THE SCIENCE & ART OF DIABETES MANAGEMENT: WHERE TECHNOLOGY CAN AND SHOULD FIT IN

FROM THE EXPERTS

MOVING THE DIAL: CAPITALIZING ON TECH FOR BETTER OUTCOMES

From sensor-augmented pump therapy to clinical data that’s more accessible than ever before, technology seems to have permeated nearly every aspect of diabetes care. The importance of technology in diabetes management and education/training cannot be underestimated.

Of course, like any clinical tool, technology must be used to its fullest potential to be most effective. As Microsoft co-founder and chairman Bill Gates once said about tech and schools: “Technology is just a tool. In terms of getting the kids working together and motivating them, the teacher is the most important.” Likewise, the diabetes educator plays a pivotal role in guiding patients in the effective use of technology, while also engaging them.

In this edition of From the Experts, diabetes education thought leaders Laurel Messer and Elizabeth Nardacci share with you their best step-by-step, practical advice on leveraging technology for optimal patient outcomes. Laurel takes a look at the many areas of diabetes care and education enhanced by a high-tech approach, while Beth focuses on CareLink® Therapy Management software as the “other” diabetes vital sign.


THE SCIENCE & ART OF DIABETES MANAGEMENT:

WHERE TECHNOLOGY CAN AND SHOULD FIT IN

BY LAUREL MESSER, RN, MPH, CDE

THE SCIENCE & ART OF DIABETES MANAGEMENT: WHERE TECHNOLOGY CAN AND SHOULD FIT IN Diabetes management is both science and art. When it comes to the science, technology is one of the most important tools in the diabetes educator’s (DE’s) toolbox. For instance, technological advances now allow us to instantly quantify glucose time in range, percent hypoglycemia, and basal/bolus percentage split. This access to meaningful patient data helps drive evidence-based clinical decision-making.

Technological innovations touch nearly every aspect of diabetes management, improving patient care and creating greater efficiencies. Examples include:

  • Sensor-augmented pump (SAP) therapy to support optimal patient outcomes
  • Easier and better clinical data collection and interpretation
  • Enhanced patient education, training, and communication
  • Customized electronic medical record (EMR) tools

OPTIMIZING SENSOR-AUGMENTED PUMP THERAPY
We now have clinical tools—such as temporary basal rates with insulin pumps, bolus calculators, continuous glucose monitoring (CGM) trend information, and blood glucose (BG) reminders—that can help us make more informed therapeutic recommendations.

As a SAP system, the MiniMed® 530G with Enlite® has been demonstrated to lower A1C and reduce hypoglycemic exposure.1,2 It’s important to leverage all components of the system to their fullest potential, including the insulin pump, the Enlite sensor and serter, the Bayer CONTOUR®NEXT LINK meter, the Bolus Wizard® calculator, CareLink® Therapy Management software data and reports, and Threshold Suspend® automation.3 All of these technology-driven features work synergistically to support optimal diabetes care.

Take, for example, Threshold Suspend, which automatically stops insulin delivery for up to 2 hours when sensor glucose (SG) values reach a preset low threshold (ranging from 60-90 mg/dL). This feature mimics some of the functions of a healthy pancreas by effectively taking action for patients when they are unable to avert or treat hypoglycemia themselves.4,5

Threshold Suspend is an excellent example of technology supporting better patient outcomes. We all have seen parents and patients deliberately keeping glucose levels elevated due to the fear of hypoglycemia, especially overnight. If Threshold Suspend is in place, we are in a much better position to convince parents or patients to lower their target to an optimal level overnight.

BETTER DATA COLLECTION FOR BETTER CARE
In a perfect world, all of our patients would upload their diabetes device information (BG meters, insulin pumps, CGMs, etc.) at home, and bring reports to the office during routine visits. However, as we all know, this does not always occur.

We are lucky at our clinic to have dedicated staff to upload device information (i.e., CareLink reports for the MiniMed 530G with Enlite) for each patient visit. This often is accomplished before the healthcare providers even see the patient.

By glancing at these reports for even a few minutes before stepping into the exam room, I have a valuable snapshot of how the past several weeks have been going: Are patients testing glucose levels? Are they receiving the insulin they need? Are there adherence concerns? These downloads provide wonderful conversation cues that can facilitate getting to the root of any challenges or issues so that they can be addressed.

ENHANCED PATIENT EDUCATION & TRAINING
Patients have different learning styles, and technological advances in multimedia and information delivery allow us to better tailor our diabetes education to suit those individual needs. As a visual learner myself, I appreciate when I can show a patient via a hands-on demonstration what I am describing. This approach tends to work best for repeatable actions such as setting up a BG meter.

