My name is Amanda Sheehan, and I will be moderating today's webinar. To share a little bit about myself, I am the lead NP in the Adult Diabetes Clinic at Joslyn Diabetes Center in Boston, and I'm also deeply involved in clinical research, looking primarily at indications and matters related to hypoglycemia. Today's webinar would not be possible without the guidance of the ADA's Time and Range Advisory Group. I would like to thank the members for all of their hard work to develop today's program. We are also very grateful for the support of Abbott and LifeScan, who has made this program a possibility. Let's see who we have joining us on today's program. Please let us know who you are and where you're joining us from. If you want to type in the chat box, the organization and the state that you're joining from. And let me just pull up the chat box. Okay, great. And thank you, everyone, for joining. So we urge you all to become members of the American Diabetes Association. Membership provides opportunities to network and grow professionally. And ADA memberships include a variety of professional member benefits, including meeting discounts, the Women's Interprofessional Network, special interest groups, the Diabetes Pro Member Forum, members-only webinars, access to our member directory, standards of medical care and diabetes, and then the Diabetes Pro Quarterly. As you can see, you would have access to a lot of great resources as an ADA professional. Visit professional.diabetes.org backslash membership for more information. And we have a link that will be uploaded to the text box with more information. And Time and Range wants to hear from you. Join ADA's newest online collaborative, the Time and Range Online Collaborative, to join the discussion. For more information, you can visit professional.diabetes.org backslash Time and Range. In the discussion, you can share best practices, you can request input on challenges, share interesting articles, expand your network, and browse the other wonderful TIR content that we've created. And Time and Range has a new home, so you can access all of the content on ADA's Institute of Learning. You can view the recorded webinars, podcast episodes, the practice pearl videos, and some really terrific infographics. Use the bio link to access content after the webinar. And that info will also be updated in the chat box. So the use of technology such as CGM and BGM with dynamic, information-rich patient applications, data platforms, and reports continues to revolutionize our understanding and care of individuals with diabetes. However, with these ever-evolving advances comes the challenge of how to adapt workflow to improve outcomes, as well as decrease the burden on patients, families, and the care team. To optimally benefit from advances in tech, patients, clients, and care teams require training, development of expertise, and appropriate onsite and digital infrastructures. Ongoing assessment, flexibility, and modification of processes to meet both the immediate and longer-term needs is essential if we are to fully access these resources during our visits, optimize the milieu of the clinic for all, and be present with our patients while we analyze the data together with the ultimate goals of improving time and range, health, and quality of life. Joining me today to discuss this important topic are Anastasia Albanese-O'Neill and Jenny Voda. Anastasia Albanese-O'Neill serves as Director of Community Screening and Clinical Trials Education at the JDRF International and is the founder of a Florida-based diabetes education nonprofit, the Diabetes Toolkit. Albanese-O'Neill formerly served as the Director of Diabetes Education and Clinical Operations in the Department of Pediatrics at the University of Florida, where she maintained an active research portfolio and clinical practice. Her research on diabetes education, quality improvement, and technology has been published in peer-reviewed journals, including Diabetes Care, The Lancet, and Diabetes Technology and Therapeutics. She was recently named the 2023 ADCES Diabetes Care and Education Specialist of the Year. Jenny Voda is a nurse practitioner at the adult clinic at the Jawson Diabetes Center in Boston. She received her bachelor's degree in nutrition and nursing education, including a doctorate degree at the University of Massachusetts Medical School. Her clinical interests include working with young adults transitioning from pediatric to adult care, weight management, and type 2 diabetes. She's deeply involved in an intensive weight management lifestyle program called Why Weight at the Jawson. This program was established in 2005 and supports patients in their weight loss goals and improved glucose management. Her research interests include medication adherence in type 2 diabetes, as well as exercise in those living with type 1 diabetes, specifically involving improving aerobic capacity. Please note that today's presentations will be followed by a Q&A session. If you have questions as we move through the presentation, please type them in the Q&A box in your control panel, and we'll be answering as many questions as we can at the end. And with that, I will hand it off to Jenny. Thank you, Amanda, for the warm welcome. I just want to first begin. I have no disclosures. So what we're going to do first, I'm just going to review the general workflow that we have at Jocelyn. And my clinic is in an urban setting, and we're very fortunate to have a lot of resources. So what I want to talk about is the similarities we can see between a clinic like mine and maybe clinics that are in more rural settings, and how we can talk about obtaining and integrating technology into our workflow. So the general workflow that we have, I broke this down into three steps. And we have the pre-consultation phase. This is when the patient arrives at the clinic, and this is the important time to ensure that the patient is downloading or sharing their data with the clinic. We have the consultation phase is when the patient is actually in the exam room and you're face-to-face with them, and the post-consultation phase. At Jocelyn, we're very privileged to have a very large education department. So oftentimes, my appointment is accompanied with an educator, and we call that a partner visit. So after the consultation with me, a lot of patients see either a diabetes educator, registered nurse, exercise physiologist, or behavioral health. So the pre-consultation phase, this is when the patient first arrives to the clinic. We have nurses and medical assistants that are trained to do vital signs. Luckily, we also have a lab on site, so they do the phlebotomy. And this is the time when we inquire about diabetes technology and try