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IHS/Joslin Vision Network Diabetes Eye Care Program 2001 Information Technology and  Program Support Conference 12 July 2001 Mark B. Horton, OD, MD Phoenix Indian Medical Center

Diabetic Retinopathy DM 4X-8X  more common among NA Virtually all diabetics eventually have DR ­ incidence and severity with ­ duration Diabetic Retinopathy is the leading cause of new   blindness in adults 8000 new cases/yr

Diabetes Mellitus in US 37% - 79% not following guidelines to prevent visual impairment and blindness 50% with DM have yearly eye exam (US) Only 40% with high-risk DR receive timely laser surgery

Diabetes Mellitus in IHS > 80,827 NA/AN with DM IHS (1999)- 54% (47% - 67%)

Annual DR Eye Examination

Diabetic Eye Exam in Past Years

Cost of Treating Diabetes Mellitus The cost of treating the diabetic patient is high >15% of health care costs (US) The cost of treating the diabetic patient with complications is higher

The Cost Savings of Preventive Eye Care in the Diabetic Patient $472 million/yr (100% level of care) 94,304 person-years of sight (100% level of care) $1000/year for each newly enrolled DM II patient $9571/year for each newly enrolled DM I patient

Genesis Legislative Language FY99    Of the funds available to the IHS for diabetes programs, the Service should fund cooperative efforts with the Joslin Diabetes Clinic in Boston to non-invasively screen for undiagnosed diabetes and diabetic retinopathy in Indian Communities

Legislative Language    FY2000    Increases to the budget request include…$1,000,000 for diabetes screening through the Joslin program,…    FY2001    Funding for the Joslin program is continued at the FY2000 level.

Legislative Future ??????????????????? FY2002- $2,000,000 FY2003- $4,000,000

National Clinical Trials: Diabetic Retinopathy Diabetic Retinopathy Study (DRS); 1971-1975 Early Treatment Diabetic Retinopathy Study (ETDRS); 1979-1990 Diabetic Retinopathy Vitrectomy Study (DRVS);  1977-1987 Diabetes Control and Complications Trial (DCCT); 1983-1993

Diabetic Retinopathy Non-Proliferative diabetic retinopathy (NPDR) Proliferative diabetic retinopathy (PDR) Vitreous hemorrhage Retinal detachment Blindness Clinically Significant Macular Edema (CSME) Loss of central vision

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Diabetic Retinopathy ETDRS: Severe vision loss can be reduced to < 2% DCCT: Other complications can be reduced by 50% End-stage renal disease Non-traumatic amputation

Visual Acuity less than 20/1000 at each visit Proliferative Diabetic Retinopathy

Goal- Preserve Vision  Identify all patients with DM  Diagnose level of DR yearly  Apply ETDRS standards of care  Apply DCCT standards of care

Telemedicine Opportunities Patient access Standardized high quality care Cost-effectiveness Disease management Education Professionals Patient

Telemedicine Challenges Professional acceptance Patient acceptance Sustainability of programs Affordability Scalability Technological Advances

Teleophthalmology Options Off the shelf “plug and play” Generic image capture and transmission No DR interface Un-validated Inexpensive

Teleophthalmology Options Specialty applications Proprietary image capture and transmission DR interface Validated Expensive

Diabetic Retinopathy Teleophthalmolgy IMAGEnet Tuba City, Rosebud, others Inoveon Oklahoma City: private company Turn-key system: $95/patient Chickasaw

Diabetic Retinopathy Teleophthalmolgy Joslin Vision Network Boston: Joslin Diabetes Center Variable configurations allowing equipment ownership and in-house operation VA (Boston), DOD (TAMC, WRAMC) HIS (Phoenix, Sells)

IHS/Joslin Vision Network Diabetes Eye Care Program   Specific language in the IHS appropriation bills for a collaborative project with the Joslin Diabetes Center using JVN

Joslin Vision Network (JVN) Quick Painless Low level illumination No pupil dilation Interleaved with other patient encounter events

JVN Physical Components JVN Image Acquisition Station

JVN Physical Components Review Workstation Image analysis- pattern recognition and data entry Automated diagnosis- based upon ETDRS Automated documentation to patient and providers Database/storage servers Data archiving and management Outcome analysis Broker Server Network- Connectivity

Schematic of Joslin Vision Network System Architecture

ETDRS Standard Gold Standard- 35mm stereoscopic color slides 7 standard fields

JVN v1.5 640x480 24 bit digital color images (jpeg) 3 overlapping 45º fields Loss of peripheral ±50% of F3, F5, F6, F7 Extrapolation of data for F3, F5-7

