In last months Editorial, I reflected on the observation that visionaries in our field are often out of our sight during years when they are already making great progress toward their vision. This has been true for many of those whom we now see as visionaries. I was prompted in these thoughts both by the passing, recently, of visionaries in our field and in our Academy, and by the marvelous opportunity we have to witness future acclaimed visionaries while they are, for many of us, in the “silent phase” of their visionary efforts. The noting of the most unusual talents and accomplishments of the Academy's past Irv & Beatrice Borish Awardees, witnessed in our Optometry and Vision Science April Feature Issue, also provided a preview of many likely visionaries in optometric research.
In that May 2010 Editorial, I also noted the vision of a colleague who may, just now, be emerging out of what I characterize as the “silent phase” of a visionary; a phase where the visionary is essentially out of the sight of most of his colleagues. From my perspective, he has been over a decade ahead of many of us in his thinking about the usefulness and potential in optometry for telemedicine applications and implementation as a significant part of optometric practice and primary health care. His entrepreneurial efforts with Eye Picture Archive and Communication System (EyePACS) have resulted in applications of optometric and ophthalmological clinical care, through telehealth store-and-forward clinical images, in over 100 primary health care centers today, mostly in California. I promised to name this mystery person in this Editorial, and briefly tell you about a visionary effort and this emerging, yet unacknowledged, visionary colleague.
Our colleague is optometrist Jorge Cuadros, OD, PhD, who lives in Northern California. In 1994 Jorge did his first telemedicine consult between UCB School of Optometry (UCBSO) Medical Eye Clinic and Buena Vista Eye Care Center in San Jose, CA. That modest beginning lead to the further development of his internet-based software. It is now used in many different locations. The early efforts were primarily a demonstration and proof of concept. In 1999 to 2000, he used free Internet programs to do a telemedicine demonstration project with the Beijing Medical University, and in 2000 worked with a vascular surgeon, Dr Jon Bowersox, in the design of the Pacific Rim Telehealth Project on a low-cost web-based program for diabetic foot wound care. That software was immediately adapted by him to eye care communication and became the first version of EyePACS, a term coined jointly in a conversation with the late Dr Jeff Berger, a retinal specialist at the University of Pennsylvania Scheie Eye Center. In 2001 to 2004, he used EyePACS for clinical consults and teaching at University of California, Berkeley School of Optometry (UCBSO) clinics, Buena Vista Eye Care, VCOM systems in Florida, and the Aravind clinic in India. In 2002, he registered EyePACS as a trademark, and in 2003 began a diabetic retinopathy screening program with Dr Phyllis Preciado, an internist at Sequoia Community Health Clinic in West Fresno, CA.
By this time many outside of optometry had become aware of his efforts. He presented EyePACS and image enhancement research at the Computer-Assisted Fundus Image Analysis conference in Torino, Italy in 2003 and published “EyePACS: an open source clinical communication system for eye care” in the journal Studies in Health Technology and Informatics.1 The following year (2004), he developed and deployed a diabetic retinopathy screening program and a teledermatology program for the Alameda County (in Northern California) Medical Center EyePACS server.
But arguably the bigger break through came in 2005 when the California Telemedicine and eHealth Center granted UCBSO over $630,000 through the California Health Care Foundation (CHCF) for development of a store-and-forward diabetic retinopathy screening program in 13 community clinics in the Central Valley of California. That started a very impressive collaborative relationship providing support of EyePACS in CHCF Community Health clinics up and down California. (That is the basis of my concluding comments in this Editorial.) At about the same time Round Valley Indian Health Service brought 10 Indian Health Service clinics and University of California, Davis into EyePACS applications to replace their email-based retinopathy screening service. Cuadros also teamed up with diabetes retinal specialist George Bresnick to perform a diabetic screening project in Guanajuato, Mexico, funded in part by the University of California UCMEXUS program. At the same time, the Whittier Diabetes Institute in Southern California adopted EyePACS on their own server for Project Dulce, a mobile retinopathy screening program.