to access devices and ensure that patients are sharing their devices with our clinic. On the right-hand side of the screen, I actually took a screenshot of our EHR system, and we have in here, we always indicate the glucometer that the patient is using and the continuous glucose monitor, as well as an insulin pump, if applicable. So this is crucial to our workflow, because this will trigger the medical assistant or registered nurse to inquire about the type of technology the patient is using and to download a report for us to review. For smaller practices, it would be very important to have a point person that is trained on the different types of diabetes platforms, and there's a lot of cloud-based platforms that we'll get into in the next slide. And this person would be able to help you obtain the data. I also encourage that all providers have logins to the most commonly used web-based platforms, so that if we're having challenges downloading the data before the consultation, you can actually do it in the exam room. In terms of workflow, this happens often where maybe the patient's running late and the medical assistant wasn't able to obtain the data, you can actually log in and do that yourself. The important thing here is to have a trained staff member who is able to download these devices. So this is just a table about the different types of diabetes technology platforms that we have. For the glucometers here, we have gluco. Our clinic has gluco integrated into the EHR system, so when we download a glucometer, we can review the report on gluco. For continuous glucose monitors, we often use Dexcom Clarity and LibreView. These are free to clinics. Anastasia, you can correct me if I'm wrong, but these should be free, so that's not a barrier for a clinic to have access to these and to review the patient data. Some patients are using an InPen, and we can review their download from the InPen app. And then in terms of insulin pumps, we have gluco, which Omnipod uses. Tandem T-Connect has a cloud-based platform, which is really helpful, Medtronic CareLink, and then also Tidepool. It's really important to figure out what are the most common types of platforms your patients are using and obtain access to them, so you can create your own login, and then also having that point person in the clinic to ensure that the patient is sharing data, which is really helpful if the patient ever calls and they don't have an appointment but they need assistance, we can actually pull up, say, their Dexcom Clarity and review their glucose in real time. And when we're talking about improving time and range, this is really crucial to have access to the data. Okay, so now the patient has moved from the pre-consultation stage to the consultation stage. This is when they're actually in the exam room with you. First thing I'd like to do is just review interval events and any general concerns that they might have. I like to review their current care plan, and the majority of the visit I'd like to spend on reviewing the data, whether this is from a glucometer, a CGM, or an insulin pump. In terms of time and range, we really want to define time and range and discuss the goals with the patient. Obviously, the goal is to minimize fluctuations in glucose. One crucial thing that I just wanted to add is that for some patients, reviewing the data is very overwhelming. So it's really important to assess the patient and their readiness to explore the data. The patient is not defined by their data, so the patient's not their time and range, they're not their A1C. It's important to help improve their management, but it can be very overwhelming. What I like to do in the exam room is we generate a PDF report, and I like to pull that up on the computer and sit down with the patient side-by-side and review it with them together. Pre-COVID, we were actually using paper copies. So we would generate the PDF and print out the either pump download or CGM, and as you can imagine, it's a lot of paper. It can be up to 20 pages for some of these reports, and it's difficult to review because it's so small, but it's really helpful to have a PDF version to review. And the post-consultation phase, I didn't make a slide about this, but essentially this is when the patient leaves the exam room and schedules a follow-up appointment. Due to the COVID-19 pandemic, out of necessity, we were forced to transition to a virtual workflow model, and one of the biggest questions we need to answer is how are we going to obtain data from patients remotely? So the steps in the workflow for a virtual appointment are essentially the same. I think the key difference here is that some of these stages are going to occur on a different day, whereas the in-person visit, it's all in one day. So the week leading up to the appointment or even the day prior is the pre-consultation. So this is when the patient will have a virtual link for the appointment. We can schedule any lab testing at a local lab near their home, or they can come in for lab work the week prior. And this is when the point person, we actually have people, staff members, calling patients to help them with linking their devices to us or downloading their devices at home in order to generate a PDF for us to review during the consultation phase of the appointment. We actually, Jocelyn created, it's a work instruction essentially for commonly used devices that we can email patients the steps on how to download these devices from home. So the day of the consultation when you actually have the virtual appointment, we have a shared drive. So all of the data for that day, all the appointments that day are in a shared drive that can be accessed from any computer in the clinic. And I can also access it remotely so that I can pull up the reports and actually share my screen. And we can do the same thing we do in person. You know, I share the screen, we review the downloads together. And then the post consultation will happen on a different day when the patient will schedule follow-up appointments. So some of the barriers that I have seen with this virtual workflow is that patients have difficulty downloading their data from home. So we really, it's really crucial to have a supportive team around you to make phone calls. And we actually have staff members that will be on the phone with the patient and step by step go through how to download these devices. So communication with your care, with the care team is crucial. I often, you know, with our care team, I often am asking, you know, the educator that maybe has an appointment right after me to help set the patient up with a link to connect their Dexcom to us or give them instructions on how to download their insulin pump from home. And then the