Patient Gateway

PG 1 Running head: PATIENT GATEWAY

Patient Gateway: Comprehensive Health Management for the Diabetic Patient Kei Cheung Chow, Kyoung A. Lee, Starr D. Spann, and Ellie Yoonjoo Yoo New York University

PG 2 Abstract The Patient Gateway Comprehensive Health Management for the Diabetic Patient system is a Microsoft Access database designed to assist clinician to track patient's appointment, medication, medication administration log, lab order and result, and teaching and evaluation. The database consists of four modules, which are patient profile module, medication module, lab and clinical findings module, and teaching and evaluation module. Each module serves its unique purpose in keeping and tracking patient's data and relates to one another. The lab result change, medication adjustment, teaching reinforcement, and appointment scheduling are related and driving one another. The system allows clinician to keep track of patient's intervention as patient's condition, lab result, and medication change.

PG 3 Introduction Diabetes is a group of diseases marked by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. Insulin is a hormone that is needed to convert sugar, starches, and other foods into energy needed for daily life. There are different types of diabetes such as type 1 diabetes, type 2 diabetes, gestational diabetes, and other types of diabetes related to genetic condition, surgery, drugs, malnutrition, infection, and other diseases. Type 2 diabetes, which is one of the nation’s most prevalent chronic diseases, accounts for about 90% to 95% of all diagnosed cases of diabetes. According to American Diabetes Association (ADA), 20.8 million children, and adults in the United States, or 7% of the population, have diabetes. While an estimated 14.6 million have been diagnosed with diabetes, unfortunately, 6.2 million people (or nearly one-third) are unaware that they have the disease. Also, diabetes is the seventh leading cause of death (sixth leading cause of death by disease) in the United States. Furthermore, diabetes is the leading cause of adult blindness, end-stage renal disease, and non-traumatic lower extremity amputation. Diabetes can lead to serious complications and premature death, but people with diabetes can take steps to control the disease and lower the risk of complication. Although well-known practice guidelines for managing diabetes exist, real-life clinical performance often falls short of benchmarks. (Weber, Bloom, Pierdon, & Wood, 2008). A cornerstone to the treatment of this population is appropriate glycemic control, which has been associated with better patient outcomes and cost savings from lack of diabetes complications needing treatment. The treatment should be included controlled blood glucose level, dietary intake, physical activity, and insulin dose and other medication. As a health care provider, we need to consider the effective method to manage and help diabetic patients. The effectiveness of diabetes electronic management systems has been demonstrated and described in the literature (Nagykaldi & Mold, 2003). Thus, we design a user friendly and easy access database, “Patient Gateway: Comprehensive Health Management for the Diabetic Patient” to facilitate diabetes management. The Patient Gateway database allows clinician to share information among health care providers, get a quick glance at the information, transform easily from one report to another, and track patient’s progress effectively. Future version of the database is planning to allow leveraging automation, such as exchanging text message and communicating both directions between patients and providers. The database consists of four modules, which are patient profile module, medication module, lab and clinical findings module, and teaching and evaluation module. Module of maintaining patient profile and appointments It has been demonstrated that electronic patient registries combined with a clinical decision support system have a significant positive impact on the documentation and delivery of services provided by health care professionals. (Nagykaldi & Mold, 2003). It is important to use electronic patient registries to effectively manage diabetes, one of the most prevalent chronic diseases in the United States. A registry is a list of all patients with a disease. This list can feed into a reminder system for monitoring and allowing for more efficient population management. Although there is a myriad of specialized information technology that is meant for individual patients (i.e., glucose meter downloads), one requires a “big picture” of what it is able to do to have a larger impact on a larger number of people. Thus, diabetes registries have already been shown an essential element for a whole series of different population management initiatives in a variety of different clinical settings. (Gabbay, 2005).

