Comprehensive Diabetes Management Program (CDMP)

1. Comprehensive Diabetes Management Program(CDMP) Introduction & Functionality Review

2. CDMP Background • Initiated June 2001 • Developed under a cooperative agreement with the DoD and the VA, overseen by TATRC. • Built on the Chronic Care Model TATRC – Telemedicine and Advanced Technology Research Center

3. Collaboration of Experts • Joslin Diabetes Center • Department of Defense • Walter Reed Army Medical Center • Tripler Army Medical Center • Veterans Affairs • Boston VA Healthcare System • Indian Health Services • Phoenix Indian Health Center • National Diabetes Program Office • University of Hawaii • Plus, private industry experts

4. CDMP Mission • “….leverage clinical information gathered in support of the CDMP and subspecialty records to affect improvements in, and insight into, diabetes health care delivery and the cost-effectiveness of delivery of these services”

5. Chronic Care Model* • Coordination with community resources • Strategic commitment of the organization • Support of patient self-management • Redesign of delivery system • Clinical decision support • Clinical information systems • By Dr. Edward Wagner www.improvingchroniccare.org

6. Deployments • Joslin Diabetes Center • Boston VA • Walter Reed Army Medical Center • Lackland Air Force – Wilford Hall • Indian Health Services – approx. 50 sites • Bay State Medical Center • Multiple clinics in Hawaii – Mililani, Waianae, and Molokai

7. Comprehensive Diabetes Management Program • CDMP is • Patient-centered • Care Team-based • User configurable • Built on available technologies and tools • Uses familiar red, yellow, green risk signals • Integrates with EMRs and other clinical DB • Expandable to additional disease states Weighs behavioral data with clinical data for a “whole patient” picture

8. Comprehensive Diabetes Management Program • Seeing through the Care Team’s lens • Current clinical & behavioral data • Scheduled Patients – 1 click away • Proactive Clinical Alerts • Reminders / Action Items • Attention to new issues • Customizable clinical guidelines • Patient Care Plan - team built

9. CDMP Provider Module • Pro-active Clinical & Behavioral driven • Alerts • Care Plan • Risk Profile • Care Team & Patient Action Items • Patient Snapshot • Patient Education Assessment • Image and Document Repository • Location and Patient-specific

10. DMEverywhere – Patient Module • Message Center • Secure patient messaging • Reminders • Home Monitoring Data Upload • SMBG, BP, Weight • Patient Education • Surveys • Labs • Health Profile

11. Survey Module • Patient Surveys • Healthcare Provider Surveys • Unique Surveys • Diabetes Behavioral Assessment • Diabetes Nutrition Assessment • Basic and Advanced • Diabetes Self-Care Profile

12. Data Warehousing and Reporting Module • Consolidates patient data from multiple-sites into one centralized, well organized data resource. • Key aspects: • Population and Patient-level reporting • Direct access to consistent, well organized data from multiple sites and studies • Research ready, anonymous data from consenting participants. • Integration of all available data (Medical, Demographic, Behavioral, and Study Specific)

13. Diabetes Eye Care & Treatment (DECAT) Module • Proven retinal imaging device and clinical service designed to prevent blindness and vision loss for people with diabetes • A nonmydriatic (non-dilated) diabetic eye evaluation that has been validated against dilated eye exams by retinal specialists and the gold standard of imaging, 35 mm stereo slides

15. Study Manager Module • Designed to handle the management of clinical trials • Population recruiting • Informed Consent • Letter Generation • Screening • Reminder Generation • Fully configurable and customizable

16. Care Provider Home Page - scheduled patients, new alerts and reminders

17. Patient Home Page - Alerts, Reminders, Care Plan, Risk Profile, and more…

18. Disease Management Framework Electronic Surveys and Scoring • CDMP is built on a web framework that can be extended to other chronic diseases. • Interchangeable components include: • Alerts - Risk Profile • Action Items - Surveys • Education Repository - Education Assessment • Care Plan - Image Catalog

19. Interchangeable Alerts • Create New Alerts • Modify Existing Alert Thresholds • Trigger Action Items • Modify Clinical Guidelines

20. Patient Level Alert Thresholds The CDMP Alert Engine now allows providers to customize alter thresholds by patient. This is especially helpful for tracking a Patient’s progress against intermediate goals.

