Online continuous quality improvement for diabetic retinopathy tele-screening.

Non-mydriatic digital fundus cameras constitute the key component for diabetic retinopathy tele-screening. This study investigated whether image capture skills acquired by non-professional photographers in a 1-day seminar and applied in a community setting may be reinforced and strengthened over time using an online continuous quality improvement (CQI) protocol. Approximately 20 amateur photographers from 13 independent sites were trained to capture images according to the recommended protocol: one 45 degrees image per eye, centered between the macula and the optic nerve, without dilation. In total, over the 19-month project period, 58 non-professional photographers captured and submitted 2,917 images. A professional photographer evaluated each image online assigning a CQI score. CQI scores indicated acquisition, and maintenance of skills was sustained over the study period. Over 93% of the images were scored as sufficient for clinical grading. Exposure and focus proved to be the most difficult skills. Skills needed to operate the digital cameras were acquired with relative ease. The online CQI protocol reinforced photographer skills over a significant period of time even when considerable turnover was experienced. The use of digital fundus cameras is easy to learn for the non-professional photographer. Their use saves the cost of a professional photographer. An online CQI protocol is also an effective tool for reinforcing and ensuring skill transfer, especially when considerable turnover in photographers can be expected.