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The idea of diabetes registries is used in our database, “Patient Gateway: Comprehensive Health Management for the Diabetic Patient” as a module entitled “Maintain patient profile and appointments”. The contents of this module include:






Patient profile Insurance Clinician information Appointment Caregiver information

There are some considerations mentioned in the first module of the database for the diabetic patient. All the contents of this patient profile and appointments have to be updated according to any changes in patients’ information, because the patient profile includes patient contact information and identification. In order to contact the patient immediately according to the result of other modules, such as medication module, lab module, and education module, the up-to-date data is necessary. Due to the limitation of time and resource in the current project, insurance information is incorporated into the patient table as a column, the same as caregiver information. Thus, one patient can only have one or zero insurance, the same logic applied to caregiver. In the future version, the relationship between patient, insurance, and caregiver will be addressed. In addition, we can use this module as a patient identifier when we need to verify a patient. As we know, “Improve the accuracy of patient identification” (The Joint Commission, 2008) is the first goal from the 2008 National Patient Safety Goals of Joint Commission’s Board of Commissioners. We should use at least two patient identifiers, when providing care, treatment, or services and conduct a final verification process, such as a “time out” (The Joint Commission, 2008), to confirm a correct patient, procedure, and site, before starting any invasive procedure. Although we input and extract data from the database, we still have to follow the proper procedure when we identify or verify the patient for patient safety. Follow-up appointments need to be updated according to patient condition change(s). The recommendation frequency for follow-up diabetic patient visits is every 3-6 months (Gabbay, 2005). However, follow-up appointments can change according to the clinical decision of health care providers. We can manage and track patient appointment effectively using this module and provide positive impact on diabetic patient care. According to ADA, the person with diabetes must be able to access health care providers who have expertise in the field of diabetes. Third-party payers must reimburse all medications and supplies related to the daily care of diabetes. However, a major barrier to optimal care for the diabetic patient is the lack of access to quality, culturally appropriate preventive healthcare, which is exacerbated by the fact that many people with diabetes, or who are at risk, do not have health insurance (Norris, et al., 2006). Therefore, insurance information should be considered when taking care of the diabetic patient. An interesting finding from 2005 National Diabetes Fact Sheet in the United States is that there are differences regarding the prevalence of diabetes by race/ethnicity, age groups, or sex. Thus,

PG 5 data in this module will provide demographic data and other baseline information for research and further study. Ongoing research and study for diabetic management is necessary for improving diabetic patient, care. Module of maintaining medication record & administration log The nurse has a special role in maintaining the medication record and administration log. The electronic medication administration record (eMAR) is designed to support medication administration safety. With error-prone paper records, which tend to get lost, are incomplete, or misread, the clinician needs a safe, effective and efficient method to ensure that medications are administered correctly. Within a hospital, drug therapies need to move quickly and accurately from the prescribing physician to the dispensing pharmacist and then to the bedside where the nurse typically administers the drug. A medication administration system that integrates the medication record ordered by the physician and medication administration system is a vast improvement over paper medication administration records. Despite the potential for decreasing errors, improper use of the eMAR may cause errors or generate unanticipated side effects (Bane et al., 2007). The design, implementation, & evaluation of eMAR are very important. Thus, a fail-safe eMAR must consist of the following functions:
Displays ordered medications for inpatients (Brown , Kobus, & Staggers , 2007).
Assists nurses with the ‘‘five Rs’’ (Right patient, Right drug, Right dose, Right route, Right time) (Brown , Kobus, & Staggers , 2007).
Assists nurses to document medications given or provide reasons for medications not given (Brown , Kobus, & Staggers , 2007).
Displays a large variety of routes for medications, from tablets, intravenous, intramuscular, subcutaneous injections to total parenteral nutrition (TPN), and sublingual medications (Brown , Kobus, & Staggers , 2007).
Handles complexities such as verifying a laboratory order, documenting a patient’s pulse before digoxin is given, administering PRN med within a certain time, etc (Brown , Kobus, & Staggers , 2007).
Tracks and trends medications due and those administered (Brown , Kobus, & Staggers , 2007).
Organizes medications for administration to a number of patients for a certain period of time, such as an entire shift, or for access to a single medication, such as a pain medication provided for a particular patient on demand (Brown , Kobus, & Staggers , 2007).
Serves as the resource document during change-of-shift report to communicate when crucial medications were last given (Brown , Kobus, & Staggers , 2007).
Functions as the integration point for orders; stocked medications in the pharmacy; interdisciplinary documentation; correlated laboratory values; drug-drug and drug-allergy interactions; medication-dispensing devices; billing; and bar-coding technology (Brown , Kobus, & Staggers , 2007). As the ADA recommended in 2007, early intervention with metformin in combination with lifestyle changes (medical nutrition therapy and exercise) with continuing, timely augmentation therapy with additional agents (including early initiation of insulin therapy) as a means of achieving and maintaining recommended levels of glycemic control (i.e., A1C < 7% for most patients) are highlights of this approach. (American Diabetes Association, 2007). The

