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BackgroundNovel telemedicine platforms have expanded access to critical retinal screening into primary care settings. This increased access has contributed to improved retinal screening uptake for diabetic patients, particularly those treated in Federally Qualified Health Centers (‘safety net’ clinics). The aim of this study was to understand how the implementation of telemedical screening for diabetic retinopathy within primary care settings is improving the delivery of critical preventative services, while also introducing changes into clinic workflows and creating additional tasks and responsibilities within resource-constrained clinics.MethodsA qualitative approach was employed to track workflows and perspectives from a range of medical personnel involved in the telemedicine platform for diabetic retinopathy screening and subsequent follow-up treatment. Data were collected through semi-structured interviews and participant observation at three geographically-dispersed Federally Qualified Health Centers in California. Qualitative analysis was performed using standard thematic analytic approaches within a qualitative data analysis software program.ResultsThe introduction of telemedicine platforms, such as diabetic retinopathy screening, into primary care settings is creating additional strain on medical personnel across the diabetes eye care management spectrum. Central issues are related to scheduling patients, issuing referrals for follow-up care and treatment, and challenges to improving adherence to treatment and diabetes management. These issues are overcome in many cases through workarounds, or when medical staff work outside of their job descriptions, purview, and permission to move patients through the diabetes management continuum.ConclusionsThis study demonstrates how the implementation of a novel telemedical platform for diabetic retinopathy screening contributes to the phenomenon of workarounds that account for additional tasks and patient volume. These workarounds should not be considered a sustainable model of health care delivery, but rather as an initial step to understanding where issues are and how clinics can adapt to the inclusion of telemedicine and ultimately increase access to care. The presence of workarounds suggests that as telemedicine is expanded, adequate resources, as well as collaborative, cross-sectoral co-design of new workflows must be simultaneously provided. Systematic bolstering of resources would contribute to more consistent success of telemedicine screening platforms and improved treatment and prevention of disease-related complications.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3427-9) contains supplementary material, which is available to authorized users.

IntroductionTelemedicine-based diabetic retinopathy screening (DRS) in primary care settings has increased the screening rates of patients with diabetes. However, blindness from vision-threatening diabetic retinopathy (VTDR) is a persistent problem. This study examined the extent of patients’ adherence to postscreening recommendations.Research design/methodsA retrospective record review was conducted in primary care clinics of a large county hospital in the USA. All patients with diabetes detected with VTDR in two time periods, differing in record type used, were included in the study: 2012–2014, paper charts only; 2015–2017, combined paper charts/electronic medical records (EMRs), or EMRs only. Adherence rates for keeping initial ophthalmology appointments, starting recommended treatments, and keeping follow-up appointments were determined.ResultsAdequate records were available for 6046 patients; 408 (7%) were detected with VTDR and recommended for referral to ophthalmology. Only 5% completed a first ophthalmology appointment within recommended referral interval, 15% within twice the recommended interval, and 51% within 1 year of DRS. Patients screened in 2015–2017 were more likely to complete a first ophthalmology appointment than those in 2012–2014. Ophthalmic treatment was recommended in half of the patients, of whom 94% initiated treatment. A smaller percentage (41%) adhered completely to post-treatment follow-up. Overall, 28% of referred patients: (1) kept a first ophthalmology appointment; (2) were recommended for treatment; and (3) initiated the treatment. Most patients failing to keep first ophthalmology appointments continued non-ophthalmic medical care at the institution. EMRs provided more complete information than paper charts.ConclusionsReducing vision impairment from VTDR requires greater emphasis on timely adherence to ophthalmology referral and follow-up. Prevention of visual loss from VTDR starts with retinopathy screening, but must include patient engagement, adherence monitoring, and streamlining ophthalmic referral and management. Revision of these processes has already been implemented at the study site, incorporating lessons from this investigation.

The AROMA project is exploring the kind of awareness that people effortless are able to maintain about other beings who are located physically close. We are designing technology that attempts to mediate a similar kind of awareness among people who are geographically dispersed but want to stay better in touch. AROMA technology can be thought of as a stand-alone communication device or -more likely --an augmentation of existing technologies such as the telephone or full-blown media spaces. Our approach differs from other recent designs for awareness (a) by choosing pure abstract representations on the display site, (b) by possibly remapping the signal across media between capture and display, and, finally, (c) by explicitly extending the application domain to include more than the working life, to embrace social interaction in general.We are building a series of prototypes to learn if abstract representation of activity data does indeed convey a sense of remote presence and does so in a sutTiciently subdued manner to allow the user to concentrate on his or her main activity. We have done some initial testing of the technical feasibility of our designs. What still remains is an extensive effort of designing a symbolic language of remote presence, done in parallel with studies of how people will connect and communicate through such a language as they live with the AROMA system.