An interview on integrating CGM data into the EHR with Grazia Aleppo, Professor of Medicine at Northwestern University.
An interview on integrating CGM data into the EHR with Grazia Aleppo, Professor of Medicine at Northwestern University.
Welcome to Diabetes Technology Report, co-hosted by endocrinologist David Klonoff from UCSF and David Kerr from Sutter Health. Welcome to Diabetes Technology Report. This is the podcast that covers diabetes technology. I'm David Klonoff. I'm an endocrinologist at Sutter Health in UC San Francisco. I'm going to introduce our co-moderator. Who will introduce our guest today? Here is Dr David Kerr.
Speaker 2:Hello everyone, david Kerr, speaking to you from Santa Barbara, california, it's a real pleasure to welcome our guest today, graziella Lappo. Hey, graziella, welcome.
Speaker 3:Hello David, both David.
Speaker 2:Yeah, We'd like to begin these podcasts with just a brief introduction. Can you tell our audience a little bit about who you are, where you are and what you're doing at the moment?
Speaker 3:For sure. My name is Graziella Lappo. I'm a professor of medicine in the division of endocrinology at the Northwestern University in Chicago. I'm an adult endocrinologist and take care of just diabetes patients every day. I just love technology and that's why I hope to be here in this wonderful meeting with each other here.
Speaker 2:Fantastic. We love you to bits. But one of the main reasons we brought you today is we were really, really intrigued by your recent article in the Journal of Diabetes Science and Technology. It was about integration of continuous glucose monitoring into the electronic health record. Can you tell us? Why did you set out to do this? What was the driver behind doing this study?
Speaker 3:The driver was that we thought we had so much information from our systems, our CGM, but then again, we want to make it much easier to our providers to take a look at the data Instead of going from place to place from software to software. This will be integrated in our medical records and everybody can access the data at any given time. I was very fortunate to have the help of this wonderful engineers I call them the geniuses because they're really the brains behind this idea to say can we actually make it happen Through the Dexcom API and we develop our own system? We were able to integrate, actually to feed the data from the Dexcom API to the Epic. We have this way to link the two together by inviting our patients to participate, by sending on my chart invitation.
Speaker 3:They basically go to their home device and they link the account and the information is on the screen for just about everybody to see and then accomplish two things. We can look at the data everywhere we are. They need to remember so many passwords and things have to go on but also we can see the actual raw data, if we wish to do that, or the specific number, if we wish to do that. But also we develop an image to report this to our colleagues, and to that we have attached instructions for our primary care provider so they don't feel sort of scared or overwhelmed into looking at these data, and we have specific booklets that we created for them, step by step, on how to view the data, interpret it and document it in the chart and actually build the code 9-5251.
Speaker 1:Grazia. What do you think is the future of continuous glucose monitoring compared to blood glucose monitoring?
Speaker 3:So I am a technology lover, as you guys know, so I would love to see no more blood glucose monitoring, if possible, and to make the CGM so available, cost-wise and access-wise to everybody. And why do I say they were so much passion? I have seen the effect, of course, in type 1 patients. We know that. But what I see in type 2 patients even more not only rewarding for the patient but also for us providers. They get so much more out of it. Why do I say that?
Speaker 3:You know, we know that patients with type 1 diabetes have been taught to check their glucose for many years. They are sort of used to doing that more or less. But type 2 patients have so much more to learn not just the number per se, but the effect of exercise, a walk after dinner, the food that they perhaps should not have chosen or they decide to choose, or a better comparison between a chicken breast and a donut. And these really are between the patients and themselves. And that makes a huge difference. It encourages patients to give so much feedback to them and really makes them do so much better.
Speaker 1:Are you recommending that your type 2 patients use a continuous glucose monitor every day or a certain number of weeks out of the year?
Speaker 3:So it depends. So when patients don't have access for that through the insurance, we do professional CGM and whenever we can we do it unblinded With the purpose to say to the patient look what your glucose levels are doing for the first five days, the following five days because we use the 10-day unblinded CGM, make some interventions and see if you make sometimes a homework and say will this work more than this? At the end of those 10 days we have in Pramina we'll review the data with them. Very often they say can I please go on this system moving forward? Which are best to do that? For those for whom we can, of course, we prescribe it. For those whom we cannot, we do CGM professionally throughout three or four times a year regularly.
Speaker 2:Grazie. Just going back to the integration, I'm intrigued. What were the sort of challenges that you faced? How involved were this and how big was the team and how much buying did you have to get from your IT department and all of those kind of political questions? Can you just describe the scenario of what went on?
Speaker 3:So I am always reminding the leadership that we need more access for the providers. But also, it turns out it was very fortunate because around that time about a year or so ago, a year and a half ago our place at Northwest Medicine started a remote patient hub, and so there was the perfect timing to say, why don't we talk about CGM, can we actually integrate? And so that became something that they were interested in, and so, because we talk about the integration, but also there was already an idea starting, they actually invested on it themselves. I didn't have to beg for anything and they put in my disposal this fantastic team. But we have to design everything from scratch. So, even though the desire was there, we had to really think it through, so it basically started from nothing. So we want to do about how are we going to do that, so not just the engineer to understand the transfer of the data, but also on our end. I wanted to make sure that the providers would have an easy work on doing this. It could be very simple, because if there's one more click, the provider wouldn't do it, and so my job was to develop the idea on how to make it simple for our colleagues, and that's why we made this BPA the best practice advice that would come in. And how do we make that happen? We said, ok, who are the patients who will be eligible for CGM? Who already use it With multiple daily user injections? Of course they will be there. And also based on the insulin users, just like the mobile studies show, it was effective. So, based on the medication list, we were able to gather this patient sort of the list of our patients, and then we combined those to the provider who had prescribed this.