PG 6 recommended early intervention for diabetic patient requires a continuing, timely augmentation therapy with additional agents. Such a complex drug therapy for diabetic patient requires a failsafe eMAR system to detect a medication interaction, ensure easy tracking of medications from the physician's order and medication safety and support patient safety. For safe medication administration, the eMAR is only as good as the drug database that supports it. The Access database of this project consists of tables storing medication record ordered by physician, administration log, and patient education. Forms of Access database allow clinicians to input data and record information effectively and efficiently. Clinicians can use query and report of Access database to retrieve correct information at the right time. The Access database is designed to promote efficacy, safety, easy access, and support for nursing practice. However, the potential impact of outpatient eMAR use on quality of chronic disease care such as diabetes has not been fully realized. Efforts to expand eMAR use should focus not only on improving technology but also on developing methods for implementing and integrating this technology into practice reality. Policy makers should demand that evidence-based quality benchmarks be met as part of this support to ensure that eMAR technology is used to enhance the quality of care. Finally, practice leaders should encourage a culture of improvement and quality within their practices and work to develop methods to improve diabetes care before implementation of an eMAR (Crabtree et al., 2007). Module of maintaining lab entry and result and clinical findings As we all know, when not properly controlled in a timely manner, diabetes can lead to many complications. One laboratory test called the “glycosylated hemoglobin represents an average blood glucose level during a 1-4 month period. An elevated result (> 8%) indicates uncontrolled diabetes mellitus, and the patient is at a high risk of developing long-term complications, such as retinopathy and neuropathy” (Kee, 2005, p. 222). More specifically, complications may include a foot ulcer, which can lead to an amputation; kidney failure; or blindness. Because patients’ conditions are widely varied, partly due to co-morbidities, we must keep in mind that treatment modalities and goals are individualized. “Many individuals with diabetes also have an associated syndrome complex including hypertension, dyslipidemia, and obesity, which along with aging, increases cardiovascular risks above and beyond the risks of hyperglycemia” (Abraira & Duckworth, 2003). In order to keep in step with the goal(s) set forth by the developers of this database, research of the guidelines and recommendations of the ADA regarding laboratory tests and results were consulted. “Achieve and maintain blood glucose levels in the normal range or as close as is safely possible; a lipid and lipoprotein profile that reduces the risk for vascular disease; blood pressure levels in the normal range or as close to normal as is safely possible” (American Diabetes Association, 2007). Other recommendations include exercising and physical activity, which lowers blood glucose levels. Changes in serum triglyceride, H DL cholesterol, and HbA1c are more favorable with low carbohydrate diets than low fat diets. The amount and type of carbohydrate, type of starch, style of preparation and degree of processing all affect glucose levels.

