It has long been known that treating diabetes is one of the most difficult of all diseases. On the one hand, this is because the person affected by diabetes does not feel anything for a very long time, which does not necessarily have a positive effect on compliance. With diabetes, as with many other indications, the earlier the disease is diagnosed and the sooner adequate therapy - accompanied by lifestyle changes - is initiated, the higher the chances of success in leading a symptom-free life for as long as possible. This requires, on the one hand, the insight to change one's lifestyle, secondly, adequate medication and, thirdly, the possibility of being able to take influence early on, quickly and in a timely manner. It only offers blood sugar self-monitoring, with the results of which a diabetic can control his diabetes. However, this individual self-management must be supplemented by cross-sector diabetes management, as was the focus of the “Diabetes Media Dialogue”, which was once again organized by the company Roche Diagnostics, which is itself embarking on the path from a diagnostic provider to a diabetes management provider has.
>> Self-determination of blood sugar, which has been possible since 1965, is not only considered the most important milestone in diabetes therapy, but is also the basis of modern therapeutic strategies and disease management programs for diabetes. On the other hand, since 2009 it has been affected by a negative final report from IQWiG on urine and blood glucose measuring strips and an equally negative decision by the G-BA in March 2011, which resulted in an active exclusion of reimbursement since October 1, 2011 when it was published in the Federal Gazette.
Prof. Dr. Florian Steger, director of the Institute for the History and Ethics of Medicine in Halle, uses examples from the history of anatomy in the 16th century, the history of bacteriology in the second half of the 19th and first half of the 20th century, and the prion hypothesis of a nucleic acid-free infectious agent from the 1982 and the discovery of Helicobacter pylori as the cause of gastroduodenal ulcer by Marshall and Warren in 1983.
Although these examples have nothing to do with diabetes at all, according to Steger, they show very succinctly from medical history why even meaningful and innovative ideas have a long path ahead of them, with numerous trials and tribulations, from the idea to its implementation in practice. Steger answers his rhetorical question as to whether “the self-image of medicine that is always innovative, committed to scientific progress and strictly objective - especially practiced medicine - can withstand the reality of medical history” quite clearly with two statements: “Progress has been made in the implementation of this medical practice is difficult” and “innovation and quality of ideas are no guarantee for rapid implementation in medical practice”. Steger continues: “All four examples can show how difficult it was for good, correct ideas, some of which were later considered to be extremely groundbreaking, to be implemented in practice. In this respect, the thesis that progress is easy in medicine, especially when innovative ideas are to be used in practiced medicine, cannot be maintained. Innovation has a rather difficult time when innovative ideas are used in medicine should come - regardless of the quality and innovative strength of an idea.
What are the obstacles to innovation that stand in the way of implementing diabetes management based on patient-generated data? These are certainly the mental perseverance of authorities and structures formulated in Steger's examples. But this is also the way in which experiences and applications find favor in practice and which do not. “Here we have an opportunity to promote or slow down innovations,” said moderator Prof. Dr. Oliver Schnell, Managing Director of the Diabetes Research Group at the Helmholtz Center Munich, spoke in the subsequent discussion. His opinion: “Innovations often come from practice.”
One such innovative step is diabetes management. It arose from the realization that, on the one hand, the therapeutic goals of diabetes patients are still rarely achieved and that focusing solely on new treatment options and the HbA1c value rarely leads to the desired success, as Schnell explained in his lecture on diabetes management the subheading “electronic gimmick or completely new process culture”. His firm belief: “The individual range of glucose profiles in diabetes patients is only revealed through self-monitoring of blood sugar.” It also reveals what - keyword glycemic variability - is not visible through HbA1c: hypoglycemia and postprandial blood glucose excursions.
Studies such as “INCA”, “STeP”, “DECIDE” (see MVF 03/11) or the new “ROSSO-in-Praxi” made it clear how innovative management of blood glucose levels can improve the outcome of diabetes patients. But it's not just therapeutic parameters such as HbA1c and body weight that would be significantly improved, according to Schnell. The quality of life also increases sustainably; a factor that, like general well-being, plays a much greater role abroad than here.
According to Schnell, all of these studies show how structured use of blood glucose self-measurement, including visualization, presentation and trend analysis of the results, pave the way for optimized diabetes management. The studies are also an example and driving force for step-by-step innovations that enable the successful use of electronically based diabetes management software. But this could only fully develop its potential if it is well embedded in training and team structures for diabetes care. However, if this succeeds, the basis will be created for the successful further development of diabetes management “on the way to personalized medicine with great efficiency and high patient satisfaction”. Schnell’s conclusion: “Diabetes management can therefore be seen as an example of a new process culture that goes well beyond purely electronic solutions.”