Sometimes, though, this approach is not feasible—for example, when a patient is learning to use a new CGM sensor. For these situations, instructional videos are incredibly helpful. A quick search for YouTube® videos, including many excellent ones produced by Medtronic Diabetes, can quickly help you locate patient tutorials.

OVERCOMING THE FEAR OF TECHNOLOGY
It’s important to gauge patients’ competence and comfort level with technology and to help them overcome any concerns or hurdles. In general, the younger generation is more comfortable with technology due to exposure, but that’s not a hard and fast rule. I’ve had older patients who are extremely high-tech, and I’ve also seen younger patients who take more time and repetition to grasp certain aspects of technology.

Practice is the best learning tool there is—even for us as DEs when we are learning new technologies so we can teach them to patients. I will always remember when bolus calculators were first added to insulin pumps. I spent several hours playing with a demo pump, methodically working through the menus and practicing giving a bolus. One of my colleagues declined to work with the actual device, instead relying on the printed menu maps. During long clinic days, I was soon able to help patients navigate through their pump menus by relying on my tactile memory. My colleague, however, was seen flying down the hall multiple times to unpin her menu map from her office wall to bring it back to patients. Likewise, most patients learn better by doing, rather than just being told what to do.

My strategy to help patients overcome the fear of technology is to expose them gradually to what they need to know without overwhelming them. I try to choose one additional skill to teach at each visit. This may mean setting target glucose levels on a meter, or challenging them to use one temporary basal setting per week. I determine what skills will be most useful based on where patients are in their treatment plans, and prioritize from there. At each visit, we build on a previous skill that already has been mastered.

OPTIMIZING EMR FEATURES
We are fortunate to be able to customize our EMR. One of the first options we implemented was a separate dosing template for insulin pump users versus injection users. This is a huge time-saver and allows for standardization across patient populations. When the insulin-dosing template is opened during an encounter, we can populate the field with last known doses. This provides a helpful starting point in order to compare doses from the last visit, while also saving transcription time. This field also automatically populates school forms/letters, which often require current insulin dosing. The investment our EMR team has made in building these shortcuts has paid dividends in increased efficiencies.

Technology also can facilitate patient communication in between patient appointments. At our practice, we have the ability to encrypt emails so that they are HIPAA-compliant. We document email correspondence in our EMR the same way we document phone calls. Many patients like having the option to email their questions.

I find it especially helpful when patients email their downloaded pump, sensor, and/or BG meter information. I appreciate the chance to carefully look through information before responding. Oftentimes, I will follow up with a phone call rather than an email so I can ask patients questions for additional context: Were they ill? Exercising? Traveling? Sometimes, a combination of technology-facilitated communication and personal interaction works best.

BALANCING SCIENCE & ART
While technology plays a key role in the science of diabetes management, it should always be balanced with the art of delivering optimal care. I am referring to simple and critical human factors that affect our patients’ diabetes journeys—stress levels, living situations, exercise preferences, challenges, concerns, and goals. These considerations are equally important for outcomes and should help guide decisions. They provide context for the high-tech clinical information that’s more readily available than ever before.

Clinical data is crucial, but it’s only half the story. It’s our job as DEs to put it all together for our patients as we support them in their journeys.

REFERENCES
1. Bergenstal RM, Tamborlane WV, Ahmann A, et al; for the STAR 3 Study Group. Effectiveness of sensor-augmented insulin-pump therapy in type 1 diabetes. N Engl J Med. 2010;363(4):311-320.

2. Agrawal P, Zhong A, Welsh JB, Shah R, Kaufman FR. Retrospective analysis of the real-world use of the Threshold Suspend feature of sensor-augmented insulin pumps. Diabetes Technol Ther. 2015;17(5):316-319.

3. Overview: Introducing MiniMed® 530G with Enlite®. Medtronic Diabetes. http://professional.medtronicdiabetes.com/minimed-530-g. Accessed May 19, 2015.

4. Medical devices: Types of artificial pancreas device systems. U.S. Food and Drug Administration. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/HomeHealthandConsumer/ConsumerProducts/ArtificialPancreas/ucm259555.htm#TSDS. Accessed May 19, 2015.

5. Threshold Suspend automation. Medtronic Diabetes. http://professional.medtronicdiabetes.com/minimed-530-g. Accessed May 19, 2015.

Laurel Messer, RN, MPH, CDE, is a proud diabetes educator and clinical research nurse who has specialized for the past 10 years in type 1 diabetes (T1D), insulin pump, CGM, and artificial pancreas device system studies. She works with pediatric and adult patients at the Barbara Davis Center for Childhood Diabetes in Aurora, Colorado. Laurel helped author the Pump and CGM Pink Panther book and has contributed to others in the series.