PG 7 Keep in mind our focus of creating this database is to help reduce the risk factors that can lead to the above mentioned complications. In doing so, we like to think that our database, is not only geared to benefit the patient, but also to benefit the caregiver in relation to the patient’s condition. Benefits to the patient include the ability to exchange information with the caregiver. For example, the patient is able to get questions answered regarding medications and/or insulin. This interaction, when viewed by the case managers and doctors, gives them a better picture of how to manage the patient’s therapy. Patients get a better idea of how to monitor their condition with immediate responses from blood glucose results and compare these levels over time. In return, the caregiver may obtain information regarding the patient’s baseline. Secondly, with the above exchange, the patient becomes educated and gains knowledge about their condition. The patient can learn the when and why values are measured. The interpretation of results may be revealed. Patient education very often leads to better management of diabetes. Consequently, values increasingly move toward the normal range. The caregiver may also notice reduced hyper/hypoglycemic episodes, which, in the end will lead to a better quality of life. Lastly, empowerment is important. The patient begins or maintains control of their condition, thus becoming more comfortable with self-care, which likely leads to increased patient/caregiver collaboration and control over their health. Another advantage to this database would afford the caregiver to obtain patient information at a glance. This enables fast retrieval of information or as learned in the laboratory setting, data extraction for the purposes of analysis, planning, and research. The clinician would be able to share information with others who are directly involved in the patient’s care, such as the endocrinologist, nutritionist and the pharmacist, to name a few. Knowledge of baseline information may be attained from this database. The clinician can gain data regarding the patient’s blood glucose levels and the glycosylated hemoglobin (HbA1c). The ability to track or trend data is gained via this system. Baseline information can be compared to future results. The clinician can make recommendations. Extreme deviations from baseline may be cause for some level of intervention. Lastly, because of the quick retrieval of data, the caregiver is able to make decisions in a timely manner. As our dataflow diagram illustrates, there are connections and associations with respect to laboratory reports and results, changes in lab results, and patient education. With this in mind, it is imperative that patients and healthcare professionals be able to share information at a quick glance, save time, allow doctors to make decisions in a timely manner and decrease the risk of complications. Patient Gateway, comprehensive health management for the diabetic patient enables us to do so. Module of medication, complication, diet and exercise teaching Type 2 diabetes was previously called non insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes. Type 2 diabetes accounts for about 90% to 95% of all diagnosed cases of diabetes. It usually begins as insulin resistance, a disorder in which the cells do not use insulin properly. As the need for insulin rises, the pancreas gradually loses its ability to produce it. Type 2 diabetes is associated with advanced age, obesity, family and gestational history, impaired

PG 8 glucose metabolism, physical inactivity, and race/ethnicity (Centers for Disease Control and Prevention, 2005). As the population of diabetes patients continues to grow, nurses and caregivers must keep up with the daunting task of teaching patients to care for themselves (Mertig, 2006). It is vitally important that the patient clearly understands how diabetes works, its’medical treatment and self management. Education allows the patient to understand why, how, and when to carry out the tests and, most importantly, to be able to translate the readings into appropriate action when necessary (Owens, 2008). As a nurse, we should assess what the client already knows, access what they need to know, assess guidelines, establish goals of client education and nursing interventions using learning principles and then evaluate the teaching process. It is essential for people with diabetes to take care of themselves. The Diabetes Learning Center from the ADA provides information about Eating and Diabetes, Factors Affecting Blood Sugar, Checking your Blood Sugar, Your Diabetes Care Team, Emotions and Diabetes, Diabetes- Heart Disease and Stroke. Based on the ADA learning topics, we developed a Medication, Complication, Diet, & Exercise Teaching module:
Diabetes - The basic: Patient will gain knowledge of what diabetes and insulin are in this section.
Type 1 diabetes - Results from the body's failure to produce insulin, the hormone that "unlocks" the cells of the body, allowing glucose to enter and fuel them. It is estimated that 510% of Americans who are diagnosed with diabetes have type 1 diabetes.
Type 2 Diabetes - Results from insulin resistance (a condition in which the body fails to properly use insulin), combined with relative insulin deficiency. Most Americans who are diagnosed with diabetes have type 2 diabetes.
Gestational Diabetes - Pregnant women who have never had diabetes before but who have high blood sugar (glucose) levels during pregnancy are said to have gestational diabetes. Gestational diabetes affects about 4% of all pregnant women - about 135,000 cases of gestational diabetes in the United States each year.
Pre-Diabetes - A condition that occurs when a person's blood glucose levels are higher than normal but not high enough for a diagnosis of type 2 diabetes. There are 54 million Americans who have pre-diabetes, in addition to the 20.8 million with diabetes.
Treatment of medication: we are planning to provide the types of medication to manage diabetes on the market.
Treatment of physical Activity: Patients learn how important physical activity is after the caregiver evaluates the patient’s ability of exercise. Modest weight loss has been shown to improve insulin resistance (American Diabetes Association, 2007). Exercise and physical activity are to be encouraged because they improve insulin sensitivity independent of weight loss, acutely lowering blood glucose, and are important in long-term maintenance of weight loss. For planned exercise, insulin doses can be adjusted. For unplanned exercise, extra carbohydrate may be needed (American Diabetes Association, 2007).
Glycemic control – After providing education about this topic, patients should be able to differentiate hypoglycemia from hyperglycemia. The ADA recommends daily blood glucose monitoring, with the frequency individualized based on several factors such as stage of the

