Welcome to today's webinar, Dr. Joanna Mitri. I'm an advisory for the American Diabetes Association Healthcare Delivery and Quality Improvement Interest Group Leadership Team. We are excited to welcome the group in a round table discussion on how to optimize outpatient diabetes visits. Here is a glance at today's agenda. We will start with introduction and announcements. We will proceed with the presentation and then we will give some times for questions and answers. After the presentation, we will spend some time answering your questions. So please don't wait until the end of the session to send in your questions. Instead, please type your questions into the Q&A box in your control panel. Please be sure to use the Q&A box and not the chat box for questions. We will be using the chat box to send you important links during this announcement segment. This is also where you can discuss related topics with other audience members. As I mentioned, I'm an advisory on the ADA Healthcare Delivery and QI Interest Group Leadership Team. I wanted to take a moment to thank all the members of the leadership team for their work throughout the year to provide opportunities to the interest group members. If you are not a professional member of ADA, please join today. ADA professional members can be members of three interest groups, as well as have access to meeting discounts, member exclusive webinars and webinar recordings. Use the link in the chat to learn more about ADA membership. The Diabetes Pro Member Forum is another benefit of ADA members. Use this forum to connect with other ADA members in your interest groups. See the link in the chat now. And lastly, here's a preview of the upcoming live webinars hosted by the ADA. To register for the upcoming webinars, please visit the link on your screen or click the links in the chat now. Now, I'd like to introduce today's presenters. Thank you everyone for coming and attending. I'll start with Dr. Mary Rhee. Dr. Mary Rhee is the chair of the committee or the working group, and she is from Atlanta. And we have next Dr. Diana Alba. Dr. Diana Alba is an early career presentative at the University of California in San Francisco. Dr. Alexander Turchin, he's an immediate past chair at the Brigham and Women's Hospital. Dr. Rajesh Garg, he's the church elect at the University of Miami. Dr. Stephen Clement, he's a CD communications director at Inova Fairfax Hospital. And last but not least, Dr. Nancy Renard. She's an advisor for the membership group. So thank you everyone for coming. Again, there's a survey in the chat. If you could please provide comment, we will follow up with an automated email. All right, thank you Joanna for the nice introductions and opening up the webinar. We are very excited about this webinar. So I'll start with how to use the templates during the clinic visits. Next please. So this is a figure that almost all of you would have seen. This has been part of the ADA's clinical standards, standards of clinical care for many years. So the idea here is not to go over this slide everything, but what I'm trying to make the point is that the center is patient care, the goals being preventing complications and optimizing quality of life, but that takes a lot of other things. So there are several processes that need to be completed to accomplish those goals. That makes the clinical care of a patient with diabetes quite complex. Next slide please. So as you know, ADA's standards of clinical care, they publish what should be included in the new patient visit and in the follow-up patient visit. And if you go over there, this is extracted from those tables from the ADA's clinical standards. For example, on a new patient, there are quite a few items that we need to complete in the medical history, in the medication, social history, physical exam, labs, referrals, and the same thing applies to the follow-up visit. Next slide please. So the follow-up visit is a little bit shorter, but still there are plenty of items which need attention. And this makes the visit, the diabetes visit, probably the most complex in endocrinology. So there is a lot to cover. And over the last 25 years or so, what I have seen is the items keep getting added to this list. It's never that something gets out of it. So we are being asked to do more and more, which is important for clinical care of the patients to provide optimal care. But the question is, how do we handle this? How do we accomplish all these tasks without getting overwhelmed and without getting burned so that we can keep doing this important work for longer periods of time? So one of the ways is to use templates, which I'm sure many of you do that. Next please. So this is one of the templates that I created probably more than 20 years ago, even before the EMRs were in common use. And what we do is basically put together all the information that we need, all the different items. Next please. Next. So it's just an example of a template, which you can create. Next please. The idea was not to go through the template. You can have your own template, but the idea is that you put together everything on one piece of paper. And then when you are seeing a patient, you just cover everything. You go from top to bottom to cover all the items and whatever is not relevant, you just delete that. Now there are many different templates. The idea is to be complete. So anything new comes, like on this slide, I still don't have the evaluation for liver function, for example. That's something that has been talked more and more about. So as I said, the things keep getting added. So I'll let Dr. Mariri go over further templates, how we can effectively use them to optimize clinical visits. Okay, thank you Rajesh. So next slide please. So Dr. Garth went through templates that you could, an example of a template that you could use for a new comprehensive diabetes visit. And as you can see with examples that he gave, that he was just showing us an example, you can create a template that is fully populated with as much of the text as you might normally expect from a new patient visit. And that would allow you to make sure you don't have to do very much typing and that you just delete the parts that you don't need. But you can also have another approach where you just make sure that you don't necessarily have all of the text pre-filled, but that you at least have keywords available in your text. And a good example is this follow-up patient visit template. And you can see in red that you can pull in information from your EMR, your electronic medical record, so that you don't have