Coordinating diabetic care
Ophthalmic Consultants of Long Island excels by using technology and a team-based approach.
BY KAREN APPOLD CONTRIBUTING EDITOR
PHOTOGRAPHY BY JSAY CREATIVE
Ophthalmic Consultants of Long Island (OCLI), a multi-specialty ophthalmology practice, has developed a niche in caring for patients who have been diagnosed with diabetes. For the practice, it is an opportunity to serve this growing segment of patients and create an additional revenue stream. In addition, through diabetic care, OCLI develops and strengthens referral relationships with primary care physicians (PCPs) as they help fulfill recommendations from the National Institutes of Health and National Eye Institute for all diabetic patients to have an annual dilated eye exam, says Tom Burke, chief executive officer at OCLI.
Brenda Jovel (left), ophthalmic technician, performs diagnostic testing as part of the patient’s annual eye exam.
Diabetes (types 1 and 2) affects more than 29 million people in the United States. Diabetic retinopathy (DR), a common complication of diabetes, is a leading cause of blindness among adults. Although early diagnosis can reduce the risk of vision loss, as many as 50% of patients with diabetes do not get their eyes examined or they are diagnosed too late for effective treatment.1
Recently, the government increased its focus on diabetic care management through such initiatives as accountable care organization (ACO) measures and electronic health record (EHR) Meaningful Use requirements. In addition, more than 90% of America’s health plans use Healthcare Effectiveness Data and Information Set (HEDIS) analysis to measure performance on important dimensions of care and service.2 Documenting that diabetic patients undergo an annual eye exam is a factor that affects the PCP’s HEDIS grades, says Nancy Fairbrother, director of business development at OCLI. Physician-specific scores are used as evidence of preventive care from primary care practices. These rates then serve as a basis for physician profiling and incentive programs.
Following up with patients
Unfortunately, PCPs can find it challenging to get diabetic patients to have an annual eye exam. Studies have characterized the annual diabetic eye exam completion rate as low among certain populations.3,4 To assist local independent physician associations (IPAs) that have diabetic patients who are non-compliant with annual dilated eye exams, OCLI offers to contact these patients, through its outbound calling center. OCLI offers these patients the annual exam in one of the practice’s 11 office locations.
Members of the OCLI team who assist diabetic patients include (from left to right) Vanessa Costantino, tech supervisor; Raymond Mariani, OD; Eric Sigler, MD; Lauren Bahan, office manager; and Tara Rabito, assistant tech supervisor.
Steven Friedman, chief information officer, was charged with creating and maintaining a database that could identify patients who have diabetes.
In addition, OCLI encourages its optometric network to perform diabetic screening exams, report findings to PCPs, and refer patients to ophthalmologists for additional treatment when warranted. This network consists of more than 500 doctors of optometry in the tri-state area and a core group of about 200 that utilize its doctors for sub-specialty patient care and regularly attend semi-annual C.E. days coordinated by OCLI.
After entering diabetic patient information into OCLI’s internal practice management and EHR database, the practice can cull the data to communicate with the patient and to manage the patient’s follow-up eye care. “When previously diagnosed patients miss appointments, we follow-up via telephone and email,” says Ms. Fairbrother. “In addition, we continuously review our database to identify diabetic patients who haven’t been seen recently and call them to schedule a follow-up appointment.”
PCPs can document that a patient received a dilated eye exam in one of two ways:
The eye-care provider can put together a consultative report that documents the patient received the exam. Or, a payer can generate a CPT code based on a visit to an eye-care provider, thereby giving credit to the PCP for having helped manage appropriate follow-up care.
IT’s role and challenges
To ensure diabetic patients stay on target with annual eye exams and that PCPs receive documentation from the patient’s appointment at OCLI, the practice charged its IT team with creating a system that would enable physicians and staff to enter the diabetic patient’s Meaningful Use data into the EHR system in a timely manner. To aid in identifying specific patients, the IT team created a method of categorizing data in the EHR according to diagnosis. This allowed the practice to extract information from the database and generate reports in the EHR system for diabetic patients.
“It was a challenge to build everything from the ground up,” says Steven Friedman, chief information officer at OCLI. “We had to design a system of checks and balances; workflows needed to be designed in both the paper and electronic realm to facilitate a process within the EHR to ensure that, if patients and PCPs were not notified per protocols, the process was corrected going forward.”
For example, when a Q/A report indicates the lack of a primary care provider follow-up letter, the scribe and doctor are notified to rectify this as soon as possible. Similarly, if the Q/A fails to catch the missing PCP communication, monthly Q/A reports can highlight this issue for management so that it is brought to the attention of OCLI’s providers.