WHY CARELINK® DOWNLOADS ARE A DIABETES “VITAL SIGN”

BY ELIZABETH NARDACCI, MS, FNP-BC, CDE

I don’t know about you, but I cannot do my job without technology. It’s the “language” I speak, and I don’t know how I could see a patient without it. As a nurse practitioner who first worked for many years as a diabetes educator (DE), I see the benefits of technology from both the provider and the DE perspective—especially when it comes to working together as a cohesive team to provide the best diabetes care possible.

While technology touches nearly every part of what we do each day, I’m going to focus on one specific area of technology in this discussion: CareLink® Therapy Management data and reports. From a clinical standpoint, I view CareLink downloads as another diabetes “vital sign,” just as valuable as blood pressure and weight, to better understand what is going on with patients at any given time.

CareLink reports provide crucial patient data. I would even go so far as to say that if for some reason I did not have access to them on a particular day, I would consider rescheduling my patients. The information is that integral to my clinical approach.

HOW CARELINK FITS IN
CareLink software, part of the MiniMed® 530G with Enlite® system, captures data uploaded from insulin pumps, glucose meters, and continuous glucose monitors (CGM) and produces reports that include helpful charts and graphs.

The reports provide information that can be used to identify trends and track daily activities, such as insulin and glucose readings and how they relate to carbohydrates consumed, meal times, and physical activity. By leveraging this information to adjust insulin pump and CGM settings, we can help patients achieve better glucose control.

MAXIMIZING CARELINK DATA & REPORTS
I have found that using CareLink allows me to spend less time interpreting data and more time discussing solutions with patients. Over time, the use of CareLink reports has even been demonstrated to lower A1C levels [Corriveau et al].

In addition, CareLink gives me insights into how my patients think. I have CareLink Pro installed on my laptop so I can review reports with patients in real time. It allows me to see how they problem-solve and how they make decisions about their diabetes. CareLink data and reports help me understand what makes my patients “tick”—what their priorities are and what their challenges are. These insights drive real conversations with patients about improving their self-care through mutual goal-setting.

In our practice, some of the ways that we leverage CareLink include:

  • CareLink Pro: The data from these reports, presented in an easy-to-interpret graphical format, provide a snapshot of patients’ highs and lows at any given time, as well as trends that may need to be addressed. When needed, the reports allow us to go deep, so that we can help patients troubleshoot any pump or sensor issues.

    In our practice, we use CareLink Pro to not only upload pumps and sensors, but also meters for patients who are not on pump therapy. Since we use CareLink so widely within our practice, we save time and create efficiencies by consistently viewing reports in a format that is accessible and understandable as well as familiar.
  • CareLink Personal: We use this tool to teach patients how to view and interpret their data. We also teach them how to read reports and recognize trends to support diabetes self-management.

We request that patients upload their data the night before their appointments. One of our upcoming pump support group sessions is focused on “How to Prepare for Your Medical Visit,” where we will discuss the importance of uploading at home to save time at the office. Patients also are expected to “do their homework” by using Medtronic’s online patient training.

We are planning to offer shared medical visits in the future with plans to review CareLink reports with patients in a group setting (following HIPAA requirements of course). This way they can learn not only from their data, but others’ reports, too.

Ideally, you should ensure that your practice’s electronic medical record (EMR) allows CareLink reports (and other data) to be imported directly into the EMR. If this isn’t an off-the-shelf capability offered by your EMR vendor, customization may be an option. While the reports can be printed and scanned without this capability, it’s clearly more time- and cost-efficient to import the data directly into the EMR.

CARELINK TIPS & TRICKS
Every team member in our practice who uses CareLink reports seems to have their “favorite” reports and data points they find useful for various reasons.

Here are some of my mine:

  • Therapy Management Dashboard: I review the statistics first, especially percentage of basal to bolus, average sensor glucose (SG) and blood glucose (BG) data, as well as standard deviation. I compare these data to the patient’s last visit. It’s especially important to compare the total daily basal and bolus percentages to the clinical guidelines (e.g., ideal percentages for adults are 40% to 50% total daily basal, and 50% to 60% total daily bolus—see more below, from the Medtronic Pumping Protocol booklet). These statistics can provide important clues about incorrect settings, “over-basaling,” and missed boluses.

    Therapy Management Dashboard

  • Adherence Report: Here I see how often the patient overrides the Bolus Wizard®. I look at frequency of manual bolusing, which can cause hyper- or hypoglycemia. While overriding is not always a bad thing, it can sometimes be a clue that the patient’s settings are not correct. The report can be a good way to flag any issues, so you can adjust the settings and recalculate if needed.
  • Device Settings Page: I copy the Device Settings Page and make sure the patient has a copy after I make changes. I circle the total daily basal dose and write in: “This is your back-up basal insulin dose.”
  • Daily Detail Report: I review the Daily Detail Report for the use of advanced pump settings such as the Dual®/Square Wave®. I look at when the patient is calibrating, which is vital to accurate sensor function.
  • I also look at the frequency of Threshold Suspend® alarms and the duration to see how the patient is using the feature, which can help determine if the sensor settings need to be re-evaluated. CGM settings typically are programmed when the patient starts pump therapy and should be re-evaluated on a regular basis. If they aren’t, alarm fatigue could result, causing the patient to stop using the Threshold Suspend alarm. These settings are dynamic and need to be changed periodically. DEs can play an important role in reviewing these settings and discussing changes with the provider, if needed.

