The Diabetes guideline implements the Standards of Medical Care in Diabetes 2006, The American Diabetes Association Guideline. It includes scenarios for the primary care clinic and for population based management of diabetes.
The Hypertension management section is based on The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
All the details of the encoding in Protégé for Diabetes have been generated as a web page [here].
These two scenarios are just the beginning. This guideline could have several additional scenarios, for example:
- All patients admitted to the hospital with the diagnosis of diabetes have alerts during the admission, as well as appropriate dismissal recommendations for follow-up scheduled.
- The home health visitor has automated alerts generated for the scheduled list of patients who have diabetes.
- A clinic manager receives a print out of all patients with diabetes whose measures are greater than a preset threshold.
This guideline exemplar uses 450 Criteria in 12 Recommendation Sets with 25 Decision Nodes, 16 Context Nodes, and 62 Action Nodes.
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Scenarios- SCENARIO 1: Diabetes Practice in Primary Care Setting
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Patient arrives at primary care clinic requesting care. The patient is checked in and is then met by the clinic nurse. The nurse initiates the encounter by logging onto the clinic information system (CIS) and selecting the patient record. SAGE is triggered and an evaluation of the potential nurse entered items is performed.
Items due are displayed to the nurse to facilitate entry of data performed else-where. When the physician logs onto the CIS, SAGE performs a series of parallel activities to assess and perform the following:
- Determines whether patient is on aspirin or eligible for aspirin therapy. If eligible, an inbox reminder is sent to the provider.
- Retrieves diabetes related lab data and determines when next set is due, setting up appropriate orders for provider approval. Diabetes lab values that are out of goal are noted and the provider is alerted.
- Blood pressure is assessed (SAGE requires an updated BP for the visit). If above goal, SAGE determines if the patient has a diagnosis of hypertension or should be given the diagnosis of hypertension. Depending on the level of the blood pressure, SAGE presents an order set to the provider with appropriate recommendations for the specific patient following JNC VII(also available here [pdf]) recommendations.
- Makes assessment for the need of nephrology or ophthalmology referrals and sends recommendations.
- Assures physician entered data (i.e. foot exam and smoking status); reminds provider of smoking cessation counseling when appropriate; and makes recommendations on cardiac risk reduction strategies when appropriate.
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Just below is a walk-through for this scenario that illustrates the ways that the Diabetes guideline functions. Each patient's values and timing of events will impact the flow. This is simply an illustration for one particular patient. SAGE interacts with the Clinical Information System in which SAGE's alerts are expressed using the capabilities of that system.
We will use specific patient values here to show how they impact the work-flow and decision making:
Primary Care Clinic Visit, Uncomplicated with goal setting Context: Middle-aged patient with well-controlled diabetes visits his primary care physician for routine management Session(s): Outpatient Physician Outpatient Nurse (Clinic Clerk initiates trigger event) The patient is an elderly man with longstanding Type II Diabetes Mellitus. He lives at home with his wife. Comorbidities include hypertension (well-controlled with recent BP averaging 125/75) and hyperlipidemia (marginally controlled with LDLs averaging 105). He reports for a routine clinic visit with his primary care doctor. Step 1 Patient checks in to clinic. Step 2 Event processor identifies check-in event with patient/clinic eligible for decision support. SAGE retrieves appropriate values and calculates alert. Data items included in this scenario are within scope of the Diabetes Flowsheet. Items include: Height, Weight, Vital signs (BP goal: <130/80) Duration of Diabetes (today minus date of onset) Glycemic control HbA1C (goal: <7%) Blood Glucose Lipid management Total Cholesterol LDL (Goal: < 100 mg/dl) Renal function Creatinine BUN Microalbumin Albumin/Creatinine ratio Creatinine clearance 24-hour urine protein Urinalysis Diabetes Education General Diet Activity HTN Hyperlipidemia Studies EKG Stress test Specialist eye exam Carotid Doppler Lower extremity Doppler Physical Exam Findings Cardiovascular: pulse