Quality Assurance for Diagnosis of Diabetic Eye Diseases
Supporting the development of quality clinical services for persons diagnosed with Diabetes will be the major focus of this initiative. The modality will be the organization of a demand driven quality assurance programs for lower level institutions. This will be primarily undertaken through the MedLink platform supported by the Sekwa Reading Center to be develop under the auspicees of world’s leading Ophthalmic Fundus Imaging Reading Center, Department of Ophthalmology and Visual Sciences, University of Wisconsin- Madison. The immediate main focus of this initiative will be the quality assurance for diagnosis of eye complications of Diabetes.
Diabetic retinopathy is the most common complication of diabetes and a major cause of visual loss. Damage (maculopathy) to the area of the retina used for fine and central vision (the macular area around the fovea) is the most significant problem in people with type 2 diabetes, though classical retinopathy with new vessels and consequent problems is also important. Interventions to control blood glucose, blood pressure can help to prevent or delay the onset of retinopathy and slow its progression, but most people with retinopathy will be asymptomatic until the damage is advanced.
With the development of imaging and laser technologies improved early detection by regular surveillance is thus essential if people with sight threatening retinopathy are to be identified in time to offer laser treatment to prevent visual loss. New therapies are being developed for retinopathy although current and improved laser photocoagulation and vitrectomy will continue as essential interventions to reduce severe visual loss from focal and diffuse diabetic macular oedema and proliferative diabetic retinopathy.
More recently with the latest progress in imaging technology [e.g . the modern easy-to-use high-resolution non-interventional non-mydriatic (no dilation of the pupil) digital fundus camera] all Diabetes care providers, including those at the community and general practice level, are now in a position to undertake regular exams of the inner eye [retina] and thereby can monitor the development of retinal microvascular abnormalties – these abnormalities being the key markers for the early detection of the microvascular complication of Diabetes.
Diabetic Retinopathy (DR) should not be considered simply as an eye problem but is one of the important microvascular complications of Diabetes from the disease management point of view.
If left undiagnosed and untreated these early signs of diabetic disease will lead to serious late stage organ tissue destruction with ultimate vision loss, renal failure, neurological complications. Unfortunately, in most societies, the clinical implications of the microvascular changes of retina has received little attention by the general diabetes care settings that until recently lacked appropriate technologies and supporting systems for monitoring diabetes patients. By incorporating such technology into the community we will be able to detect and monitor the diabetic microvascular complications in the primary care setting showing demonstrating to patients the observable evidence of the insults of diabetes. Quantitative and qualitative grading scale systems of diabetic retinopathy are now available to be used by a third-party independent service provider and can be integrated into the clinical practice for both ophthalmologists and general practitioners. The crucial issue is that these systems includes fundus photograph reading systems that adhere to a rigid standard and is under a continuous quality control framework.
With available technologies local healthcare professionals (doctors and nurses) can gain the skills for detecting diabetic eye changes. By empowering community health workers to detect pathological changes of the eye related to diabetic disease it is our belief that the community health service will gain in local trust and that both unknown diabetes and undiagnosed diabetes related disease will be more readily detected. It should also ultimately lead the local population to more readily utilize community services for both detection and management of diabetes and other chronic diseases.
Service Model – MedLink Health System
DaAn Health is now in cooperation with Sekwa developing a cloud based platform named MedLink. Med-Link Professional – Med-link Health (Med-Link) . Building on its cloud based laboratory service management system the MedLink platform has as its main aim to facilitate the continuing improvement of the quality of medical services at community level through development of intuitive networks through a universally accessible cloud based health management service system.
The Med-link Service Concept has been developed with the main aim to make it widely accessible to individual users and smaller health service entities providing a basic Patient Information Management Platform (PIMP) that is open for individual and institutional healthcare providers. The system gives possibility to develop multiple ‘add on’ for specific specialized needs that can subsequently be made available to the greater user network.
Med-link Professional is to our knowledge the first and to date the only ‘Cloud Based’ Health Service Management System being developed in China in Chinese for both Chinese Health Service Systems and health providers outside China with Multi-language capabilities
The main features includes Dedicated Cloud based management system Basic Interface for Patient Information Management with Multi-language Capabilities for specialized program management.
Quality Assurance in Detection and Grading of Diabetic Retinopathy
A PPP business model is now being developed by Daan Health in cooperation with multiple stakeholder in Guandong Province and discussions are underway with Tsinghua University First Hospital for development of a service project for Chaoyang District of Beijing. Sekwa Institute of Medicine will be the main unique service provider for all image analysis based on the the process flow diagram below that has been successfully piloted in multiple Community Health Service Centers in Guangzhou (Topcon Fundus Imaging with the MedLink cloud based portal).
