In the name of God

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In the name of God
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TeleDiabetes Shared Care(TDSC)
A clinical management software system for the
diabetes clinics in the Iranian Diabetes Network

• Bagher Larijani Endocrinologist, Head of
  Endocrinology and Metabolism Research Center,
  Professor of Endocrinology, Tehran University of
  Medical Sciences. emrc_at_tums.ac.ir
• Eiman Rahimi MD, MCSE, Administrator of Medical
  Informatics, Endocrinology and Metabolism
  Research Center. e_rahimi_at_yahoo.com
• Mohammad-Reza Amini MD, Secretary of
  Endocrinology and Metabolism Research Center.
  emrc_at_tums.ac.ir
• Abbas Shojaei MD, Brainbench Certificated
  Developer, CEO PegahSoft. dr_abbas_shojaei_at_yahoo.c
  om

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Diabetes Mellitus

• The most common metabolic disease
• A chronic disease with high prevalence in Iran
  (3.5 5)
• Rapidly growing prevalence worldwide and in Iran
• Disproportionately expensive and a real
  socioeconomic burden (98b in USA)
• Devastating complications (54b) including
  blindness, kidney failure, heart failure, foot
  amputations, and ultimately death
• A threat to individuals and public health

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Existing DM Patient Records

• 56 no documentation of glycemic control, only
  15 HbA1c checked
• 55 no lipid profile, many undocumented or
  untreated dyslipidemia
• 1/3 no eye or foot exam
• Non-specialists see most patients
• 69 of visits last less than 15 min
• Inappropriate care ? ?lives, ?expenditure

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Iranian Diabetes Network(IDN)

• An integrated research network
• Collaboration with all the universities of
  medical sciences over Iran
• Pilot phase standard diabetes clinics in 12
  major cities of Iran
• More clinics in other cities in future

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Objectives of IDN

• To ascertain the current state of knowledge in
  the field of diabetes mellitus in Iran
• To identify the fields in which no research is
  being carried out
• To manage needed epidemiologic and clinical
  surveys for prevention and control of diabetes
  and its complications
• To facilitate
• Proper care and management
• Education of diabetic patients

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Diabetes Clinics

• Well arranged for standard managed care
• Standard and unified services to the diabetic
  patients according to guidelines
• Collaborative research projects
• Unified nationwide diabetes care plans
• Educational facilities for healthcare workers
• Integrated through a web based software network
  (TDSC)

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Diabetes Team Members

• Endocrinologists (as the head of team)
• General practitioners
• Nurses (for patient education and care)
• Referral Specialists
• Nutritionists
• Podiatrists (for diabetes foot care)
• Nephrologists
• Obstetricians/Gynecologists
• Cardiologists
• Surgeons

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The TeleDiabetes Shared Care (TDSC)

• The clinical information system implemented over
  these diabetes clinics
• Multidisciplinary and integrated team approach to
  patient care
• Standard uniform delivery of care and research
• Standardized and effective clinical data
  acquisition, storage, inquiry, and interchange

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The TeleDiabetes Shared Care (TDSC)

• Feasible and easy to implement anywhere
• User-friendly easy to use and learn for the end
  user
• Internet-based centralized organization and
  distributed management of diabetic patients'
  clinical information

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DC
DC
EMRC
DC
DC
A Diabetes Clinic (DC)
DC
DC
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TDSC Software

• Customize an existing system or develop a new one
  from scratch?
• Expert developing team
• Time delays ? standstill
• Study and analyses
• Developing
• Testing
• Fine Tuning

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Which Software?

• Domestic and International softwares e.g. Diabeta
  3, NovoNet, DEMS,
• Desires
• Standard
• Comprehensive
• Satisfy all or most of our needs
• Affordable

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Hakim Software

• Developed by PegahSoft Group (a team of
  physicians and engineers)
• A general clinic software tailored to special
  needs in Iran
• Already met most of our needs
• Great flexibility to put up with our special
  customizations
• Piloted in Mashhad, and soon in Dr. Shariati, and
  Imam Khomeinis Hospitals

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Justification

• Telemedicine ? costs gt normal care
• Compare that cost to the cost of
• Renal failure, and going on dialysis
• Having a stroke
• Going blind
• We hope to prevent blindness, strokes, and heart
  attacks.
• We hope it's obvious that telemedicine is better
  in the long run.