other thing that we have done differently with this virtual workflow model is the day after the post consultation, we've had some barriers with patients scheduling follow-up appointments, whether, you know, our scheduling office is playing phone tag with them and we're not getting these appointments scheduled, especially for high risk patients. It's crucial if we want to see them in a short interval of time. And we know that, you know, we can help improve time and range and improve their diabetes management if we have more contact with them, if the patient has more contact with the care team. So the nurse practitioners in our clinic are actually trained to schedule appointments, which is a new thing with this virtual care model. And it has been extremely helpful because before I leave the visit, the virtual appointment, I can say, okay, if I need to see someone in two weeks or a month, we can actually schedule it right then and there. So there's no barriers. The virtual workflow model has been really great to follow up with patients that have barriers to coming into the clinic. The clinic where I work is in an urban setting. Traffic is horrible. Patients have to take off, you know, half a day from work to get into the clinic. Parking is costly. So for patients that we need to see more often, seeing them virtually is really helpful. We just need to ensure that they're able to either share their data with us or they know how to download their data from home. And we can be really productive virtually. So, all right, I will pass it over to you, Anastasia. Thank you so much. That was really, really terrific. I don't think, and thank you to the organizers for inviting me to join you here today. Prior to being at JDRF, I was in clinical practice for 14 years at the University of Florida and at the end of that run, I directed our pediatric diabetes clinic. And I don't think I need to convince anyone on this call that CGM is a powerful tool to improve outcomes in diabetes. And I would just draw your attention here to data from the T1D exchange that was published by Foster and her colleagues in 2019, looking at 2016 to 2018 data. And here in solid black is people who were using no diabetes technology, so just injections only with a blood glucose meter. The horizontal stripes represent only a pump. And what we see is a pretty dramatic drop when we add MDI to CGM, and that's here in white. So, we see a drop in A1C, and I know we're talking about time and range, and we'll get to that. But when you look at adults, so 26 years and older, the people who are doing the very best in terms of A1C, at least based on these data, were people who were using injections and a CGM. Now, these data have probably changed since we've automated insulin delivery, but I just want to use this graph to draw to your attention the power of continuous glucose monitoring and all of the tools, all of the insights it brings for the person wearing it. So, similarly, we see data from the Diamond study, which included individuals with type 1 and type 2 diabetes, but I just want to draw your attention quickly to this graph on your right, which shows this shift. Again, in hemoglobin A1c, I know we're talking time and range and we're going to get there as a field, but look at this improvement in glycemic outcomes for people, again, circling here using continuous glucose monitoring. And then finally, these are data from the SWEAT collaborative, which is an international group that extracts data from charts and benchmarks in 19 countries worldwide. Again, linked to A1c because that's the measure we currently have. But all the way on your right is people using continuous glucose monitor and, again, monitoring. And look at this change. When things got approved in Europe, this bar on your right is showing the people who had a target A1c of below 7 or 53 millimoles per mole, as used in most places on the globe. And look at that increase for people who use continuous glucose monitoring. So I'm not going to dwell on the data, but if it's not something that you are currently supporting in your clinic or you're looking at ways to do that, just know that the data are behind you. What I found in my own clinical practice, and I think we're still experiencing this today, is sometimes there are personal barriers, meaning we don't have a team that knows enough about CGM or how to implement it, or we have organizational barriers. Maybe we don't have the support in terms of a builder for our electronic health record who can help us facilitate an improved workflow and break down some of these barriers or get the software on our machines and clinic. You know, in our clinic, we have the hospital computers and the university computers, and we had two different IT departments. So there's a lot of coordination there and breaking down some of those organizational barriers in terms of making sure the software is on every machine so that everybody can get to the data during a clinical visit. Let's talk about some personal barriers. I think this is a really important study from Molly Tannenbaum and her team. She, for a long time, I believe was at Denver. I think she's still there, but she interviewed 209 diabetes providers. Some were MDs, some were diabetes care and education specialists, but she found they sort of could be separated into three categories. About 20%, so two out of 10 were ready. They were ready to adopt technology and specifically this was related to continuous glucose monitoring. Then there were some people who were cautious. They were uncertain about it, uncertain about their own skill set, uncertain about their own ability, and they may have had some possibly implicit bias about the person with diabetes in front of them and their willingness to adopt continuous glucose monitoring. And then a full four out of 10 were not ready. They said they were not ready to implement technology in clinic. And so I guess I would challenge you to think about where you fit or where your organization fits or your colleagues fit into this circle because we've got a lot of people who are cautious and not yet ready. I know this is 2018, but as we think about continuous glucose monitoring and then we think about automated insulin delivery, I think as clinicians, we need to think about how can we get ourselves ready? Something we worked on is doing wear and shares in clinic. We brought in the devices and everybody put them on their body, diabetes or no, to experience what they felt like, to see what it was like to have tape all over your body, to see how it felt to pull that tape off of your body and to demystify the device. You can make this happen in partnership with your rep or others. So we really encourage you to get some of these devices on