Framework for a National Teleretinal Imaging Program to Screen for Diabetic Retinopathy in Veterans Health Administration Patients

Article excerpt

Abstract--Digital retinal imaging with remote image interpretation (teleretinal imaging) is an emerging healthcare technology for screening patients for diabetic retinopathy (DR). The Veterans Health Administration (VHA) convened an expert panel in 2001 to determine and resolve the requisite clinical, quality and training, information technology, and healthcare infrastructure issues associated with deploying a teleretinal imaging system. The panel formulated consensus recommendations based on available literature and identified areas of uncertainty that merited further clarification or research. Subsequent VHA experience with teleretinal imaging and accumulated scientific evidence support nationwide regionalized deployment of teleretinal imaging to screen for DR. The goal is to screen approximately 75,000 patients in the first year of the program, which commenced in 2006. This program will increase patients' access to screening for DR, provide outcomes data, and offer a unique platform for systematically evaluating the role of this technology in the care of diabetic eye disease and routine eye-care practice.

Key words: diabetes, diabetic retinopathy, eye-care delivery, healthcare technology, rehabilitation, screening, telemedicine, teleretinal imaging, VHA, visual impairment.

INTRODUCTION

The Veterans Health Administration (VHA) has almost 5 million patients currently receiving healthcare services each year at an approximate cost of $27 billion. The prevalence and rising incidence of diabetes are major challenges for the VHA, in which an estimated 20 percent of the patient population has diabetes mellitus. Prevention of visual impairment and blindness through timely assessment of and early intervention for diabetic retinopathy (DR) is a major healthcare need that the VHA must address.

The prevalence of DR increases steadily with longer duration of disease such that more than 75 percent of patients who have had diabetes for 15 years or more have DR [1-2]. The value of screening for DR is well established for patients with diabetes [3-4]. Such screening is part of routine VHA practice and has established guidelines and performance measures. Achieving timely and appropriate rates of screening for DR remains problematic. Major barriers to screening include inadequate access to care and patient misconceptions about the value of regular eye examinations (exams) [5]. Indeed, anywhere from 34 to 65 percent of patients with diabetes in the private and public sectors have annual eye exams [6-9]. The VHA has excelled in this area in comparison with the private sector [10]. To further improve this performance in the face of challenges such as increasing patient needs and the geographic distribution of the patient population, the VHA has sought alternative methods for screening and evaluating patients with diabetes for DR and other diabetes-related eye conditions.

In fiscal year (FY) 2000, the U.S. Congress recognized the importance of preventing blindness from diabetes by recommending that the VHA collaborate with the Joslin Vision Network[TM] (JVN[TM]) (Joslin Diabetes Center, Boston, Massachusetts) to implement a technologybased platform that uses nonmydriatic digital retinal imaging and remote image interpretation (teleretinal imaging) to assess DR. This teleretinal imaging system was an outgrowth of a pilot program developed by the VHA and implemented in FY1999 in collaboration with the JVN[TM], the Department of Defense, and the Veterans Integrated Service Network (VISN) 1. Prior to pilot testing teleretinal imaging in other VISNs, the VHA convened an expert panel to address issues of clinical application, quality and training, information technology, and healthcare infrastructure with regard to deployment of teleretinal imaging programs. This article details the recommendations of the panel, identifies remaining areas of uncertainty, and describes the systematic national deployment of VISN-based teleretinal imaging programs. …