Disruptive Technology and Data-Driven Analytics Helps Close Care Gaps and Improve Overall Patient Outcomes
Gateway Medical Associates is a large physician-owned practice in Pennsylvania. Founded in 1996, Gateway consists of both physicians and allied health providers across nine different sites. Gateway strives to provide excellent care for their patients and is at the forefront of doing so using cutting edge, disruptive solutions.
Gateway has always been a data driven organization, dedicated to providing excellent care for its patients. In early 2016 a serious need to improve compliance in the quality programs became apparent. With more than 7,000 patients in their diabetic population, they simply could not get them to visit their eye doctor for the required annual diabetic retinal exam (DRE). Not only is the DRE vital to identifying sight-threatening eye disease in the advanced stages but it also identifies disease early enough to reverse the risk of blindness. Diabetic Retinopathy (DR) is the leading cause of blindness in working age adults. The onset can be gradual or sudden and it is preventable.
Gateway, like other health care organizations, is held accountable for ensuring its patients receive this exam but had no means for ensuring examination and diagnoses other than recommending a visit to an eye care professional. However, Gateway’s Primary Care Physicians (PCPs) and Endocrinology health care providers found that their patients were not following through with the ophthalmology visit. They identified several barriers preventing patients from getting this exam including confusion about insurance, misconstruing it as an optical exam for glasses, access to an ophthalmologist, and general hardships of making another appointment.
Identifying the patients who needed a DRE was the easy part. Ensuring that the exam was completed was the missing piece. Heavily involved in quality programs and risk-based contracting, the organization realized that they could be penalized for not attaining Healthcare Effectiveness Data and Information Set (HEDIS) quality scores and low-performing ACO measures. Gateway needed to remove all barriers to the exam not only to better care for their patients, but to close this care gap and raise their performance.
To accomplish this the Gateway organization needed a technology that would seamlessly integrate into their existing infrastructure. It would also need to provide a means for completing the DRE in their offices, as well as identify and diagnose all pathology.
Gateway partnered with IRIS, an FDA Class II retinal telemedicine platform that supports automated processes and establishes clearly defined workflows to perform diabetic retinal exams and identify all diabetic retinopathy in their patients before it caused blindness. With a goal of reaching more than 85% compliance, Gateway deployed the platform in eight clinics in October of 2016. Gateway chose the IRIS equipment model with all tabletop cameras due to the ease of use, automation, and image quality.
Standardized workflows, supported by technology innovations, create a programmatic approach to operationalizing and institutionalizing the IRIS process. The IRIS program provides a diagnostic solution and is fully supported by a bidirectional Allscripts EHR interface to capture all diagnostic information, document outcomes, and ensure results which are delivered as discrete, structured data to the medical record.
Gateway places a high value on the importance of data as it relates to quality care. Every patient seeking treatment has a printed report card that considers everything from demographic information and insurance to any relevant quality measures that are outstanding. This allows easy identification of patients needing an IRIS exam. Any employee, clinical or administrative, can administer the DRE, which typically takes less than five minutes and doesn’t require patient dilation.
After the high-quality images are taken, they are sent via the FDA II diagnostic telemedicine platform directly to the Gateway Eye Specialists in the IRIS Reading Center for expert interpretation by licensed eye care providers in Pennsylvania who provide a diagnosis. The results are returned back into the patient’s charts via the EHR integration along with referral recommendations. From there, data is generated to kickoff the referral and billing cycle.
Before starting the IRIS program less than 50% of Gateway’s patients with diabetes had received a diabetic retinal exam. Consequently, Gateway had less than 50% compliance on this HEDIS measure, lower performance in KPIs for their ACO affiliations, and less favorable positions with payer contracts due to lower STAR performance. They had everything to gain in finding a solution: reducing cost, improving quality, and increasing access.
In 19 months –4153 unique patients examined (4810 exams total) of 7,774 total patients with diabetes
Closing Care Gaps:
- 1,198 identified with some form of eye pathology (24.9%)
- Other suspected diseases include Dry and Wet AMD, glaucoma, epiretinal membrane, and cataracts
- 678 diagnosed with diabetic retinopathy
- 14.1% were diagnosed with diabetic retinopathy that otherwise would have gone undiagnosed and untreated
- 203 IRIS saves (4.2%) – diagnosed with advanced stages of sigh-threatening disease
A Diagnostic Solution and Workflow Integration
Gateway is committed to utilizing technology and innovations to better serve their patient populations. While closing this care gap was the biggest concern, choosing a solution that was easy to use, could seamlessly integrated into day-to-day clinical operations, and provide comprehensive data analytics to track performance was important.
“We were concerned that this would be one more thing to do, one more stop on the way to the exam room. The last thing we wanted to do was add to our clinical staff’s workflow,”said Meghan Fleck, Gateway Quality & Pay for Performance Manager. “However, from the beginning, we involved everyone in the process and IRIS helped educate our staff. Training has gone very well and adoption is constantly improving. The flow is smooth, from greeting the patient to the vital signs to the IRIS test to the exam room.”
It has been difficult convincing patients of the value of this exam and helping them understand their insurance and costs. Gateway put programs in place early on to work closely with patients to reassure them that the cost was either covered by the organization or their insurance provider. Getting patients to understand their own insurance is sometimes challenging and takes time.
“Gateway is committed to providing the DRE to all our patients, so we take the time to work with them ensuring they better understand how their insurance works, and for those who need it, we work with them on cost,”said Fleck.
Ophthalmology and Primary Care Collaborate to Prevent Blindness
Before implementing IRIS, the physicians at Gateway were referring their patients to visit an ophthalmologist to receive their annual DRE. However numerous barriers prevented Gateway physicians from checking the quality box, including appointment no-shows or lack of specialist follow-up with primary care.
With IRIS, 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.
Initially Gateway encountered some challenges including perceived patient value and pushback from local eye care providers. However, once Gateway began receiving reports from the IRIS program showing the number of patients with severe disease, everyone realized that they were identifying disease in people that wouldn’t have discovered it until they were in crisis.
“When our physicians started testing patients in the office that weren’t compliant, they started getting reports back showing disease almost immediately,”said Susan Fleck, Gateway Director of Operations. “They saw patients in need of interventions that weren’t getting them, which is what they needed to recognize this was the right thing to do. Once the eye specialty physicians started seeing patients come to them with diagnosed pathology they fully understood that we are sending patients that they might not see until it was too late to save their vision.”
The Halo Effect: Improving Compliance and Responsiveness
With the help of their IRIS Client Success Director, Gateway has gone from a nearly 30% quality score to nearly 90% in less than a year.
In less than 19 months, Gateway has examined more than 4,800 unique patients, diagnosing 25% with some form of ocular pathology. More than 14% of their patients have been diagnosed with diabetic retinopathy and they have saved 203 patients from advanced stages of sight threatening disease.
Those patients are all being referred to Ophthalmology and Retina Specialty based on the level of severity, providing a referral stream that did not previously exist for those practices. In what Gateway and IRIS are calling the ‘Halo Effect,’ as the program continues, compliance is increasing across the board. The IRIS program has made the PCP, specialists and patients more engaged, which ultimately leads to better outcomes. Gateway is dedicated to providing full spectrum care to its patients. Offering IRIS provides more comprehensive care and serves as a better data point on patient’s overall disease management.