Hello, everyone. Welcome to today's webinar hosted by the ADA Diabetes Technology Interest Group. I'm Yaoguang Zheng, assistant professor at NYU Myers College of Nursing. My research focuses on leveraging mobile health and continuous group monitoring for diabetes management. I'll be the monitor of today's panel. So next, here is a glance at today's agenda. We'll provide a few announcements and we'll introduce our experts in a few minutes. The presenter will be taking questions from the audience at the end of the event. Please don't wait until the end of the session to send in your questions. Instead, go ahead and type it into the Q&A box in your control panel. Please be sure to use the Q&A box and another chat function for questions. During this announcement segment, we'll use the chat box to send you important links and you can also use this place to chat with your audience. The diabetes technology hosted a webinar on February 20th, also related to CGM. If you missed it, the recording is at the ADA Institute of Learning. You can scan the QR code or see the link in the chat to review. As an ADA member, you'll have several benefits. One is connecting with members of the interest group on the Diabetes Pro member forum. Continue the conversation about the topics covered in this webinar. See the link in the chat. So finally, I would like to introduce today's panelists, Drs. Eric Johnson and Dr. Rama Gentidani. First, Dr. Eric Johnson is a professor and a director of interprofessional education at the University of North Dakota School of Medicine and Health Science. Dr. Johnson is a past member of the ADA Professional Practice Committee and a past chair of its primary care advisory group. He has led initiatives with American Medical Association and ADA North Dakota Affiliate. His research covers diabetes, tobacco-related disease, interprofessional education, and chronic disease management. He is strongly interested in team-based technology management of diabetes. Dr. Rama Gentidani is a professor and leading endocrinologist specializing in diabetes care and quality improvement. Dr. Gentidani is also the medical director of diabetes quality and a vice chair of medicine for quality and innovation at Sanders Sinai Medical Center in Los Angeles, California. Additionally, she chairs the National Epic Endocrinology Steering Board and advocates for diabetes technology integration. Now, let's welcome Drs. Johnson and Gentidani to present their talks. Thank you. Thank you and good afternoon, everyone. I will share my slides. So this afternoon, I'll be talking about overcoming barriers and implementing continuous glucose monitoring for us as clinicians. Our objectives are to understand a brief introduction to continuous glucose monitoring, or CGM. We'll learn about barriers to implementing CGM in your practice. We'll learn about some pitfalls in CGM implementation. And we'll understand strategies for effective implementation for CGM in your practice. This is our agenda, and I will close out. Let me clear this. With some things about how we do it in our small regional health center here in northeastern North Dakota, northwest Minnesota. So let's start with a brief introduction to CGM. Now, I know most of you are very familiar with continuous glucose monitoring. We'll just set the table here for this. So we can get real-time insights. CGM technology continuously tracks glucose levels, offering intermittent or real-time data. Continuous glucose monitoring data is sent to a receiver or a smartphone, which provides users with real-time insights on glucose levels. And it's important that we make this actionable data for our patients. And then, of course, these also, some of them have alerts for glucose levels, either high or low, and also for rapidly rising or rapidly dropping blood sugars. The benefits are, in some populations, we see improved glycemic control by having this real-time data available to patients. We have reduced hypoglycemic events in some populations as well, and we can have informed decision-making. And patients can make informed decisions regarding their own care, and quite often will say, I didn't know this food did this particular thing, or I didn't know that 15 minutes of walking would do this. So they can gain some insights right away after beginning to use one of these products. And this can lead to increased patient confidence. Patients often report increased confidence in managing their diabetes effectively, leading to better health outcomes with actionable steps. Current usage and adoption rates, I think we can safely say that they are increasing, and this is affecting diabetes management. But there are some factors that are influencing adoption across all populations, and that might include lack of awareness of benefits, accessibility of devices, and training for use in diabetes care. So let's move on then to the heart of our talk, talking about barriers to implementing CGM. Of course, there are certain technology requirements in IT integration, and Dr. Gyanchandani will be talking about this in more detail. But basically, CGM systems must be compatible with current technology to ensure efficient data management and accessibility for users. And I'll talk a little bit about how we do this in our health center. We need a robust IT infrastructure that's essential for effective management of data in CGM systems. And it's important that we support seamless operation. There can be challenges, as workflows can be complex and resource-intensive, and this can require careful planning and execution to have this be functional with an electronic health record. Data storage is important as well. It's nice to be able to go back and look at previous data for comparison, and that's crucial for effective patient monitoring. Electronic health record compatibility is also essential for data sharing across systems. We find this to be very important, especially with all of the telehealth that we do. And we want to have seamless data sharing, as this improves clinical workflows and improves patient care through timely access of information. With our team, of course, we're all sharing this with each other, like many of you do with your teams. The diabetes educator