to always type in the patient's name, for instance, their age and their sex, those are already pulled in for you. But you have certain keywords like diet and exercise, just as a reminder to ask about that. Or you might include whether they have chest pain or shortness of breath or claudication as a reminder. And always to have information about their diabetes history, such as the type of diabetes, how long they've had it, what complications they have, if they smoke, and the other usual annual screening dates that we need to keep track of, such as their eye exam, their comprehensive foot exam, their urine albumin to creatinine ratio, and their dental exam. And these things can be easily copied and pasted from a previous visit, and you would just update it for the current visit. And of course, you would have medications for the diabetes meds, any adverse drug reactions. And this is on two columns, not because that's how it would look on your visit encounter, but just to have it all fit into one slide. And if you have someone who's got type 1 diabetes or type 2 that you have on a pump, you can have a template for insulin pump information, such as the model and whether or not it's paired with a CGM, and the basic information you would want to get out of the pump. I like to have a lot of my glucose data grouped together. So I can pull in the last three A1Cs from the EMR and have them listed. And then you would want to document home glucoses, particularly hypoglycemia. So that's listed just as a prop, again, just to remind you to ask. And then, at least for me, I group it by whether they do finger stick glucoses with home flow glucose monitoring, or whether they have a CGM. And then I have text pre-filled that I would normally get out of their CGM report. And if they only use one or the other, I would delete the text that's not relevant. So if someone's using a CGM, I would delete the part where it's asking for information from the meter or from their log, and then vice versa. Next slide, please. And then, again, everything in red would normally be things that you could directly pull from the electronic medical record. You would just have it, and it would be pre-filled for you. And, of course, you double-check it, and you can add or subtract things that are not accurate. And then, for the physical exam, it would pull in their vital signs. And I just like to keep the physical exam as free text that I can just type in, but other people like to have it pre-filled, whichever way you like it. Next slide, please. And then, for the pertinent lab, again, you can add a PSH level if you like, especially if you have a Type 1. And those lab values can also be pulled in from the most recent labs that they've had. And you just have to make sure that you keep an eye on it, because sometimes the most recent labs might not be that recent, or sometimes it might be absent if it's been a while. And then, for the assessment and plan, there are certain items that you will always list as part of your assessment and plan for most of our patients who have diabetes. These are probably the most common things that we list. You can always change the titles or change how you want to do it. Sometimes I'll have a Type 1 who doesn't have high blood pressure or hyperlipidemia, so I would just delete those two items. And you would just adjust it as needed. I have a space after the first item, which is type diabetes, just to leave space for me to free text whatever I got from that visit to update it. And then I'll add in new plans, and then the rest of the things that I tend to always include. Okay, next slide, please. You can also create, in a lot of EMRs, just different templates that you can add in to the template you already have. So sometimes I'll add in or bring in a template, and in the middle of the note, there's a certain key strike that I can use that'll bring in individual templates. So I could have one that's just for insulin pump, let's say you mostly see Type 2, so you don't want that already in your note. Or if I know I'm gonna start a GLP-1 or an SGLP-2 inhibitor, there are things I always say to them, and I always check on. For instance, for a GLP-1 receptor agonist, we have the Maglutide as our formulary drug. I already have a template schedule put in, and I make sure I ask them whether or not there was a family history of medullary thyroid cancer or a personal history of pancreatitis, and I make sure I talk to them about potential benefits and risks, and I just like to have that documented. So I go ahead and have that already as a little template that I can add in. Next slide, please. And just as a quick example of how this would work, so if you have a template like we started on the left, when you actually pull that information from a patient, you'll see what it might look like on the right. So let's say it's Mr. John Smith, who's a 62-year-old male. The red text is already pulled in from the EMR, and then the blue text is what I would type in. I forgot to add an exercise, but, you know, I would always, that prompt for exercise would also have me add something about exercise, and then I could say whether or not they have chest pain, shortness of breath, or claudication. Next slide, please. And the same is true for the diabetes history. So the template is what you would see on the left, and then once it's filled out, you'll see what it looks like on the right in blue, and the red is pulled in from the EMR. And a lot of this diabetes history doesn't really change much from visit to visit, so I will go to the previous note, I'll copy and paste, and I'll update the medications to make sure the doses and the drugs are still up to date. And I would update the dates of these annual screenings that we do, but it also just reminds me where we were at the last visit. Next slide, please. And you can see that if I don't have a pump patient, on the right, I've deleted the parts that aren't relevant, and if they have a CGM, I just get rid of the part that's showing that the meter or the glucose log data, and I only fill in the parts that include the CGM data. Next slide, please. And from the medical record, all the red is pulled in directly from the EMR. I always go through the medications for the patients to make sure there's nothing that's different, and I update the medical history and their allergies. Next slide, please. And again, the red is already pre-filled, and the blue I fill in from the exam. Next slide, please. And the labs are also just pulled in directly from EMR. This is kind of what it would look like from my laboratory. Next slide, please. And