Implementation of Teleophthalmology to Improve Diabetic Retinopathy Surveillance: Qualitative Interview Study of Clinical Staff Informed by Implementation Science Frameworks

Abstract

Background The store-and-forward camera-based evaluation of the eye, or teleophthalmology, is an effective way to identify diabetic retinopathy, the leading cause of blindness in the United States, but uptake has been slow. Understanding the barriers to and facilitators of implementing teleophthalmology programs from those actively adopting, running, and sustaining such programs is important for widespread adoption. Objective This study aims to understand the factors that are important in introducing teleophthalmology to improve access to diagnostic eye care for patients with diabetes in primary care clinics by using implementation science. Methods This qualitative study in 3 urban, low-income, largely racial and ethnic minority–serving safety-net primary care clinics in Rochester, New York, interviewed nurses and physicians on implementing a teleophthalmology program by using questions informed by the Practical, Robust Implementation and Sustainability Model and the Consolidated Framework for Implementation Research. Results Primary care nurses operationalizing the program in their clinics saw increased work burden and a lack of self-efficacy as barriers. Continuous training on the teleophthalmology process for nurses, physicians, and administrative staff through in-service and peer training by champions and superusers were identified by interviewees as needs. Facilitators included the perceived convenience for the patient and a perceived educational advantage to the program, as it gave an opportunity for providers to discuss the importance of eye care with patients. Concerns in making and tracking referrals to ophthalmology because of challenges related to care coordination were highlighted. The financial aspects of the program (eg, patient coverage and care provider reimbursement) were unclear to many staff members, influencing adoption and sustainability. Conclusions Streamlining processes and workflows, training and assigning adequate staff, effectively coordinating care between primary care and eye care to improve follow-ups, and ensuring financial viability can all help streamline the adoption of teleophthalmology.

Stakeholder perceptions affecting the implementation of teleophthalmology

“…Technicians wished for more extensive hands-on training with formative feedback, administrators for clearer blueprints for operations, and physicians for clearer instructions. Ongoing training for all team members was also identified as a particularly important topic by Ramchandran et al [30] Substantial evidence supports the utility of formative feedback, defined as specific, timely, supportive, information conveyed to the learner in response to an action with the intent to modify the learner's thinking or behavior, in the development of procedural and motor skills [44]. Administrators whose responsibility included securing funding and space identified the need for "blueprints" for success, or advice from more experienced peers.…”

“…Using a multilevel determinant framework [ 29 ], this study elicited insight from patients, providers, and staff critical to the implementation and early operation of a comprehensive teleophthalmology clinic in an effort to identify remaining unmet needs and eventually facilitate long-term sustainability. At the time of publication, only one other study exploring obstacles perceived by teleophthalmology clinic staff existed [ 30 ].…”

Advances in Teleophthalmology Screening for Diabetic Retinopathy

“…For example, primary care clinic staff are rarely dedicated to teleophthalmology screening and have many tasks to juggle. 32 Dilation may cause delays in workflow and ultimately compromise staff buy-in. Nonophthalmic staff may also be unfamiliar with dilation and lack the tools and expertise to handle complications.…”

“…102 Clinicians and health care administrators have cited low reimbursement as a barrier to the sustainability of teleophthalmology programs. 32 Patients also reported high out-of-pocket costs as a barrier to the use of teleophthalmology. 103 In order for teleophthalmology to make a population-level impact, payment reform is sorely needed.…”

“…These staff members have limited bandwidth and may not always be able to incorporate tele-screening into their typical workflow. 32 Health care worker burnout and subsequent exodus due to the COVID-19 pandemic have further exacerbated the issue. 105 The solution to this issue should be tailored to the needs and resources of each individual program.…”