- Step 1-Level I: Non Mydriatic Images – DR Yes or No
- Qualification/Certification of reader: JCPI Grading System
- Algorithm: (i) JCPI Category 1 – Message automatically generated to care provider and patient; (ii) JCPI Category 2 – Images automatically forwarded to step 2-Level II readers
- Step 2 – Level II: Non Mydriatic Image Clinical Significant DR – Yes or No
- Qualification/Certification of reader: JCPI Grading System
- Algorithm: (i) JCPI Category 2 – No referral with message automatically generated to care provider and patient; (ii) JCPI Category 3 – Images automatically forwarded to Step 3- Level III readers
- Step 3 – Level III: Mydriatic Image DR – Specialist Assessment
- Qualification/Certification of reader: ETDRS Grading System
- Algorithm: Detecting Diabetic Retinopathy
Quality Control and Clinical Audit for Diabetes Care
(1) Main Aim
The project Quality Control and Clinical Audit for Diabetes Care will have as its main aim develop a general Information Management Framework for Best Practice
The project will be developed based on a Continuity of Care Framework including the following four main components
Development of datasets of interest for clinical audit (ii) Framework for automated capture of anonym patient centric data of interest, (iii) Development of a data analysis model using Methodology for Outcome Monitoring with Statistical Process Control , (iv) Development of a training model for user[1] and the US DQIP [2] accountability and quality improvement. Example of a quality improvement cycle [3]
(4) Statistical Analysis Framework and Tools
In cooperation with project partner data analysis will be undertaken with the R Statistical Package. The “R” Statistical Package is an open source integrated suite of software facilities for data manipulation, calculation and graphical display (http://www.r-project.org). “R” includes a well-developed, simple and effective programming language which includes conditionals, loops, user-defined recursive functions and input and output facilities with capabilities for: (i) effective data handling and storage facility, (ii) a suite of operators for calculations on arrays, in particular matrices, (iii) a large, coherent, integrated collection of intermediate tools for data analysis (iv) graphical facilities for data analysis and display either on-screen or on hardcopy,
INTERNATIONAL DIABETES FEDERATION – JOINT CLINICAL PRACTICE INTERNATIONAL
According to IDF’s Diabetes Atlas [4] there are over 130 million people living with diabetes in the Western Pacific and over 387 million people have diabetes globally with dramatic increases seen in countries all over the world primarily related to changing lifestyle. Diabetes Mellitus Type 2 (DMT2) now figures as the most prominent emerging chronic disease [5]. Diabetes carries with it substantial immediate and long-term healthcare costs with the greatest social and economic burden carried by the financially disadvantaged the most devastating being in low- and middle-income countries, where four out of five people with diabetes are living and where general access to diagnosis and affordable care for chronic disease and diabetes is especially limited .
Diabetes is a major health burden with grave impacts on the society, family and person concerned, if not diagnosed, managed or controlled. There are now proven strategies to prevent the onset of diabetes and its complications, which will save lives and money in the long term. However, due to the non-acute nature of these silent conditions, these preventive strategies which have proven to be efficacious in controlled settings, are often not implemented in the real world due a lack of motivation, mandate and care coordination, as well as insufficient resources, support and incentives.
In the updated draft of the Global Plan of Action for the Prevention and Control of NCDs (2013–2020), the WHO articulated its vision of a world free of avoidable burden of Non Communicable Disease based on the overarching principles of using a life-course approach to empower people and communities and adopting an evidence-based and multi-sectoral strategy through partnerships . Despite the challenges due to diabetes in the WP Region, researchers and care professionals had provided notable examples in early detection of diabetes and its complications through government policies as well as prevention of onset and progression of diabetes and its complications using innovative and collaborative approaches. A multi-pronged strategy using both bottom up and top down approaches to raise awareness, detect early cases and prevent diabetes and its complications has been proposed by the Western Pacific Declaration on Diabetes.
Joint Clinical Practice International is a joint initiative with the IDF, DaAn Health and Sekwa. The pilot project will include the SEARO and Western Pacific and includes two main components i) Integrative healthcare delivery approach and ii) community based delivery model for eye screening
Community-Based Integrative Healthcare Delivery Approach
Using a population-based case identification and multidisciplinary team approach for disease management through an integrative framework, (2) promote behavior changes in patients to foster self-care, (3) introduce tools to allow family physicians to modify their practices, and (4) encourage local community action to support patients and providers.
Community Mobilization: Strategies within the community will be initiated to mobilize local resources within patient and provider groups. This will include local leaders, religious leaders, health professionals, pharmacists, people with diabetes and volunteers. Women volunteers and members from all sectors of the rural society will be recruited.
Meetings will be held with patient representatives, local leaders, religious leaders, health professionals, pharmacists to explore the establishment of additional patient support mechanisms such as support groups, becoming a leader and a resource to the community. In addition volunteers will be trained to identify undetected cases of diabetes with risk score (a non invasive assessment for diabetes). Physical activity will be promoted through organizing local sports including football, group exercise sessions and walking groups.
Assessment: The preliminary assessment of the project will focus on the stakeholder participating in the project: patients with diabetes, family physicians, local leaders, religious leaders, health professionals and pharmacists. In addition number of activities for volunteer and the local leaders, religious leaders, health professionals and pharmacists for educational dissemination will be assessed. Finally the number of undetected cases of diabetes through community volunteers will be registered.