can see the same information that I can see. The pharmacist can see the same information that I can see, and so on and so forth. Training primary care providers is essential to effectively utilize CGM technology for patient care, especially with the growth that we are seeing, and since a majority of persons with diabetes are cared for by their primary care provider. Proper training enables providers to accurately interpret CGM data, leading to improved patient outcomes and personalized care. And this can lead to more optimal patient care, as well-trained providers can offer optimal care based on CGM data, enhancing the overall management of patients' health. Of course, not only are there barriers, there's a few pitfalls in CGM implementation as well. Interpreting the results accurately is very important, and gaining experience so that we can use this data effectively and interpret patterns and trends is very important in making clinical decisions in an informed fashion. And understanding CGM data enables healthcare providers to make more accurate and timely clinical decisions for their patients. For example, when we think about patterns, maybe we're seeing somebody who has a lot of overnight hypoglycemia, or maybe they have significant postprandial hyperglycemia. Analyzing these types of patterns and making this into actionable data can be very helpful for us and for our patients. There are billing and reimbursement challenges as well, and this is often complicated due to differing insurance coverage. I will say that most of the companies that we serve where I live, if you're on insulin, you can get a CGM. However, there are a few policies that we service that allow persons with diabetes to get a CGM, whether they are on insulin or not. But there is still some variability among payers. And clinicians face challenges with this inconsistent coverage from insurance providers for CGM services, and this can complicate access for our patients. So navigating the reimbursement process is essential for clinicians to ensure patients can afford CGM technology. Now, it also can be that different payers may pay for a certain CGM and not another CGM. It doesn't matter that much to us. We tend to prescribe to the formulary, and we find that that works out very well for us and getting coverage for our patients. Time constraints are something that all of us as clinicians deal with all of the time. The impact of time limitations affects every single thing that we do, and CGM is no exception. Time constraints can certainly hinder our ability to thoroughly analyze CGM reports, which, of course, can negatively affect our patient outcomes. Implementing efficient workflows, which I will share with you what I do, can help clinicians maximize their time for reviewing critical data and improving patient management. Dedicated time for data analysis is essential for clinicians to interpret CGM reports effectively and enhance patient care. Other pitfalls in CGM usage that we might think about, including data overload. We're managing and interpreting large volumes of data throughout the day, not just CGM, but just about everything else that we do, and we need to be able to avoid information fatigue. Users can have errors, too, with just the usage of these devices. There are some common mistakes in sensor placement and usage, and you probably will hear about that in a separate session in this series. But we want to train patients to avoid errors so that they can consistently get accurate data and avoid frustration with the use of these devices. So let's talk now about some strategies for effective implementation. Training and support are critical, and providing training resources for yourself and your staff is very important. This includes information technology services within your own clinics and hospitals, but also from external sources. We have found over the years that industry representatives for these devices have been very helpful, and we don't hesitate to call on them if we have some issues or concerns. Enhancing data storage is important, and Dr. Jian Shandani will talk more about this in detail. But effective data storage is essential for managing continuous glucose monitoring data efficiently and securely. There are integration benefits. This can improve communication between health care providers, which can enhance patient care. All of us at a team have the data available to us. And streamlined data allows health care providers to make more informed decisions that enhance overall patient outcomes. Best practices for CGM use. I'm sure you're hearing a lot about this in this series, but we should fully understand and make sure that patients fully understand their technology and how it works to maximize its benefits. And I'll talk a little bit about how I do that. Patients must learn to interpret their own CGM data effectively. Just having the data is not enough. We need to avoid therapeutic inertia by actually taking action on the data. And regular follow-ups are important to discuss CGM readings and optimize treatment plans. It just can't be out there in space just running. We need to take this data and actually do something with it. And I find that the more I do that, I have less trouble down the road with certain patients. Maybe we won't have to make quite so many adjustments, or maybe patients will get very adept at using their own data and making some clinical decisions on their own, which can promote efficiency at future appointments. We need to develop comprehensive training programs and thorough programs are essential for clinicians to use CGM effectively. We find that we get good support from industry representatives, but also attending series like this that you're attending today. Training should include comprehensive data interpretation. I know that you've already had a session on this, to empower clinicians in making informed decisions for patient care. Clinicians need to be trained on the proper usage of CGM devices to ensure accuracy and efficiency, and educating patients about CGM technologies enhances their understanding and can promote better outcomes. So what do we do in our little health system, as far as getting the word out about these