Telemedicine Removes Barriers, Helping to Improve Patient Outcomes and Raise Quality Performance in Indiana and Ohio
American Health Network (AHN) is Indiana’s largest physician-owned group practice with over 70 offices, and more than 200 primary care physicians and specialists located throughout Indiana and Ohio. AHN is driven to provide exceptional care to its patients by providing high-quality, cost-effective care, supported by a robust electronic infrastructure.
AHN counts 27,000 patients in its diabetic population. In 2016 half of them, which include a mix of Type 1 and Type 2 patients, were not compliant with an essential annual diabetic retinopathy exam (DRE). This care gap meant these high-risk patients had the potential for undiagnosed diabetic eye pathologies, and were at increased risk of blindness. Diabetic Retinopathy (DR) is the leading cause of blindness in working age adults. Without examination and diagnoses, AHN couldn’t deliver preventative and interventional care to this specific patient population. With little success, AHNs Primary Care Physicians (PCPs) would refer patients to Ophthalmology, but patients were not following through. This was due to a number of challenges and barriers including patient education about the risk, the burdens involved in additional doctor appointments for patients who are already under the care of multiple physicians, costs associated with specialty care, access to care, and the confusing nature of today’s insurance environment.
Understanding that diagnosed diabetic retinopathy provides PCPs with a new level of information to help manage and control patients with diabetes, and knowing that this diagnostic exam is best for patient care, AHN realized they had to remove barriers for the patients in need of this test. From a financial perspective, AHN also recognized that the significant care gap could cause the organization to be penalized because it was not attaining Healthcare Effectiveness Data and Information Set (HEDIS) quality scores, had lower performance in ACO measures, and have less favorable positions with payer contracts due to lower STAR performance.
To improve patient outcomes and help raise quality performance, AHN required an end-to-end solution to identify non-compliant patients, provide a simple patient exam experience with diagnostic capabilities, and activate referral, billing and reimbursement processes.
Partnering with IRIS, AHN deployed an FDA Class II retinal telemedicine platform developed to help end preventable, permanent blindness caused by diabetic retinopathy. The AHN primary care group initially deployed the platform in four sites, with the goal of expanding to 24 clinics, reaching more than 85% of patients.
The IRIS technology supports automated processes, and establishes clearly defined workflows, which allow the practices to easily institutionalize the diabetic retinopathy exam. The technology also provides a diagnostic solution and an EHR interface that delivers discrete, structured data to the medical record, improving quality.
Standardized workflows, supported by technology innovations, create a programmatic approach to operationalizing the IRIS process. Additionally, the IRIS program is fully supported by a bidirectional NextGen EHR interface to capture all diagnostic information, document outcomes, and ensure results. The IRIS program uses a hybrid equipment model and a combination of tabletop and handheld cameras specific to the needs of each practice.
The IRIS end-to-end service begins with the patient identification processes, and is integrated into existing exam workflows. Any trained AHN staff member, clinical or administrative, can administer the DRE, which typically takes less than five minutes and doesn’t require patient dilatation. In this collaborative model, high quality images are sent via an FDA II diagnostic telemedicine platform directly to AHN Eye Specialists for expert interpretation, diagnostic reports and referral recommendations. Findings and recommendations are delivered directly back to the originating primary care physician, and directly into the EHR upon grading physician signature. From there, data is generated for the referral and billing.
Diabetic retinopathy is the leading cause of preventable blindness in the United States in people 20 to 65 years of age. At current rates, one in three Americans with diabetes will have diabetic retinopathy by 2050. Early detection can reduce the risk of severe vision loss by 90 percent, and can also significantly reduce long-term healthcare costs.
As diabetic retinopathy progresses, therapies become aggressively more expensive, and blindness in adults puts financial, socioeconomic, and other costly burdens on the healthcare system, the community, and most importantly the patient. For example, the cost of retinal drug therapy is now the second most expensive pharmaceutical drug group behind cancer treatments. Early detection results in early treatment with less expensive therapies.
However, for AHN’s diabetic population, following through on referrals for the essential diabetic retinal exam was a challenge.
“There are a number of barriers that prevent our patient population from following through on their annual eye exam,” said Deana Doepker, AHN Director of Business Development. “Many patients are unaware of the risk they are under simply by having diabetes, and many patients can’t afford the cost associated with multiple co-pays for specialty care. Add to that the confusing nature of insurance and the burden of managing multiple physicians and appointments, and it isn’t exactly easy for the patient, so the exam just doesn’t get done.”