body for that experience. Again, and people with and without diabetes. I also want to draw your attention to a couple things that are now in the literature. And this first is some professional competencies from our colleagues at ADCES. And this was led by a primary care. The first author here is a primary care physician who is a diabetologist, but he works in adult primary care, but sees a lot of individuals with diabetes type one and type two. And these competencies are really about staff knowledge. So if you haven't looked at these yet, I would encourage you to. It's an open access articles. There's no firewall, no barrier to get to it. But these are recommendations like the following. If you're the person in the call center scheduling the visit, you should know the components of that person's continuous glucose monitor and make sure they bring them all to the visit. There's nothing worse than a visit when the reader doesn't arrive and you can't actually get that CGM working at the visit. So it's not just the MD, it's all the way through that multidisciplinary healthcare team, including our colleagues in staffing and coding and all of those other departments. So have a look at this paper for some ideas about what kind of training you might provide internally based on your practice setting. And then this next article I want to draw your attention to comes from ACE, so the American Association of Clinical Endocrinology. This is a really nice clinical practice guidelines. So if you haven't looked at it, I encourage you to do so. But it's talking about what metrics should you track, and it also talks about what you should know before you prescribe. So if you're going to prescribe something, you need to know how it works, and you need to know how to help your staff support the individual using it. So again, I would really encourage you to have a look at these both publicly available, very new guidelines, 2021 and 2022 for the one I just showed you on getting technology into clinical practice. So, I like to think of all of you on this call as technology champions. There has got to be somebody in the clinical practice who is going to take the lead and integrate that technology into the clinical paradigm so that we get better outcomes, and we get better quality of care, and ideally we get that quadruple aim of improved clinician satisfaction. It is frustrating to have a diabetes visit without data. It is frustrating to suspend a diabetes visit, talking about how you're going to get the data out of a device. We want to be having a conversation with the person in front of us, and so we need to get some of these things out of the way by designing better systems that motivate us to work together and really focus on that individual sitting in front of us. So I have a little roadmap here. When Jenny and I were talking about this presentation, we wanted to talk about kind of she's got an established workflow. I wanted to flashback to when we set up the workflow at the University of Florida. So here are some of the things, if you haven't set up a workflow, you might be thinking about, and they are as follows. I have a little button I have to push here. Here we go. So think about the need in your clinic panel. Who are the people that you see, and what devices work for them? In our case, we established what we called a decision support class. We initially offered it in person. It was a group class, but then during the pandemic, we started offering it virtually, and then it was like open seating. It was great. The way we booked that class is we did it kind of on an airline model, meaning we overbooked it because we always had no-shows, but we wanted people to learn about the available technology so that they could choose one that best fit into their lifestyle and ideally get some hands-on with the device before it was prescribed. So we're very clear, and I'm taking you all the way back to 2015, 2016, that there was a need for an increased utilization of continuous glucose monitoring in our clinic. Again, I come out of pediatrics, and so we thought it is time to focus on a better workflow so we can support CGM. We established a team and included a coder in our case because we wanted to try to bill for this if we could. We also wanted to include our diabetes educators and all of our staff and a number of other folks. We designed a workflow, which I'm going to share with you. We trained staff. Again, a lot of that on-body wear, and everybody did it, our medical assistants, some of our call center folks, our fellows. Everybody had access to the devices. It wasn't just the educators and the providers. We implemented the plan, and then we constantly evaluated how things were going because things that we designed initially really didn't work very well, and so we improved upon them. I think we're going to get to questions in the chat at the end. We were, I would say, not a first adopter, but we were an early adopter, and I have a picture that those of you who know CGM well will recognize as the old G4 or G5. This device was tricky to get on your body. It wasn't just a single touch button that inserted the sensor and removed the needle. There was a lot of hands-on, and a lot of people were nervous about this, and we felt very strongly that people needed training. Our frustration at this time is for our publicly insured families, training wasn't covered, and for our privately insured families, training was sometimes covered for reimbursement, so we really didn't have a way to do this. I'll answer questions about how we did get that done at the end, but we felt like with this technology, we needed training just to get it on your body. We also needed training to understand the data, things that Jenny talked about. What is time and range? This past weekend, we had a time and range cornhole game, red, green, and yellow, and really focused on more green, yes, less yellow, and red to get people to focus on that target range, but there's a lot of ways you can do that. Let's talk about our process. Back in 2015, there was no 95249, which is a placement code for personal continuous glucose monitoring. Both professional and personal continuous glucose monitoring were billed using code 95250, which is still used, and then the interpretation code is down below there, 95251. We were not billing at all for interpretation. We couldn't bill for publicly insured kids in our clinic, and we were having some success billing for privately placed devices with private insurance, and the challenge here is that I was always trying to make a case for more educators, more diabetes educators, and more people to work on CGM, but when we are constantly losing funding, it's very hard, and I was just trying to keep the lights on