care practices that follow the company’s recommended best practices do well with IRIS, Crawford said-the ones that struggle are those that do not have buy-in.

“It’s the primary-care practices that say ‘We’ll try to this out’ that get marginal improvement,” Crawford said. “We work hard to ensure that the practice is invested and have adopted a system-wide approach to improving outcomes.”

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Yvonne I. Chu, MD, MBA

E: ychu@bcm.edu

Dr. Chu did not indicate any financial interest in the subject matter.

Sunil Gupta, MD

E: guptasunil@icloud.com

Dr. Gupta is founder and chief medical officer of Intelligent Retinal Imaging Systems.