then I didn't fill in this just because I think it was pretty self-explanatory, but that's how we use the templates. Everyone has a different preference, and you can always customize it according to your EMR and what's available there. So I think that's it for our, thank you. Thank you, Dr. Rhea and Dr. Garg. Next is data. Data play a key role in diabetes management, so Dr. Alba will walk us through workflows for managing data from CGM, pumps, and glucose logs. Diana. Great. So we all know that innovations in the diabetes devices technologies have actually resulted in the development of expanding a range of products. So we have glucometers, CGMs, we have pumps, but most importantly, we have data now that we can use. And so patients are actually now able to download and synchronize their diabetes data from all of these devices to a variety of other devices and actually send the data to us or give us electronic access so they can actually get diabetes guidance. We all know about the benefits of having access to all of this data. So we can have in-depth knowledge of the fluctuations in blood glucose levels. We can actually make therapeutic decisions. And most importantly, we can actually use this data for patient education. Unfortunately, there are a lot of, or there's some limitations or challenges when it comes to actually having access to the data. One of the major challenges actually is how to capture and analyze the data. And so a limitation of downloading digital data is that a significant portion of the data that is actually captured by the patients, they actually never transfer to us for review. And this could be whether, because the devices are not compatible with the computers that we have in our clinics, or there's some software limitations, or even actually some institutional information technology policies that further complicates the patients and our own ability to analyze and review the data in a meaningful way. Another issue is the diversity of devices, the operating systems, and even the data capture systems is also challenging. However, proprietary software is sometimes recommended for patients to use at home and for us to actually use in our clinics to download and display the data from the devices and actually make the data analysis easier for all of us. Staffing issues is another major challenge right now, because now you need someone, or you actually need to dedicate your own time to capture the data, or you need to have a dedicated member of the staff who can actually help you with this. And then when we think about more resource-poor settings, this actually really limits what devices we can use based on insurance coverage, as well as the patient preferences. And so you have to keep in mind when you're trying to implement this in your clinic, maybe even the patient demographics. So if you have a practice that sees more older type 2 diabetes patients who are in non-intensive insulin or maybe non-insulin therapy, you might actually recommend more a professional CGM, especially if in your clinic you don't have a lot of experience with CGMs, or maybe you don't have a lot of staff helping you with this. But in many cases, patients actually might not feel comfortable downloading the data on their own or actually sharing the data with the clinic, or actually they don't have the electronic devices to do this. Next. And so when you're trying to, or when you're making the decision to actually integrate these various diabetes devices into a clinical setting, it's important for the healthcare provider to consider a number of factors, including how familiar you are with the devices, your practice demographic, the staffing resources that you might have, and the office workflow. And so you need to consider what is the level of expertise in the clinic with these devices? Is there gonna be a diabetes educator or a staff member available to provide training and patient follow-up? Is the practice staff to handle additional documentation and even like thinking about billing? So a key to a successful program is actually identifying a staff member within the clinic who is gonna be trained to use and maintain the devices. Is the person who's gonna insert the sensors, provide instructions to the patients, is gonna download and disseminate the data to the other providers, and is gonna help maybe with the prior authorizations. And another major point is also to train a backup staff member. So when the designated staff member is not available, you have someone to able to help you with this. And so this role can actually be filled by a medical assistant, a licensed vocational nurse, a dietician, or a diabetes educator. So what to do with data overload, right? Now you have access to all of this data. And so the most important point is actually to develop, to develop a systematic or a step-by-step method of actually accessing and downloading the data and then have a way of reviewing the data that you kind of do it the same way every time. So it can make the interpretation of the data more efficient. And this might include just printing out the reports and use it to focus the patient conversation during the visit. It might require someone kind of logging into the cloud or logging into each software to download the data and then figuring out a way to integrate the data into the electronic medical records. Next. And so ideally you will have a workflow like this. Your patient is able to upload the data to a particular device, a software, or to a system like Typo. And then a member of the clinic is able to log in, get all of the data reports, and actually directly upload them into the electronic medical records for the physician or for the provider to review them. Next. And one more. However, we know this is not the case in many practices. And for example, my clinic is in the county hospital and our workflow is more like this. So a patient is gonna check in for their appointment. Then you have a clinic staff member who is gonna download the data available. So they might need to log it into Dixon Clarity or the Freestyle Libre website or any other software to get some of the glucose or the pump data. But to be honest, in most cases, in our staff members actually have to connect the reader or the device to a clinic computer to actually upload the patient's data and generate a report. And once we have that report, we actually print it. And even in some cases, we actually just get glucose logs handwritten by our patients. And so once the physician or the provider has the paper report, they can use it to review the results with the