and the doors open. How did we do that? Well, I will tell you it was a success. From 2015, we went from 7% CGM use, and this was primarily the in-light at the time, in 2019 to 75% durable use, meaning people who had continued use of the devices, and these are data from the T1D Exchange. The University of Florida is a member of the T1D Exchange Quality Improvement Collaborative. They now have 52 clinics. If you're not a member, you should get involved, but I can show here, and this is from my colleague, Dr. Laura Jacobson, that as of June 21st, that durable CGM use was above 85 and approaching 90% of our clinic panel, so we managed to get a process in place that seemed to work and seemed to support continued use of these devices, and I will just show you that things changed a lot. I have 2019 data, so I'm sorry it's a little bit old, but to fund our efforts, we were getting it covered, so we weren't having any out-of-pocket expense, or we were minimizing that. We were minimizing what we had to write off, and we were able to actually get things covered so we could get these devices on people and increase access, so this was a success story, and you see that new code come in. Now, I like to give credit where credit is due, and I'm going to talk about the model we built. These are two medical assistants who are still working in pediatrics at the University of Florida. I saw Marilyn over the weekend. Like I said, we had a diabetes event here in town, and she is still working there. These two individuals were central in our process, and I'm going to talk a little bit about how that works, but what they did is for both virtual visits and in-person visits, collected, made sure that the data were in our EHR so they could be readily accessed, and our data were put into our EHR as discrete variables, so let me talk a little bit about that. We were lucky to have a builder. We used Epic, and so we were lucky to have a builder that could help us create these discrete fields. What was the start date? I think you can see up top here. What was the brand and the model? Supply details. This really helps with prior authorizations to know if they're getting it through DME or pharmacy and who they're getting it from because some are more challenging than others, and so this was really important for us to support families when they ran into supply issues. We also looked at wear time because we found that to be a really important variable to outcomes, and then time and range over 14 days. These were pulled out of the AGP, most often out of clarity, but we ended up using multiple software systems. Why was it important to input these data? This is what Marilyn and Sonia did in advance of the visit, whether right after the person checked in, they saw them first in the room, or a virtual visit in that Zoom call before the clinician came on. Again, we wanted these metrics in the chart. We wanted to know if they were using the CGM, what their time and range was, and what their wear time was, and of course, we had A1C as a discrete variable as a lab. The reason this was important is because once these were in Epic as discrete variables, we could pull them into any template that identified these data where they live. Let me give you an example of what that looked like. All of this non-English language up here are all of where those data points are, and then at the touch of a button, when the MD or the nurse practitioner goes in the room and opens this template, all of that personalized data flows in. What CGM they're wearing, how often they're changing it, where they put it, what their time and range was over the past 14 days. We also paste in the AGP, our medical assistants do that, and then this is the interpretation piece along with specific interpretation. The time it takes to enter the data into the chart for our clinicians was minuscule because it's really literally done at the tap of a button, thanks to Marilyn and Sonia, our excellent medical assistants. I want to talk about a process, and these are a little bit of out of order, but the first thing we did, and at first people grumbled about it, but we built a standard operating procedure, and we wrote it down, and we shared it with everybody during clinic, during division meetings and department meetings, and we went over it as a team with our staff, we built in redundancies. This is really important to know who was doing what, especially if we had people float to our service, or we had new people come on, it was really easy to train everybody in the process. I talked about how we have the flow sheets to collect those discrete variables. Every clinician used the same template to start. Now, all the individualized data would flow in, and they could personalize that as much as they wanted, but these two middle points were very important. One is the data went into the EHR the same way, we could pull it back out the same way, and because the templates were standardized, it was really easy to do chart review. I will also add that the iCode project is working at flowing those CGM data directly into the EHR, and that is like a dream, but we're not there yet, and so for now, this persists. And then we wanted to work on a process for that administrative paperwork. Where were those prior auth requests going? How were they getting there? Were they getting lost in a queue somewhere? So I'm going to say a little bit about that. This is our process. I won't get into the weeds, but I'm happy to share it with anybody on the call, and this process right here is for setting up the individual with the CGM. What we learned was if we set them up well at the beginning, meaning not only did the person learn how to put on the CGM, but they were able to connect it to the reader or to their phone, and then set up that phone or learn how to upload data at home from the reader, and get it into, in the case of Dexcom Clarity or in the case of the Libre Review, this was essential to facilitate our clinical processes. At the bottom of this, you can see the names of the templates that we used. So these are the only templates we would use around CGM, and some of them were specific to CGM models. You can see at this time, we've got G6 and Libre and others, and we also had school orders because we worked in peds. In addition, if someone was not using a continuous glucose monitor, this is the referral that was standardized that everybody knew about and would cue our scheduling staff to set people up into a CGM placement clinic and to do all of that education. Sometimes the training was done by a nurse practitioner, the placement and training. Sometimes the placement and training were done by a nurse practitioner and a diabetes educator in tandem. But again, this is that prescription