In 2018, UPHCS was awarded a total of $65,000 in grant funding from the Blue Cross Blue Shield Foundation of Michigan – Investing in Upper Peninsula Health program, with $20,000 coming from a co-sponsorship provided by the Superior Health Foundation. The funding was used to launch an initiative in Ontonagon and Houghton counties.  Through partnerships with Upper Great Lakes Family Health Centers and Aspirus Ontonagon, the project integrated telehealth technology into primary care clinics to increase access and availability of retinopathy screenings for diabetic patients in the region.

Diabetic retinopathy (DR) is the leading cause of blindness among working-age adults in the United States.  More than 40% of diabetics, aged 40 and older, have DR, many with a vision threatening form of the disease.  Early detection and treatment of DR can significantly reduce vision loss.  Although annual retinal screens for diabetic patients are recommended, the rate of diabetics in the UP who are getting their screens every year is below national benchmarks (as low as 23% in some populations).  Many factors have been identified as contributing to these low rates, but the simplest explanation is that DR often has no symptoms until it is too late to treat and the shortage of eye care professionals in the region makes appointments inconvenient for patients.

The goal of the UPHCS DR Screening Telehealth project was to reduce the incidence of vision impairment from DR and other vision threatening illnesses among diabetics by reaching them in primary care clinics. Funding was used to purchase digital retinal cameras and train staff in primary care clinics to acquire high-resolution digital retinal images from patients. Staff then securely transmitted relevant clinical data and images, for review by an off-site eye care professional, through a secure third-party network. These remote specialists then provided a report indicating the patient’s retinopathy level and make referral recommendations.  Additionally, because it was not enough to simply identify patients with vision-threatening retinopathy, funds were used to coordinate care and train local eye care specialists to screen the images so that they could take part in the process and help direct appropriate follow-up care for their patients in their communities. Primary care clinics benefited because the service was simple, inexpensive, and billable to most insurances.  Eye care professionals benefited because they could conduct screens at their own convenience and bill insurances for the service.  Most importantly, patients benefited because they were more likely to get their annual DR screening and less likely to suffer vision impairment as a result.

37 diabetic retinopathy screens were conducted as a result of this project, of those, 13 diagnostic reports included retinal pathology and treatment recommendations. The project did not reach the level of activity that was hoped for, largely due to staff turnover requiring additional training and hardware with a steep learning curve. However, compliance with recommended diabetic retinopathy screenings did increase by over 40% across participating clinics.

Although the project did not meet all of its ambitious objectives, there were a number of valuable take-aways from the project including:

• The RV100 digital retinal imager from Hillrom can be difficult to use in the acquisition of images of sufficient quality that they can be screened for vision threatening pathologies. It requires precise and intricate movement in order to align the hardware correctly and can necessitate a substantial commitment of practice time, by users, in order to efficiently and reliably acquire usable images.
• Norway Eye Care was an excellent partner on this project. Working with professionals from the region seemed to engage all parties more deeply. They were reliable, thorough and easy to work with.
• Primary care clinicians simply engaging their diabetic patients about their diabetic retinopathy screenings regularly helped to improve patient compliance with those recommendations.

The project has been replicated under the current Diabetic Retinopathy Telehealth Program, expanding to a total of seven locations, and upgrading from the RV100 to the RV700 digital retinal imager, which is significantly easier to use.