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Indian Health Service The Federal Health Program for American Indians and Alaska Natives

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Frequently Asked Questions

eye exam
Q. Who is eligible to host a deployment of the IHS-JVN Teleophthalmology Program?

A: Any Indian Health Service, Tribal, or Urban Indian Health Program (I/T/U) is eligible for a deployment of the IHS-JVN. Specific sites selected for deployment are determined based upon site interest, capacity, public health criteria, and IHS policy.

Q. Is this program available to other than American Indian/Alaska Native facilities?

A: No

Q. How do I apply for hosting a deployment of the IHS-JVN Teleophthalmology Program?

A: Send an email message to the director of the IHS-JVN Program (mark.horton@ihs.gov) requesting consideration for participation in the program, and supply the following information:

  • Facility name and location
  • Prevalence of diabetes in the population served by the facility
  • Diabetic retinopathy examination rate for the past three Government Performance and Reporting Act (GPRA) years.

Q. Does the IHS-JVN hosting sight have to buy the equipment and service?

A: No; virtually all direct costs of the deployment and operation of an IHS-JVN Imaging Acquisition Station are borne by the IHS-JVN Teleophthalmology Program. This includes the following:

  • All Equipment, software, and services directly related to imaging and transfer of the image
    • Camera, imaging computer, connectivity hardware
    • JVN/Chronic Disease Management Program (CDMP) software
    • Technical and clinical support
    • Maintenance/repairs
  • Reading and reporting services
  • Quality assurance (QA)
  • Initial and recurrent Training and certification of Imager

Q. What costs does the IHS-JVN hosting site bear?

A: The hosting site supplies the salary for the imager. This is almost always a part-time position. The hosting site must also supply the space to house the Imaging Acquisition Station.

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Q. Who can be an imager?

A: A special background or previous training is not requisite for imager trainees. This skill level for this task is defined in a Position Description classified at GS4-5, and is well within the capacity of an existing clerk. Previous medical or nursing training is not required. More important than the background of the imager is the immediate availability of the imager, since this is almost always a fractional FTE duty. The imager should be selected based upon interest and consistent availability to the imaging station.

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Q. How much time is required for imaging duties each day?

A: The total time required by the imager is generally dependent upon the size of the active diabetic registry and the ability of your staff to effectively recruit patients for IHS-JVN imaging. If imaging is available every ordinary work day, approximately 1 hour of imaging per day is needed for every 600 patients with diabetes. The preferred method for patient recruitment is all patients with diabetes, regardless of when their last diabetic retinal occurred or when their next exam is planned.

An alternate method is to image only those patients who have not had an exam in the past year. If this method is used the number of patients needing imaging to bring your total annual diabetic retinopathy examination rate to a theoretical 100 is shown in the following table:

Approximate Daily JVN IAS Patient Demand
DM Prevalence Annual Diabetic Retinopathy Examination Rate
  30% 40% 50% 60% 70%
300 1 .75 .75 .5 .5
400 1 1 1 .75 .5
600 1.75 1.5 1.25 1 .75
800 2.5 2 1.75 1.5 1
800 2.5 2 1.75 1.5 1
1000 3 2.5 2 1.75 1.25
1500 4.5 4 3.35 3.5 2
2000 6 5 4 3.5 2.5
2500 7.5 6.5 5.5 4.5 3.25
3000 9 8 6.5 5.25 4

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Q. Who owns the IHS-JVN equipment?

A: The IHS-JVN Teleophthalmology Program retains ownership of all equipment and software supplied by the program.

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Q. Who maintains the equipment?

A: The IHS-JVN Teleophthalmology Program maintains the equipment and updates the software as needed.

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Q. Where do I get technical and clinical support for operating the program?

A: The IHS-JVN Teleophthalmology Program clinical and technical support via a three tier help desk as needed.

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Q. What is involved in the training for the imager?

A: All imagers are trained to demonstrated proficiency. This typically requires 2½ to 3 days and occurs at the IHS-JVN offices in Phoenix, AZ. Most of the imagers are Native Americans, and training at PIMC allows them to train in an IHS facility on IHS patients with a Native American trainer. This has been a feature of the training that has been

appreciated by the imager trainees.
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Q. What type of patient should undergo imaging?

A: The primary purpose of the IHS-JVN Teleophthalmology Program is to increase the annual diabetic retinopathy examination rate. There are different patient recruitment strategies to achieve this. The greatest clinical and business potential is achieved when all patients with diabetes are targeted for imaging. At a minimum, all patients with diabetes who have not had an eye examination within the past year should undergo IHS-JVN Imaging, but this program can serve any patient with a clinical need for retinal teleconsultation.

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Q. How are patients recruited for imaging?