for that CGM placement. And again, reviewed by our coders to make sure we had everything in place. Now, Jenny mentioned something really important. Sometimes people would come into clinic after the CGM was placed, and the data were not flowing, or they were having trouble with connectivity, or we couldn't get the data out of their phone, or they'd forgotten their passwords. What we did in those cases, or frankly, that first visit, that first one-hour CGM placement and training visit was not enough, and we learned that was true in many cases. Some people just aren't as comfortable with technology, and when we think about equity, we give people the education and training that they need to support that durable use. We created this referral sheet. This referral sheet was really important because we could talk about whatever it is we wanted them to do. So was it individual DSME? This is that referral for that, we called it the group basic technology class, but that's that decision support class. And you could also refer for CGM, and you see a checkbox here for CGM, and you could note what follow-up this person needed, including connectivity, but it might be talking about time and range, and this was time especially with an educator. All right. So we also had standardized, again, standardized templates. These are training templates. So we have a placement template, an education template, and then the interpretation templates that were used at every sort of return visit or a telehealth visit in between. And again, here's that example of that interpretation note, which could also be embedded into an evaluation and management visit. So just a return three-month visit. We also pulled the key teaching out of the manufacturer's educational material and put it into standardized instruction templates that we could print and send home with people and were also available in MyChart. So if you put a continuous glucose monitor on somebody and they have to take it off 10 days later for the first time, instructions are really helpful. What parts to keep, what parts not to throw away, or if you can throw the whole thing away, they're all different. So I just wanted to share that these were those core teaching materials that really help with that distress 10 or 14 days later. So which metrics should we collect? Well, the ACE document talks a lot about metrics, but when we got started in 2015, these were our metrics. The first couple of years we were looking at, do people just keep these on their body? Remember, we were back in the days of G4 and G5, they were hard to put on. We didn't have the approval of Libre. Others like the metronic devices required some technique in terms of tapes. So we really want people to keep these on their body. In years three and four, we were looking at wear time and time and range. And then we were looking at movement in A1C, but maybe one day we'll get rid of A1C and we'll just be looking at time and range. We were also very curious about satisfaction and reduction in hypoglycemia. These were additional end points that we tracked. And then we looked at, can we sustain this program? And we also looked for grant funding and we got some really nice grant funding during the COVID pandemic, which allowed us to put CGM on at diagnosis, which was a huge change. It changed our workflow, but it actually set people up with CGM as really a fundamental glucose monitoring tool. All right. So we all know we need objective data during visits. I think Jenny did a beautiful job talking about that, but how can you do that? So I wanted to share some sort of key points here, and there are some asterisks, which we put in that are very important, but if you're just getting underway, you need to create a process to log in, access, and review data. Now, we were lucky because the data were automatically in that template that had been populated by our medical assistants, but sometimes you wanted to go in and look at the dailies or look at a different time period. So in the very old days, we didn't have a clinic account. We would document in the individual charts that person's username and password. And that's tough because if the password changes or it doesn't get documented well, that's a challenge. So I don't really recommend no clinic account, and as Jenny showed, a lot of the accounts are free. A shared clinic-wide login, some practices use that still, but it's really frowned upon by IT people, and particularly the privacy people. That's really not a good way to go because if somebody leaves and they leave with that password, it's not good. And in our case, we couldn't get that past our IT folks, which is probably the right thing. What I recommend is using one of the portals. Most clinic portals are free. You have individual staff accounts and somebody administers it. So when I left the University of Florida, I still worked there in nursing, but not in clinic. They could delete me as a staff user, and then I don't have access to anybody's private health information. So really recommend finding an administrator for your clinic who will manage those accounts, who can add and delete individual staff users, but make sure everybody has their own single sign-on. Really important. And then you need to find out when you're setting up software, what are the risk assessments required by your institution? In my case, I had to put a risk assessment through the hospital and a risk assessment through the university because the computers in our clinic, some were owned by the university and some were owned by the hospital. You need to figure out who can install software on which computers. And in some cases, we actually had to have somebody there for that installation process because updates couldn't happen automatically. You might wanna make sure that you don't miss a software update on one of these clinic portals. So make sure that you have a process for doing that. And again, get with your privacy office or officer to make sure that they are in the loop on what you're loading on machines. All right. So again, this is just a review of how the data flows into Epic or is keyed into Epic. And actually a lot of our nurse practitioners, diabetes care and education specialists and MDs also key data in during visits. And those were the data we were collecting. And then this is how the data transforms from a template into an actual note that you can read. A pain point for many practices are prior authorizations. I'm sorry, I have my angry face emoji. I'm not angry at anybody for it, but it's really painful. And you need a process. So in our case, and I'm not privileging, I don't own stock in any of these companies. I'm not privileging one over the other, but the one we used was Cover My Meds. It