patients during the visit. They keep the report with them while they're finishing their notes. And then once all of the documentation is completed, the provider returns their report to the front office staff to actually have it scanned into the medical records. And so again, as you can see, it's very complicated and not an efficient kind of workflow, but it's what we have right now. Next. And so I just wanted to give some examples of how we actually upload the data into our medical records and document that it was reviewed. So at the top, I usually have a smart phrase that I can use so I can quickly summarize CGM data. And I have a similar one for glucose data. Other colleagues actually prefer to take a picture of like the main review of like the report that you get. In this case, it's from the lead review. And using the Canto mobile app, you can actually upload the data into Epic, which is what we use in our hospital. And then you can actually put that picture into your reports. And next. One more. And so this is usually also what I see in clinic. We actually just take pictures of the glucose log data that the patients bring into the clinic. We can outload it into our notes, or as I mentioned before, directly scanning to the electronic medical records. So you can actually review them with the patients in future visits. Thank you, Diana. As much as data is important in diabetes management, it can be overwhelming. However, looking at the data and turning the data points, the diabetes data points into accessible, actionable, and meaningful insights can be helpful for you to manage your patients. So there are platforms that integrate data from pumps and CGM data like Medtronic, Tandem, Omnipod, Libra, and Xcom, and more, and they can put all in one location. So this platform allow us to upload data from the devices. This could happen during an office visit, or you could do it when your patients are at home and you could invite them to upload those data. So this is very helpful because once you have one platform, you avoid those multiple applications and multiple login. If you want to have a meter that is downloaded or a CGM or a pump, instead of going on the company's website or the platform that they have to upload the data, you can just log in onto one platform. And here on this slide, you see that there are two platforms that are widely used. One of them is Tidepool, and one of them is Gluco. They have different features and may have other different features in different countries or different versions. But if this is something you would want to consider for your practice, there are things that you can look at for in those applications or platform to see what you want to look at. Do you want things, for example, are the EHR connection? Do they connect to the EHR or do they integrate within your EHR? Things are like, what are the models that they have to create clinician's account? How many accounts you can put under one platform? Other thing is like, do you have to have an email entry every time you have to download? How do you search for patients? If you want to search for all of them at the same time, how do the reports come up when you print them? Are they friendly? How do you view them? How do the patients have to do? What are the steps that the patient have to do for you to download those things? And time, date of the reports, of the downloads, all of these kind of viewing features that come up, those are things you may want to consider and compare those two platforms. And the bottom of this slide, you can see examples of things you can, that may be printable from those platforms. With that, I'd like to pass it on to my colleague, Dr. Turchin, who will be talking about a unique feature or unique set of data that come from CGM and how to use that for diagnostic purposes. Thank you, Joanna. Next, please. Perfect. So what I'm going to change the talk a little bit, and I will spend the next few minutes talking about how we as endocrinologists can help our colleagues, in particular, our primary care colleagues, make the best use of CGM data. And specifically, I'm going to talk about providing diagnostic CGM as a service. And the goal here really is to facilitate the use of diagnostic CGM by primary care providers, because we know that it's a really powerful tool, but some primary care practices may not be fully set up to take full advantage of that. And the model here is, for example, radiology. When we order an X-ray, what we do is we write the order, the patient goes somewhere, has the X-ray, comes back, and then the X-ray is interpreted by a professional bariardiologist, and the report goes back to the referring provider. The patient doesn't actually need to see another physician. And this is exactly the model that we have envisioned and implemented at our practice for diagnostic CGM as a service. The way it works is that a referral is placed in the EHR. Then the patient sees a nurse who places the continuous glucose monitor. Then after 10 or 14 days, the patient mails back to our office their continuous glucose monitor and their diet and medication log. And then the chronologist interprets these CGM tracing in combination with a diet and medication log and the patient's electronic health record, and sends their report with recommendations back to the referring provider. Next, please. So the benefits of this approach are that primary care providers can use diagnostic CGM without setting up the necessary infrastructure, just like every practice doesn't have to have their X-ray machine. They don't need to set up the diagnostic CGM each in their own practice. Patients are not quote-unquote captured by endocrine because sometimes this isn't desired by the referring provider. And also this is much faster. I'm sure in many of your practices, just like in ours, if the patient wants to see an endocrinologist, there is a wait list for a few months. Now the diagnostic CGM, because an endocrinologist isn't involved, can happen much faster within a couple of weeks. This, of course, is also a revenue stream for endocrine and a potential revenue source because the patient comes in, they get this information, and then potentially the primary care provider may decide that this patient would in fact benefit from being seen and managed by endocrine. A few practicals. There are two CPT codes involved with this. One is for placement, the other one for interpretation. And these are the average Medicare reimbursements, which is significantly higher for placement compared to interpretation. Next, please. And this is just a sample, real, but