AHN is on a mission to improve the health of its patients. Without all of the information, it is a challenge to ensure the diabetic population is receiving the most comprehensive treatments to manage and control their disease. In 2016 only half of AHN’s patients with diabetes were receiving annual eye exams, leaving 13,500 patients unexamined and at risk. Removal of these barriers would be critical to closing this gap and ensuring every patient with diabetes receives an exam. While improving outcomes was the primary driver behind the organization’s efforts to seek a solution, from a financial perspective, AHN had much to gain from closing the gap. Penalties for not attaining Healthcare Effectiveness Data and Information Set (HEDIS) quality scores, lower performance in KPIs for their ACO affiliations, and having less favorable positions with payer contracts due to lower STAR performance, all have the potential to impact the organization’s bottom line.
A True Diagnostic Solution Creates ROI
While not primarily driven by ROI potential or even the expectation of reimbursement, AHN initially believed that placement of the DRE within the primary care setting would not qualify as reimbursable as a fee-for-service. However, AHN soon realized that this was not the case as long as a true diagnostic result could be delivered.
“We understood the challenges that were preventing our patients from receiving the exam and felt placement in a primary care setting would be an optimal solution regardless of reimbursement potential,” said Dr. Ben Park, M.D., President, AHN. “We were pleasantly surprised to discover the IRIS process would qualify as reimbursable as fee-for-service and increased Risk Adjustment Factor payments for at-risk populations. Upon learning more about the IRIS solution and its ability to provide diagnostic results, we made the decision to deploy their FDA Class II retinal telemedicine platform as a pilot in four of our primary care locations.”
Ophthalmology and Primary Care Collaborate to Prevent Blindness
IRIS allows AHN to leverage the AHN Eye Clinic to interpret patient exams, and operationalizes the exam into existing workflows making it easy for both patient and provider. Performed by any trained AHN staff member, the photographer takes a picture of the patient’s retina and transmits the image via the Cloud to AHN’s internal interpreting providers where a diagnosis is made.
The entire exam is performed in the PCP office, takes less than five minutes to complete, and most often does not require dilatation, making it convenient for patients and simple for the provider, who can integrate the process into existing workflows. Results are transmitted into the patient EHR, allowing the primary care physician to make necessary referrals or suggestions for follow-up.
“The IRIS program supports the collaboration between primary and specialty care, which is a significant factor behind its success,” said Deana Doepker. “Telemedicine allows us to conduct the exam as part of the primary care workflow and leverage the expertise of our ophthalmology team, allowing us to simultaneously improve quality, while increasing access and reducing cost of care.”
Improving Access and Closing Care Gaps
Since implementation, the organization has examined more than 1000 patients, diagnosing 31% with some form of ocular pathology, 10.5% with diabetic retinopathy, and a little more than 4% with advanced stages of sight threatening disease. Referrals to Ophthalmology are increasing at the same rates based on level of pathology and severity in areas where AHN Ophthalmology has a presence, and community ophthalmology practices are also receiving patients from this new referral stream where AHN does not have offices.
On the first day of implementation, Dr. Mark Benson of AHN Avon met with a patient who had no symptoms of eye disease and very little interest in having a DRE. “This patient was diabetic and hadn’t seen an eye doctor in at least two years,” said Dr. Benson. “He told me his vision was just fine but I convinced him to take five extra minutes so we could take a picture of his eye. Much to his surprise the results we received that the same day revealed significant degenerative retinal atrophy. I have since referred him to a retinal specialist, and he is now under treatment to protect his vision. He is also very thankful that he decided to have the exam.”
Bringing the DRE to Primary Care Organization-Wide
Since implementation, HEDIS scores are steadily increasing across multiple payer contracts with several offices trending above 90% total compliance. The HCC/RAF scores in risk-based contracts are also steadily improving, which means payers are compensating AHN to care for this high-risk population, yielding a satisfactory ROI for AHN.
Early results and the demonstrated value of the AHN/IRIS solution is enabling the organization to undergo a system-wide expansion by July 2017, with the goal of reaching more than 80% of its diabetic patient population.
“The true measure of our success is ensuring our diabetic patient population is properly diagnosed and receives the appropriate treatment to save their vision,” said Dr. Park. “Implementation of this program has allowed our physicians to do what they do best—provide outstanding care to all of our patients with diabetes.”
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