The momentum was gathering and optometry's involvement, through Cuadros and his UCBSO appointment, was facilitating extensive reach into primary health care.
The most impressive advances in this involvement have come in recent years through agreements with the CHCF—http://www.chcf.org. That development deserves the brief recounting of the chronology.
In 2005, CHCF supported a UCBSO pilot initiative through the California Telemedicine and eHealth Center, funded by CHCF, to further develop EyePACS, the open-source, web-based software program for capturing and delivering retinal images. The program was quickly implemented in 13 CHCF “safety-net” community health clinics for diabetic retinopathy screening in the Central Valley of California, with fundus cameras, UCBSO photographer training, an on-line internet-based webinar learning center, and clinical remote fundus image reading by UCBSO readers using the internet. (At this time EyePACS was also being used for diabetic retinopathy screening by 37 other entities and clinics in California and Mexico outside of the CHCF supported pilot program.)
Pilot project CHCF safety net clinics experienced considerable improvements in diabetic retinopathy screening rates and more timely referrals to specialists for treatment. In addition, the clinics used the retinal images as powerful tools to engage patients in diabetes self-management. A 6-minute video describing the program can be viewed at: http://www.chcf.org/projects/2009/diabetic-retinopathy-screening.
The pilot CHCF-supported safety net clinic program was expanded statewide in December 2007 by these expanded clinic sites, including the provision of an additional 26 fundus cameras for the sites, with a goal of ultimately providing services to a targeted 100 safety-net clinics and 100,000 diabetic patients. CHCF provided $1.76 million in funds. Expert consultation and leadership was provided by Jorge Cuadros, who was by then an assistant clinical professor and director of clinical informatics research at UCBSO. Since 2007 the UCBSO program, with CHCF support, has developed photographer training and certification and support for diabetic retinopathy screening in about 50 community clinics throughout California. It has created a team of optometry and ophthalmology certified readers who provide internet-based reports and recommendations on eye care referral to the primary care physicians at the community clinic sites. The fundus image readers are certified through an on-line program jointly created by Drs Cuadros (optometrist) and Bresnick (retinal ophthalmologist). To advance the connectivity of EyePACS to general health care records, in 2008 Cuadros developed interfaces with i2iTracks (a chronic disease registry program), Epicare-an Electronic Medical Record, and Eyescape, (a retinal imaging program). On November 1, 2009, CHCF entered an additional agreement, with support to UCBSO, “to provide funding to further develop EyePACS, improvements, enhancements, inventions, technology, and support tools to facilitate adoption of EyePACS in the community safety net clinical settings.”
In 2009, Cuadros and Bresnick2 published an article in the journal of Diabetes Science Technology describing EyePACS and its applications. I recommend this as an article of interest for Optometry and Vision Science readers.
This adventure, essentially by a determined single individual with a vision of the potential for optometry's involvement in primary health care as primary eye care providers, appears now to have reached an important stage. Cuadros' EyePACS development has been central to that vision. UCBSO leadership is convinced that the optometrist of the future will be active with these tools and enjoy growing primary care relationships that help patients as a result. In fact, the involvement in primary care settings and the issues of “store-and-forward” imaging have become part of the training curriculum at UCB for the last 2 years. I think we are seeing the fruits of a powerful personal vision by a determined, patient and hard working colleague. The path he has taken and the vision he holds is worthy of our attention, as are the implications for the future practice of ophthalmology and optometry assisted by growing advances in technology, access demands for care, and the creative evolution of patient care delivery.
Anthony J. Adams
1.Cuadros J, Sim I. EyePACS: an open source clinical communication system for eye care. Stud Health Technol Inform 2004;107(Pt 1):207–11.
2.Cuadros J, Bresnick G. EyePACS: an adaptable telemedicine system for diabetic retinopathy screening. J Diabetes Sci Technol 2009;3:509–16.