the identified report that we provide to the referring clinician. It describes, as you can see here, the patterns that the endocrinologist noted. And in the CGM tracings, and then some recommendations based on these patterns and the patient's meal and medication log, and also the patient's overall medical conditions as per information obtained from their electronic health record. And this completes my part, and I'll pass the baton to my colleagues. Thank you. Thank you, Dr. Turchin. And next but not least is working, how to work with medical staff and the team, which is really a very important component into running a successful diabetes clinic. It does apply to all the clinics, but diabetes is specifically more complex as it involves different pieces in terms of managing the data and communicating with the patients. So Dr. Clement, Dr. Rennert, and Steven Clement, Dr. Clement, we will be discussing this portion with us. Steven? Actually, I'm gonna start. Thank you, Joanna. And I wanna thank my colleagues for really informational presentations on how to optimize the use of EMR templates and recommendations on how to capture all the data from advanced diabetes technology, which is now the standard of care. And I imagine some of you may be thinking, wow, this is really great, and how can I possibly do this in the 15 to 20 minutes that are allotted for my follow-up visits? So Dr. Clement and I, in this last section this evening, we hope to present some strategies and some ideas to get you thinking about possible ways to transform your own practice settings to improve care. We're gonna try to be inclusive and present options. We understand there's a lot of variability in our professional settings, and we just hope that it'll be helpful and maybe some ideas will help you to spur some positive change. So the most important key point here is that you're not alone, or you should not be alone when you're seeing patients, and so enter a medical teamwork. Diabetes care is a team sport. So I'm gonna talk about first the team members, who is on the team, who could potentially be on the team, the idea of everybody working to the top of their scope of practice, and all of these many tasks that you just heard about, dividing them and conquering. Next slide, please. So different resources, different types of practices, these are some of the team members that you may have access to. Also many smaller practices are now part of large systems, so there may be some resources available to you, maybe not on site, but in the system that you can also take advantage of. So some of the members might include mid-level providers, PAs, nurse practitioners. Many of us have nurses, either RNs and or LPNs, medical assistants, of course, that will help to room our patients. The clerical staff can also be involved. Some of us are in teaching settings where we have students and trainees, and many of us have on-site diabetes educators or access to diabetes educators. Clinical pharmacists are a relatively new addition to the team, but their scope of practice over the years has increased, and they can be very helpful with placing CGMs, for example, giving injections, whatever. They have that in their scope of practice. Behavioral health and social work is really important to pretty much all of our patients, and I would encourage you to include them on the team, even if they're not directly on site. Some of us have access, especially if we take care of underserved patients, to community health workers who can really pull things together for patients. And then in all of these fields, some of us work in settings where we have trainees or learners that can also be utilized. So next slide, please. So everybody to the top of their scope of practice, and the idea is we're gonna talk a little bit about tasks and communication, but the idea is to try to split things up so that everything gets done, but as a team, everything gets done, so not one person has to do everything. So we heard a lot about the template and some of the things that almost always happen there, so diabetes education, various consults, ophthalmology, et cetera, immunizations that are recommended, and these sorts of things can often be completed by members of your staff. They can, you know, when's the last time you went to the eye doctor, document it, and if the record isn't available, try to get it. When's the last time you went to diabetes education? They can also ask about immunizations and indicate if the patient refuses, and then that can be proposed to the provider to decide whether or not that's a good idea for that patient. With diabetes, we saw there's a lot of data, there's a lot of labs and maybe some imaging, and those things can be pulled together ahead of time, ahead of the visit so that it's available for you, preferably in the chart, the electronic medical record at the point of care, the same for consult reports so that you don't need to go start looking for them. So all of the data around advanced diabetes technology with CGM and insulin pumps already talked about a number of different scenarios. So depending on your setting, you may or may not have the resources to be able to assign a single person to either be sure that the data are available or to help the patients to upload the data. So another idea that some folks might wanna do is to think about something called a diabetes pre-visit or a nursing visit, where the patient can do this either remotely or in-person if they actually need something done in-person, and that's sort of a setup for the visit so that when there's no downtime and it doesn't hold up the flow. And then the other point is just making sure that your team is communicating. So many of us have huddles usually at the beginning of the day, sometimes afterward as a debrief. We may have meetings around certain patients or certain issues in the office that need some additional attention, but the idea is just to make sure that everybody's talking and knows who's doing what. And the idea is again, to try to divide all of the tasks, there are a lot of them, and try to get them all done as a team. And now I'm going to turn it over to Dr. Clement. Thank you, Nancy. That was awesome discussion. And I get to bring up the back of the task of this is the last part of the lecture. So on this slide, I tried in not very good way to basically make a sort of a storyboard, so to speak, in terms of taking it from the side of the aspect of, let's look at the patient. What does granular in a very granular, very specific standpoint, what does the patient have to do to show up, for