Conflicts of Interests Disclosure

• Private investment – Merck – Pfizer – Glaxo

• Consultant and Research funding – NEI – Kellogg Foundation

• University of Michigan • Duke University • Intellectual property

– Statins for glaucoma – EMR decision support and data

entry

• AAO Foundation – Hoskins Center for Quality and Safety

• American Board of Ophthalmology

• Centers for Disease Control and Prevention

• ARVO Foundation for Eye Research

• American Glaucoma Society • American University

Professors of Ophthalmology – AAMC Council for Faculty and

Academic Societies

National Academy of Medicine Report

• Facilitate public awareness through timely access to accurate and locally relevant information;

• Generate evidence to guide policy decisions and evidence-based actions;

• Expand access to appropriate clinical care; • Enhance public health capacities to support vision-

related activities; and • Promote community actions that encourage eye and

vision-healthy environments.

Future Directions for Improving Access and Care Delivery

What is our “Goal” ? Prevent (and restore) vision loss through a public health systems approach in the US

Themes

• Elements of an integrated care system as

embodied in NAM recommendations

• Progress towards an integrated system

1. Continuous Improvement System (s) – CQI, Lean, TQM

Chen CL et al. N Engl J Med 2015;372:1530-1538.

2. Need for Evidence-Based Unified Guidelines to Reduce Variation and Drive Payment Policies – example of preoperative testing and office visits

for eye surgery.

3. Integrate Care Across the Health Delivery System (diagram from Milani RV, Lavie CJ, Am J Med 2014)

4. Integrate Health Delivery and Public Health Systems

• Partners in Work – Eye care specialists – Primary care providers – Schools – Public health departments – Social welfare departments – FQHC’s – NGO’s – Others

Date of download: 11/6/2016 Copyright © 2016 American Medical Association. All rights reserved.

From: Current and Future Status of Diversity in Ophthalmologist Workforce JAMA Ophthalmol. 2016;134(9):1016-1023. doi:10.1001/jamaophthalmol.2016.2257

Proportions of Ophthalmology Faculty Members Stratified by Sex, Race, and Ethnicity From 2005 Through 2015The data source is the Association of American Medical Colleges Faculty Roster, 2005-2015 (December 31 snapshot). URM indicates underrepresented in medicine.

Figure Legend:

5. Enhance Diversity of Workforce

Themes

• Elements of an integrated care system as

embodied in NAM recommendations

• Progress towards an integrated system

1. Integrated System with Practitioners Performing Trained Functions (Rao GN, Barrie Jones Lecture, Eye, 2015)

Figure 3. Distribution of eye care resources in the “pyramid model.”

April Y. Maa, Barbara Wojciechowski, Kelly J. Hunt, Clara Dismuke, Jason Shyu, Rabeea Janjua, Xiaoqin Lu, Charles M. Medert, Mary G. Lynch

Early Experience with Technology-Based Eye Care Services (TECS) : A Novel Ophthalmologic Telemedicine Initiative

Ophthalmology, 2017 VA System http://dx.doi.org/10.1016/j.ophtha.2016.11.037

Management of Glaucoma Suspects Through OCT

• AAO Poster 87, Kaiser Permanente, 2015

• Following suspects (discs or risk factors, but normal VF and RNFL thickness)

• First 100 at one year results – 9 patients with > 10 micron loss in any quadrant – Average RNFL loss was 1.1 microns

2. Moving Care to the Community and Home and Away from “Health Care Facilities”

Source: Paul Lee

Spec

trum

of c

are

End

of l

ife

Wel

lnes

s

Expanded Opportunities for Care

• CDC Efforts – Walmart – UAB – Community Groups

with glasses – Wilmer – Senior Housing /

Vans – Wills

• Community Health Centers (Jamaica)

A patient email: “Hi doc, I just wanted you to take a look at

my transplant….”

Courtesy of Mia Woodward, MD

3. Leverage New Technology / Innovation Aravind Eye Hospital System

Date of download: 1/12/2017 Copyright © 2017 American Medical Association. All rights reserved.

From: Development and Validation of a Deep Learning Algorithm for Detection of Diabetic Retinopathy in Retinal Fundus Photographs JAMA. 2016;316(22):2402-2410. doi:10.1001/jama.2016.17216

4. Incorporate Social Determinants of Health

Knowledge

Action

Data

Analytics

Digital Knowledge Objects

Knowledge Management

Secure Message

Virtual Visits

Home Visits

PRO, Vitals/Physiology Activity/Sleep, etc.

Mobile (Apple, Android), Sensor, Device, IOT

Real-time Streaming Analytics

Machine Learning,

AI

Precision Services

Connected Home Care

Team

Doctor Nurse

Visiting Nurse

Allied Health -Pharm

-Dietician -EMT Peer

Advisor Network

Health System Data EMR, RDW, etc. (>300, e.g. Cards)

Enterprise analytics roadmap

Patient Perspective

Health System Perspective -Quality -Financial

Payer Perspective

Patient+

Family

Algorithm Development

Clinical decision support

Outcome Evaluation

Data Aggregation

5. Integrated Data Analytics across Care Stakeholders

Evaluate your own data – Benchmark your outcomes against your practice

colleagues or national averages Manage your patients at a population level – Look at a specific group of patients based on

conditions, risk factors, demographics or outcomes

– Identify trends and track interventions – Answer specific clinical questions

Value of IRIS Registry Courtesy of Flora Lum, MD, AAO

Future Directions for Improving Access and Care Delivery

What is our “Goal” ? Prevent (and restore) vision loss through a public health systems approach in the US

Figure 1. Photographs of on-site glaucoma detection examinations and treatment. Clockwise from top left: intraocular pressure measurement (Goldmann Applanation Tonometry), Wills Eye Van for team and equipment transportation to community sites, laser peripheral surgery and imaging equipment

Michael Waisbourd, Noelle L. Pruzan, Deiana Johnson, Angela Ugorets, John E. Crews, Jinan B. Saaddine, Jeffery D. Henderer, Lisa A. Hark, L. Jay Katz

The Philadelphia Glaucoma Detection and Treatment Project : Detection Rates and Initial Management Ophthalmology, Vol. 123, 2016: 1667–1674

http://dx.doi.org/10.1016/j.ophtha.2016.04.031

Insurance and Use of Eye Care Zhang X, et al, Arch 2008

Figure 1. Flowchart showing cycle time intervals: 1 = documented in VistA for both Technology-Based Eye Care Services (TECS) and the New Comprehensive Clinic (NCC); 2 = time stamp when technician opens Medflow for both TECS and the NCC; 3 = time stamp when tec...

April Y. Maa, Barbara Wojciechowski, Kelly J. Hunt, Clara Dismuke, Jason Shyu, Rabeea Janjua, Xiaoqin Lu, Charles M. Medert, Mary G. Lynch

Early Experience with Technology-Based Eye Care Services (TECS) : A Novel Ophthalmologic Telemedicine Initiative

Ophthalmology, 2017, Available online 9 January 2017

http://dx.doi.org/10.1016/j.ophtha.2016.11.037

Importance of Patient and Family SES Factors: Likelihood of Visit Based on Ocular Diagnosis

LL = Low income / Low education, LH = Low income / High education, HL= High income / Low education, HH = High income / High education