This presentation was done by Dr Dgambar Naik MBBS, MD (Medicine), DOIH, DHA, FIAE, FAIMP (Cardiology) About 3,300 Diabetologist attended this forum and gave enthusiastic response to Diabetes Complication Management supported by algorithm based program to deliver CDSS (Clinical Decision making Support System) tools

1. D I A B E T E S C O M P L I C AT I O N S
Disease Management Software
Doctor’s Empowerment : Smart E.H.R. (Medical Algorithm)

2. Disease Management E.H.R.
Challenges & Solution
2
Pain Point Macro Problem
EHR Solution
CDSS Tools
1 Time utilization Less productive
2 Diagnosis - Prognosis Not protocol
3 Dr’s treatment Single Dr : multiple issues
4 Referrals Biased - inconsistent
5 Basic Investigation Irregular
6 Comprehensive care reminder Unavailable
7 Clinical practice audits Not practiced
8 Providers team knowledge Inadequate
9 Patient neglects Diabetes No illustrative EHR
 Preventive Care
 Proactive Diagnostic
Tools
 Predictive - Risk
stratification
 Progressive -
Treatment Goals
 Patient Convenience
& Cost
 Protocol driven
process

3. Disease Management E.H.R.
Think !!!
3
Current Approach
Can we improve our Clinic system ??

4. Disease Management E.H.R.
Power of Smart E.H.R.
Protocol
Personal
Guideline
Satisfied
Patient
Easier
Referrals
Holistic
Approach
Quicker
Patient
Counseling SMART
Electronic
Health Records
4

5. Disease Management E.H.R.
Diabetes Systematic Management Cycle
5
ASSESS
•History
•Diagnosis
•Risk Mapping
PLAN
•Health Status
•Age - Support
•Realistic Goals
•Agreement
IMPLEMENT
•Manage Weight
•Nutrition Therapy
•Lifestyle Change
•Exercise - Yoga
EVALUATE
•Trend Analysis
•Successes
•Side-Effects
•Cost Factor

6. Disease Management E.H.R.
Clinical Decision Support System (for Drs)
6
Multi – Disease : Multi-organ co-morbidities
Decision Support : Evidence based and intelligent
Supports all Therapies : Diet – Lifestyle – Exercise – Education
User-friendly : many tasks managed safely by Drs Assistant
Protocols driven : Globally acclaimed and updated standards

7. Disease Management E.H.R.
Information Delivery Flow
7
Data In Report
No need of Computer
Cloud based – no installation
Accessible Anytime - Anywhere
This facility is available only for the Dr’s Clinics. In the Hospitals Dia-Bese Apps are commonly used

8. Disease Management E.H.R.
Data Input
8
Patient Form
(User-friendly)
 Name / Contacts
 Vitals – Anthropometry
 Medical History (self)
 Medical History (family)
 Life-style Habits
 Co-morbidities duration (yrs)
 Pain – complaint
 Lab results
 Medication listing
 Machine results
 Patient Social – habits details
Dia-Bese Allied Clinics
ELECTRONIC HEALTH RECORDS
Diabetes Management Form – 1
PERSONAL DETAILS / CONTACT
G Title First Name Middle Name Surname UID Ref Reg Ref
Date
Today
Mr.
Ms
Mrs
Birth Dt. Age Blood Gr Occupation Religion Race
Area City State Pin
Mob Ph Res Ph Office Email
Relative Kin Phone Family Dr. Specialist Dr.
Yrs Mth Type 1 Type 2 LADA MODY DOY GDM
DIABETES PERIOD / TYPE
Birth Dt or Age Blood Gr. Occupation Refered by
Address
City / State Pin Code Email ID
Tel (Mobile) Tel (Work) Tel (Home)
Dia Yrs - Mths Type 1 or 2 GDM Others
Allergy / Intolerance Anti-Diabetic Others
Diabetes
Parents
Diabetes
Bro-Sister
IHD HTN ESRD Stroke Malignacy
1 Smokng Cigarettes / day nos. yrs. Paan Yes * No Chew Tobac Yes * No
2 Alcohol numbers / week Whisky - peg nos. Wine - glass nos. Beer - glass nos.
3 Time spent (hrs / day) Travel hrs. At work hrs. Sleep hrs.
Sedentary Light Morderate Very Active Extra Activity Exercise / wk
Negligible 1 - 3 days 3 - 5 days 6 - 7 days Heavy training
HTN CHD IHD Angina MI
Angioplasty
Stent
CABG
Bypass
TIA Strokes Stent
PERSONAL DETAILS / CONTACT
……………………………………………………………………………………………………………………………………..
DIABETES
FAMILY HISTORY
LIFESTYLE QUERIES
4 Physical activities
MEDICAL HISTORY (Duration - years in grey box)
CVD
times min / d
G Title First Name Middle Name Surname UID Ref Reg Ref
Date
Today
Mr.
Ms
Mrs
FAMILY HISTORY
Height Waist Hips BP Pulse SpO2
cm cm cm
kg ft-in inch inch
Weight
/
ANTHROPOMETRY

9. Disease Management E.H.R.
Patient Report (1)
9
Clinical History
Health Trend

10. Disease Management E.H.R.
Patient Report (2)
10
Organ Risk Indicator
Medicine Prescribed

11. Disease Management E.H.R.
Patient Report (3)
11
Side - Effects
Knowledge Level
Education

12. Disease Management E.H.R.
Health Graded Screening Packs
12
Risk-wise Diabetic Patient Package
Pack
Rates
Regular Mild Moderate Sever
A Consultation - Counselling
GP 200 3 4 7 8
Diabetologist 500 2 4
Dietician 250 2 4 6 12
Total Consultation - Counselling 1,100 1,800 3,900 6,600
B Lab Tests
HbA1c 350 2 4 4 4
FBG - PPG 200 2 2 4 4
Lipid profile 350 1 1 1 2
Kidney profile 150 1 1 1 2
Liver Profile 200 1 1
CBC 150 1 1 1 2
Electrolytes 300 1 2
Thyroid profile 400 1
Total Lab Tests 1,695 2,510 3,355 4,820
C Machine Tests
BP 4 6 9 12
ECG 250 1 1 2 4
USG Ultra Sound 500 1
2D Echo 1,200 1
Diabetic Foot check 400 1 1 1
Diabetic Retino check 300 1 1 1
Total Machine Tests 250 250 500 2,700
D Dia-Bese (London Report)
Health ID Card 50 1 1 1 2
Health Profile (Basic) 200 1 1 4 6
Health Profile (Advance) 350 3 6
Health Passport 500 1 1
Total Consultation - Counselling 250 250 2,400 3,900
Patient Package Total Costs (Gross) / year 3,295 4,810 10,155 18,020
Health package selected on the basis of Health
Status Index

13. Disease Management E.H.R.
Health Informatics Offerings
Electronic PassportHealth I.D. Card
Health Profile
13
Doctor’s Clinic
High-Risk Patients Summary

14. Disease Management E.H.R.
DIA-BESE : Innovation Selection
14
DST – L ockh eed Martin I n d ia Growth Program

15. Disease Management E.H.R.
Take away : Roadmap
15

16. Change Leadership : Global Healthcare