Diabetes Reality went live in Taranaki on 27 Nov 2022!
- "Diabetes Reality" (RdR) serves as an integration facilitator aligning with the Ministry of Health's Quality standards for diabetes care, as outlined in December 2020. This platform enables the efficient deployment of new community-based roles, adapting to evolving service needs while maintaining compliance with MoH standards.
- As an open API with robust partner support, RdR is poised to integrate seamlessly with existing primary, NGO, and secondary patient management systems over time. It not only fosters integration but also establishes a networked approach to collectively enhance outcomes across various time frames. Crucially, it transforms provider-consumer relationships from hierarchical and transactional to collaborative partnerships with the community.
- In 2023, RdR will introduce Clinic Schedule optimization using a patient TRAFFIC reporting tool. This tool employs individualized care plans to direct patients to the appropriate healthcare professionals, locations, and appointment times. Each patient is assigned a specific color-code indicating their care requirements (e.g., Red for Physician, Orange for Diabetes CNS, Green for self-management in primary care). This information is displayed on a timeline, facilitating the tracking of patient needs against service capacity. TRAFFIC, an acronym for Tracking REALITY ActionPoints 2 Funnel Frequency Into Clinical Consults, aims to optimize each step of the patient journey to convert clinical consults into measurable outcomes.
- RdR also features a patient-facing portal through the mobile app HealthCart, empowering patients to actively participate in their diabetes management and overall health. Automated CarePlans generated within RdR, along with corresponding color-coded alerts, are swiftly accessible to patients through the mobile app, typically within an hour of blood test results and clinical consultations.
- Furthermore, PowerBI is utilized to create interactive dashboards aligning with the Ministry of Health's diabetes care requirements. Microsoft PowerBI serves as a unified, scalable platform for self-service and enterprise business intelligence, facilitating easy data connection, modeling, and visualization. This technology enables the display of live dashboards, personalized with key performance indicators (KPIs) and branding, to gain deeper insights into diabetes care data.
Diabetes Reality Background
A Diabetes Service Level Alliance Team (SLAT) has been in place in Taranaki since 2019. This SLAT was established to improve the diabetes outcomes in Taranaki and specifically to improve performance against the diabetes standards. The SLAT represents iwi, primary care, and Taranaki DHB. During 2020 SLAT initiated the use of a software application RenalReality (already in use in Taranaki since 2012), to design with the intention to implement the following:
- Combined primary/secondary data dashboard aligned to MoH standards
- Integrated podiatry service spanning across the community and specialist service delivery.
- Psychosocial screening tools and assessments
- Standardized overall physical health risk assessments
Service design and vision
With the in-principle support of the Taranaki Alliance Leadership Team (TALT), the SLAT is moving forward with a full-service re-design. The intention will be a single, community-based service, enabled through strong co-design, strong leadership, a pro-equity focus – including the addition of kautautoko / non-clinical roles, and digital enablement. The intent is for all of the service spanning iwi, primary care, and specialists to be aligned under a single whanau ora based outcome and evaluation framework and a new commissioning approach. So, while its patient-focused, the diabetes care provider can also be provided with guidelines-directed action plans.
- Vision to create a service to ensure that whanau with diabetes are supported to manage their diabetes
- Access to services that are tailored to their needs empowers the patient and their whanau towards self-management
- To build community and service resilience by live monitoring of KPIs as per the MoH NZ model of care
Current issues as of 2020
It will be critical for this service, spanning multiple providers, to be able to work as a team with the patient and their whanau and to be able to monitor outcomes ensuring that the service is reaching and adapting to needs. Specifically, the service needs to ensure that it works in partnership with Maori and can work towards eliminating inequity.
Currently, the patient record is siloed to services; this leads to duplication of effort, gaps in care, and no shared accountability around outcomes. We are proposing a single, interoperable portal named ‘Diabetes Reality.’ This will enable the service to:
- Have a single register for all patients with diabetes in TDHB
- Access to consistent care planning
- Standardized clinic notes and screening to ensure that all parts of the service are uniformly recorded and accessible
- Automated Clinical decision support
Phase 1: DiabetesReality Sept 2022
The portal is based on ‘Renal Reality,’ initiated by TDHB. After nine years of operation, it has made considerable quality improvements and resulted in annual cost savings of $600k ( 2.2 million per annum to 1.6 million per annum). Several other renal centers are now adopting renal Reality.
