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How an intelligent device can cut the mustard. Dr Julian Brown. What Was Meant by This ?. Succeed Come up to Expectations Provide High Quality. Obviously I must Have Been Good ?. 2006 +201% . The Story. 2006: I became our PCT Prescribing Lead.

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What was meant by this
What Was Meant by This?

  • Succeed

  • Come up to Expectations

  • Provide High Quality



The story
The Story

  • 2006: I became our PCT Prescribing Lead.

  • My Surgery was highlighted as having significantly high admissions for diabetes.

  • My Surgery was terrible.

  • They sent me to Chicago.

  • I decided to create an IT solution

  • www.diabetesmanager.org.uk


The result
The Result

  • Went from one of the worst to the best in 1 year.

  • No insulin initiations.

  • Reduced Admissions.

  • Reduced overall spend

  • Best HBA1C control 2009



What had we done
What Had We Done?

  • Performance Tracking

  • Risk Stratification

  • Integrated Care

  • Self-Management Plans

  • Patient Access


Performance tracking
Performance Tracking

  • Accurate Benchmarking of how the surgery and PCT is performing on clinical markers.

    • NICE

    • QOF

  • How we were performing in terms of outcome data.

  • How we were performing in terms of cost.



2 risk stratification identification of high risk patients
2. Risk Stratification:Identification of High Risk Patients

Six types of High Risk Patients

  • 1. Those that have poor end-point data.

  • 2. Those that have deteriorating end point data.

  • 3. Those that fail to have screening

  • 4. Those who are not on or not collecting appropriate medications

  • 5. Those that are on inappropriate medications.


2 high risk patients a poor end point data
2.High Risk Patients:a. Poor End Point Data

  • The System will automatically create weekly league tables by each parameter.


2 high risk patients b deteriorating scores
2.High Risk Patients:b. Deteriorating Scores

  • Looking at flux of endpoint data helps identify patients earlier.


3 integrated care sharing the ehealthcard
3. Integrated Care: Sharing the eHealthcard

  • Secure online for ease of access by:

    • GPs

    • Other HCPs

    • Patients


3 summary reports
3. Summary Reports

  • Allows quick overview of patient

  • Allows pre-diabetes clinics

  • Allows remote clinics

  • Allows compliance issues to be identified.


7 liaising with specialists
7. Liaising With Specialists


7 liaising with specialists1
7. Liaising with Specialists


3 patient self management plan 7 essential steps for diabetes perfection
3. Patient Self Management Plan 7 essential steps for diabetes perfection.

  • Blood Pressure Control

  • Blood Sugar Control

  • Cholesterol Control

  • Weight Control

  • Healthy Lifestyle

  • Medication Compliance

  • Regular Screening


Self management plans
Self-Management Plans

  • Encourage Patients.

  • Educate Patients.

  • Essential in achieving long-term diabetes control.

  • Reduce complications.

  • Reduce costs.

  • Makes the Patients Happy


How did diabetesmanager work
How did diabetesmanager work?

  • Web based application.

  • Automated Data Extraction from GP systems

  • Remote performance tracking of all diabetes patients.

  • Automated self-management plans for every patient.

  • Allows online access for patients

  • Allows online education and remote specialist clinics.


Why not apply the same logic to medicines management
Why Not Apply the Same Logic to Medicines Management

  • 7% all emergency admissions medicine induced

  • 60% of these preventable

  • Each one costing average £5000





Surgery portal
Surgery Portal

  • Identifies at risk patients

  • Updated Weekly

  • Confidentiality Maintained

  • Surgery Has Control


Preventing emergencies
Preventing Emergencies

  • Identifies the Patients who don’t come to see us.

  • The ones that manage to get themselves on drugs that are dangerous for them.

  • The ones that aren’t taking their protective medications.

  • QOF!


Better integration
Better Integration

  • Patients

  • Practice Diabetes Nurses

  • GPs

  • Specialist Nurses

  • Podiatrists

  • GPs specialist interest

  • Consultants

  • Commissioning Leads

  • Medicines Management

  • online, webinars , emails, reports

  • Communication!


The future
The Future

  • Better outcome for patients

  • Better education of patients (autotranslationetc)

  • Increasing Self-management

  • Reduced need for medications.

  • Easy patient alerts

  • Easy patient tracking

  • Better outcomes for HCPs.

  • Reduced Emergencies.

  • Reduced Admissions

  • Better project and formulary compliance.

  • Better use of services.

  • Identification of GP Surgeries needing extra resources.

  • Better education

  • Online referrals


This can become a thing of the past
This can become a thing of the past!

  • Microvascular

    • Neuropathy

    • Retinopathy

    • Renal Disease

    • Diabetic ulcers

  • Macrovascular

    • Heart Attacks

    • Strokes

    • Peripheral Ischaemia

    • Diabetic Ulcers


And more importantly it transforms patients
And more importantly – it transforms Patients

  • Janet

  • She used her selfmanagement plans & diabetesmanager.org.uk for 12 months


To this one
To this one!

  • Same patient after 12 months using her self-management guide

  • www.diabetesmanager.org.uk

  • Time for live demo


Does this cut the mustard
Does this Cut The Mustard?

  • 2009 QIPP arrived

  • Quality

  • Innovation

  • Prevention

  • Productivity

  • The Future of the NHS

  • £20 billion Savings



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