inventory, cardiac auscultation, bruits Neurologic: DTR, vibratory, Semmes-Weinstein monofilament Feet: pulses, architecture, skin, nails Medications Smoking history Alcohol use Consult History (Nurse Educator, Cardiology, Ophthalmology, Endocrinology, Nephrology) Diabetes Complications & Comorbidities Step 3 SAGE calculates which items are due today and issues alerts as appropriate Step 4 The nurse rooms the patient. Step 5 The nurse accesses the patient's medical record from the monitor in the exam room. In her Inbox is a "Documentation""Diabetic Flowsheet Updated" notification under the Care Support Folder. Step 6 The nurse clicks on the "Documentation" message and she navigates to access the Care Support Diabetic Flowsheet via the Inbox. It appears as a form with historic values filled in. The Height, Weight, and Vitals are highlighted, indicating that these measurements are needed now. Most recent glycosylated hemoglobin and home glucose measurements are also highlighted. Step 7 The nurse measures height, weight, and vitals and records them on the flowsheet. These are within normal limits. The patient's wife gives the nurse the patient's home glucose monitoring booklet, and the nurse records the values in the flowsheet. Values range from 45 to 180. Step 8 The nurse closes the patient record and leaves the room. Step 9 The doctor enters the exam room. Step 10 The doctor accesses the patient's medical record. In her Inbox is a "Diabetic Flowsheet Updated" "miscellaneous message" and "documentation" (foot examination is due). Both are listed under the Care Support folder. Step 11 The doctor double clicks on the "miscellaneous" in the in box and navigates to the in box list screen that states "The Hemoglobin A1C is out of the target goal of < 7%". She decides to view the accesses the Care Support Diabetic Flowsheet and notes that the patient's HbA1C level has been about 8% during the past several checks. The last value is highlighted as being out of goal. The doctor decides that since the patient is very elderly and has difficulty maintaining goal glucose levels without hypoglycemia, a goal of 8% is reasonable. Step 12 The doctor navigates to the Care Support Maintenance Screen and clicks on the HbA1C Goal button and modifies the goal from 7% to 8% for the hemoglobin A1C. Step 13 The doctor returns to the Care Support main Flowsheet screen. The most recent labs were done on the morning of this visit. Lab values other than HbA1C and blood glucose are within normal limits, though LDL and triglycerides are borderline. Microalbumin is trending upward, but is still within normal limits. Step 14 The doctor elects to place the next lipid panel, microalbumin, and HbA1C in six months. She navigates taken to the Order Entry screen where she approves the orders "6 month Future Diabetes Orders Set". This order set present the option for reports to be provided to the patient by visit, e-mail, or telephone. Step 15 The doctor returns to the flowsheet. Physical exam of the feet is highlighted, indicating that this should be recorded now. Step 16 The doctor performs an interval history, and a physical exam. She fills in the flowsheet with exam findings, which are all within normal limits. Step 17 In the Clinic Visits section of the flowsheet is the recommendation that the patient return to clinic in 6 months. The doctor accepts this recommendation. Step 18 The visit concludes, and the doctor exits the patient record. No changes in diabetic care are needed at this time. Step 19 The patient checks out of clinic with the clinic clerk. Step 20 When the clerk accesses the patient record she sees the 6 month labs and visit ordered., SAGE informs the clerk that the patient needs a follow-up appointment in six months, with labs preceding the visit. The clerk and the patient make the appointment. The clerk instructs the patient to report to the lab on the morning of the appointment.
- SCENARIO 2: Managing diabetes for a population of patients
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On a regular schedule, like every Sunday at midnight, a background batch program starts within the clinical information system for an outpatient health clinic. The program checks the patient records of all patients enrolled in the diabetes guideline. The patient record is reviewed for diabetes related items that may be overdue or soon to be due, but not yet ordered.
Appropriate orders are set up for the primary provider to assure appropriate monitoring of this chronic disease state.
- Initiates a weekly or real time batch program to determine if patients enrolled in the diabetes guideline are up to date with diabetes related assessments.
- Sets up appropriate orders for diabetes related testing and consultations that are overdue.