devices? Well, annually, we do a two-hour Grand Rounds presentation on diabetes technology, and as a team, we stay in contact with industry representatives, and we attend conferences and webinars like you're attending today. Many patients are unaware of CGM technology and its potential benefits for managing diabetes effectively, although I would say, in my experience, this seems to be changing rapidly. Access to CGMs can be limited by financial barriers with variable insurance coverage, which can make it difficult for some patients to obtain necessary devices. For example, typically you need to be on insulin for coverage where I live, although some plans do cover CGMs just for a diagnosis of diabetes. And now there are new over-the-counter devices as well, which I'm not promoting specifically, I'm just citing them as examples of other alternatives that are now available. And insurance coverage issues can really vary quite a bit. Geographic factors can limit access to CGM as well. Typically, we like to have a nurse or a certified diabetes care and education specialist start a CGM and do that instruction for a patient, and we can do that through telehealth as well. We do a lot of telehealth as a system because we have many remote patients in many remote communities that we serve. There are some patient engagement strategies we should be thinking about as well. Engaging patients with their data is crucial for improving health outcomes and self-management, and clinicians should provide education on how to interpret CGM data for patients. And this can enable them to make better decisions and do better with the device. Empowering patients to make informed decisions based on their CGM readings can lead to improved health management and outcomes. So what do I do? Well, I do my interpretation with the patient with their report open on a computer screen, and I encourage them to look at their own reports periodically and message me with their questions. So I'm sitting in the room with the patient. We have their data open on the screen. We actually talk through it together. And that really only takes about two or three minutes to do that. And they learn a little bit each time about interpreting their own data. They need regular follow-up and support, and that's important to monitor patient progress and ensure effective use of these devices. We want to make sure that we have actionable insights based on CGM data. For example, I gave the example of maybe a patient with a pattern of post-meal blood sugar elevations. Well, an actionable step might be that those meals could maybe be a little bit smaller, or maybe we make an adjustment with their medication. Maybe they increase their activity level during those times. There are many small steps that we can give patients just based on this data alone that can make big differences down the road. And I've established a routine for myself to review CGM data to encourage better patient engagement and adherence to treatment plans. Of course, I've talked about time constraints and patient education challenges. This is all linked to time management issues, which we all deal with every day with everything that we do. And addressing time management is essential for optimizing CGM use. As I've stated, it's not just enough to have the data. We actually need to do something with it. We need to overcome some gaps in technology-based diabetes care as well. Sometimes there are provider biases about maybe who would be a good candidate and who wouldn't be. Of course, we always think about other social determinants or drivers of health. And there's a conversation happening right now in the community about whether technology is actually widening the inequity gap. So think about who can make the leap in your practice if you're not already using these devices to their maximum benefit. It's important to avoid bias, and I think it's important to remember that insurance coverage does exist for diabetes technology, and that includes Medicaid and Medicare. So don't assume it won't be covered. And racial and ethnic minorities and those of lower socioeconomic status have higher rates of diabetes, may have worse outcomes, and are less likely to be offered diabetes technology. And then the geographic disparities that I mentioned as well. So recommendations for clinicians are to advocate for the adoption of continuous glucose monitoring in their practices. Seek out training opportunities like this series, as that is vital to enhance skills in utilizing CGM technology effectively. And this also includes optimizing IT infrastructure. And patient education is essential as well for improving patient outcomes and engagement. So how do we do it in our clinic? Well, think about who is on your team. The primary diabetes provider, a nurse, a certified diabetes care and education specialist, dietician, advanced practice nurse or physician assistant, a PharmD, or maybe others. But not every practice will have all of these team members. So get the necessary technology for your practice. As you probably all know, CGMs have downloadable data sets that can also be uploaded to commercial websites that are maintained by the company that makes the device. And the responsibility of downloading or uploading this and compiling this data can fall on a diabetes educator, which we sometimes do. But in our primary care practice, we have a nurse or medical assistant who's trained on these devices. In fact, we have two or three nurses who are trained on these devices, and they know how to access the data and get that to us in a timely fashion during the clinic visit. All of the major manufacturers have software that can be installed on an in-house computer where the data can be downloaded either to paper, which we don't do, but more to an electronic file, which we do. And that may be uploaded into the medical record, or the devices can automatically upload their data to a commercial site maintained by the company that makes the device. Once you've done a few of these and have developed a routine, the flow is usually good. And doing this in advance is best, but if it's done during the office time, during the clinic time, the appointment time, you may do the encounter first and