A: The initial goal of the IHS-JVN teleophthalmology Program is to increase the annual diabetic retinopathy rate at its hosting site. The patients should be recruited from the clinic where your patients obtain primary care of their diabetes. The most efficient method targets all patients with diabetes. At a minimum all patients with diabetes who have not had an eye examination within the past year should be selected from your primary care or diabetes clinic for IHS-JVN imaging. This is best done using Electronic Health Record or iCare tools.

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Q. Who reads the images?
A: Certified JVN readers at the IHS-JVN National Reading Center in Phoenix interpret the retinal images.
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Q. Our eye doctor prefers to read the retinal images. Is this possible?

A: The IHS-JVN images may be viewed locally for serial comparison of certain features of the fundus and external eye. However, these images cannot be read locally for diabetic retinopathy diagnosis. The JVN system has been carefully tested to establish validity with the Early Treatment Diabetic Retinopathy Study (ETDRS). It is vital that this fidelity with the ETDRS be maintained since this is the gold standard for evaluating diabetic retinopathy, and thereby is a qualifying method for diabetic retinopathy surveillance under Government Performance and Reporting Act (GPRA).

To maintain this validity the JVN process must be strictly followed. This requires adherence to the entire JVN process including equipment, software, and staff. The JVN imagers and readers are specifically trained and certified to use JVN system to produce results that maintains a high degree of fidelity with ETDRS. Any deviation, such as using non-certified readers or non-JVN diagnostic reading technology, would invalidate the process. For these reasons the images obtained from all IHS-JVN Imaging stations must be evaluated at the IHS-JVN National Reading Center. The JVN readings/report is the highest quality and only validated outcome of the program. The readings/report comes free of cost to the hosting site, so there is little evidenced based reason to consider local reading of the images.

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Q. Is credentialing and privileging required at the hosting site?

A: Imager:
Your Imager will obtain training and provisional certification by a JVN imager trainer. Imaging services can be delivered by your imager staff based upon job description or Position Description, and doesn't require privileging except as required by your Medical Staff Bylaws.
Reader:
The JVN images are read and reported by a trained and certified Reader at the IHS-JVN National Reading Center. This reader is a licensed optometrist or ophthalmologist that is privileged for clinical and telemedicine services at the Phoenix Indian Medical Center (PIMC). The IHS-JVN readers also should be privileged at your facility. This is done using the Centers for Medicare and Medicaid Services (CMS) method of Reliance Privileging of telemedicine providers. This process relies upon the credentialing process of PIMC, but privileging of each IHS-JVN provider is still granted by your Governing body. This carries several administrative and operational requirements that will be carefully discussed before deployment.

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Q. Does the Centers for Medicare and Medicaid Services (CMS) or The Joint Commission (TJC) have any special requirements for supplying this telemedicine service at our facility?

A: CMS and THC standards require that telemedicine providers be credentialed in your facility. This is provided by CMS Reliance Privileging of telemedicine providers. While many TJC standards apply to telemedicine as a component of general healthcare service delivery, LD LD.04.03.09 and MS.13.01.01 apply specifically to telemedicine.

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Q. How are reports obtained from the Telemedicine Program?

A: The JVN report is available to the hosting site by requesting mailed paper reports, utilizing the web based report retrieval, or the automated electronic return of the report to RPMS/EHR.

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Q. Where do the retinal images reside?

A: The retinal images are stored on the computer that drives your JVN Image Acquisition Station (IAS) and the image storage server located at the IHS National Reading Center in Phoenix. Your staff may view these images at either location.

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Q. How can I know that the JVN system is safe and effective?

A: The JVN has been tested in controlled studies that have passed the scrutiny of academic peer review. These studies have clearly demonstrated the validity of the JVN as compared to the Early Treatment Diabetic Retinopathy Study (ETDRS). Since the ETDRS is the gold standard for evaluating diabetic retinopathy, the JVN should be considered safe and effective. The following references provide the details of these validation studies:

  • Sven Bursell, et al. Stereo non-mydriatic 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.
  • Anthony Cavallerano, et al. Use of JVN digital video non-mydriatic retinal imaging to assess diabetic retinopathy in a diabetic outpatient intensive treatment program. Retina, 2003; 23(2), 215-23.

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Q. Would a live examination be better than JVN imaging?

A: The conventional and most prevalent method of evaluating diabetic patients for retinopathy is a dilated retinal examination by an ophthalmologist or optometrist. However, the gold standard for establishing the level of diabetic retinopathy is a photographic method established by the Early Treatment Diabetic Retinopathy Study (ETDRS). The JVN has been proven to hold a high level of concordance with the ETDRS. For this reason IHS statistical methods tally a JVN examination as equivalent to a conventional live examination. However, all supra-threshold JVN readings are referred for live examination to confirm or rule-out the need for referral for treatment.

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Q. Does and IHS-JVN examination replace a complete eye exam?