Using this platform, we redesigned RR to include people with diabetes (RdR - Renal and Diabetes Reality) using variables like HbA1c to monitor diabetics patients automatically to:
- Enhanced patient experience and outcomes for all patients with diabetes in Taranaki.
- Service ability to ensure the workforce continues to be matched to patient/community needs
- Support resilience of iwi and primary care service, ensuring that the system is supported by strong evidence-based decision-making in a collaborative environment.
- Enables CNS and non-clinical workforce (kaitautoko) to work in the community with immediate two-way access to a centralized portal.
- Develop a platform that can draw from multiple data sets, with links to a single outcomes framework at an operational level.
Phase 2a: DM Dashboard Nov 2022
An RdR status bar will appear at the top half of the dashboard to provide crucial patient data, including name, date of birth, ethnicity, and age.
If the patient is on any form of dialysis or needs a renal referral, this will be indicated in the status bar. Any alerts, like social or high-risk concerns, will be marked in Red or Green on the right-hand side of the patient's name.
Time since Diabetes diagnosis will also be included in the status bar, and this is determined by when the HbA1c recording met the DM standards threshold for newly diagnosed diabetes mellitus.
Additionally:
- Current Renal modality / Referral pending based on DM eGFR<45 and/or uACR>30
- DM Patient goals and experiences
- Digital tool monitors and the last date of assessment
- Cause of DM and CKD with clinical background shortcut when user clicks on it
- DiT Snapshot and relevant clinical risk scores
- Primary service contact and Cluster with Staff links
- Noticeboard of any recent or upcoming events of note for the patient
Phase 2b: DM Dashboard with advance management TABS March 2023
Phase 2b will complete the diabetes Dashboard with PowerBI, where advanced management Tabs (Forms) are added to allow specialty-orientated data to be entered and processed. These variables are used through evidence-based algorithms to produce automated care plans and alerts. Users will be able to enter data in preset formats for others to use and see, but also for data to be analyzed and projected as KPIs in keeping with MoH standards for Digital Diabetes care as per NZ MoH.
The following TABS is planned as part of the Diabetes design process in phase 2b by September 2022:
- F1 - Physical Health and CV score
- F2 - Mental health scoring
- F3 – Nutrition / Dietician
- F4 – Foot protection
- F5 – DiT MDT forms
- F6 – Diabetes in Pregnancy forms
- Existing medication tabs and Clinical background currently used in RenalReality 2.5
The road ahead for diabetes reality
The initial phase of this development will have a clinical focus, benefiting health consumers by ensuring that the services they engage with provide accurate and timely information. This enhancement will bolster the capacity of healthcare providers to deliver high-quality and effective care. Patients will undergo appropriate screening and classification based on clusters and teams within RdR.
As the service paves the way for new non-clinical roles (kaitautoko), it will introduce a more flexible approach to care. In the second stage, designed with patients in mind, health consumers will actively participate in developing a portal that empowers them to self-manage and comprehend their care better. They will gain swift access to available services and have the flexibility to connect via modern platforms and technologies.
The service's goal is to become 'digitally enabled,' granting kaitautoko and CNS working in the community access to diagnostic tools seamlessly integrated with 'diabetes reality.' RdR will generate automated alerts featuring algorithm-based recommendations for next steps (action plans). The objective is to create a service adaptable to patient needs, where patients are familiar with their care team and can readily access the necessary support.
This innovative approach embraces teamwork, leverages a new workforce, engages in partnerships with Maori organizations for co-design, and places emphasis on the holistic well-being of individuals and their whanau. It establishes a digitally enabled service that optimizes resource utilization, thereby freeing up capacity for care. This approach not only supports immediate improvements in outcomes but also lays the groundwork for intergenerational changes necessary to enhance the health outcomes of all diabetes patients in the Taranaki community.
As the service paves the way for new non-clinical roles (kaitautoko), it will introduce a more flexible approach to care. In the second stage, designed with patients in mind, health consumers will actively participate in developing a portal that empowers them to self-manage and comprehend their care better. They will gain swift access to available services and have the flexibility to connect via modern platforms and technologies.