review the data at the end of the appointment. So I do this all the time. We get the patient in the room. We get their vital signs. The nurse takes their device to go get the data off of it. I actually go ahead and start my visit with the patient, and we do everything else first, and then we do the data at the end. And from a time efficiency point of view, that really helps a lot. And we found that industry representatives were very happy to help us get set up. So I see the patient. As I mentioned, I get everything else done first. It takes about two to three minutes to discuss the CGM report. I spend about two minutes putting my interpretation into the EHR, which I have shared with the patient in real time while they're sitting there with me. And this gets smoother the more of these that you do. It's important to document appropriately for billing services, and we should be knowledgeable about the necessary coding, which I will share with you. And reimbursement processes and documentation requirements are critical for us to achieve proper reimbursement. You can be reimbursed for interpreting these data sets. We use the CPT code 95251. Your chart notes should include many of the other things that normal chart notes include. And then an ambulatory glucose profile can be part of the note. Now I have this set up as a dot phrase in Epic. Those of you who use Epic know what a dot phrase is, but it's just a kind of a preload of what I need to make the documentation. This just takes a couple of minutes, and then an interpretation. So maybe your interpretation is consistent post-meal blood glucose elevation, or maybe your interpretation is consistent overnight hypoglycemia. You can't just record the data. You need to have an interpretation as well. So Medicare coverage requirements. Of course, you must have diabetes and be treated with insulin. You need to make treatment adjustments based on those results, and be seen in the office every six months. There is some variability in CGM coverage. You're gonna find that out the more of these that you do. But at the same time, we're seeing better and more coverage all the time. And the impact on patient, of course, is going to be very positive. So as we move toward our conclusion, we'll summarize some key points. I've talked a little bit about benefits of CGM technology, which you have heard in other sessions. We've talked about the barriers and pitfalls to implementation. We've talked about strategies for integration, and I've talked about how we do it in our small regional health center as well. Future advances. Of course, sensor technologies are getting better all the time with accuracy and reliability, as well as just being able to wear it for a longer period of time. Some of these go up to 15 days now. Better integration with electronic health record will certainly enhance data sharing, and that's getting better as well. And I think we should assume that artificial intelligence will be playing a role in enhanced data analytics going forward. These are my references. I'd be happy to share my slides. Some of this material comes from the American Diabetes Association Standards of Medical Care and Diabetes 2025, and that is the end of my session. I will go ahead and pass it along, and we'll answer questions at the end. Good afternoon, everyone. Can you see my slides? So I'm Roma Ghenchandani, and I'm going to talk to you about integrating some of this wonderful sensor data into your electronic records. As Dr. Johnson just mentioned, this is such an amazing development for all our patients with diabetes and has enhanced our diabetes care dramatically. So I have no disclosures, and as diabetes experts here, you all know we've been so comfortable with diabetes devices for all these years. Insulin pumps are as old as the 1970s, and automated insulin delivery systems, SPARC pens, and now other simpler systems, many of them can be integrated into EMR. So how does this process work when your patient comes to the clinic? So right now, if you're not integrated, you have a patient who has a CGM system. The patient may be connected wirelessly to the cloud of the manufacturer, or may have to download with a physical connection to a computer, and then this computer can be at the patient's home or it can be in your clinic. You print out a report. Some of this computer data goes to the cloud, and then you take this report, you scan it into the EHR. It can live in some drawers and paper, as many of you know, and some folks actually type this data into the EMR, and then this is with the healthcare team. When some folks take these papers, if you have Epic and Haiku, you can take a picture in Haiku, then you load it on and the picture is turned around. So it's very messy. You also have this voluminous data. These CGMs give you so much blood glucose data, which you cannot leverage for population health because none of it is actually gathered in any systematic form. So this is, iCode is a conglomeration of folks, which is led by Dr. Espinoza and Dr. Klonoff, and they came out with some recommendations that if CGM is integrated into the EMR, how this should be done. So this is a long document, but the guidance is that healthcare organizations caring for patients with CGM should pursue integration because it improves patient care, it improves documentation, it improves your clinical workflow. Many things can happen faster in the clinic and much more efficiently, and there's overall improvement in quality and outcomes. The stakeholders who do this integration should be mindful of access to technology on vulnerable populations and the ability to access and receive care. The patient should always have rights to retain their health data and know who it is being used by and for what purpose. And the CGM aggregators and healthcare organizations should allow patients to view which institutions are accessing their data and have options for that access. So on the left was our old way of getting the CGM data into a clinic, and the right side is sort of an ideal state. I don't think we are perfectly there yet, but pretty close. So this is CGM data uploaded to the manufacturer's cloud. As you all know, all the CGMs have manufacturer's clouds. This