21. Patient Clinical and Behavioral Alerts • View individual Alerts – view data that triggered the alert • Closing Alerts requires a follow-up action

22. Patient Snapshot CDMP Patient Status, Clinical & Behavioral Overview

23. Clinical Data Graphing • Quickly see trends & raw data • Customize high / low thresholds • Graph - lab & vitals signs, patient blood glucose data

24. Interchangeable – Risk Profile • Uses familiar Red, Yellow, Green risk indicators • Evaluates real-time clinical and behavioral data • Incorporate new rules • Available as a stand-alone web service

25. Reminders / Action Items • Manually create Reminders • Assign to Care Team Member or Patient (DME) • Automatically generate Action Items based on Alerts

26. Behavior & Nutrition Surveys • Scored Behavior Assessment • Physical Wellness, Psycho-Social, & Self-Management • Auto-generated Alerts based on replies • Simple & Advanced Nutrition Assessments

27. Education Assessment • Patient Education Assessment • Pre & Post Assessment • Built on ADA Education Guidelines • Customizable Assessment Areas

28. Care Plan • Physical Wellness - Readiness to Change • Patient Education - Self-Management • Action Items

29. Image Catalog • Images are a big part of patient records. CDMP can import a wide variety of images. • Patients can upload standard JPG or GIF photos • DICOM images • Integrated with JVN • Radiology • EEG/EKG

30. JVN Eye Care Summary Report Access to DR diagnosis, treatment and follow up details

31. JVN retinal image display • Powerful point of education • Start a conversation

32. Patient Nutrition The nutrition sub-module provides clinicians with an overview all nutrition related data including patient surveys; provider assessments; and assigned resources.

33. Integrated Home Monitoring CDMP allows clinicians to register a patient’s 3rd party home monitoring station in the application. This allows for seamless, automated home monitoring data integration.

34. Integrated Home Monitoring Clinicians are alerted when new home monitoring data is available and can review newly received data for their full patient panel from a single worklist view.

35. Integrated Home Monitoring Home monitoring data is presented for analysis using a variety of both tabular and graphical formats. From this view Clinicians can take immediate action by either altering the patient’s careplan or sending a private message.

36. User report creation and publishing CDMP now includes a complete reporting toolset which allows users to both create and publish integrated reports for any authorized CDMP data. Reports can also be developed at the administration level across multiple CDMP sites.

37. Expanded Disease Coverage Through new collaborations the CDMP has been successfully extended to support patients with Chronic Kidney Disease both independent of and co-morbid with Diabetes. Pilot projects for CVD and Hepatitis are also underway.

38. DME – Diabetes Management Everywhere • A secure HIPAA diabetes management portal that lets patients • Refer to current and past Care Plans • Upload blood glucose, blood pressure, & weight to Care Team • See the trends in their A1cs, weight, and other statistics • Send non-urgent email questions to Care Team • Send and receive email reminders about appointments, etc. • Join on-line conversationsabout diabetes issues • See and download vetted information about diabetes

39. DMEverywhere Home Page

40. DMEverywere Vital Signs

41. DMEverywhere Health Profile

42. DMEverywhere Trends – Blood Glucose Uploads

43. Study / Trial Management • Fully integrated with CDMP or Standalone product • Designed to handle the management of clinical trials • Population recruiting • Informed Consent • Letter Generation • Screening • Reminder Generation • Fully configurable and customizable

44. Data Warehouse / Clinical Studies Database • Consolidates patient data from multiple-sites into one centralized, well organized data resource. • Key aspects: • Direct access to consistent, well organized data from multiple sites and studies • Research ready, anonymous data from consenting participants. • Integration of all available data (Medical, Demographic and Study Specific)

45. Data Warehouse / Clinical Studies Database • Key Aspects continued… • Fully time stamped data allowing accurate "point-in-time" analysis across any dimension. • Easy preparation of data sets for analysis with statistical tools such as SAS or SPSS. • Secure internet based access for effective remote collaboration.