Transcript tsar bomba briefing

Content:
Slides 2-10 Anna Winkowski
Slides 11-20 David Madison
Slides 21-26 David Mishler
Patient Adaptive Diabetic CDS (PAD-CDS)
David Madison
David Mishler
Anna Winkowski
MED INF 406 – Spring 2009
Project Description
The Patient Adaptive Diabetic Clinical Decision System (PADCDS) better known as MyDM, delivers a comprehensive webbased patient-centric clinical decision system based on a
longitudinal care record. Major features include:
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User interface hosted on Apple iPhone™ (you carry the CDS with you).
Access to expert community via SMS messaging.
Maintenance of a consistent & longitudinal health record via Microsoft
HealthVault™ - eliminating hand-off errors.
Integration with wireless glucose meters for automatic transfer of
readings to the iPhone using Bluetooth™.
Modular & installable clinical decision trees on the server side –
accessible to the user via application update push.
A1C estimation & trending algorithm – viewable by user.
Clinical data transfer to EHR (if supported)
Diabetes Facts
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A disease in which the body does not
produce or properly use insulin (a
hormone needed to convert sugar,
starches and other food into energy)
Cause remains a mystery but genetics
and environmental factors (obesity, lack
of exercise) play roles
Diagnoses based on Fasting Plasma
Glucose Test or an Oral Glucose
Tolerance Test
Source: American Diabetes Association
Types of Diabetes
Type 1 Diabetes
Type 2 Diabetes
Diabetes Complications
•Heart
disease and stroke
account for 75% of deaths in
people with diabetes
•High blood pressure-73% of
diabetics have a blood pressure of
130/80 or higher
•Blindness 12,000-24,000 new
cases each year. Keeping BS close
to normal reduces damage to the
eye by 76%
•Nervous system disease 60%
to 70% of diabetics have mild or
severe nerve damage. 30% have
impaired sensation in their feet
•Kidney disease-diabetes is the
leading cause of kidney disease
•Amputations-diabetes is the
cause for >60% of non-traumatic
lower limp amputation
•Complications of pregnancybirth defects in 5%-10% of
pregnancy. 15% to 20% of
spontaneous AB
Economics of Diabetes
23.6 million or nearly 8% of
the US population have
diabetes w/ nearly one-third
undiagnosed
$174 billion-total annual economic cost of diabetes
in 2007
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$58 billion indirect costs (increased
absenteeism, reduced productivity, disability,
etc.)
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$116 billion for medical expenditures ($27
billion diabetes care, $58 billion for chronic
diabetes-related complications, $31 billion for
excess general medical costs)
Goals
Support Selected Healthy People 2010 Diabetes Goals
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[5-1] Increase the the proportion of persons with diabetes who receive formal
diabetes education. Target: 60% (baseline 45%).
[5-6] Reduce diabetes related deaths among persons with diabetes. Target: 7.8
deaths per 1000 (baseline 8.8).
[5-7] Reduce deaths from cardiovascular disease in persons with diabetes. Target:
309 deaths per 100,000 persons with diabetes (baseline: 343 deaths).
[5-10] Reduce the rate of lower extremity amputations in persons
with diabetes. Target: 1.8 lower extremity amputations per 1,000 persons with
diabetes per year (baseline 4.1 lower extremity amputations).
[5-12] Increase the proportion of adults with diabetes who have a glycosylated
hemoglobin measurement at least once a year. Target: 50% (baseline: 24%).
[5-13] Increase the proportion of adults with diabetes who have an annual dilated
eye examination. Target: 75% (baseline: 47%)
[5-14] Increase the proportion of adults with diabetes who have at least an annual
foot examination. Target: 75% (baseline 55%).
[5-17] Increase the proportion of adults with diabetes who perform self-bloodglucose-monitoring at least once daily. Target: 60% (baseline: 42%).
Source: Healthy People 2010 Report, Objective Section 5.
Goals
Support ADA Diabetes Clinical Practice Recommendations for 2009
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Self-monitoring of blood glucose (SMBG) should be carried out three or more times daily for
patients using multiple insulin injections or insulin pump therapy.
Perform the A1C test at least two times a year in patients who are meeting treatment goals
(and who have stable glycemic control).
Perform the A1C test quarterly in patients whose therapy has changed or who are not
meeting glycemic goals.
Use of point-of-care testing for A1C allows for timely decisions on therapy changes, when
needed.
Lowering A1C to below or around 7% has been shown to reduce microvascular and
neuropathic complications of type 1 and type 2 diabetes. Therefore, for microvascular disease
prevention, the A1C goal for nonpregnant adults in general is 7%
Source: ADA Standards of Medical Care in Diabetes for 2009, Position Statement
Stakeholders & Objectives
Diabetics: Validation group, ADA, prospective new users
- Improve HbA1c management.
- Reduce medical errors due to episodic complications.
- Provide portable longitudinal care record.
- Reduce ER visits
Clinical Care: CMO, CQO, Care Providers
- Reduce medical errors at diabetic patient handoff points
- Reduce incidence of diabetic co-morbidity by improved disease management and insulin compliance.
