Closing the Gap in Diabetic Eye Care: Technology Solutions to Boost Screening Rates

Diabetes is one of the most significant chronic conditions affecting Americans today, with about 38 million people currently living with the disease—roughly 1 in 10—and more than 1.2 million newly diagnosed each year as prevalence continues to rise. For many of these individuals, the most serious threats are not day-to-day glucose fluctuations but the long-term complications that quietly damage vital organs over time. Among these complications, diabetic eye disease stands out as both common and highly preventable, making it a critical focus for clinicians, payers, and health systems committed to value-based care.​

Diabetic eye disease is an umbrella term that includes diabetic retinopathy, diabetic macular edema, glaucoma, and cataracts, all of which are more common in people with diabetes and can lead to irreversible vision loss if not detected early. Diabetic retinopathy is the most prevalent and well-studied of these conditions and progresses over the years as chronic hyperglycemia damages the retinal microvasculature. The International Diabetes Federation estimates that roughly 1 in 3 adults with diabetes will develop some degree of diabetic retinopathy, and among those who have had diabetes for 20 years or more, that risk climbs to nearly 60 percent. In the United States, recent estimates suggest that millions of adults already live with diabetic retinopathy, underscoring the gap between recommended screening and real-world practice.​

Clinically, this matters because diabetic retinopathy is the leading cause of blindness in adults ages 20–74, yet it is largely asymptomatic until vision is already compromised. Patients often feel well and see normally even as early retinal damage is progressing, which means they do not seek care until they notice blurring, floaters, or dark spots—signs that the disease is already advanced. 

From a population health perspective, this asymptomatic course is a double-edged sword: the condition is highly preventable and treatable when caught early, but it requires systematic, proactive screening to identify at-risk patients before they have symptoms. 

Without a deliberate strategy, even engaged patients and high-performing practices will miss opportunities to prevent avoidable blindness.​

Recognizing this, the Centers for Medicare & Medicaid Services (CMS) tracks diabetic eye exams as a core quality measure, evaluating what proportion of patients with diabetes received a retinal or dilated eye exam by an eye care professional in the past 12 months. 

For primary care organizations operating under value-based contracts, performance on this measure influences both quality ratings and financial outcomes. However, achieving high performance is not straightforward. The eye exam is delivered outside the primary care setting, and primary care providers are already stretched managing multiple chronic conditions, preventive screenings, and social needs that are directly within their workflow. Eye exams and foot exams are among the evaluations most likely to be overlooked, even in otherwise well-managed diabetic populations.​

There are also structural barriers. Coordination between primary care and eye care specialists is often fragmented, with limited interoperability between EHR systems and inconsistent exchange of exam reports. Practices rely heavily on manual outreach, asking front-desk or care coordination staff to call patients one by one to determine whether an exam was completed, where it occurred, and whether results are available. For patients who have not yet had an exam, additional calls, reminders, and follow-up with specialists add even more time and complexity. This staff-intensive model is challenging to scale and competes directly with other high-value tasks such as care management, medication reconciliation, and social needs screening

Patient behavior compounds these workflow challenges. Because diabetic eye disease typically has no symptoms in its early stages, many people with diabetes underestimate their personal risk. Studies indicate that about six out of ten people with diabetes skip their recommended annual eye exam, often because they feel fine and do not appreciate the potential consequences of delaying care. Education during office visits helps, but in a 15–20 minute encounter, there is limited time to fully convey risk, address misconceptions, and support appointment scheduling and follow-up. As a result, even motivated clinicians and patients can fall short of guideline-recommended care, and organizations see this reflected in their quality performance data.​

Digital communication tools designed for population health offer a path forward by shifting this work away from phone calls and into automated, patient-friendly workflows. Quincy for Population Health is one such solution, using a conversational chatbot to engage patients with diabetes at scale. Instead of staff dialing each patient, the chatbot sends tailored outreach to all diabetics without an eye exam on file.  The chatbot reinforces why the annual retinal or dilated eye exam matters, explains the risk of silent vision loss in accessible language, and then asks whether the patient has had their exam. When the patient responds, the chatbot can capture key details, such as where the exam was performed, enabling the organization to close documentation gaps.

For patients who have not had an eye exam, the same conversational flow can nudge them to schedule one and, when appropriate, provide location options or referral information aligned with the organization’s network. This experience is convenient and familiar for patients, who can respond at their own pace on their mobile device, without installing an app or waiting on hold. 

For care teams, the impact is twofold: significant time savings as manual phone outreach is reduced or eliminated, and a more complete, timely dataset to support accurate quality reporting and care planning. By automating outreach, education, and data capture, Quincy enables clinical staff to focus on higher-touch activities while improving screening rates and performance on key measures for diabetic eye disease.

In an environment where diabetes prevalence is rising, and diabetic eye disease remains a leading cause of preventable blindness, health systems need solutions that extend beyond the exam room and scale across their diabetic population. 

Combining evidence-based clinical guidelines with intelligent, conversational technology positions organizations to identify risk earlier, close care gaps more efficiently, and deliver on the promise of value-based care—preserving vision, improving quality metrics, and ultimately enhancing quality of life for people living with diabetes.​

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