OCLI receives referral letters through various means (e.g., fax, mail), which can make closing the communication loop with referring PCPs difficult. To address the challenge, OCLI performs quality assurance reporting “to assist with missed letters,” Mr. Friedman says. “We attempt to alert our doctors and staff with EHR reminders regarding the need for referrals and communication. We also provide newly diagnosed patients with educational materials, which encourage them to have a PCP, or we refer them to one.”
Relationships with PCPs
Proper management of diabetes requires early communication with the patient’s PCP.1 The process begins when the primary eye-care provider screens the diabetic patients for DR and other related diseases.
“By communicating findings with PCPs as well as additional specialists, we can ensure early detection and management of co-morbidities,” says Eric Sigler, MD, one of four vitreo-retinal specialists at OCLI.
“Ophthalmologists and PCPs can cooperate with each other quickly and inexpensively through the use of mandated technology, either the practice’s own EHR or add-on software technology,” says Ray Mariani, OD, an optometrist at OCLI. “Real-time updates of a patient’s diabetic ophthalmic health status can be uploaded to a PCP’s inbox before the patient leaves the eye doctor’s exam room.”
By sharing the patient’s records securely with the patient’s PCP, OCLI creates “relationships with potential referral sources,” Dr. Mariani continues.
Katherine Abramonte (right), patient care coordinator, greets patients as they arrive.
Through its outbound calling center, OCLI contacts diabetic patients to schedule their annual dilated eye exams.
Ana Reusch, surgical coordinator, provides patient education.
“These inter-specialty relationships can become local business alliances that expand or differentiate your practice,” he says.
Adds Dr. Sigler, “Ultimately, improving patients’ quality of life through eye care increases overall health-care compliance and helps maintain strong relationships throughout our referral network.”
To build and maintain relationships, an OCLI practice liaison visits PCPs routinely to share the practice’s diabetic eye exam report process, including how patients are identified to ensure a report is completed.
OCLI has 29 ophthalmologists and three optometrists who screen patients for disease and treat them, including patients with complex retinal problems. But, each team member at OCLI plays a vital role in caring for diabetic patients. This team approach begins with education.
“We convey to our technicians and scribes the importance of properly performing appropriate testing, capturing information correctly, and maintaining awareness of follow-up appointment creation in the database,” Ms. Fairbrother says.
OCLI technicians obtain information regarding a patient’s chief complaint and medical, social, and family history and perform visual acuity tests. They dilate the patient’s eyes, perform optical coherence tomography (OCT) exams, take fundus photos to track changes, and perform fluorescein angiography exams to check for leaking blood vessels in the retina, explains Keshia Beckford, clinical manager at OCLI.
The doctor will also perform slit lamp exams and ophthalmoscopy. These may all be aspects of a diabetic patient’s annual eye exam.
Scribes are responsible for ensuring that physicians dictate letters regarding diabetic patient findings to PCPs. They communicate with front-end staff to ensure that patients make follow-up appointments at check-out.
OCLI strives for patient care that is both thorough and efficient. By designating certain staff to specific tests — for example, one technician performs OCT testing only and another performs fluorescein angiography exams only — the entire diabetic eye exam, from check-in to check-out, takes 45 to 60 minutes. Technicians are cross-trained to fill in as needed for workups and scribing.
After the exam, patient care coordinators (PCCs) send letters to a patient’s PCP via an EHR fax, regular fax, or mail. PCCs enter the PCP’s information into the patient’s EHR, Ms. Beckford says.
Administration apprises all stakeholders in the practice of the group’s progress through reports that “highlight the number of diabetic patients seen in a given period and from that subset, how many had letters sent to their PCP,” Mr. Burke says. The reports can be location and/or doctor specific to trend progress. Administrators also present data to ACOs and IPAs to demonstrate efficiency.
Caring for diabetic patients is a team effort, with EHR playing a vital role. Ultimately, it’s a winning endeavor for OCLI, its patients, and PCPs. OP
1. Comprehensive Eye Exams: Vital but underutilized preventive healthcare tools. National Council on Aging. https://www.ncoa.org/wp-content/uploads/Comprehensive-Eye-Exams-Health-Brief.pdf. Accessed January 27, 2016.
2. HEDIS & Performance Measurement. National Committee for Quality Assurance. http://www.ncqa.org/HEDISQualityMeasurement.aspx#. Accessed January 27, 2016.
3. Hatef E, Vanderver BG, Fagan P, Albert M, Alexander M. Annual diabetic eye examinations in a managed care Medicaid population. Am J Manag Care. 2015;21:e297-e302.
4. Maclennan PA, McGwin G Jr, Heckemeyer C, et al. Eye Care Utilization among a High-Risk Diabetic Population Seen in a Public Hospital’s Clinics. JAMA Ophthalmol. 2014;132:162-167.