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The disconnects that exist in health care stand out most starkly in the care of patients with chronic systemic diseases. When that systemic disease is diabetes, eye care practitioners face a daunting challenge. Every eye care practice has many diabetic patients. In the United States, about 9.3% of the population has diabetes, including 21 million diagnosed cases and an estimated 8.1 million people who have the disease but have not been diagnosed.1 Diabetic individuals are at higher risk for death, as well as for kidney failure, heart disease, stroke, lower limb amputation, and other serious health problems.1
Many diabetic patients have diabetic retinopathy (DR), and all are at risk for this complication, the leading cause of vision loss and blindness for American adults.2 Of diabetic patients aged 40 years and older, 4.2 million (28.5%) have DR, and 655,000 (4.4%) have sight-threatening advanced disease.1
The prevalence of DR places eye care practitioners in a key role on the care team for patients with diabetes. Too often, however, that team is not coordinated. Primary care practitioners (PCPs) diagnose diabetes, but who makes sure that patients attend their eye exams? Do PCPs, endocrinologists, and eye care practitioners routinely, efficiently share information about these patients? When patients require an optometrist’s referral to an ophthalmologist, how is information shared and distributed to the team?
Tools and technologies exist today to facilitate external communication with referral partners and other health care providers. If we use them to their full potential, we can work together to change how we manage diabetic patients and deliver better care.
EYE CARE AND PCPs
When a PCP diagnoses diabetes, the patient should be told to get an eye exam. Most primary care offices, however, do not schedule that appointment for the patient, so the onus is entirely on the patient. Some patients might take a few years to schedule an optometry appointment.
This can be frustrating from our perspective. In a perfect world, PCPs, endocrinologists, eye care providers, and other specialists would share information on diabetic patients, and nothing would fall through the cracks. It is easy to understand that a primary care clinic with 5,000 diabetic patients might have a hard time monitoring whether each patient gets an eye exam. However, if that clinic made eye care appointments for its patients and then monitored compliance, it might find that 80% of those patients received eye exams in a given year—an excellent reflection on the clinic. What is more, if that clinic then talked to an office like mine about the patients who did not receive eye exams, my team could be very effective in making those appointments and getting people into our office.
Today, we primarily rely on patients to initiate scheduling appointments on their own. Once the patient is in my office, we take the responsibility of making sure that he or she returns each year, scheduling the next exam before the patient leaves the office and following up if an exam is missed.
Some of our interactions with ophthalmologists hew closer to the “perfect world” scenario described above. Our office uses technology from Illuma Care Connections to seamlessly communicate with patients and the team of doctors coordinating their care. Illuma is a company that provides outreach services to patients to help them make appointments and ensure their compliance with diabetic eye exams. It also provides a network that lets us share data and communication with other providers.
PCPs using this technology can easily send us a patient’s blood sugar test results and other relevant data before an exam. Every time a diabetic patient has an exam, my office sends a report to the patient’s PCP noting the results. If the PCP is on our system, the report, called a continuity of care document (CCD), is delivered in XML format for upload into the practice’s electronic health record (EHR).
Inside and outside our network, this follow-through helps us build relationships and effectively communicate to PCPs that optometrists are an active part of the diabetic health care team. We let PCPs know that we are part of the medical model, managing care for complex patients, in addition to performing refractions and vision wellness checks. When PCPs understand that, referral momentum builds. They give diabetic patients our name.
COLLABORATIVE MANAGEMENT WITH RETINA SPECIALISTS
The goal of collaborative management of DR is to track the disease, refer the patient to a specialist when needed, stabilize the eye, and ensure that the patient receives continued monitoring under our care. This requires good communication on the part of both our practice and the retina specialist, starting with the referral decision. Sometimes the decision is very clear, but other times I need a quick consult. If so, I can use my phone to take a photograph of an optical coherence tomography image or capture a fundus photograph and send it to the specialist. Our system passes information easily to and from all our devices in a HIPAA-compliant manner.
When patients need specialist care, we schedule the appointment before they leave the office. When this is done, I can then communicate effectively with the retina specialist via the Illuma system so that he or she quickly understands the patient’s situation. The CCD includes a lot of information to demonstrate meaningful use of EHR, but it also allows me to put a note in the report that quickly explains why I am referring the patient (for example, for possible proliferative DR). The specialist does the same thing in a CCD when sending the patient back to me (noting, for example, that the patient is stable, will require follow-up every 6 months, and should come back if X, Y, or Z is detected).
If you work in a large multispecialty practice, this type of communication takes place routinely through your EHR. Mine is an individual practice, as is that of the retinal specialist with whom I collaborate. There are many more individual practices than large groups. Before technology such as that offered by Illuma, all the practices I worked with were using different technologies; some were still faxing paper documents. The Illuma technology is a beautiful connecting piece that can bring multiple independent practitioners together under one common “roof” (regardless of EHR platform), allowing them to remain independent but to function like a large group.
REWARDS FOR DIABETIC PATIENTS
The greatest advantages of a coordinated approach are better, more complete care and reduced likelihood of vision loss. But the rewards go even further than that.
For diabetic patients, we provide in-depth education about the pathology and seriousness of DR. As part of this education, we outline the patient’s own active role in controlling his or her disease and preventing vision loss. We make it clear that patients cannot just show up to an exam and let us take care of it all: They must be part of the diabetes treatment team. We emphasize that patients who understand the disease and communicate with doctors about their backgrounds, daily lives, and symptoms get better care and stay healthier.
Patients also need to see us practice what we preach in order for the lesson to sink in. If we optometrists do not seem to know what is going on with patients, they may think the situation is unimportant and show a similar lack of commitment. However, if we communicate with them and the rest of the team—by always following up and making sure eye exams take place—we reinforce the seriousness of the problem and emphasize our support for their care and compliance.
1. National Centers for Disease Control and Prevention. National diabetes statistics report, 2014. https://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf. Accessed June 30, 2017.
2. National Eye Institute. Facts About Diabetic Eye Disease. September 2015. https://nei.nih.gov/health/diabetic/retinopathy. Accessed June 30, 2017.
Chad Fleming, OD, FAAO
• owner, Wichita Optometry, Wichita, Kan.; founder, OptometryCEO
• financial disclosure: consultant/speaker, Illuma, iMatrix, J&J Vision Care, OptometryCEO, RevolutionEHR, SolutionReach, Weave
• 316-650-4505; firstname.lastname@example.org