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Here are examples of the standard terminology used in this guideline, organized by Virtual Medical Record (VMR) class. In each class, there will be terms of different types. For example, to describe an allergic reaction, one needs the allergen, the type of reaction, and the severity of that reaction. Here we see codes from SNOMED Clinical Terms (SNOMED CT), and Logical Observation Identifiers Names and Codes (LOINC®), NDF-RT, and International Classification of Diseases, Ninth Revision (ICD-9).
The project maintains SAGE-defined concepts in separate SAGE terminologies that are linked to existing standard terminologies if the SAGE concept is either derived from or should be an addition to the external standard. For example if a SAGE concept was defined as a collection of LOINC concepts, it is maintained as a member of the SAGE LOINC terminology. If a concept's intent is consist with a particular terminology's intent, such as SNOMED CT and is a reasonable candidate for inclusion in a future release, it is maintained in the appropriate SAGE-linked terminology, such as SAGE SNOMED CT.
The concepts listed here are examples of the coded values used in each of the Virtual Medical Record classes. They are NOT examples of the class instances themselves. For example, Adverse Reactions requires a substance, like B-lactam, and a reaction type like Anaphylaxis. So, both concepts would show up under Adverse Reaction.
The Diabetes Guideline uses 333 concepts:
| VMR Class | Number of Concepts |
|---|---|
| AdverseReaction | 6 |
| Encounter | 2 |
| Goal | 24 |
| MedicationOrder | 28 |
| Observation | 66 |
| Problem | 186 |
| Procedure | 1 |
| Referrals | 2 |
| VMROrder | 18 |
- AdverseReaction4 of 6
- Nonsteroidal antiinflammatory agent [SNOMED CT 16403005]
- Adverse Reaction [SNOMED CT 74069000]
- Angiotensin-converting enzyme inhibitor agent [SNOMED CT 41549009]
- Angiotensin II receptor antagonist [SNOMED CT 96308008]
- Encounter 2 of 2
- Ophthalmic Examination and Evaluation [SNOMED CT 36228007]
- Physician Visit with Evaluation and/or Management Service [SNOMED CT 108219001]
- Goal 4 of 24
- CHOLESTEROL.IN HDL:MSCNC:PT:SER/PLAS:QN [LOINC 35197-3]
- Hgbn A1C all clinical [SAGE LOINC C5]
- Systolic BP (observable entity) [SNOMED CT 271649006]
- TRIGLYCERIDE:SCNC:PT:SER/.PLAS:QN: [LOINC 14927-8]
- MedicationOrder 4 of 28
- Aspirin (product) [SNOMED CT 7947003]
- Losartan 25 mg tab [NDF-RT C45108]
- Thiazide Diuretic Oral Preparation for Hypertension [SAGE NDF-RT C11]
- Spironolactone 25 mg tab [NDF-RT C51264]
- Observation 4 of 66
- Albuminuria (finding) [SNOMED CT 20430005]
- Body weight only (SAGE DM) (CONCEPT EXPRESSION) Body weight: NOT: Reference weight [SAGE SNOMED CT C25]
- CREATININE:SCNC:PT:SER/PLAS:QN [LOINC 14682-9]
- Hemoglobin A1C All Clinical [SAGE LOINC C5]
- Problem 6 of 186
- Atenolol allergy (disorder) [SNOMED CT 293965006]
- Metolazone allergy (disorder) [SNOMED CT 295026008]
- Rauwolfia antihypertensive allergy (disorder) [SNOMED CT 295051009]
- Hemorrhagic pulmonary edema [SNOMED CT 276637009]
- Cerebrovascular accident (disorder) [SNOMED CT 230690007]
- Cardiomyopathy [SNOMED CT 85898001]
- Procedure 1 of 1
- Creation of vascular bypass (procedure) [SNOMED CT 23075000]
- Referrals 2 of 2
- Referral to ophthalmologist (procedure) [SNOMED CT 308479007]
- Referral to nephrologist [SNOMED CT 11911009]
- VMROrder 4 of 18
- ALBUMIN:MCNC:24HR:UR:QN [LOINC 21059-1]
- Hemoglobin A1c measurement (procedure) [SNOMED CT 313835008]
- Creatinine Measurement, Serum (procedure) [SNOMED CT 113075003]
- Protein:MCNC:24H:UR:QN [LOINC 2889-4]
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Example "rules" or logic statements for this guideline include:
- Set default treatment goal for glycemic therapy
- Glycohemoglobin routine monitoring
- Diabetic education monitoring
- Diabetic nutrition education monitoring
- Physical activity program
- Blood pressure monitoring
- Blood pressure treatment goals
- Patients with multiple risk factors and ACE inhibitors
There are an additonal 28 logic statements.