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Estimates and Optimism

• Coverage of about 300,000 patients in 18 months
• Active participation of primary care physicians,
  diabetes-expert nurses other health care
  professionals
• Financial and administrative support of MOH,
  Takfab, other domestic intl NGOs assure
  continuation of the project
• Benefit for diabetic patients

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TDSC Software Features

• HakimDiabetes

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Technical Features

• Internet based
• SQL 2000 client/server architecture
• VB coded, will be upgraded into .NET framework
• Simple telecommunication the system can operate
  from a dial-up to VSAT

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TDSC Telemedicine

• Improved sharing of high quality information
  between diabetes care team members, and between
  diabetes care clinics in different locations
• Teleconsultation
• Teleradiology
• Tele-education

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TDSC as a CIS

• Quick and easy retrieval analysis of online
  electronic record information about patients or
  groups of patients by privileged clinics and
  providers
• Timely access to both patient data and valid and
  applicable evidence
• Diabetes Guidelines
• Clinical Decision Support

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TDSC as a CIS

• Prospectively planned and scripted visits
• Monitoring one-to-one and group education of
  patients
• Close online follow up of patients
• Close administrative monitoring of providers
  clinical competency
• Monitoring of treatment goals

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TDSC as a CIS

• Effective aggregation and timely display of data
  used by team members
• Performance reports of providers
• Performance reports of patients and their
  adherence to the goals

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TDSC as a CIS

• Appropriate preventive care
• Active participation of patient in disease
  management

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Some Kinds of TDSC Data

• Outpatient and inpatient clinical data
• Referral specialists suggestions
• Educational milestones
• Nutritional regimens
• Pharmacy or Prescription
• Laboratory or ancillary testing results
• Billing and Insurance
• Administrative
• ...

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Flexible and Extensible

• Adaptable with our users specifications
• Customizable EPR and workflow according to
  specific settings or culture of each clinic
• Easy to add new drugs, tests, pick up lists,
  prescription templates, report templates, letter
  templates

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Staged Input of Records

• The pre-evaluation stage by a trained assistant
  interviewing the patient to
• enter or review demographic information
• Flag recent events (e.g. out-of-system
  ophthalmology visit, death of family member)
• Complete a screening ROS and medication
• Providers encounter
• Focused examination
• Patient education
• Dietitian visit

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Data Entry

• Easy and rapid
• Data input using pick lists and radial buttons
  minimizing keyboarding during the encounter
• Tree structure of signs, symptoms, physical
  findings, lab, other data
• Data entry into tree or free forms of the fields

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Flexible User Interface

• Customizable templates of specific data fields
  for special visits or parts of an encounter with
  the emphasis on shared care (modules for every
  member of the multidisciplinary team either in
  tree form or free form)
• Eye or feet complications and exams
• Diabetes medication or education
• Lab results
• Action Plan

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Flexible User Interface

• As few screens as appropriate during the
  encounter
• Interactive or offline data entry
• Allow prospective structured data entry

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Standards

• Dataset based on NDOQRIN (Australia), DEMS (Mayo
  Clinic), Belgium, and NHS (UK)
• ICD 10 support of diagnoses and medications term
  coding
• Messaging protocols HL7 v. 3.0 CDA compatible
  (Clinical Documentation Architecture)
• Imaging processes DICOM 3.0 support

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www.tdsc.ir

• A secure website
• Links to and administrative control over all the
  collaborating diabetes clinics over IDN as well
  as the central database
• Dynamic customized EPR generated for the patient
  or privileged providers

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www.tdsc.ir

• Statistical reports available to public and
  privileged users
• Tutorial contents and online help material for
  privileged users
• Public and professional educational material
• Expert consultation system (future)

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Decision Support System

• Personalized guideline suggestions for patients
• Collect providers notes in a structured format
  for analysis
• Integrates lab and other data in the same record
  for real-time access to current and historical
  data
• Integrates graphical display to help feedback
  performance information, trend curves, and goals
  to the provider and patient

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Decision Support System

• Remind providers of routine preventive care
• Issues that needs special attention are flagged
  (e.g. Foot At Risk is flagged if an abnormal
  vascular or neurological examination of the foot
  is documented)
• Link to patient education material and medication
  information

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Decision Support System

• Link to prescription information and monitor for
  medication contraindications or interactions or
  clerical errors (e.g. metformin use in a patient
  with deteriorating kidney function)
• Expert system in consultation (step-by-step
  intelligent consultation) in the next version

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Decision Support System

• Suggest future arrangements
• Schedule next visit
• Lab tests needed before the visit
• Immunizations schedule
• Medication renewal and monitoring
• The diabetes educator reminder to contact the
  patient if a goal should be reviewed or
  accomplished before the next visit

