A Collaborative Continuing Education & Performance Improvement Initiative

Representatives from UK HealthCare CECentral, DKBmed, RealCME and Regeneron Pharmaceuticals accept the Outstanding Educational Collaboration Award at the 2020 ACEHP Awards Dinner. Pictured (left to right) are Anna Muehlenhaupt (DKBmed), Lindsey Labriola (Regeneron Pharmaceuticals), Scott Noonan (DKBmed), Stan Pogroszewski (DKBmed), Kimberly Northrip (CECentral), Jasleen Chahal (CECentral), Alexandria Sehon (CECentral) and Dean Beals (DKBmed).

Diabetic retinopathy (DR) is the leading cause of blindness among working-age people in the United States, affecting more than half of the 18 million adults with diagnosed diabetes. Yearly eye examinations for people with diabetes can reduce blindness by > 95%; however, many people with diabetes are not being screened for diabetic eye diseases at the frequency recommended by the American Diabetes Association (ADA). Primary care providers are often unfamiliar with new retinal imaging modalities available for use in the primary care setting, even though these modalities can improve screening rates in patient populations. At the University of Kentucky, only 33% of patients with diabetes had documented retinal screens prior to the implementation of this project, according to information obtained from electronic medical records.

In 2018, a group of interdisciplinary organizations came together to address this gap in knowledge and clinical care of diabetic retinopathy by primary care providers and increase the annual screening rate for diabetic eye disease in 23 primary care clinics across Kentucky. Figure 1 lists the collaborating partners on this initiative. The program was supported by an educational grant from Regeneron Pharmaceuticals.

Kimberly Northrip, MD, Director of CECentral framed the novel approach of working outside a single health system. “The University of Kentucky is a land-grant institution with a strong sense of responsibility for the Commonwealth. We at CECentral apply this philosophy to providing professional development to healthcare providers to support their work in making Kentucky healthy. That’s why we reached out to community clinics across the state beyond those managed by the University of Kentucky.”

Figure 1: ODM Collaborating Partners

This initiative required collaboration in three main areas:

• Deployment of technology to allow screening within the primary care clinic, as well as to bridge the distance between the rural clinics and access to ophthalmology services,
• Development and dissemination of high-quality education for community providers and their patients, and
• Performance improvement and academic detailing to facilitate implementation of knowledge and technology.

"By offering these screening tests in a more accessible venue, we are reducing the barriers of time and access to care, which will likely lead to more patients with diabetes receiving the recommended yearly eye testing," said Dr. Ana Bastos de Carvalho, clinical instructor in the University of Kentucky's Department of Ophthalmology and Visual Sciences, and co-director of the performance improvement program called Optimizing Disease Management (ODM): A Vision for Eye Screening. "We expect to detect more pathology and also to detect it earlier on and therefore allow for better visual prognosis."

The Alliance for Continuing Education in the Health Professions (ACEHP) played an important role in the initial collaboration of this project. At the 2018 ACEHP Annual Meeting, DKBmed and UKHC CECentral met to discuss adapting a project similar to one DKBmed completed in collaboration with RealCME and Lancaster General Health, a 34-practice health system in Lancaster, PA. Critically, UKHC CECentral was interested in collaborating with community clinics throughout Kentucky in order to have a statewide impact and to address geographic health disparities related to access to care. In February 2018, the planning committee with representatives from CECentral, DKBmed and RealCME held their first meeting.  

“Improving patient outcomes is always the goal of the education and performance improvement programs that we create with our partners,” said Dean Beals, president of DKBmed. “After our successful program with Lancaster General Health, we were excited to team up with UKHC CECEntral and the University of Kentucky to expand this important program. All of the partners were enthusiastic to bring education to primary care providers and recommended eye screening to vulnerable patients who may not otherwise have access to ophthalmologists.”

UKHC CECentral then met with UK Telemedicine and Ophthalmology to develop an approach to retinal screening in community-based clinics. Input from a wide array of community clinics played a critical role in developing the educational approach. Faculty from UKHC CECentral worked with DKBmed and RealCME to develop and submit a grant application to Regeneron Pharmaceuticals. The grant was awarded in August 2018. The collaborators began developing the educational curriculum starting in October of 2018. Primary care providers received education about the importance of regular screening for diabetic retinopathy and common treatments. They were also trained to use the specialized  handheld cameras. Clinic implementation began in January 2019.

Linking education to clinic processes and technology access created a feedback loop: the performance improvement initiative generated data that guided the manufacturer, Volk Optical, to incorporate improvements in screening technology and software based on real-world clinical need. The technical improvements then facilitated better workflow and, therefore, improved screening rates at clinic sites. Together, collaborators improved patient access to diabetic eye disease screenings in the primary care setting. Screening rates increased over the implementation period in all participating clinic groups, as outlined in Table 1.*

Table 1: Diabetic Eye Disease Screening Rates: Improvements in Screening and Documentation

by Clinic Group

*Data from the project are still being finalized. All data reported here are initial figures and may change after further analysis.  

**UK Family Medicine clinic group had an increase of 105% over the implementation period.

***FHC – Iroquois had an increase of 20.5% over the implementation period. 

“Measuring changes in actual practice behavior is a challenge we face daily with medical education programs,” said Steven Haimowitz, president of RealCME. “The collaboration among the stakeholders of this initiative enables us to correlate results from educational interventions with changes in clinical measures using real world data. It’s affirming to demonstrate how improvements seen in the interventions created for this curriculum result in improved screening rates, ultimately leading to reduced levels of blindness in the UK patient population.” 

Preliminary results indicate the greatest increase in screening rates occurred within rural clinics, where access to eye care is most limited, whereas rates in urban clinics remained fairly consistent. Rural clinics may benefit from improved access to screenings and technology, while urban clinics may need training to improve patient follow-up and clinical documentation in busier clinics. Future education and performance improvement programs should provide tailored interventions to address clinical care gaps based on differing geographic limitations between rural and urban clinics, as well as workflow barriers.

The project team learned many important lessons throughout the design and implementation of the program. One such lesson was learned when the project team attempted to onboard three new community clinics in the middle of the implementation phase. Recruiting new clinics was due to the withdrawal of four clinics from the program because of multiple hacking attempts on their electronic medical records and the inability to provide required data for the study. Based upon the challenges encountered during this process, the project team recommends addressing unexpected clinical emergencies in the future by prioritizing the continuing education, performance improvement, and academic detailing in existing clinics at all staff levels. Emphasizing the importance of implementation in clinics that are already involved in a project is more likely to lead to improved educational and patient outcomes.

By collaborating across a variety of different organizations, the ODM project team created an initiative that increased provider knowledge and access to new eye screening technology, while positively impacting patient health by improving access to annual diabetic eye screenings and specialist care. 

“We worked very hard to facilitate great partnerships by prioritizing the needs of the clinic providers and their patients. This collaboration highlights the importance that continuing education and evidence-based practices can have on reducing health disparties. We are excited about future opportunities to partner with clinics and educational partners in order to continue addressing the needs of both patients and providers across our state,” said Jasleen Chahal, Grants Program Manager at UKHC CECentral.  

As a result of this initiative, the project team was honored to have been awared the Outstanding Educational Collaboration Award in 2020 by the Alliance for Continuing Education in the Health Profession (ACEHP). The partners on this project are grateful to ACEHP for creating a space in which these deeply collaborative projects can develop and for recognizing the novelty and impact of the project. 

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