Table 1.

Possible interventions to promote widespread implementation of teleophthalmology for diabetic eye screening in the USA

Category	Barriers	Possible interventions
Camera technology	High proportion of ungradable images Cost Space/portability	Single- or two-field fundus photography imaging protocols Selective use of dilating eye drops to obtain gradable images as needed Use of confocal and wide-field imaging cameras Each camera serves patients from multiple clinic sites Less expensive camera technology Handheld, smartphone-based, and compact tabletop cameras
Cost-effectiveness	Unclear billing and reimbursement models Unclear return on investment	Demonstration of a variety of financially sustainable billing models Improved insurance reimbursement for telemedicine services Tailored tools for calculating return on investment for individual health systems
Organizational/systems	Need to tailor implementation to individual health system Incomplete documentation of diabetic eye screening Limited communication regarding diabetic eye screening	Toolkit guiding tailored implementation of teleophthalmology to an individual health systems’ needs and resources Improved methods for primary care providers and clinic staff to access and update diabetic eye screening records Improved methods for communicating diabetic eye screening reports to primary care providers (e.g., standardized workflows and reporting forms, electronic health record interoperability, national or state-wide registries, regulatory mandates)
Clinical personnel	Imager and grader training/capacity Obtain provider and staff buy-in and sustain engagement	Training existing staff or hiring additional staff if needed for imaging Partnering with local eye doctors and reading centers and/or use of artificial intelligence software for grading images Engage providers and clinic staff to integrate teleophthalmology and streamline clinic workflow Provide financial incentives, audit and feedback reporting, and reminders to discuss diabetic eye screening with patients (e.g., best-practice alerts)
Patients	Lack of knowledge Time and financial constraints	Recommendation of teleophthalmology by primary care providers Patient education materials and publicizing teleophthalmology Providing teleophthalmology in primary care, pharmacy, or employer screening Offer convenient, same-day imaging Low-cost pricing and lower patient co-pays through improved insurance coverage Outreach to patients with reminders when due for diabetic eye screening (e.g., phone, text, mail)