made it very easy to process prior authorizations for many of the families we served, but not all. There was training required. We had to get Adobe Pro accounts for the people who used Cover My Meds, but it cut down on a lot of hours and frustration chasing down prior authorization. I would also say that you need to build checks into your system because sometimes things break down. And I would encourage you to frequently sort of assess your process to reduce inefficiencies. A lot of times we found that there were duplicated efforts, and here is an example of how that happened. The prior authorization might come in through a queue in the EHR and get kind of caught up where nobody was working that queue and it sits there for five to six days. So meanwhile, the pharmacy faxes something over and it gets into the patient's chart elsewhere. And then the patient or the individual with diabetes gets frustrated and they send over the prior authorization. And then you have two to three staff members working on the same prior authorization and everyone is unhappy with the process. So really think about what some of those challenges are. That issue with the queue, the work queue in Epic was a huge issue for us. Things would sit in there and not make it to the chart sometimes for two, five, 10 days. That's not an acceptable timeframe to get this stuff processed. So if that's happening, maybe you need backup staff to work that queue and other processes. So really think about these sort of impediments to providing good care, because what we don't want is especially somebody new to CGM to not have supplies because of a prior auth issue and then not be able to use the device and monitor their glucose. So I'm almost done. Insurance coverage is another challenge. What's covered by whom? I'm going to point you over to ADCES because they have a website called Dana Tech and they have this cool new tool where you can type in the state you're in and the plan they have, and you can see what's covered. And this is really important to sort of offset some of those challenges at the front end. And so some takeaways. First, set up a clinical process, whatever it might be, and then really reward people for following it. You need a plan or some kind of standard operating procedure. You need to figure out how you're going to set up templates in your electronic health record and how you're going to manage referrals, not only for setting the device up, but for that follow-up education. And don't let these get stale. Look at your metrics and see if you're making progress. Are you increasing the number of people who utilize the device and utilize it well? Thank your team. I went around constantly thanking people for doing the above. And share your success internally within the division. Recognize people for getting it done, but also externally and up the ladder about how important this is. We always lose money in pediatric diabetes. It's just a fact of life in pediatric endocrinology, but to show those individual outcomes was very powerful. And as we move to sort of value in care, hopefully those will continue to take an increased sort of weight and recognition. You need to advocate to reduce disparities. We were able to get public insurance in our state to cover CGM training and education for all of our families. That was very important. But we have a lot of people here in the state of Florida who are underinsured. And so we looked at some grant opportunities to facilitate that. And this was led, I showed our MAs at the beginning of this for a reason. They really led this process and were really fundamental in making sure that it happened. I just want to say that as clinicians, if we can't or we don't offer evidence-based technology to people with diabetes, we're creating disparities in care. We're creating diabetes technology haves and have nots. And so I really want to send home that message that we want to make sure everybody's up to speed on implementing glucose monitoring in clinic. Thank you so much, Anastasia and Jenny. Really fabulous presentations provided by both of our speakers. We'll now transition to the Q&A portion of the program. So if you've not done so already, please submit your questions in the Q&A box. So I will go ahead and get started. The first question that came up is, can you discuss the implementation of personal CGM versus professional CGM? Who would like to take that? I guess we can both answer. So in terms of the way our practice works, we have a diabetes technology team. So if I want to order a professional CGM for a patient, I place the order with the reasoning why I want this to happen. And our diabetes technology team coordinates the appointment with a diabetes educator. It's usually a registered nurse to apply the device onto the patient and to schedule the appointment with me, usually two weeks later to remove the device, download it, and the diabetes technology team or the point person, the medical assistant will download and generate the PDF for me to review with the patient electronically during the consultation. In terms of a personal CGM, that workflow is challenging. The first thing is to try to figure out where the patient is going to get the device. And I utilize our staff to help me, the diabetes technology team to help me figure out if the patient is going to say, get a CGM through pharmacy benefits, or if it's going to go through DME and they will coordinate that process, whether we need a prior authorization and any signatures that we need on my end. I don't know if your practice is a little bit different, Anastasia. Yeah, so I hope I showed you our personal CGM process and the SOP was there. I'm happy to share it with anybody on the call. There is some pre-work in terms of creating the letter of medical necessity and getting that approved in any prior OSS. And that SOP, this is personal CGM, would designate who does that work and how it happens. That referral actually triggers both of those processes. So it triggers our medical assistants to get that paperwork in and also schedule the visit. And if it's looking like there's trouble, we can schedule that visit later. And then what I talked about was also sort of that placement piece and the follow-up education. For professional CGM, I'll be honest, we used it a lot in 2016, 17, and 18, a lot less frequently in the past couple of years, but that same referral can be used for professional CGM. There's a checkbox where you can check personal CGM or professional CGM. And the evaluation notes actually have, actually the placement note template has a personal CGM option or a professional CGM, which cues coding people down the road to how to bill for that because they're different codes. And all of those things, we