example, to a face-to-face visit? They have to get to your clinic. They have to park their car. They may not, if they're taking public transportation, how do they get there physically to your place? So I would recommend if it hasn't been done in the past is that kind of put all this together and you can actually put a little storyboard. So this is a little storyboard I put together for our clinic that one of our clinics we use. So eventually the patient gets there. So that's the first arrow. And then the patient checks in. You can see there, the patient's checking in and the secretary's getting their information. And then part of that is that do they ask the question, oh, did you upload their data? Now, our clinic tries to get 100% of data before they actually come in. And this is done by one of our nurses that is responsible for uploading all the data or making sure all that data is into the system in some form or the other for that individual provider. So hopefully that happens, but if it doesn't, it can be checked by the front desk. Okay, so that's the first step is make sure, do they have the data there? So you can see in the next storyboard is that they're getting their blood pressure done. So this is the MA right in the middle there. There it is, check in, there it is, transfer the data. Thank you. Vital signs and remove the shoes. I remember in our first fellowship we would always remove the shoes. So I'm really curious, how many of you still do that? Actually have the patients remove their shoes and put some little footies on. We forget to look at their shoes and the patients forget to show us and they can't feel their feet. So it's actually not a bad thing to do. And then once all that's done, then you actually do have your face-to-face visit where you are looking at the data. You probably have a computer there and you can look at the data depending on how the room is set up and actually share. I think that the current mode, we do this in the hospital all the time. We want the patient to see what we're looking at too. We want them to see the data. So next, so you can see, and actually there's a little nod to JDRF. This was actually on Google. JDRF had a nice little graph there. It said, we're looking at the data. So review the data, whether it's the lab data, the CGM, the blood sugar data, while you're talking to the patient and do it at the time. And then now we get the decision part. The diamond is that this is where the decisions are happening, where you jointly make decisions with the patient to decide, okay, what are the next steps and what need to be done to make things a little bit better? You ask questions, what are the control, the screenings? And then once that information is done, then put together in writing some form of jointly agreed on recommendations that the patient can see and they can agree with and say, yeah, I can agree to that. Hopefully get buy-in from that. And then you print it out and give it to the patient and send it to their system, and that's the end. Now, obviously that's noise, never the end, it's always more. And with the EMR, there's all kinds of ways that patients can communicate with us, but that's really the end of that face-to-face visit. So for example, at the end of the visit, you may have made very specific changes on insulin regimen or new medications, and you may ask the patient, send me a message in about a few days, how did that work? And then at that point, that's where you continue the dialogue as an outpatient. And I think I'll stop there. Oh, we got one more, thank you. So all these tasks have to be divided into basically summarize what happens, who's responsible for the pre-visit, the MA, the nurse, who collects the labs, and it's separate section for the visit itself. Is it the MA, the nurse, who does what? And so these are the type of things you can use basically as sort of a checklist. Are these all these things covered and who covers them? The visit, obviously the provider is the one that does most of this work here. And then there's a follow-up plan that's made and printed and sent to the patient as well. And that is my last slide. Thank you. Thank you, Dr. Clement, and thank you to all the panelists. Please, I wanna remind everybody to type questions in the Q&A section, and we will be taking those questions to the panelists. Before I open it up to the questions, I like the patient journey, Dr. Clement, that you talked to us, walked us through. Can you just briefly comment again on how do you kind of get feedback? How do you figure out a patient journey and get feedback from that? Yeah, well, your team, your team has to figure that out. The patient's not gonna figure that out, but it's important to keep it patient-focused, almost like a board game. It's like, what happens here, what happens there? It's a chronology so that as a patient flows through this path from the beginning to the end, that someone's responsible for all these things. If not, then it's probably not gonna get done. Patient flow is big, big stuff in systems. We're in a very large system here. We have patient flow projects for the ER. How do patients get through the ER? We have patients flow on the inpatient side from the time they get admitted to the time they leave and follow up. So there's lots of interest on doing patient flow. And it's pretty easy to make these diagrams. You can make them up yourself. And it just, it helps you put it on paper so you don't forget what happens and who's responsible for it during the pathway. Totally agree. And then while we're still in the patient journey and the worker, how the patient visit works, can you, Dr. Renner, tell us a little bit about what are some technology workarounds to help manage efficiency when practices don't have sophisticated EMR or large clinical team? We know that not everybody has the luxury of having a great EMR or a team that is large and multidisciplinary. What does, who does what in practical terms? Can you comment a bit on that? Yeah, thank you for that question. So a lot depends on what resources you do have. Most of us do have EMRs, but they may or may not be able to handle data. Many of us, like myself, I do not have access to Tidepool, for example. So you kind of have to assess what options that you have. Most of the time, one of the things you can do is have your staff members. I know that I have my nurse, for example, who will be sure that the CGMs are downloaded, the pumps are downloaded. Patients are in fact actually wearing the devices so that when they come in, we have data. Some of the EMRs will allow you, I think