Q: Why is it best to define outcomes for every patient as an individual and not on a population basis?
Cavale: There is no average patient. Every person has different lives, backgrounds and support structures. For example, I recently saw an 82-year-old man, just out of the hospital after multiple hypoglycemia-related falls. The hospital endocrinologist took him off the insulin he had been on and started him on pills. His sugars rose again once he got back home, because his wife didn't manage his carbohydrate portions or snacks. My goal for him is a good defense: managing his diabetes with as little insulin as possible and avoiding falls or hospitalization.
In contrast, I saw a 32-year-old woman who was placed on oral medications, but who could not control her high blood sugars despite making smart food choices. My goal for her was to introduce insulin and optimize the benefit from it—to play offense and get good control as quickly as possible.
The trend toward population health and diabetes tends to standardize everything. We can, however, use population-based statistics to identify problem populations.
Q: How is your practice maximizing technology use right now to achieve patient goals?
Cavale: We use technology to complement the human touch. First, once we start patients on new medication or insulin, we use messaging boards within charts to exchange messages internally, to keep reminders to follow up with patients, to make sure patients make necessary appointments, like the RD (registered dietitian), and to monitor drug side effects.
Over a decade ago, we also designed a "matchbox"-like device with multiple "tentacles" for most blood glucose (BG) monitors. We extract their standardized data directly into the patient chart in our electronic health record.
Now we use newer technology, Glooko, that downloads similar information as a PDF but shows more detailed trend and variations. A patient might be fine all day but their sugar rises after 8 p.m., so we make a recommendation to specifically correct that trend. We can compare the graph to two or three months ago, and say, "Look at how good this looks now!" It encourages patients who can then see a workable solution.
We download and review data from insulin pumps and continuous glucose monitors (CGMs) that fully assess a patient’s glucose patterns and connect them to specific actions like sleep, eating or exercise. Patients get feedback and we make targeted medication and behavioral changes.
Given wait times and insurance network issues, we're designing a program that performs a detailed medication review, conducts a CGM study and provides specific recommendations to PCPs based on the data. This is offered at a fixed cost and can be scheduled within a day or two. PCPs can implement our recommendations without the wait time and utilize appropriate community resources.