JVN v1.5 Advantages No film costs or delays Electronic image transmission Easier and cheaper image archiving less technician skill No pupil dilation patient more comfortable and happier

JVN v1.5 : Validation Study 54 pts (108 eyes) Two independent masked readers 35 mm vs JVN images and algorithms Adjudication by senior retinal specialist

JVN v1.5 :Validation Study    Sven Bursell, et al. Stereo nonmydriatic digital-video color retinal imaging compared to ETDRS 7-field 35-mm stereo color photos for determining level of diabetic retinopathy. Ophthalmology 2001 Mar;108(3):572-585    The use of the JVN system and imaging device can produce a determination of clinical diabetic retinopathy that is comparable with ETDRS photographs.

Goals of the IHS/JVN Diabetic Eye Care Project Establish the utility of the JVN in an IHS setting Improve adherence to scientifically proven clinical standards of diabetes eye care Improve/promote access to diabetes eye care Enhance the quality of diabetic eye care Enhance the educational opportunities for  patients and providers in the clinical setting

IHS/JVN Diabetes Eye Care Program Phase I Deployment Phoenix Area: PIMC 5/00 Examining station in Primary Care Building Reading station in Eye Department Tucson Area: Sells 9/00 Examining station in eye clinic

IHS/JVN: PIMC IAS in Primary Care Clinic waiting room GS-5 Imaging Technician, new employee Passive patient recruitment Pts waiting for PCMC appt Pts waiting for chart update Pts waiting for pharmacy Pts visiting randomly Some public marketing

IHS/JVN: PIMC Access JVN visit into MR/PBS PCC initiated by IAS Imaging procedure documented Pt education documented Technical notes Superbill notations made Reader contacted as needed for stat reading PCC transferred to reading station

IHS/JVN: PIMC Access JVN visit into MR/PBS PCC completed by reader Dx and plan documented Automated letters generated MR signed Superbill completed Data entry Patient business

Monthly Workload 5/00 – 6/01

Monthly Live Exams and % of Referrals 5/00 – 6/01

PIMC DR Eye Exam Rate 5/00 – 6/01

Comparison of patients imaged vs not imaged

Comparison of patients imaged vs not imaged No differences in: computer determined duration of diabetes systolic or diastolic blood pressure creatinine value cholesterol value foot exams diabetes education

IHS/JVN 28 Feb 01

Patient age and ability to grade images at PIMC

Analysis JVN functions appropriately technically capable of acquiring and reading images Referral rate is high; higher threshold likely as more experience is obtained Able to implement in a primary care setting Approximately 1%/month rate of increase in DR exam rate Patient acceptance appears to be high

Analysis Personnel Imager- the capacity (technical and program) of the person capturing the images is absolutely critical but well within the capacity of GS4-5 staff Readers Not the same as evaluating live retinas Ophthalmologists are not the best readers, but make excellent adjudicators if specifically trained

Analysis Organization clinic staff must view this as an important activity Location image capturing should be integral to the clinic visit primary care setting

IHS/JVN: PIMC Active Recruitment PCMC pts without eye exam in the past year Other PIMC clinic pts without eye exam in the past year IAS recruitment

IHS/JVN v1.5/JVN2 JVN 1.5 Revolutionary State of the art Limited Scope Limited scalability in the IHS Cost Orphaned hardware Complexity (hardware and software)

IHS JVN v1.5/JVN2 JVN2 New standard for state of the art Interactive across multiple diabetic disciplines Scalable HL-7 and DICOM compliant

IHS/JVN2  DOD, VA, IHS Collaboration- design development Department/Agency Specific Criteria

IHS/JVN2  IHS Emphasis Multi-disciplinary virtual diabetes center Minimum foot-print Onsite and on-line education for patients and staff Scalable Upgradeable Portable/Hardened

IHS/JVN Deployment Strategy JVN2 Gather experience Gather momentum Gather installed user base Gather political support Funding Community acceptance IHS National Reading Center

IHS/ JVN2 Deployment JVN2  roll-out  4/01 Testing in Boston b-testing at PIMC 08/01 IHS deployment Q4 FY01 ~15 sites with funds through FY01 5-6 FTE Readers (IHS National Reading Center) Recurrent funding?

IHS/Joslin Vision Network Diabetes Eye Care Program 2001 Information Technology and  Program Support Conference 12 July 2001 Mark B. Horton, OD, MD Phoenix Indian Medical Center