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Decision Support System

• Who attend the clinic or not
• Who are missing a key evaluation
• Ophthalmology evaluation
• Influenza vaccine
• HbA1c check
• Medication adjustment
• Who are doing well and who need intense support
• Personalized follow-up by phone, postal, email

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Blood Glucose Control
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Blood Pressure Control
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Management of Dyslipidemia
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Kidney Assessment
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Eye Examination
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Combination Therapy
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Oral Medicines
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Therapeutic Regimens
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Image Handling

• Portrait, lesions, any diagnostic images
• DICOM 3.0 compatible image processing (OSIRIS)
• Symbolic and schematic diagram of different
  organs, limbs, and nervous system
• Annotations and highlights on parts of the picture

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Prescriptions

• Definable prescriptions, diagnostic requests,
  verifications, and certifications per specific
  diagnoses
• Categorized list of diagnostic and therapeutic
  interventions to select
• Prescriptions or certifications definable drug
  lists with proper drug preparations and
  instructions for a prescription
• Save a prescription for later use

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Correspondence

• Automatically generated letters, printed at the
  end of a consultation, ensures fast and efficient
  communication of patients information.
• Grammar casts (ordinary sentences with dynamic
  parameters of the pt.)
• Fully editable (formatting, inserting logo,
  mottos, health ads, )

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Correspondence

• Customized summarization of data for different
  purposes (interns, referring physicians,
  residents, specialists, the patient herself, )
• Translatable to different languages

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Financial Management

• Calculates the expenses by
• Type of insurance providers share
• Type of contracts with providers
• Discounts
• Printable financial reports for providers and
  insurance services
• Printable bills for patients

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Scheduling

• Scheduling different services in the clinic for
  each patient by the secretary
• Definable calendar of services and their working
  timetable
• Calendar of duties for each provider

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Extensive Search

• Simple or complex searches by
• Patients demographics
• Date range
• Signs and symptoms
• Diagnostic tests and their results
• And every parameter in a record
• Showing the results in various chart types (bar,
  pie, line, area, )

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Security and Auditing

• Secure transactions and maintenance of clinical
  data
• Secure sessions by defining user access levels,
  permissions, and privileges (integrates into the
  Active Directory)
• Comprehensive audits monitoring user
  transactions, modifications, and data
  manipulations
• Fault tolerance secure backup policies or
  redundant measures (offline and offsite media, or
  replicas over the network)

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Messaging and Alerting

• Flexible messaging between the team members
  (secretary, colleagues, the provider herself)
• Alerts, notes, memos, and reminders
• Definable
• Time to live
• Time to show (beginning, during, or end of a
  visit, or event triggered)
• Frequency to show

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Scalability and Maintenance

• Scalability from one PC on its own, to a system
  supporting many concurrent users
• Maintenance a low level of maintenance required
  to keep the system running, at both a user- and
  IT-level

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Help and Support

• Step-by-step tutorials and help within the
  application and the Website
• Comprehensive support a friendly help for all
  aspects from organizing, training and talking
  through user rights, to IT server maintenance and
  support.
• 24/7 customer service

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TDSC Tele-homecare

• For rural and inner-city patients (in future)
• Patients will receive comprehensive information
  through their computers on how to manage their
  disease
• Patients will check their BS, BP, and other
  factors ? data entered into the website for
  analysis

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TDSC Tele-homecare

• Data in abnormal range ? automatic alert sent to
  a doctor or nurse as soon as it happens to make
  adjustments
• limitless chances for rural patients to receive
  treatment e.g. in every climatic situation
• They can get visits' as often as necessary

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Joslin Tele-homecare

• Joslin Center for Diabetes, New York City
• 28m federal grant over four years
• 1500 rural and inner city diabetic patients
• 750  with free PCs, internet access, and health
  monitoring equipment
• a blood sugar monitoring device
• an automatic blood pressure cuff
• a camera hooked up to the PC
• 750 with only the usual care from their doctors

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Equipments in Each Clinic

• A Microsoft Windows 2004 server
• A PC or laptop computer with Microsoft Windows XP
  for every physician during interactive clinical
  visits (estimated number for each clinic is 7
  diabetes-expert physicians)

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Equipments in Each Clinic

• A central UPS to supply the network devices
• A licentiate diabetes-clinic application client
  software installed on each client computer
• A dial-up link (or higher bandwidth Internet link
  if available) shared over the clinic LAN,
  connecting each client software to the Internet

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Equipments at EMRC

• A central powerful Microsoft Windows database
  server for management of all the clinical data
• The administrative version of the TDSC software
  installed for administrative purposes and remote
  assistance
• The Internet address www.tdsc.ir assigned to the
  host in TUMS

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Thank You