ENGAGING PATIENTS
Engaging patients so that they understand the value of the CareLink reports in optimizing their therapy is a critical part of the equation. It’s important to teach patients that the CareLink information is theirs—they own it and are responsible for it. They are not uploading it for me—we make that clear to them, in a supportive and collaborative way. Educating patients about how to view their data and look for trends is an ever-evolving process. We are always building on and reinforcing their knowledge in that area.

Some patients at first think they are not going to be able to use the software—usually because they are concerned they might make a mistake. However, once we build their confidence through support and education, they realize that using the software is not difficult at all. Plus, when they see how the CareLink data and reports can help guide their therapy for optimal results, they recognize and embrace the value of this information.

RESOURCES FOR EDUCATORS & PATIENTS
When patients begin using CareLink Personal, we provide them with in-person training, as well as take-home instructions that they can refer to as needed. Here are some helpful Medtronic resources for CareLink Personal and Pro that we frequently reference to inform and support our training and education:

SOURCES
Corriveau EA, Durso PJ, Kaufman ED, et al. Effect of CareLink, an Internet-based insulin pump monitoring system, on glycemic control in rural and urban children with type 1 diabetes mellitus. Pediatr Diabetes. 2008;9 (Part II):360─366.

Bode BW, Kyllo J, Kaufman FR. Pumping Protocol: A guide to insulin pump therapy initiation. Northridge, CA: Medtronic Diabetes Medical Education. 2012. https://s3.amazonaws.com/medtronic-hcp/Pumping%20Protocol%20-%20a%20Guide%20to%20Insulin%20Pump%20Therapy%20Initiation.pdf. Accessed May 27, 2015.

Product education: Exploring CareLink® software and reports. Medtronic Diabetes. http://www.medtronicdiabetes.com/customer-support/education/mylearning/product-education. Accessed May 4, 2015.

Report Reference Guide: CareLink® Pro. Medtronic Diabetes. https://s3.amazonaws.com/medtronic-hcp/CareLink%20Pro%203.3%20Report%20Reference%20Guide.pdf. Accessed May 4, 2015.

Bolus Wizard® Quick-Reference Guide for the MiniMed® 530G Insulin Pump. Medtronic Diabetes. https://s3.amazonaws.com/medtronic-hcp/Bolus%20Wizard%20Quick%20Reference%20Guide%20for%20MiniMed%20530G.pdf. Accessed May 4, 2015.

Dual®/Square Wave® Quick-Reference Guide for the MiniMed® 530G Insulin Pump. Medtronic Diabetes. https://s3.amazonaws.com/medtronic-hcp/Dual-Square%20Quick%20Reference%20Guide%20for%20MiniMed%20530G.pdf. Accessed May 4, 2015.

MiniMed 530G with Enlite: Threshold Suspend automation. Medtronic Diabetes. https://professional.medtronicdiabetes.com/minimed-530-g. Accessed May 4, 2015.

Getting started with CareLink® Personal software. Medtronic Diabetes. http://www.medtronicdiabetes.com/sites/default/files/library/download-library/workbooks/GSG-CareLink-web.pdf. Accessed June 26, 2015.

System Administration Guide: CareLink® Pro. Medtronic Diabetes. https://s3.amazonaws.com/medtronic-hcp/CareLink%20Pro%203.3%20System%20Administration%20Guide.pdf. Accessed May 4, 2015.

User Guide: CareLink® Pro. Medtronic Diabetes. https://s3.amazonaws.com/medtronic-hcp/CareLink%20Pro%203.3%20User%20Guide.pdf. Accessed May 4, 2015.

Elizabeth (Beth) Nardacci, MS, FNP-BC, CDE, guest editor of this issue of In the Know, is a family nurse practitioner at Capital Region Diabetes and Endocrine Care in Albany, New York. Her special interests include diabetes technologies, including professional and personal CGM and insulin pump therapy, chronic kidney disease, and renal transplantation. She is a principal investigator in the OpT2mise international pivotal trial for use of insulin pump therapy in type 2 diabetes. Beth serves as an advisor to the American Association of Clinical Endocrinologists Task Force on Continuous Glucose Monitoring. She was a recipient of the Juvenile Diabetes Research Foundation’s Inspiration Award and has made numerous presentations and published clinical papers on diabetes technologies. Please send your feedback to IntheKnow@medtronic.com.