Advantages of IT-supported diabetes data management
Dr. described the fact that diabetes management also represents a very elementary electronic solution. Wolfgang Hauth, resident doctor in a diabetological practice in Alzey, in his lecture “Diabetes data management and processes - requirements for information and knowledge management in a practice”. In his experience, the medical care of people with diabetes, a very heterogeneous group of patients with very different diabetes problems, can only be successful if the expertise of numerous professions is organized into a cross-institutional treatment path. But it would also have to be ensured that the relevant information about the patient is available along the treatment path at the same time as the patient is at the scene, which, according to Hauth, requires some challenges to be overcome within the facility.
This included an internal process landscape, but also the development of collaborations as well as the control of information and the joint development of knowledge. Hauth's plea for a consistent IT infrastructure: "In their daily routine, doctors and diabetes consultants in a practice need support tools in order to properly channel and use the flood of information that hits them."
For Hauth, an important part is the electronic diabetes data management, which in his opinion ensures that a valid database is available for therapeutic decisions when advising people with diabetes. It accelerates the processing of data, creates time resources to deal with the patient, but also increases the educational importance of metabolic control. That's why he has described a fixed process in his practice about how diabetes data is to be prepared, what functions the diabetes consultants have, when which data is collected and when it is to be presented to the treating doctor.
A microscopic example of this process chain begins when a patient enters the practice:
1. The diary is received
2. The blood glucose meter is inspected (e.g. cleanliness)
3. If necessary, a device check is carried out
4. The saved data is read out
5. The data is evaluated
6. A correction suggestion is entered into the electronic patient record (EPR).
7. If necessary, a consultation appointment will be arranged
According to Hauth, this first step process not only leads to better data quality, but also to time savings because the data, which guarantees a quick overview of metabolic quality, no longer has to be transferred manually. But the blood glucose meters that are required to be brought along during the process would also be better cared for by the patient.
All in all, for Hauth, IT-supported diabetes data management represents a “critical success factor”, which is primarily manifested in the following points:
• Information and knowledge (strategy)
• Process orientation (effectiveness)
• Resource orientation (efficiency)
• Quality of teamwork (shared view)
• Career satisfaction
What is at the beginning in diabetes is already common practice in therapy management for the indication epilepsy, for example, as Dr. rer. nat. Thomas Peckmann, Healthcare Manager at Desitin in Hamburg, presented.
IT-supported therapy management is not a vision
In order to make the diagnosis and treatment decision easier for this difficult indication with its around 30 different syndromes and subtypes, Desitin has collaborated with the Department of Epileptology at the University of Bonn (Prof. Dr. med. CEJ Elger - see MVF 06/11) and one A working group of resident neurologists and neurologists from the BVDN developed the “EPI Scout”. The program, which was developed by medomus Technologies & Services GmbH, uses the patient's own and third-party history to provide information about the type of seizure and - in the case of an epileptic seizure - the underlying syndrome and then, in accordance with the guidelines, makes suggestions for possible pharmacotherapy . In addition, the software also offers tips for correct ICD-10 coding as well as extensive documentation options. In addition, all information can be transferred to the respective doctor's information system via standardized interfaces.
And for therapy management, the Hamburg company makes the electronic seizure calendar “EPI-Vista” available online free of charge. In addition to their seizures, the patient can document their medication and a lot of other information. The heart of the software developed by dr.heydenreich GmbH in Greifswald is an overview graphic in which all information is placed in a temporal context, which enables an immediate assessment of the course of the disease, even over long periods of time. The patient also has the opportunity to give their doctor or a clinic access to their seizure calendar: But the doctor can also add entries so that complete documentation is created in the form of a medical record.
EPI-Vista is also part of the first integrated care contract (IV) according to §140a-e SGB V for children and young people with epilepsy in Schleswig-Holstein. Its contractual partners are the Knappschaft, the German Health System Consulting and Desitin, the first pharmaceutical company in the IV.
And what about diabetes? This is where initial discussions are held, as Ralf Kai Decker, Head of Marketing & Sales, Roche Diagnostics Germany, describes in the following interview (see page 17 ff.). <<