then gets from the cloud. A team member orders the CGM data into the EHR and the data is instantly available for clinical review. So this can be done in two ways. If the patient can come to the clinic, patient arrives to the appointment, checks in, patient's device is synced with the transmitter to the patient profile, and there's a PDF report and flow sheet statistics which are sent to the EHR or EMR. In remote sync, it's a different process in which the patient syncs their devices at home, and the PDF report and the flow sheet are sent to the EHR on a cadence. Some people do it every 15 days, every 30 days, but the problem in remote sync is that if a patient has a high or low blood sugar, which is of severe low or severe high, who responds to that? So those are some of the thoughts with a remote sync. We do more of on-demand where the patient syncs their device at home and on-demand order is placed in the EHR and the order is received and PDF report and flow sheet statistics are sent to the EHR. So what are the barriers to this integration? As Dr. Johnson said, there's a lot of barriers here. The technical barrier, this is a lot of data. You need a good platform, you need a lot of technology, you need a group of technologists to help you and then store all this reams of data. There is time for staffing. The person who helps you with the CGM, just getting the CGM set up takes time and work. There are a lot of troubleshooting issues that happen and you have to have a good workflow development. There are legal and compliance issues for patient data sharing, data privacy and liability and of course, this is all expensive. There's a personnel, technology, cost of creating and maintaining the integration, including software, data subscriptions and staff. So this takes all of this on the right to make it happen. So I'm gonna tell you a little bit about our journey outpatient diabetes technology integration at Cedars. So we acquired two platforms. One is Gluco. Gluco has a lot of devices, all the blood glucose monitors, which are Bluetoothed. It has Dexcom and it has some of the pumps. It did not have Libre when we integrated, which was a couple of years ago, but it does have Libre now. When you integrate with these platforms, you have to connect it to your EMR with a system or an aggregator or integrator. This is Redox. We use Redox, which is an HL7 V2-based integration and now we also use FHIR. When this is integrated, the report summaries and flow sheets are supported by this integration and data and applications are launched in EHR with a one-click. So here is all of the CGM, comes from the CGM patient platform to the manufacturer's cloud. The aggregator takes it all, puts it into EHR and every time I want it, I have to release an order. So what is the clinic workflow? So we created an enrollment order for Gluco or Libre and this is an order which was created. So here is our CGM orders. This is Gluco enrollment, where you have to first enroll the patient. Then you have to request metric and PDF reports. This is Libre report, Libre enrollment. Libre has three reports. It has a AGP or the ambulatory glucose profile, the GPI and of course the Libre report of daily metrics. So once you enroll the patient right here, you place the order. This is the order. The most important thing is the patient's email. So if there's a mistake in the email, which always is a problem, sometimes patients don't remember their email and other things, there's two emails or if there's a partner's email being used, that doesn't work out well. So your email has to be perfect, the same email which is on their LibreView account. And then you have to put a standing order. That means every time you want an order, this can be released. So if you have Epic, this is how a standing order looks like. You put, we put in about 20 or 25 instances of orders that we can order and you accept the order. The patient gets an email notification. On the left is the Libre. So you have to verify the email to complete the signup and then you verify it. On the right side, this is the glucose. It tells you to connect with your care team. Each team has, your care team will have a code and then track your glucose and it'll give you personalized insights and some education. So what about patient agreements? So patients have to consent to some of this. So this is our consent process in which glucose will tell you to add Cedars-Sinai or your institution to see your CGM data. And this is Libre telling you that you want to confirm the practice can connect with your data. So there are two workflows. So you can place the order through Gluco in the Gluco app and you can invite the patient. You complete the enrollment, patient gets connected and their data, you have standing orders in CS-Link which is our Epic. An alternate method is you can go through the Gluco app and you can register the patient's account and the mobile setup and add the clinics ProConnect code. This seems to be an easier process but all emails have to be matching. The standing orders have to be there so they can be released every time you're needed. This is when patients come in. We hope that this is done before they come in. Getting patients set up with all the apps takes a long time to happen. And this is some of the biggest barrier to a smooth integration. With Libre, same thing. You can release the order from the chart or you can connect the patient through the Libre view. And then once the patient is connected, you release the standing order. The clinic staff enrolls, make sure the patient is connected and you can look at the data. So here is how you would order and receive the PDF and reports. So here is a standing order. I go to order review. I take, I want a daily log order. So I release that order right here. It takes a few minutes. The final result comes into the chart and then the scan is there on the bottom. So you open the scan and then you have the AGP report that you can view in your chart. It's really a neat process. You can see everything in your EMR. This is for gluco in other orders. I've already put the order. This is my final result. This is the final result. I see the scan. When I click on the scan, I can see my