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disease, periods of instability, special circumstances, age, and type of insulin regimen (Owens, 2008). Teaching of diet: After being diagnosed, patients may become frustrated with the idea of having to adhere to a limited and confused about food selection and portion. A dietary pattern that includes carbohydrates from fruits, vegetables, whole grains, legumes, and low-fat milk is encouraged for good health. Monitoring carbohydrate, whether by counting, exchanging, or by obtaining experienced-based estimations remain a key strategy in achieving glycemic control(American Diabetes Association, 2007) Complication: Patients will learn possible complications which are heart disease and stroke, high blood pressure, blindness, kidney disease, nervous system disease, amputations, and dental disease by CDC National Diabetes Fact Sheet 2005. Individuals with type 2 diabetes are encouraged to implement lifestyle modifications that reduce intakes of energy, saturated and trans fatty acids, cholesterol, and sodium. As stated earlier, patients are encouraged increase physical activity in an effort to improve glycemia, dyslipidemia, and blood pressure. To reduce the risk and/or slow the progression of nephropathy, optimize glucose control (American Diabetes Association, 2007). Diabetes in Adults with Special Needs – In this section, we incorporate special needs during acute medical conditions, such as pregnancy, etc. Self-management – Consider Client Noncompliance: Not all diabetic patients are motivated to learn and manage by themselves. While applying this module, we will assess any barriers.

After providing the above education to the patient, an educator or provider will evaluate the patient’s knowledge, and then it is entered into the database. Depending on the patient’s response, more education will be provided or existing information will be updated. Conclusion Patient Gateway is a comprehensive health management for the diabetic patient and is designed to facilitate the work of a diabetes clinic, inpatient facility, and homecare agency. It is a useful and user-friendly tool, which allows for effective managing and tracking of patient appointments and updating necessary information in an instant. It displays orders, allows for medication documentation, and provides continuity of care for in/outpatient status. The Patient Gateway benefits patients and caregivers via exchange of information. It provides the most basic diabetic education to the most up-to-date and sophisticated educational tools and then evaluates patient knowledge. In the project four modules are designed including patient profile handling patient demographic data, caregiver information and insurance coverage, medication module handing medication record and administration log, laboratory and clinical findings module handling lab data, fingerstick log and clinical findings, and patient teaching module handling diabetes management instruction and patient evaluation. Each module serves its unique purpose and is discussed previously. However, the interaction and integration of all modules are needed to enhance the effectiveness and efficiency of the whole system. The module of laboratory and blood glucose level test is the process driving the interaction among modules. If patient’s lab of HbA1C changes, MD may intervene to adjust patient’s medication. When the medication has been changed for a while, a new lab order for HbA1C or fingerstick order may be issued to follow up. Patient teaching may also need to be reinforced if