someone showed an example of this, to take a photo. You can scan it and then put it in as a PDF. So there's many different ways to do that. And it just depends a lot on who you have. But the other thing to consider is what the top of the scope of practice is. I think sometimes we often don't really know that. And it does vary sometimes by state, by state licensing. So it's a good idea to figure that out because it may be that in addition to getting those data, you may be able to utilize many of your staff members to apply the CGMs, to do education. So I think the big thing to do is to figure out what is the top of the scope of practice and who do you have on your team and then figure out who's gonna do what, trying to get as much information as you can at the point of care so that it doesn't hold up the flow and also so you can continue your visit and have all that information to talk about with patient. Yeah, thank you. This is very helpful and indirectly addresses one of the questions that came up in the chat. So how do you handle now that Glucoke is charging for downloading some of the devices? So we understand, I'll take that. And I don't know if my colleague have something else to comment, but we understand that Gluco may have additional fee sometimes. And that's why I think not all practices may be able to afford that. I mean, where I work, we believe that it was for us worth the expense because it saves a lot of, it helps us with the efficiency. So it's kind of like an investment if needed, but certainly something to consider. And while we're still on this topic, Dr. Alba, is there an app that you use to copy pictures of CGM or glucose reports into your notes? Yeah, so I mentioned Kanto. I can put it on the chat, but Kanto runs on iPad. The other one that we use is Haiku. Haiku, I think it is. It runs on Apple and Android smartphones. And I think I can find from UCSF, there is like a document that shows you how to upload the pictures. And so I can put that on the chat. That would be wonderful. Thank you, Diana. And Dr. Turchin, I think it's great that you talked us through the diagnostic CGM. Can you tell us a little bit about the challenges that you have encountered in implementing this service? Sure, so one of the main challenges for us has actually been financial sustainability. And part of the reason for that was the structure of, the financial structure specifically at our institution. So as I already mentioned, there is one charge for placement and there is another for interpretation. And if they all go into the same pot of money, then everything is fine. But at our institution, depending on different practices work differently, but in many of them, these go to into different pots of money. Like the placement goes to the hospital, whereas, and then the providers only get the interpretation. And interpretation is really a relatively low amount of money. And interpretation of a diagnostic CGM tracing together, when done properly together with a medication and food log together with reading their chart and understanding their past medical history, that takes a fair amount of time. And the currently provided reimbursement really doesn't reflect that. So for practices with this split billing, that was a challenge that we encountered. Thank you. Yeah, but certainly a great service with a lot of value for patients or for a primary care who may not have the ability to do that. And if they have like an endocrine practice nearby, they could count on the service at least to get some diagnosis on what's happening. Things that we cannot get from A1C, which is a great segue for our next question that came in the chat. It's about, it's to the whole panelist. It's about how to leverage CGM data for treatment decision, especially in comparison to A1C. Would anybody want to comment on that from the panel? I'm happy to comment on that one as well. Since that question often also comes from our primary care colleagues, when we let them know about the availability of diagnostic CGM as a service, they would like to know how to use it. So there are a few examples that I can give. One is it can help you determine the actual pattern of where the blood glucose levels are high and when they're low, because hemoglobin A1C just kind of gives you the overall level. But that overall level can mask, for example, fasting hypoglycemia in the morning and in combined with postprandial hyperglycemia in the afternoon. Together, these will average out and you may have a reasonably looking hemoglobin A1C, but in fact, the patient will be at risk from hypoglycemia and also having hyperglycemia at other times. Another example is that hemoglobin A1C doesn't always reflect the average blood glucose levels. And in my practice, it happens periodically that a patient comes in and they bring their self-measured blood glucose log. And then I measure their hemoglobin A1C and these do not match. And sometimes hemoglobin A1C is higher than what would be expected from the self-measured blood glucose and sometimes it's lower. And the arbiter here can be diagnostic continuous glucose monitoring because that will first just generally provide you with blood glucose levels and also it'll calculate what hemoglobin A1C would be expected to be based on these blood glucose levels. And I have several patients in whom in this way, I determined that hemoglobin A1C is actually not a great way to monitor their blood glucose levels, that a continuous glucose monitor reflects it better. That really is the gold standard. And finally, we also use it for patient education, especially in patients with new-onset diabetes, like new-onset type 2 diabetes. This just gives the patient a glimpse as to what happens to their blood glucose when they eat this or eat that or exercise. And it's this kind of real-time window into the blood glucose changes can be really revealing for the patient. Thank you, Dr. Turchin. It's actually, I like to add to this last point. When I put patient on CGM, I really emphasize this point that A1C, they come in asking about their A1C, but when I start them on CGM, I tell them that how they could really understand a lot, that the data is first, I tell them the data is for you more than it is for me. So they can start understanding how this food affected the glucose, how an activity affected. So how specific behavior, stress, all of those, the more they look at it, the more they understand how the little things that they do every day may affect the glucose in one direction or another. But to complete this, how it compares to A1C, to address the question that came