AGP report and I can also see all the logs and daily record. Of course, I cannot show that all in here. The other beautiful thing is that below this order, you can see the Libre or the epic glucodata down here. You can see all of what Dr. Johnson had said. He has a dot phrase. You can see that all here. You can also trend it. So here is all the Libre data in a flow sheet telling you which is a patient, how much in target, below and above target. And you can look at this flow sheet over time. And this is wonderful data to show you how the patient has improved. So here is my patient who was in range when I saw first time, 81, went up to 88, 95, 97%. Then above range keeps going down. Below range is very low. And this is a patient on a pump. I can also see the total insolence in this patient. And I can see the patient actually uses a, was using a ton of insulin. I was trying to come down on the insulin dosing just because the patient was over-insulinized. And I can see that I'm reaching some of my goals. The patient's devices are recorded. So you're never wondering what device the patient has. So we know the patient has here a Dexcom G6. When it goes to a G7, that'll be recorded in the next time. And then, of course, you can see how much the GMI is trending. And here's the GMI going from 6.1 to, sorry, 7.1 to 6.5. And the best thing is I can put a dot phrase. I don't have to type anything. And all of this gets populated into my note. I do have to interpret this if I want to bill for a CGM interpretation with the code Joshua Johnson had just sent out before. These are all our dot phrases. So you put a dot phrase and the whole report pours in. So this is all the CGM data. This is the device data. This is the pump data. This is the sensor, the glucose data. With Libre, unfortunately, there's just one report. And then if you want the whole PDF in your chart, which is a very big amount, you just put this dot phrase and we can see all the PDFs in our report. So what impact has this had in our clinic? So we started this up in June of 23. And this is for one year. We looked at nearly a year of data. This is glucose data in a year with after setting this whole thing up, we connected about 400 patients and 181 were connected remotely. For Libre, we were about 172 patients connected and most of our patients were connected remotely. In one year, this is the amount of orders that we placed. And looking at it until last five, well, sorry, 3-31-24, the Libre, the adult clinic, we had about 454 patients and then 100% of our patients were remotely connected. This is glucose. This is more Dexcom data and pumps. So this is our adult clinic. So the adult clinic was the one using Libre Pediatrics since they are more pump-based. They use a lot of Dexcom. So that's why we don't have much Libre data. Hopefully that'll change with the pumps being integrated to the Libres now. So here are the adult clinics over time. You can see the number of pumps, sorry, the CGMs and devices connected are going up. And as you also see that the remote connections are increasing over time. This is a pediatric clinic. This has sort of been steady because it's a smaller clinic with smaller amount of patients. When you look at the type of devices that are connected, of course, this is glucose, it's the G7 more, G6, and then you have the insulate and then many other devices and pumps. And then we went out to see after integration what our providers thought about this integration. So it was a long survey, but I'm just gonna give you a gist. So these are two questions. One was, does having the patient's diabetes device data during an appointment impact the engagement and managing their diabetes? And of course the answer was significantly increases the engagement. And do you like having this? And of course they all loved it. So I cannot imagine any of our providers going back at any different system. They're so used to seeing all this data in this chart and expecting it there now. There were some free comments, able to adjust medications regimens better with better information, patients more involved as we talked about, we absolutely improve glycemic control and medication adherence, ability to review enhances patient engagement and compliance, appointment is more comprehensive, informative, and more educational for the patient. And what are the benefits of integration overall? So the informative appointment we talked, the smooth clinic workflow, data is available in the EMR at or before the appointment, I look at it before, sometimes for very complex pump patients, especially I will look at it before and make changes or think about changes as I enter. Sometimes it's very hard to do all of that at an appointment when you're having so much conversation and troubleshooting other patient issues. It facilitates telehealth visits. So if you have all that data, you can do a wonderful telehealth visit. The capability for remote patient monitoring is enhanced with all of this integration. You can bill for CGM interpretation because you can just have this electronic data in your chart. It improves your documentation, it reduces typing all of the stuff into the chart. It tracks the glucometrics, which is my favorite. You can see what happens to the patients over time. It increases patient communication and safety. So in the past, we had mislabeled reports, some different patients report, patient reports you couldn't find two months later being scanned the chart and that problem is solved here. You save a lot of paper cost in the clinic and you don't know how much that is. You facilitate population health. We can go back and look at groups of patients to see how we can flag those with high and low blood sugars and stratify patients on how to improve data outcomes. And then if we all get to do this, we can share some of this data with national collaboratives and use it for research in QI. And you can save a lot of trees if you don't print out this data for sure. You all know how big CGM data is. So this is our process and what we've done with the integration. And I do believe that by automating and streamlining informational needs of the busy practitioner computer assisted diabetes applications have a potential