A: No; a periodic complete eye examination is a component of good health care for almost everyone. The IHS-JVN examination is equal or better than a live eye examination for the purpose of achieving standard of care for diabetic retinopathy surveillance and diagnosing diabetic retinopathy, but it does not replace other features of a complete eye exam such as a check of intraocular pressure or glasses. However, it does meet/exceed the standard of care needed to avoid the consequence of the leading cause of new blindness among working age adults, diabetic retinopathy. An additional evaluation is not needed unless there is another reason for an eye exam, e.g. pre-existing eye condition other than DR, need for new glasses/contact lenses, periodic general eye evaluation, etc.

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Q. Usually a diabetic eye examination requires dilation of the patient's pupil with eye drops. Does the JVN system use eye drops?

A: The IHS-JVN system uses a specially designed camera that does not require pupil dilation in most cases. In certain cases with unusually small pupils a very weak and short acting drop may be used to improve image quality.

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Q. We already have a retinal camera; can it be used with the JVN system?

A: No. The JVN imaging device is one component of a standardized program and cannot be replaced by another design. This imaging device, like all hardware, software, and processes of the JVN system must remain standardized to maintain its validity with the Early Treatment Diabetic Retinopathy Study (ETDRS). For this reason, non-JVN imaging devices must not be used.

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Q. Will the JVN system produce a change in our eye department workload?

A: Yes. Most health care facilities in the IHS are able to provide diabetic retinopathy examinations to approximately 50% their known patients with diabetes each year. Participating in the IHS-JVN Teleophthalmology Program can substantially increase this examination rate. Referrals from the program must receive a live examination, so any effectively deployed IHS-JVN system is certain to increase the patient load on the system used to provide eye examinations. However, when properly implemented, the program reduces the number of routine diabetic retinopathy exams by offloading this lower acuity disease and substituting a smaller number of patients with more severe disease. The net change is one of increased efficiency rather than increased workload.

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Q. Can the JVN system identify eye disease other than diabetic retinopathy?

A: Yes. The JVN system can identify most clinically evident eye diseases visible within the imaging fields used for evaluating diabetic retinopathy. This covers a wide range of diseases including macular degeneration, glaucoma, hypertensive retinopathy, and many other diseases with clinical finding in the posterior ocular fundus.

  • Sing-Pey Chow, et al. Comparison of nonmydriatic digital retinal imaging versus dilated ophthalmic examination for nondiabetic eye disease in persons with diabetes. Ophthalmology, 2006;108(3):833-840.

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Q. How is the IHS-JVN Teleophthalmology Program funded?

A: The IHS-JVN Teleophthalmology Program is funded by appropriation language that provides funding specifically for this purpose. This language specifies the use of the JVN system.

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Q. Has the JVN system been shown useful in Indian country?

A: Yes; Analysis of the pilot study of the IHS-JVN Program at the Phoenix Indian Medical center showed a dramatic and continuing increase in the annual diabetic retinopathy examination rate as compared to the control site without the program. This study was continued for 3 additional years, demonstrating a sustained benefit that was linked to a similar increase in laser treatment for high risk DR. Additional details of this study is available in the following citation: Wilson C, Horton M, Cavallerano J, Aiello LM. Addition of Primary Care-Based Retinal Imaging Technology to an Existing Eye Care Professional Referral Program Increased the Rate of Surveillance and Treatment of Diabetic Retinopathy. Diabetes, Vol. 28: 318-322, 2005. The following graphs depict this outcome:

 
Thumbnail - clicking will open full size image - Retinal exam rates among people with diabetes shows increases of about 5% at a clinic without a JVN image acquisition station and the exam rate increased by about 25% at the clinic with a JVN image acquisition station.  This comparison was from the start to the end of an evaluation period (from March 2000 to December 2001).
Graph 1
 
Thumbnail - clicking will open full size image - The percentages of diabetic patients with retinal examinations were measured at a clinic with a JVN image acquisition station and another clinic without.  The clinic with a JVN acquisition station had a high exam rate throughout.
Graph 2
 
Thumbnail - clicking will open full size image - The chart compares the rate patients received a retinal exam and those that received laser treatment.  JVN resulted in a 50% increase in diabetic retinopathy surveillance and 51% increase in laser treatments for diabetic retinopathy.
Graph 3

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Q. Is the IHS-JVN Telemedicine Program experimental?

A: No; telemedicine is an established method for examining the eye for diabetic retinopathy, and is being used by large healthcare programs to improve compliance with standards of care and reduce avoidable vision loss due to diabetic retinopathy. The American Telemedicine Association has developed practice recommendations for teleophthalmology (diabetic retinopathy), including performance measures. The IHS-JVN program performs at the highest ATA performance category (ATA Category 3), and is not experimental or novel.

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Q. Does the IHS-JVN Program conduct research on American/Alaska Natives?

A: No; the IHS-JVN Program carefully analyzes the performance of the program to ensure its quality and identify opportunities to improve eye care in Indian Country, but no Native American or Alaska Native is subjected to research.

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