Community Based Delivery Model for Eye Screening
From March 2014 The Sekwa Institute of Medicine and Da An Healthcare Group of Sun Yatsen University , Guangzhou PR of China and local governments, launched a unique initiative for the development of a Diabetic Retinopathy Screening and Detection Delivery Model for China with the aim to improve the diagnosis and control of diabetes at community level. The following components are included in this model:
The ETDRS classification system of diabetic retinopathy is used for the diabetic retinopathy grading. This classification was developed by the Early Treatment Diabetic Retinopathy Study (ETDRS) and has been considered as the “gold standard” for classifying the severity of diabetic retinopathy. The concept of independent third-party services making it possible for the project to use this gold standard (ETDRS) to provide reliable clinical scientific data for medical research clinical evaluation, management and clinical follow-up. To facilitate the clinical practice for ophthalmologists in Diabetes Care adopting the international standards for diagnosis and management.An accreditation system for fundus photography reading accessible to all partners in the network will be established.Quality-Controlled Clinical Laboratory Tests Support – high standard quality-controlled clinical laboratory tests support to the community to further ensure the improvement of the diabetes community care. The Regional Medical Centers – Qualified regional centers approved by an internationally certified accreditation system for general diabetes care will be established. 8. VALUE DRIVEN GROWTH MODEL IN HIGH VOLUME HEALTHCARE ENVIRONMENTS
The MedLink /JCPI model is conceived as a value driven growth model that will work in a feedback loupe as both the providers and consumers are empowered in partnership to attain better health outcomes. From the providers side this will be the mastering of skills through practice that will be achieved in positive feedback from the consumers. The philosophy draws on the term ‘Accountable Care Organization’ (ACO) coined in 2006 by Elliot Fisher of the Dartmouth Institute for Health Policy and Clinical Practice. These agreements align high performance (e.g., good outcomes) with financial rewards to encourage providers to maximize efficient utilization of healthcare resources, while providing the most appropriate care for the patient. As both health providers and consumers become more sophisticated and patients become more engaged participants in their healthcare, they may have increased expectations about how providers will respond to their efforts. It is in this realm that the new emerging virtual care market will play an increasing important role and is already being seen in many western economies.
China already enjoys the most intense usage of online synchronous and non-synchronous models for personal communication and commerce. China is now the world’s largest online retail market. By 2013 online shopper numbers reached 302 million, and the online retail transaction volume in exceeded 1.85 trillion CNY, equivalent to 7.8 percent of total retail sales of social consumer goods. E-commerce has further promoted the improvement of logistics services, and Internet finance has begun to force innovation and development in the traditional financial sector. 81 percent of Chinese families engaged in online shopping in 2013, and clothing, books, digital products and home appliances were the preferred choices. Online retail sales have penetrated to every corner of China. The industry not only promotes consumption, but is also conductive to expanding employment and encouraging business startups. A total of 9.62 million people nationwide have opened online shops or work for online stores. As they become better equipped to remotely transmit healthcare data to their doctors, for example, they may naturally assume providers are equally well-equipped to provide feedback on that information in real-time—or at least something close to it.
From the consumer perspective our growth model draws on the growing market segment that in the west is termed virtual care that is demanding unscheduled access to primary healthcare services without consideration of health system or pre-existing clinician relationship. This population segment has given rise to a new set of “on demand” primary healthcare delivery channels. Virtual primary healthcare is the use of electronic mediums to deliver primary care including: education, prevention, diagnosis, treatment and disease management.
There are two major models of virtual care:
• Synchronous: models that connect people and providers in real-time
• Asynchronous: models that deliver care to people without requiring real-time interaction
Synchronous care uses technology like phone, video or chat to connect patients and providers (and sometimes clinician-to-clinician) in real-time for a wide-range of medical conditions. Synchronous virtual care, while a novel application of technology, improves clinical efficiency only to the extent it reduces travel for the clinician or patient. In rural areas with large distances, traditional synchronous tele-medicine adoption is widespread; however in the urban areas where most of the population lives, there is less efficiency to be gained and the increased transaction costs have outweighed the benefits.
Asynchronous care solutions create efficiency in an entirely different way. Asynchronous care focuses the clinician’s interaction to the most essential elements, allowing batching of the clinician’s time to capture scale economies. Starting in the form of secure e-mail, asynchronous primary care models made a major jump in the 2000’s as technology took the unstructured e-mail and incorporated evidenced-based protocols and linked the patient’s medical history in a highly structured manner. This transition allowed asynchronous virtual care to use sophisticated computer algorithms (and in some cases consumer devices) to collect all the necessary information and organize it efficiently without direct patient-clinician interaction. The shift from synchronous to asynchronous has major advantages for virtual primary healthcare. The use of cloud-based technology is core in the concept. Below we illustrate a predicted growth model for the MedLink as services expands from a service driven by a public private partnership that has an narrow professional focus developing into to a broader service concept that includes to both the health providers and health consumers .
Reference & Notes:
http://www.oecd.org/health/health-systems/33865546.pdf
http://www.ncqa.org/tabid/139/Default.asp
http://seer.cancer.gov/qi/process.html
http://www.idf.org/diabetesatlas/5e/western-pacific
http://www.diabetesresearchclinicalpractice.com/article/S0168-8227(13)00395-1/fulltext