to curb healthcare costs while significant improving care for large patient populations. So I thank you and we will all take questions now. Thank you. All right. Thank you so much, Dr. Johnson and Dr. Chitani. I think this is a really excellent topic to talk about the current barriers and also the potential solutions. This is so important. So we have several questions here. First question, when can we expect to see CPT codes for evaluation of CGM data by non-prescriptive healthcare providers like RDRN or CDCIS to build for their services? I can answer some of that. I think CDCISs who are, I think not RNs, but some of the RDs, et cetera, are allowed to prescribe. I'm not 100% sure, but there are some groups of CDCISs who can use this interpretation, but I'm not sure when this is all going to be allowed. Great. Thank you. Dr. Johnson, do you have anything to add? No. I mean, that's where we're at with it. It'd be nice if it was more uniform. I'm not sure when we can expect it. I believe that it's coming, however. Okay, great. Thank you. Our next question is for the Gluco. What is the cost to have a provider subscription with the Gluco? Gluco is quite expensive. It all depends on what type of contract you get, how many patients you have. It can run from a few thousand to 20 or 30,000. So I think you would have to, and what type of integration you get. So I think there's many levels of integration that you can get with Gluco. And I think it will all depend on what terms you work out with them and what type of patient population you have. I will say EPIC is working, if you are using EPIC, EPIC is working significantly hard on building CGM integration. And hopefully, if things work out right in two or three years, you will have that done for EPIC also. So you may not have many needs, but some of the integration will happen. The next one, actually in the chat box, can you use the discrete data in the flow chart, flow sheet to easily report the digital measures for reporting the GMI, et cetera? So are you talking about if there's ADA certification? I'm not sure GMI is ADA certificate, but I'm sure if you can collect the data. We are working on population health now. If you have all your patients, you can get your average GMIs or whatever time you need. For HEDIS, we don't report to HEDIS. We don't do that here. So I'm sure that can happen. If you're just using GMI, you'll have all this data and your analysts can surely pull it out. Great. And I think I do have some questions. So first one, would this automatic integration approach apply to all CGM devices and or all vendors of the EHR system, like the Steiner or EPIC? Oh, I cannot hear you, Dr. Janchandani. You're mute. Sorry. It's OK. EPIC, for sure. Anyone can get this done in EPIC with Gluco and Libre. And I think Dexcom also offers you now the ability to. And I don't think of it's much cost to the healthcare provider, the healthcare organization. But Gluco, I think, can join with Cerner. And I believe most of them would be able to join with Cerner. But I'm not sure about Cerner. Gotcha. Are there any, like, or could you please maybe provide your vision on implementing this automatic integration approach at a national or international scale? Yeah, because currently we know that very few clinics can use this automatic integration approach. I think if the EHR vendors take it on themselves, if we can push them to do this, I think that is where it's the biggest benefit. Each of us paying for Gluco or getting Libre to integrate, it makes a lot of work for each system. And it takes a lot of energy and time to do that. Lots of dedicated personnel. But if the EMR comes with some of this built in and the ability to do that, I think that is the key. Many of the EHRs are going internationally. And so hopefully once you have it all, all this information is there to share. You know, the device companies have all this data in their clouds. So I'm sure they see it all. So I'm pretty sure if the EMRs can get it. It's just a collaboration between the EMR and the device integrator. Medtronic doesn't connect with any system. They are on their own. And so we haven't been able to integrate Medtronic at all. And nobody has yet. Yeah, that's true. So Dr. Johnson, I know you're working at primary care, basically. So from your point, do you think this automatic integration or are there any like barriers or potential solutions where this is a great or ideal solution for primary care providers using CDM? I think for us to have full integration, it would be prohibitively expensive, probably for our system. We do the basics for all of them. We have Tidepool. We have Gluco. We have Dexcom. We have Libre. But it's just enough to access the data. We actually still have to manually put it in our chart, which is not a huge process. But somebody has to actually do it. For us to achieve this level of sophistication for a small system like us would be difficult at this time. However, if the EHR companies take this on, that's going to solve a lot of problems for everybody. Yeah, that's what the ADA needs to push for. Yes, they should be advocating for that. Yeah, definitely. I think this is because today we discussed the automatic integration in the EHR or ENR. But actually, we know we have a lot of researchers using the CDM for the research. And for the researcher who has a research server, it also needs a certain type of automatic integration. I think this approach, we probably can think of how to integrate with researcher servers. Yeah, that's great. And Dr. Johnson, I do have another question for you. So you mentioned about the training for the PCP to use the CDM. And we know there are a larger group of the PCP right now trying to use the CDM or probably prescribe CDM for patients. But for some certain area, certain PCP haven't realized the CDM to use. Do you have any vision for the solution for those areas to use? Well, I think once you pick one and get started with one, you just kind of learn it as you go. But attending a series like this that ADA is sponsoring is very important. I know that the first session was focused on interpretation of data. And that type of program is very important. And usually, there are programs like this