The service's goal is to become 'digitally enabled,' granting kaitautoko and CNS working in the community access to diagnostic tools seamlessly integrated with 'diabetes reality.' RdR will generate automated alerts featuring algorithm-based recommendations for next steps (action plans). The objective is to create a service adaptable to patient needs, where patients are familiar with their care team and can readily access the necessary support.
This innovative approach embraces teamwork, leverages a new workforce, engages in partnerships with Maori organizations for co-design, and places emphasis on the holistic well-being of individuals and their whanau. It establishes a digitally enabled service that optimizes resource utilization, thereby freeing up capacity for care. This approach not only supports immediate improvements in outcomes but also lays the groundwork for intergenerational changes necessary to enhance the health outcomes of all diabetes patients in the Taranaki community.
additional features added for RdR in 2023
Clusters
All patients can be managed as part of a Cluster, which is set up based on GP practices in Taranaki.
By uploading the GP practice, the patient can be registered with one Diabetes team.
Ethnicity
Patient lists (CaseLoads and Modality-based work lists) can be filtered using primary ethnicity.
You can also sort or reduce your list using a different part of patient demographics.
Allocations
Clinicians can now link patients to users, which generates CaseLoads and work lists. Filters/sorting methods also allow for organizing your patient list by a clinician in any of the RRT modalities or DM Teams.
Diabetes in Pregnancy
By combining HCG tests and HbA1c levels (HbA1c>40 plus a positive HCG test), RdR can opportunistically screen for gestational diabetes, with an alert-based addition to the RdR database of patients.
additional features planned for RdR in 2024
Clinic schedule optimization (TRAFFIC)
We are implementing a Clinic Schedule optimization system through a patient TRAFFIC reporting tool. This tool utilizes individualized care plans to guide patients to the most suitable healthcare provider, location, and appointment time. Each patient will be assigned a specific color-coded classification based on their needs, and their timeline will be synchronized with the clinical space and capacity in real-time. The goal is to enhance the efficiency of patient transitions between community and specialist care services by leveraging real clinical data from RdR.
Patient facing mobile app (HealthCart)
The patient-facing portal, known as the HealthCart mobile app, empowers patients to actively participate in the decision-making process when it comes to managing their diabetes and other health aspects. RdR generates automated CarePlans, complete with color-coded alerts, which will be accessible to patients on the portal within an hour of blood tests or clinical consultations.
This ensures that patients have timely access to their personalized care plans and vital health information.
Careplans shared with primary care providers
The majority of individuals with diabetes can receive effective management within the community and primary care settings.
RdR care plans help us identify patients who have the capacity to independently manage their diabetes with the right guidance and action plans.
Through automatic communication with the patient's mobile app, we can actively involve them in the management of their chronic conditions, ensuring their engagement in the process.
PowerBI generated MoH dashboards
Through PowerBI, we can harness vast amounts of data and create visual connections for our users and decision-makers. By aligning with the Ministry of Health's care standards, we can develop dynamic and interactive dashboards that present these data items in a user-friendly manner, simplifying decision-making and strategic planning.
Additionally, this capability enables us to generate reports in accordance with MoH requirements promptly whenever necessary.
planned upgrades for 2024 - managed scheduling
reality "traffic" report
We employ Funnel analysis to comprehensively comprehend each step essential to achieve the desired outcome, as defined by their individualized care plans. These care plans are generated through automated algorithms that adhere to international best-care guidelines for patients with kidney and diabetic conditions.
Funnel analysis enables us to visually represent the considerable number of patients entering the funnel from various starting points, primarily determined by the date when care plans are generated.
The clinical outcomes that we can analyze on timelines encompass:
1. Clinic conversion rates – the rate of patients attending consultations on time.
2. Patient engagement – compliance with repeat blood tests as recommended.
3. Service capacity – the availability of space to meet patient needs effectively.
4. Evaluating the influence of the automated TRAFFIC report on patient outcomes, such as HbA1c levels, urine proteinuria, and eGFR progression in the context of chronic kidney disease (CKD).
Clinic conversion rates
Converting the upcoming consultations, as specified in each patient's care plan, into actual clinical appointments is essential. This conversion rate can be continuously monitored in real-time, serving as a key performance indicator (KPI).