actually had a separate SOP for professional. It's a lot simpler process. There were a couple of ways we did it, depending on which one you were using. Sometimes we provided an envelope where people could mail it back for scanning and evaluation. And in other cases, depending on what the provider recommended, people would come back in and we would couple that with education. So, and again, happy to share those out. Okay, great. In that same vein, we had two questions about, will the slides be available and would it be possible to have access to the EPIC templates that you shared? Great. Nobody at EPIC is angry, but we're looking at the people with diabetes and if this facilitates clinical care, we're in. So just please get with me on how I can share those. Okay, great. And the slides will be available on the Time and Range platform. And we would encourage you to share the links to those with your colleagues as well. Okay. And then, are there any online resources that you like to utilize to help patients troubleshoot in sharing their technology when they're at home? Any outside resources that you go to specifically? I know in our clinic, our education department developed these instructions for patients to download devices. Although I believe that most of the, like continuous glucose monitors, there are instructions on how to generate a sharing code on their website. And then same with the certain insulin pumps, like the tandem pump, I believe there are instructions. But specifically, we essentially created our own to kind of simplify it for the patient. Yeah, so just following on that, I think those are great recommendations. I think the device manufacturers have information on how to do that. But what we found was a great use of technology like this, as long as somebody had video available or even phone connectivity, was actually to schedule one of those virtual education visits. That's what that second referral was for. And walk through it with the individual or the family in their home. Everything is different. And so I think it's really important to be able to understand what's happening right there on that person's computer and what some of the barriers are. Even teaching people how to share screenshots and do different things, that was really important. I think a frustration for us was often, it was people who did not have a compatible phone. And that's something really important upfront is to understand compatibility when you're placing the order, making sure you're getting a reader if somebody doesn't have a compatible phone. But a lot of times people who don't have a compatible phone might not also have a laptop or desktop computer in the home. They might be doing things off of that phone that they are using. Really finding ways to connectivity, other ways to connect through a phone, upload data through a phone were important that were alternates to direct streaming from the device to the phone app. Great. And then I have another question here about how do you deal with challenges when there's a smaller practice trying to establish a workflow to obtain the data? What recommendations could you give there? I would say the key recommendation is to create a point person that is going to be trained on how to obtain the data. So the point person should have logins to the commonly used platforms that your patients, that the patient population uses, whether it's Dexcom Clarity, Freestyle LibreView, and whatever pumps your patients are using. I mean, the support staff is crucial. As well as, I encourage all the providers to have logins as well, because if the workflow is disrupted and the patient's late and the medical assistant is not able to do that, you can actually obtain the data yourself, although it takes time during your appointment, but that's just in cases where the workflow is disrupted. But I would say that's probably my biggest recommendation is to find a staff member that is interested and willing and teachable that you can train to do this. Yeah, I'll just echo that. I call that person the diabetes technology champion. Every practice should have a champion. And the truth is we shouldn't layer on work without rewarding these champions. So if it includes some kind of small increase or a better title or recognition in some way, don't just add work without adding some kind of support and a leadership role. I also meant what I said when there are leaders at every level in the organization. The champion, the technology champion can come from any level, but they need to have enough autonomy to sort of drive the process. And I couldn't agree more. Everyone in the clinical practice should have a login so they can access data. We shouldn't be having visits without objective data. It doesn't make much sense anymore. So everybody should be able to access that. But I think we also need to support that champion. And we need to get that support up the line. So you need support from the C-suite or from leadership or whomever that is. If it's a small practice, everybody needs to be on board in particular. And you need a redundancy. If that person isn't there, the whole clinic can't fall apart. So who's their backup in terms of knowing how those processes work? Yeah, I think that's critical. And we've been dealing with challenges too, just in terms of staffing and the pandemic. And we've started to set up these monthly meetings so that staff at every level, from scheduling to check-in to the MAs to the NPs, so we can all get together because workflow is a flow, right? It's a process and we have to be able to adapt when resources are shifting as well. And then I think also just support each other and stay in a good mindset because it's not easy. And if we're not communicating, then we're nowhere. So it looks like we are out of time. I would just like to thank our speakers for a really terrific presentation. Thank you also to Abbott and LifeScan for their support of today's program. And of course, thank you to all of you for joining and participating and your really fantastic questions. Be sure to check out our TIR resources. TIR has launched webinars, podcast episodes, practice pearl videos. We encourage you to share the link to the ADA's Institute of Learning and Online Collaborative which are in the chat and share those with your colleagues and on your social networks, please. And upon conclusion of the program, you will receive an email to complete a brief survey and please provide feedback today for the presentation. Thank you again for your time and we look forward to connecting with you at the next Time and Range webinar. Thank you.

webinar

Amanda Sheehan

continuous glucose monitors

CGM

workflow

benefits of CGM

challenges

prior authorizations

insurance coverage