- Improve patient’s ability to self-manage diabetes through in-hospital deployment of MyDM.
Senior Management: CEO, CFO
- Reduce cost of chronic diabetes disease management.
- Improve hospital capacity by reduction in resources necessary to manage diabetes.
- Improve hospital’s ability to meet increasingly restrictive PPS DRG standards.
- Increase “best place to work” metrics.
- Reduce costs and complexity of HIT infrastructure.
iPhone MyDM Medical Appliance
Familiar
Convenient
Portable
Long battery life
Expandable
iPhone MyDM Medical Appliance
Blood Sugar button
Receive glucose
reading, date and
time via Bluetooth
Separately set
Alarms for glucose
checks as desired
iPhone MyDM Medical Appliance
HbA1c correlates with
blood sugar control
MyDM device calculates
estimated HbA1c from
average of blood sugar
readings
iPhone MyDM Medical Appliance
American Diabetes Association
•Dietary advice
•Support groups
•Newsletters
•Self-assessment exams
•Exercise programs
iPhone MyDM Medical Appliance
EXPERT answers
provided in sms text
messages
Similar to
www.chacha.com
iPhone MyDM Medical Appliance
GUIDE ME—Advice:
•Ill unable to eat
•Undergoing medical testing
•Change in physical activity
iPhone MyDM Medical Appliance
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Series1
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Scattergram Blood sugars by time of day
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Series1
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HbA1C trend overtime-reflects control
iPhone MyDM Medical Appliance
PHR
•Patient Health Record
•Medications
•Allergies
•Surgeries
•Family history
iPhone MyDM Medical Appliance
MD Setup
•Medication, dose
•Goal blood sugars, HbA1c
•Responses to elevated
blood sugars
CDS Diagram MyDM iPhone
Model availability
Available now
Need development
Extensible model to include:
Lipid management
Exercise programs
Additional guideline alarms based on
age, sex, ethnicity
Enrollment in research studies
Earn discounts from insurer based on
documentation of compliance
Architecture
MyDM
Web
Portal
Community
cha-cha experts
Always-on feedback
HL7 CDA CCR
MyDM App
(on iPhone)
Clinical User Data
(Multi-user)
Alerts, reminders
Microsoft
HealthVault
PHR
Database
Glucose Meter
TreeAge Pro Interactive
Pulse Ox
HL7 CDA CCR
Clinical User Data
(Multi-user)
Weight Scale
User Interface
TreeAge
Decision
Tree
Library
Data
Crawler
Clinical Decision
Support
HL7 XDR (IHE reliable
Cross-enterprise document
Sharing)
EHR
Clinical Records &
Applications
Architecture
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(A day in the life…)
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MyDM on iPhone captures glucose readings
using Bluetooth enabled devices.
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Readings are sent to MyDM web portal.
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Glucose management CDS monitors readings,
computes trends, and develops quality metrics
(A1C < 7%, glucose reading compliance, …)
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A crawler application on the server periodically
processes new data information, converting it to
HL7 CDA CCR format.
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New CCR records are published to PHR.
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If EHR support is available, CCR is sent in IHE
reliable cross-enterprise document mode (XHR)
to the EHR.
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MyDM and/or EHR can generate alerts and
reminders, which are pushed to the iPhone.
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A Longitudinal health record (from PHR) is
available from the iPhone.
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Expert guidance & episodic diabetes
management are available to the user
Evaluation Philosophy
Friedman’s “smallball” with a twist – the
addition of principles fromThe Agile Manifesto
(www.agilemanifesto.org).
“Agile” projects start with small feature sets,
build that functionality, test, deploy and
obtain feedback. Each successive iteration
adds new features and feedback. Keep
repeating until sufficient marketable
functionality – and for building future product
releases. “Smallball” adds evaluation
feedback at every step.
Source: Friedman et al, Evaluating Measures of Success using Clinical Decision Support,
AHRQ National Resource Center for HIT web seminar, January 21, 2009.
MyDM runs on an iPhone – why not use a cell
phone metaphor for “instant on” feedback?
Continuous multi-media feedback – send a text message, leave voice mail, send e-mail.
Provides a highly satisfying and intuitive evaluation mechanism for all stakeholders.
Captures problems as well as improvements and new features. Creates a sense of
community in that all users feel highly involved in the product evolution.
Limitations
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Applications
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Price
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At $199 for a 8G and $299 for a 16G, not many patients would be able to
afford the device. However, majority have a cell phone so maybe have a
downloadable application that could interface with most cell phones
Complexity
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Need to partner with Apple and the glucometer manufacturers to have the
applications added and available to patients
System has comprehensive approach that could slow development and
deployment – although a “community” could build up by user adoption.
Implementation skill set
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Software skills: Apple iPhone, Cocoa, Objective-C, TreeAge decision tree
interfacing, database, data mining & analytics, HL7 CDA and XDR, and
Microsoft HealthVault (SDK, C#), and EHR interfacing.
Clinical skills: Development and evaluation of decision trees, management of
expert cha-cha community, EHR order-entry and alarming development.
Questions?