Patient engagement
The effectiveness of this system will be gauged by assessing patient engagement, including their attendance at clinical consultations and adherence to repeat blood tests as prescribed in their care plan.
Service capacity
The decision to see patients as per their care plans, ensuring they receive care from the appropriate provider at the correct time and location, will primarily depend on service capacity. This capacity can be tracked as a key performance indicator (KPI).
Impact asessments
The implementation of the REALITY Traffic report through Funnel analysis is anticipated to have a positive impact on clinical outcomes, specifically in terms of patients' kidney function (eGFR), blood sugar control (HbA1c levels), and kidney health (urine ACR). This report will help optimize the patient care journey, ensuring that the right patients receive the right care at the right time and in the right location.
an itemized list of RdR v2.6 upgrade
- In Phase 1 of this clinical development, we focus on optimizing the management of diabetic patients within the REALITY system. Here are the detailed steps and enhancements:
- Patient Filtering: Diabetic patients are accurately identified using clinic codes spanning the last two years. Clinic codes used for Renal patients are also considered. Additionally, opportunistic screening is implemented for diabetics, including patients with high HbA1c levels (>65 in the last two years). These patients are initially allocated to the "Diabetes Reality" cluster 0. If available, they may be assigned to clusters 1-5 based on GP cluster information when added to the RdR database.
- Diabetes Team Allocation: Each patient is allocated to a default "Diabetes Team" within the system. Staff links are established to determine caseloads. Each patient can have one or more staff links, with the default link being "Diabetes Reality."
- Caseloads are subsequently based on these staff links.
- Manual Updates: After adding patients to RdR, staff links, clusters, and allocations can be manually updated as needed.
- Laboratory and Radiology: Hourly laboratory results are incorporated into the system, building upon the existing RR2.5 process. Diabetes-specific results are added, and the inclusion of radiology results is under consideration.
- Additional Variables: Several variables are introduced for comprehensive diabetes management, including DM auto antibodies (GAD, IA2, islet cell), celiac serology, cortisol, C-peptide and insulin levels, zinc transporter antibody, and HCG levels for Gestational diabetes screening. Ultrasound results from USKUB and fetal growth scans are also planned for inclusion.
- Diabetes/Metabolic Algorithms: These algorithms align with RR2.5, with the modification of splitting blood pressure (BP) and HbA1c into two separate care plans, each with its own action points.
- Phase Two (Version 2.6.1): This phase introduces a dedicated Diabetes dashboard, which allows users to seamlessly navigate between Renal and Diabetes dashboards based on their profile settings.
- Status-Based Patient Management: Various status levels are implemented to facilitate comprehensive diabetes care:
- Status 1 (Renal Referral Recommended): Patients meeting specific criteria, such as urine ACR>30 and eGFR<45 on multiple occasions, trigger an automatic event under "ENCOUNTERS" indicating "Renal Referral recommended."
- Status 2 (Patient Goals and Experience): A menu item for recording patient goals and experiences is created under "Encounters." The structure mirrors the provided worksheet in Excel.
- Status 3 (Digital Tools and Monitoring): A menu item for digital tools and monitoring related to diabetes is established under "Results." Tertiary menu items align with the corresponding data in the Excel sheet. The last Insulin Pump result and possibly the previous Uric Acid POC test are triggered.
- Status 4 (DIT Snapshot): A menu item under "Encounters" captures a snapshot of Diabetes Integrated Treatment (DIT) data, mirroring the Excel sheet. Quaternary items are triggered based on the highest numbered and lowest value in the outcome column.
- Status 5 (Social Risks and Concerns): This status is consistent with "R" status, with optional configurations for RdR.
- Dashboard Completion: The dashboard is finalized in accordance with the attached slides, offering a comprehensive view of patient data and progress.
- Data Export: Excel data export functionality is enabled across all patient grids and lists, including reports. Options for
- Increasing items per page to 500 are provided for enhanced data access.
- Primary Contact Details: The patient dashboard includes pop-up access to primary contact details, improving communication and patient information access.
- These enhancements in Phase 1 and Phase 2 of development aim to streamline the management of diabetic patients within the REALITY system, providing clinicians with comprehensive tools and data for effective care delivery.