CoxHealth: Closing the Diabetic Eye Exam Care Gap


Included on Missouri’s “Best Hospitals” list by U.S. News & World Report, CoxHealth is Missouri’s only locally-owned, not-for-profit health system, operating five hospitals and more than 80 physician clinics. Each facility offers a caring, highly-trained staff and state-of-the-art technology to meet the community’s healthcare needs.

CoxHealth Plans, an affiliate of CoxHealth, is the only locally-based health insurance company in the Ozarks, providing insurance solutions for thousands of members across Missouri and nationwide.


CoxHealth serves roughly 24,000 patients with diabetes, yet their compliance rate for diabetic retinopathy eye exams was just 32%. This care gap was both clinically and financially detrimental. Clinically, patients had pathologies that were undiagnosed, preventing CoxHealth from providing interventional care. Financially, CoxHealth was hurt by not attaining HEDIS quality scores. From a Health Plan perspective, CoxHealth Plans was only reaching a Star Rating of 2.

To address this care gap, CoxHealth required a solution that was easy for its physicians and clinic teams to use. Workflows needed to be standardized with minimal impact to providers, and the solution needed to be as automated as possible. For these reasons, a programmatic approach, supported by a bidirectional Cerner EHR interface, was the only way to drive desired results.

The Solution

Fourteen clinic locations were targeted where a majority of diabetic patients are treated. These locations include primary care, endocrinology, and a residency program.

Technical and clinical workflows were streamlined. Technology teams built the interface to return discrete data directly into the Cerner EHR the next day.

Today, CoxHealth is closing the diabetic eye exam care gap. They also are elevating HCC RAF scores in risk-based contracts, which means Cox is recognizing increased payments from its payers to care for at-risk members.

Achieving these quality outcomes provides the best level of patient care and increases revenue from quality incentives, enabling CoxHealth to remain progressive in its mission to improve the health of the communities it serves through quality healthcare, education and research.


In the first six weeks of the program, 1,040 patients received the diabetic retinopathy exam (DRE).

Closing Care Gaps:

  • 150 patients (18%) were diagnosed with diabetic retinopathy who otherwise would have gone undiagnosed. Of these patients:
    • 136 were diagnosed with non-proliferative diabetic retinopathy
    • 14 were given proliferative, vision-threatening diagnoses

Improving Risk-Based Performance:

  • 150 diabetic retinopathy diagnoses will directly elevate HCC RAF scores in patients with risk-based payer contracts
  • 54 Macular Edema diagnoses will also elevate HCC RAF scores in patients with diabetes

Improving Outcomes:

  • 328 total eye pathologies were identified; these patients will be referred to an ophthalmologist for treatment they otherwise would not have received.

Automating Results

  • Discrete data is now integrated directly back into the patients’ charts, allowing Primary Care Providers to see end-organ damage and create more aggressive care plans. By managing the disease in Primary Care, expensive therapies may be minimized or avoided altogether. This provides a reduced cost of care for this patient population.

Hitting Deadlines:

  • Set and hit the goal of a 10-week implementation with all 15 exam sites live and fully trained to provide CoxHealth with the necessary performance to positively impact 2016 performance.
  • Closing a Care Gap While Integrating a System
  • At CoxHealth, the Diabetic Retinal Exam (DRE) was a care gap for patients with diabetes, who are required to have a retinal exam annually, at minimum. While implementing the IRIS diabetic retinopathy solution was important, integrating the solution into the CoxHealth EHR was an essential component toward this goal.

“Without the integration, you would almost be defeating the purpose of the DRE, which makes it easier to conduct, to complete, and to have a physician review and act on the results, said Dr. C. Mark Costley, Medical Director, Regional Services, CoxHealth.

The implementation was completed in 10 weeks, which was a very aggressive timeline for any project at CoxHealth.

“We felt we needed to place a sense of urgency on this project to ensure it got done,” Dr. Costley said. He noted that such timing was necessary to meet major payer schedules for increased RAF (Risk Adjustment Factor) scores. “We needed to get at least 5 or 6 months of data utilization to try and make an impact on RAF scores since that is probably one of our weakest areas: HEDIS measures and payer metrics.”

Patient and Provider Satisfaction a Key-Value of the Implementation

Brock Shamel, Administrative Director, Cox Medical Group, said the IRIS diabetic retinopathy telemedicine solution allows CoxHealth to offer diabetic retinal exams simply and affordably.

“This solution not only closed a care gap for CoxHealth patients with diabetes, but also significantly supports our ability to improve our compliance rates,” Shamel explained.

Primary care physicians can now provide more comprehensive care to their diabetic patients, eliminating the need for multiple appointments and office visits. Additionally, they can spend more time focused on the patient as they are no longer tasked with time-consuming duties.

“As population health makes its way into our day-to-day operations, our physicians shouldn’t have to handle redundant tasks. They are a high-cost resource that should focus on diagnosing and providing care and maintenance to patients. Otherwise, they tend to disengage,” said Shamel.

CoxHealth credits its successful implementation to the buy-in of its internal leadership team and the collaborative partnership with IRIS.

“We sold our executives on superior patient care, access, ROI, and an elevation in RAF scores. The physicians know this is best practice and their patients are receiving the right standard of care. And, it’s one more burden we can remove from their workload,” Dr. Costley said.



On the Road to Achieving Quality Scores

The results gleaned to date are where CoxHealth expects them to be. Six weeks after implementation, nearly 200 DREs a week are being performed. To reach its projected target, it will need to complete 14,000 exams to achieve top levels; 12,000 minimum.

CoxHealth describes the implementation as one that they would like to emulate in other areas of the organization.

“We’d love to make this the culture of change,” said Dr. Costley. “If we can get the compliance results and provide better quality care with this change, I think we can do anything.”

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