Post on 23-Dec-2015
IHS/Joslin Vision NetworkDiabetes Eye Care Program
2001 Information Technology and
Program Support Conference 12 July 2001
Mark B. Horton, OD, MDPhoenix 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
4755
67
5561
47 49
6052 50 52 56 54
010
20
3040
50
6070
80
90
100
AB AK AQ BM BL CA NS NV OK PX PO TC AVG
Diabetic Eye Exam in Past Years
20%
30%
40%
50%
60%
70%
80%
92 93 94 95 96 97 98 99
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
GenesisLegislative 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
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
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 visitProliferative Diabetic Retinopathy
0
5
10
15
20
25
30
1 2 3 4 5
Years
Eve
nt R
ate
(%)
DRS Untreated Eyes
ETDRS by eye
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 NetworkDiabetes 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 ComponentsJVN Image Acquisition Station
• Retinal Image Acquisition
• Integrated Electronic Medical Record
• Patient Education• Data transmission over
existing WAN
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
Diabetes Management andEducation on WWW
JVN Hub Site, FDDIRing, Intranet
INTERNET ACCESS
Central JVN Serverand Data Store (1Terabyte)
Central JVN Reading CenterEMRS and Automated Diagnosisand Treatment Plans
Central JVN ImagingWorkstations EMRS andEducation Modules
Remote Imaging Work StationEMRS and Education
Remote Imaging Work StationEMRS and Education
Remote ImagingWork StationEMRS andEducation
Remote Hub SiteDataStorage(50Gb)
Remote Reading CenterDiagnosis and Treatment
Broker
RPMS
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/JVNDiabetic 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/JVNDiabetes 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 Workload5/00 – 6/01
32 35 35
48
18
0 0 0
52
87
100 98
115
94
0
20
40
60
80
100
120
nu
mb
er
of
imag
es
ob
tain
ed
May
Jun
Jul
Au
g
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Ap
r
May
Jun
Monthly Live Exams and % of Referrals 5/00 – 6/01
0
10
20
30
40
50
60
70
80
nu
mb
er o
f im
ages
ob
tain
ed
0
10
20
30
40
50
60
70
80
PIMC DR Eye Exam Rate5/00 – 6/01
4950
5655
4749
5051
48
51
45
54
51
5455
40
42
44
46
4850
52
54
56
58
DR
Exa
m R
ate
Comparison of patientsimaged vs not imaged
•Mean age 50 yrs
•Gender (%F) 65
•HbA1c 8.7
•Yearly Eye Ex 55%
•Diet control 16%
•Oral control 30%
•Combination 42%
•Insulin control 14%
Essentially no difference between the two groups
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/JVN28 Feb 01
331
46
281
2850
180
50
100
150
200
250
300
350
Total PIMC Sells
ImagedUngradeable
Gradable rate: 86% 90% 64%
Patient age and ability to grade images at PIMC
0102030405060708090
100
Graded vs Non-graded images
Ag
e (
years
)
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-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 NetworkDiabetes Eye Care Program
2001 Information Technology and
Program Support Conference 12 July 2001
Mark B. Horton, OD, MDPhoenix Indian Medical Center