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