Speaker 3:And by doing this, all BPAs coming up, the provider has to click one button, that's it, and the buy chart is automatically sent to the patient. It's personalized, comes, let's say, from me or from our other provider, and that was it. Everything else was done in the background. So whomever uses this? In fact, now we have a medical assistant really ordered, so it's that simple. The second thing we had to do simple for a provider was find the tab on the chart. If you have to look for it, you're not going to do it. So we have a tab that says CGM and shows some up and down. There's a little scribble in there and they just click on the tab and the information comes automatically for the previous two weeks. They can change if they wish to, but they don't have.
Speaker 2:And I guess the question is if other hospitals and other places are interested. Is it okay for people to reach out to you and learn what you've done, because it sounds like there must have been some negative or problems along the way. Hold on, let me tell you.
Speaker 3:So it's not always pink. The challenges were two. First of all, we had to make sure that the actual patient read the message and signed up, and so now we're doing with that, bulk orders, so we know that we capture as many patients that we could. We're just doing a pilot right now. Remember, it's not for the entire institution. We had to make sure that the data was correct and stuff like that. But the challenges are basically two. One is the patient doesn't read their MyChart messages, which happens right, and two, if we don't nudge them to do it in the clinic. So when you do that at the same time, it becomes a done deal. Otherwise we have to connect with the patient again until they actually remember to connect the two.
Speaker 3:So we're still working how to optimize this portion of our pilot to say, okay, the order is simple, the method is simple. Everybody is getting invited, actually clicking that allow or link the account. So there are always challenges and we're learning from how to implement this in a much larger scale and that's why right now we've been doing some steps. We started with some, a couple of providers, and then we're extending now to all the providers in the endocrinology practice with many satellite places. We're just in the central region, which is the downtown Chicago area, the faculty practice. That are central, northwest, south regions. We're not extended to them just yet. We're trying to really optimize the process and also the patient process as well. So that's the barriers so far.
Speaker 1:Grazia, how do you find that this integration project has led to improved clinical care?
Speaker 3:First of all, the patients call us. Very often they say I have an issue with my CGI and sometimes it's difficult to go to another computer, open another thing. So we have the data right there, the nurses can see it, you can say the patient is sharing with you in the chart. So I know the message, I look immediately. For example, a patient had a hypoglycemic episode and I try to find the number. So I looked with the exact number and saw how long it lasted. So that was helpful for me to really fix it. I sent a message back with some planotherapy, change, insulin decrease the dose done.
Speaker 3:In addition to that, when we can do that, the patient feels more comfortable say I'm having a challenge and they're actually finding to be very positive for the patient, because what patient ever contacts you between visits? They usually don't, but when they see the numbers and they have a challenge and they want to fix it before the next six months or three months and they contact you. For me it really is two minutes. I open the chart, look at the tab, look at the data. If I can, I drop the code because I have a dark phrase that I can use to do all the glucometrics done. The patient has feedback. It's a touch point between visit. The glucose will be better whether high or high per decrees hyperglycemia and I was able to provide a service. I think that's all positive.
Speaker 2:Gratia. I just wanted to clarify is this only with the DEXCOM type of continuous glucose monitoring or the other ones?
Speaker 3:So we are in touch with Abbott, of course, but it's a matter how they export their data. So right now we're receiving through the API it's already available to other entities from DEXCOM. Abbott is a different system, so we're working together with them to understand how we can get the data pushed, not pulled. We push the data into the medical records right now.
Speaker 1:Gratia, now that you have access to all this data. It certainly was expensive to get to this point. Are you able to do any billing for services now that this information is in the chart? Does that help your hospital financially?
Speaker 3:Yes. So the purpose was okay. We have data available and you will know that you can do a non-face-to-face interpretation, even up to once a month, and you drop the code 95251. So that accomplishes several things. We inform the patients that we do that because we always use the code in our regular visits, but we always have the patients. Should you have an issue, you are able to do that just when we drop the code. But for us it's so much easier now because it's when I open my encounter. I click the tab. I don't have to go to a different place and because I don't have to even copy all the numbers, I put our dot phrase and it's already there and there is a table, a tab, that says charge. Yes, I'm done so. We provide services all the time and I'm not trusting that we are greeting none, not even the least. But why not improve the patient's care and also help us do some more RVUs and some benefits financially? Since there are so few procedures, that is not something to frown upon.
Speaker 1:Grazia, did you read the iCode standard? I did. What did you think I?
Speaker 3:even discussed it in my presentation. At the end of society, of course, because that is the basis on starting all this. All this is important for just everybody because, remember, when the CGM is stuck in a software, all the other providers don't see that, but the primary care with whom I co-share, the manager of the patient can go in the very same tab to look at the very same data that I'm using, that I'm looking at. So that is so helpful and also it's safe, it's encrypted. It's all the things you guys talk about in the iCode. Yes, it was a fantastic publication. Thank you for mentioning it.
Speaker 1:Well, grazia, I want to thank you very much for taking part in this podcast. I want to thank Dr David Kerr, my co-host, and we look forward to the next podcast. We are available on Spotify, the Apple Store, the Diabetes Technology Society website. So until our next podcast, see you later, bye, thank you Bye-bye.