Here are two rules from the Diabetes Logic relating to Glycemic Control:
Glycemic control and monitoring
Recommendation set: Glycemic control and monitoring
[B-Level Evidence
Develop or adjust the management plan to achieve normal or
near-normal glycemia with an A1C test goal of <7%.
Expert Consensus
Less stringent treatment goals may be appropriate for patients
with limited life expectancies, in the very young or older
adults, and in individuals with comorbid conditions.
*all guideline source data in [] ]
Assume that enrollment is automatic for all patients with clinical
problem of diabetes mellitus, and that goals for care are maintained
in record and possibly adjusted by clinician when clinically
appropriate.
Diagnosis of diabetes ::= Problem of diabetes mellitus on problem list
Hemoglobin A1c test ::= any 43396009 (includes LOINC 17855-8; 17856-6; 4548-4)
Hemoglobin A1c goal ::= Exists some Goal.value {such that code =
HEMOGLOBIN A1C TEST AND effective_time < now AND state = ACHIEVE
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Rule 1: Set default treatment goal for glycemic therapy
========================================================
IF DIAGNOSIS IS DIABETES
AND
HEMOGLOBIN A1C GOAL IS NIL (DOES NOT EXIST)
THEN
SET DEFAULT HEMOGLOBIN A1C GOAL value = 7.0
Last hemoglobin A1c ::= Exists some Observation.value
{ such that code = HEMOGLOBIN A1C TEST and
effective_time = last effective_time in database for this record }
Last hemoglobin A1c datetime ::= Exists some Observation.effective_time
{ such that code = HEMOGLOBIN A1C TEST and
effective_time = last effective_time in database for this record }
Change in diabetic therapy within three months ::= Exists some Medication order
{ such that code = 373245004 AND effective_time > (TODAY = 3 months)
AND
((dose_quantity or frequency_of_administration differs from previous
record for this drug) OR (stop_date > (TODAY - 3 months)) }
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Hemoglobin A1c order ::= Exists some Order { such that code =
HEMOGLOBIN A1C TEST }
[Expert Consensus
Perform the A1C test at least two times a year in patients who are
meeting treatment goals (and who have stable glycemic control) and
quarterly in patients whose therapy has changed or who are not meeting
glycemic goals.]
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Rule 2: Hemoglobin A1c routine monitoring
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IF DIAGNOSIS OF DIABETES
AND
EXISTS NO ACTIVE ORDER (CODED_CONCEPT = HEMOGLOBIN A1C)
AND
( (LAST HEMOGLOBIN A1C = NIL)
OR
(LAST HEMOGLOBIN A1C < HEMOGLOBIN A1C GOAL
AND
LAST HEMOGLOBIN A1C DATETIME < (TODAY - 6 MONTHS))
)
OR
( (LAST HEMOGLOBIN A1C = HEMOGLOBIN A1C GOAL
OR
CHANGE IN DIABETIC THERAPY WITHIN THREE MONTHS)
AND
LAST HEMOGLOBIN A1C DATETIME < (TODAY - 3 MONTHS))
)
THEN
ADVISE HEMOGLOBIN A1C IS DUE
AND
ISSUE ORDER HEMOGLOBIN A1C
CENTRAL ALPHA AGONISTS IF NO CENTRAL ALPHA AGONIST THERAPY AND ((NUMBER OF ANTIHYPERTENSIVE MEDICATIONS > 1) OR (STAGE 2 BP ELEVATION) ) THEN RECOMMEND LOW DOSE CENTRAL ALPHA AGONIST IF CURRENTLY ON CENTRAL ALPHA AGONIST THERAPY AND DOSE OF CENTRAL ALPHA AGONIST < MAX DOSE THEN RECOMMEND INCREASING DOSE OF CENTRAL ALPHA AGONIST