PG 10 HbA1C is changed. Patient’s appointment may also need to be adjusted for the change of patient's medication and HbA1C. In order to implement the interaction among modules, a table of interventions is designed to allow clinicians to input the planned intervention with pending status, record the execution of intervention by changing the status as executed, collect the triggering factors and provide data for the report that can be reviewed by the clinician for the plan of intervention. In order to prevent and manage CVD, which is the major cause of mortality for individuals with diabetes, ADA recommends that blood pressure should be measured at every routine diabetes visit and patients found to have systolic blood pressure 130 mmHg or diastolic blood pressure 80 mmHg should have blood pressure confirmed on a separate day (American Diabetes Association, 2007). The table of clinical findings in the Access database serves the purpose of collecting patient's blood pressure data, providing reports of patient's blood pressure trend and allowing the clinician to intervene at the right time. For lipid management for diabetic patient, ADA recommends that in adult patients, test for lipid disorders at least annually and more often if needed to achieve goals. In adults with low-risk lipid values (LDL < 100 mg/dl, HDL > 50 mg/dl, and triglycerides < 150 mg/dl), lipid assessments may be repeated every 2 years (American Diabetes Association, 2007). The lab module of the Access database is designed to allow the clinician to record the lab order for lipid, collect lab result and store the record of medication adjustment and teaching reinforcement. Thus, the interaction and integration of all modules can enhance the effectiveness and efficiency of the whole system. The projected timeline for the project is the following: 1) 2) 3) 4) 5)

Database design period is 2 weeks User testing and feedback period is 4 days Database refinement period is 1 week Beta test in a clinical site with real patient and feedback collection is 1 month Database refinement period is 2 weeks

Steps 4 and 5 should be continued to refine the database until all major issues are resolved. The evaluation should continuously monitor the database to ensure meeting its intended goals and objectives and gather and integrate user comments, evaluate clinical outcomes related to the database, and maintain current clinical content. Other issues needed to be considered are the user interaction satisfaction & learning curve. Is the application easy to use? Is the application fast enough? What is the degree of ease to learn? How useful is the online help manual and tutorial? All these questions will be addressed during the design and execution of the user-training phase. Program response time, networking either wired or wireless, and database backup issue will be addressed during the implementation phase. The Access database is the only database and programming tool used in this project. The data type of comment column in most tables is text which allows the field to store either text or numbers with 255 character maximum and is not searchable or queryable. If other database and programming tools are employed, the function of the system can be enhanced by sending email or text message notifying the clinician of lab results, facilitating communication between patients and healthcare providers via patient portals, creating chat rooms for patients to form their own support group, and providing podcast to enhance patient education.

PG 11 In the market, various medical information systems are developed to assist the patient in monitoring his condition; improving his health and thereby reducing the risks of the aforementioned complications; and fostering collaboration between the patient and the caregiver. However, a few systems are specifically designed for a patient with a particular condition. The Indiana University-Diabetes Research and Training Center plays an active role in incorporating new technologies into clinical care. They were the first center to investigate the use of computers in analyzing self-obtained blood glucose data and the first to conduct randomized control trials of point-of-care laboratory assessment and telecommunications technology in diabetes management (Clark et al., 2001). The harbor software is a comprehensive outcomes based support system for all diabetes programs and its home page is http://www.harborsoft.com/Diabetes/diabetes.html. The DiabetEASE system offers an advanced web-based diabetic health monitoring system and its home page is https://www.diabetease.com/dcs/public/index.jsp. Another system is the patient portal. The portal was designed to provide patients with a secure means of electronic access to preventive health care reminders, information concerning their medications and health histories, educational materials, and self-management resources concerning diabetes-related risks (Hess et al., 2006). Because of the aforementioned features, the portal allowed patients to enhance their communication with their caregivers, and have a greater role in managing their diabetes and other conditions. It allowed access of information outside of business hours, which can potentially, decreases demand on the caregivers’ time and foster smarter healthcare consumers. They could also print out information and forward it to other locations, such as radiology or laboratory offices. The features patients were most attracted to were the personal log, which allowed daily documentation of glucose levels. Another was a calculator that used the log to determine diabetic management over three months. Lastly, links to diabetic web sites. A motivation for designing these medical information systems was dissatisfaction with patientcaregiver relationship. Patients were mainly unhappy with the caregiver’s responsiveness, inability to obtain medical information and administrative problems with the office. Conversely, there was disinterest in the portal because of difficulty in using the portal and possible loss of satisfactory patient-caregiver relationship. With all of the beneficial features, some patients were not amenable to the idea of having to subsidize the cost of maintaining the portal. When promoting technological tools, it is important and useful to incorporate ease of use, security, and reassurances that collaborative relationships between caregivers and patients will be maintained.

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