at ADA every June, especially on the primary care track. So I think it's just exposure, finding those resources. We have found in the past that industry representatives are very helpful for us. So I think there's a lot of places to find that information. You just have to be willing to take those steps. Yeah, yeah, definitely. I think there are a lot of maybe the gaps or the work that we need to further inform the people to use the CDM maybe appropriately. Or we probably need to also provide more guidelines. Like right now, from the ADA, we have the guideline from standard of care. But other than that, we probably cannot find the detailed information about the specific use of the CDM. I'd also like to say that training the residents. I focus a lot in training my internal medicine residents and my family practice residents to show them this is the technology and teach them. Because what you learn in training makes a world of difference in moving that forward. So I think even the internal medicine groups, if they start working on this a little bit, and we promote it in that area. We have many pharmacists. We have a pharmacy group that supports our diabetes care. And many institutions have that. And they're good at doing some of the CGM interpretation and management. Boy, I couldn't agree more with that. Getting residents trained on these is huge. And then that's just the norm for them. I do this for family medicine residencies in North Dakota. And they are very interested in learning it. So this won't be foreign to them when they get out. Yeah, yeah. We probably can also start to introduce this for the medical students or even the student from nursing school. Because some of my research assistant working with this stuff, they are all very exciting about the diabetes technology. Yeah, I agree. So next question. What's your experience with Tidepool? And is it user friendly? Our experience with Tidepool has been very positive. Great. I've been using it for a little bit. And I did use it a few years ago before we were integrated. And it's a wonderful tool also. Nice. There's another one. What do you think is the biggest stumbling block in guiding PCPs to do this? To do CDM interpretations and put in charges? I think the perception of time crunch is probably it. I think a lot feel that this is something extra that they need to do for every appointment. And I have found that over time, it's just now it's part of the appointment. It's a very smooth process. And it actually saves me time down the road. I think I have to do fewer interventions with those patients at future appointments. So I think I save a lot of time by doing that. But I think it's just getting started. You have to do those first one, that first one, or those first five, or those first 10. And just start to get comfortable with it and get smooth with it. And use dot phrases or tools that are available through your record that maybe you need to create. I sometimes do a screenshot of the AGP and upload that into the chart. And that can be very helpful, too. That's a time saver for me. I agree with everything Dr. Johnson has said. I also would say that it's like everything in investment. It takes a little time. And the primary care is just so much, much more complex stuff. This is really easy stuff for them. So if they put their mind to it and just someone trains them on it, I think it'll be very easy. And actually, as Dr. Johnson rightly said, it'll save a lot of time. And it'll engage their patients much more in this process. I'm sure you see this all the time. Just by putting a CGM on somebody, they're often better. That's just doing that act makes them better. And I think that saves us all time later. Yeah, I totally agree. I think we answered this question. I do have another question because I think we talk a lot of using the CGM in PCPs. But I think in your clinical experience, have you seen any of the barriers to use CGM in hospitalized patients? Yes. Or any barriers or something related or the difference from the PCPs, the CGM barriers? I think my experience with our hospital teams is, again, they just need to grow into it a little bit. They're used to doing eight finger sticks a day. That's just that's the way they operate. And they just need to gain some confidence in training. And they just need to gain some confidence and trust with the devices, just like the rest of us needed to going along. I think we're seeing more of that, actually. I'm having fewer patients complain about it anyway. So we, if patients in our hospital, if patients have a CGM at home, we allow it. We also just, if a patient needs it, we start it on discharge. Many of the companies have a hospital to home program in which you can keep these devices. You can order them for the hospital to home program and send patients on them. And especially if you're remotely integrated, or if you're integrated, that actually works out really well for patients. Because FDA has not approved CGMs in the hospital, I think when that happens, things will change. But I finished a study in Michigan where I was a few years ago, in which we use CGMs in the ICU, and they work very well. You can reduce the checks, but you have to build a validation process with POC because CGMs are not perfect. They have many, patients in the hospital have so many continuous changes and medications, et cetera. So there's got to be a process of validation. And once your process is set up, I think CGMs, and many hospitals like Scripps in San Diego, which actually use CGM throughout the hospital, and many other who use them in different areas. So I think it's coming. It's just, and once it comes, I think that you'll see them used in the outpatient much more. Okay, that's great. So I think we have two more minutes left. One more minute to have any other questions. Okay. So I didn't see any other question, but I think thank you so much for our panelists for this wonderful talk and the insightful discussion. So thank you so much again, and take care. Thank you, everyone. Bye. Thank you.

continuous glucose monitoring

CGM integration

primary care

electronic health records

EHR integration

patient engagement

healthcare training

FDA approval

data management