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4 TH ANNUAL HEALTHCARE INFORMATICS SYMPOSIUM APRIL 29 TH, 2011 RICHARD RJ KEDZIORA Design and Implementation of a Diabetes Medication Computer Assisted.

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Presentation on theme: "4 TH ANNUAL HEALTHCARE INFORMATICS SYMPOSIUM APRIL 29 TH, 2011 RICHARD RJ KEDZIORA Design and Implementation of a Diabetes Medication Computer Assisted."— Presentation transcript:

1 4 TH ANNUAL HEALTHCARE INFORMATICS SYMPOSIUM APRIL 29 TH, 2011 RICHARD RJ KEDZIORA Design and Implementation of a Diabetes Medication Computer Assisted Decision Support (CADS) System

2 Funding / Disclosures Founding Partner/Owner - Estenda Solutions Funding from U.S. Army Medical Research and Materiel Command (USARMC) AMEDD Advanced Medical Technology Initiative (AAMTI) program. Congressionally Directed Medical Research Programs administered by Air Force in partnership with University of Pittsburgh Medical Center - sponsored by the honorable U.S. Representative John P. Murtha PI on grant COL. Robert Vigersky M.D. at Walter Reed Army Medical Center

3 The Problem Not enough endocrinologist to treat patients with diabetes – most care is managed by primary care doctors Most patients not goal (A1C 6.5 – 7%) SMBG Issues SMBG not used effectively by patients / providers SMBG perception is that it is not used to adjust medications Large number of drug and combinations Therapy is not adjusted frequently enough

4 Potential Medication Combinations Drug classes include: biguanide, DPP-4 inhibitor, GLP-1 agonist, secretagogue, TZD, AGI, and basal insulin Excluded: Colesevelam and Bromocriptine 68 potential treatment combinations 8 mono 26 dual 31 triple 3 quadruple

5 The Solution - CADS Designed for primary care doctors to assist in better decision-making in modifying patients drug regimen to bring their blood glucose into better control. Currently Type 2 (Type 1 planning) Idea, concept and rules developed by COL. Robert Vigersky, M.D. - Director, Diabetes Institute, Endocrinology Service, Department of Medicine, Walter Reed Army Health Care System, Washington DC David Rodbard, M.D. – Biomedical Informatics Consultants, LLC, Potomac, Maryland

6 Journey Multiple facilitated group clinical chart reviews to reach consensus Initial standalone prototype development using CLIPS and Microsoft ASP – early 2000s Experimented with DROOLS moved to table-driven algorithm coded in Java Production system coding and integration with CDMP Clinical Trial 2011 – 2012 and beyond FDA Validation

7 Input Age, Gender, Type of Diabetes Self-managed blood glucose data (SMBG) Current and past medications Adverse Reactions Labs (A1C, ALT, Creatinine) Significant Diagnoses Renal, Hepatic, Gastrointestinal, Cardiac Target A1C




11 SMBG Testing Protocol For 3 months Twice daily (or more depending on DR. discretion) Once a week Before meals (x3) and bedtime = 4 tests Once a month Before and 2 hours after meals (x3), bedtime and night at approximately 3AM = 8 tests

12 Pre-Analysis Availability of SMBG SMBG correlation with most recent A1c Identification of problem time-frames based on SMBG data Hypoglycemia Hyperglycemia Variability

13 Analysis Overall quality of glycemic control Effectiveness of SMBG testing Inappropriate medication combinations Existing Medication Contraindications Age, Gender, Labs, Diagnoses Based on SMBG profile analysis and medication effectiveness First, address Hypoglycemia Then address Hyperglycemia

14 Algorithm for Treatment of Type 2 Diabetes Monotherapy or Combination Therapy Diet and Exercise If A1C > 6.5% Adequate Not adequate Follow-up q 3 mo Other Oral Combinations Oral Agent Plus Insulin at Bedtime (Glargine or NPH) Split-Mixed Insulin or Lispro or Aspart qac + Glargine or NPH qhs Adequate Not adequate Follow-up q 3 mo Adequate Not adequate Follow-up q 3 mo

15 Recommendations Modify the existing regimen because of contraindications Increase or decrease the dosage of current medication(s) Add additional oral agents/basal insulin 5+ medications or 4 with hyperglycemia - recommendation to consult endocrinologist

16 Additional Output Where testing can be improved FDA Warnings Rosiglitazone use has been severely restricted by the FDA because of concerns that it causes an increased number of cardiovascular events. Continued use requires your patient be enrolled in a risk evaluation and mitigation strategy program established by GlaxoSmithKline. You should consider switching this patient to pioglitazone at an equivalent dose… SMBG Profile by Time Period Min, Max, Average, Standard Deviation % high, % low based on thresholds







23 Algorithm Development Started with Expert Rules System Initially used CLIPS Migrated to DROOLS Final solution - Table-driven logic with algorithm coded in Java Number of combinations Ability for versioning and customization by individual non- rule experts


25 Next Steps A one-year multi-site IRB-approved, cluster- randomized controlled trial Expand rule base to include Insulin dependant Type 2 Type 1 Expanded pattern recognition and treatment plans Post-prandial fluctuations Trends during day or night Hypoglycemia followed by rebound "Somogyi reaction Dawn Phenomenon

26 Publication Rodbard and Vigersky, Design of a Decision Support System to Help Clinicians Manage Glycemia in Patients with Type 2 Diabetes Journal of Diabetes Science and Technology, Volume 5, Issue 2, March 2011

27 Thank you! Richard RJ Kedziora Office: (610) Cell: (610)

28 CDMP Background Complete customizable web-based clinical application for management of patients with chronic disease. Based on the Chronic Care Model, it was originally designed for military healthcare to better manage patients with diabetes. Evolved into a generalized chronic disease and population health management system supporting the Patient Centered Medical Home model. For details visit:

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