in the chat, obviously, Dr. Turchin addressed that, but a lot of time you will see some sort of correlation, right? So it's not correlated. What you see on the A1C reflects the average glucose in general, but those are the things that you cannot see from A1C is what really matters the most, in my opinion, things that you may get an A1C that is within range, but you're really missing a lot of hyper and hypoglycemia that go undetected. And that will really affect your management because with a normal A1C, you wouldn't make a change to the treatment, but with seeing those changes, you're still gonna make a change in your treatment plan. While we are on the CGM, I just have one question for all the panelists and a comment. So we, you know, the CGM is very useful and being used more and more often. And many of us who mostly our practice is focused on diabetes, we are getting used to looking at those data and spending less and less time. So one of the things is being more efficient because diabetes visits are complex and take a lot of time. And so probably right now, I probably spend five minutes and becoming maybe two times more than what I spent on a glucometer, but there are a lot of clinicians who are not as comfortable or as used to looking at the CGM data as we are, or those who are focused on diabetes. So I know there are some softwares that are decision supports that can read the CGM data and give advice, just like the EKG, you know, the machines can give advice. So I'm just curious if any of you uses that in your clinic because I tried to use it in my, you know, clinic in my practice, but it was expensive. So we dropped the idea. Does it help? Does it not? And so basically how can you advise people to be more efficient with CGM data? I would say use it. The more you use it, the better you get at it. And just some practical things. Look at the standard deviation. Some people don't, you know, it's right there on almost all of them. And so, or something to look at the variability. Variability a lot of times is ignored and that's the most important thing. If you have a huge variability, the patient's going to be suffering from that. Anyone has experience with the decision support software for CGM? No. I have not used it. I think that if people just get familiar with the report, often just the first few pages and then, you know, two weeks of quickly looking through the daily patterns, I think it's very useful. I don't know that the software is, you know, like that is an ideal approach because if you're looking at an EKG, for example, you're interpreting that in it by itself. There's no other information that you're using. But when we look at the CGM report, we're also looking at their medication log, at their food log, we're taking their best medical history from the chart. Let's say they have heart failure and then we're going to recommend an SGLT2 for post-prandial hyperglycemia. Or if they had a stroke, then we're going to recommend the GLP-1, et cetera. So it's, I think this could be challenging for clinical decisions. Especially in type 2 diabetes. But in, so there are some FDA-approved actually software that are available where you enter all the information, height, weight, insulin doses, and then it gives you advice based on the CGM data, how to adjust insulin. I personally, I haven't used that, Rajesh, but I also wonder how using that may add an additional burden or step to the provider where they have to enter info and decide if they want to judge. Again, I haven't used it, but I'm just guessing that this also involves adding another set or another platform where you have to enter information to get the recommendations. But I do like what Dr. Clement said that, I mean, there are many methods that are out there on how to become efficient and effective of reading CGM. Like how do you start? What do you look at first? So kind of you would develop a systematic approach in interpreting CGM. So it kind of be a little bit more quicker and more efficient in getting that done in a systematic way. Yeah, I would agree with that. What I usually do, and I mirror that in my template, is just look at the percent of data captured, look at the big things, look at the hypoglycemia, look at the glucose variability, that sort of stuff first, and then start looking at patterns, and if necessary, dig deeper. And that's basically how I teach it and how I go over it with primary care as well. So you're right, having a system and just following that. And I also have a little section in my EMR right underneath where I enter the data that says diabetes insights, which just reminds me to enter what I'm thinking about when I'm actually looking at those data, so that when I get down to my assessment and plan, I have everything already documented. So you're right, just finding a system and hitting the high points, I think initially, digging deeper when you need to. Thank you. We're right at the hour and I don't want to keep people holding. However, I do want to very quickly address the last question from the Q&A is about when issues come up in the data management systems, who handles that? I agree, it can be very disturbing to the clinic. If something arise when your patient is there and you're trying to download and you have to troubleshoot, this is one of the things that you want to look at, those platform or those systems, do they have a good support team or is your staff trained well enough to kind of handle? But also what I would add is when things like that arise, we need to have a backup plan in a way, like, are we ready to just take the device and look at it manually as we used to do before having those in place? This is something we got used to, like if like EHR stops working or and you have the patient in front of you. So kind of something to keep going with the clinic and not to disturb the flow. Again, we are at the hour and I would like to thank my colleague and panelists here who prepared together, we've prepared over the last couple of months for this live webinar. I do wanna thank you all for joining at this late hour of the day and staying till the end and asking all those questions. And last, I do wanna remind you that you will be getting an automated email from the ADA encouraging you to respond to the survey. Please provide your comment and feedback. With that, I would close the session. And again, thank you and have a great evening.

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outpatient diabetes visits

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CGMs

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