creating the virtual team

Dis Manage Health Outcomes 2008; 16 (3): 145-153REVIEW ARTICLE 1173-8790/08/0003-0145/$48.00/0

© 2008 Adis Data Information BV. All rights reserved.

Creating the Virtual TeamApplication to Diabetes Mellitus Disease Management

Roger Mazze1,2

1 International Diabetes Centre, Park Nicollet, Minneapolis, Minnesota, USA2 University of Minnesota Medical School, Minneapolis, Minnesota, USA

Contents

Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1451. Virtual Team Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1462. Virtual Teams and Clinical Decision Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147

2.1 Organizational Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1472.2 Clinical Pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1472.3 Measurement and Incentives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148

3. Electronic Media and Clinical Decision Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1493.1 Electronic Self-Monitored Glucose Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

4. Role of the Person with Diabetes Mellitus in the Virtual Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1505. Implications and Future Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1526. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

The increased reliance on patient self-generated data has had a major impact on the development of the virtualAbstractteam in the management of diabetes mellitus. Only recently has the concept of the virtual team been takenseriously in the management of the individual with diabetes, in part due to the availability of large amounts ofpatient self-generated data. Team development, especially for a virtual team, is a careful process, in which self-assessment, team building, and identification of roles and responsibilities take place before the team performs.This process has been termed ‘forming, storming, norming, and performing’ in recognition of the stages of teamdevelopment and the importance of passing through each stage before initiating the next. Research has identifiedfour additional factors that need to be addressed for the virtual team to complete its development and to assureimproved clinical outcomes: organizational support, a common approach to diabetes care based on specificclinical protocols, ongoing measurement, and incentives. The creation, organization, and implementation ofvirtual teams depend upon several inter-related factors. The ideal model permits synchronized communicationsbetween team members so that timely decisions can be made in a transparent manner, enabling the person withdiabetes to fully participate. From a structural perspective, the team needs organizational support, common careprotocols, a means of measuring performance (including, but not limited to, outcomes), and incentives for allparticipants.

With the advent of electronic and computer-based diabetes has been to adapt new technologies to the changing nature ofmanagement technologies almost 2 decades ago, the transforma- diabetes care and to simultaneously improve the quality of diabe-tion of the multi-disciplinary healthcare team, synonymous with tes management while lowering the cost. The fundamental ap-excellence in care for diabetes mellitus, began. Since then, the goal proach has been to increase utilization of electronic media to

146 Mazze

collect and communicate vital self-care data to support evidence- The increased reliance on patient self-generated data has had amajor impact on the development of the virtual team in diabetes.based clinical decision making, while reducing reliance on person-The concept of a virtual team became important in the manage-to-person interactions. The purpose of this exposition is 3-fold:ment of the individual with diabetes primarily because of (i) the(i) review the evolution of team care in diabetes; (ii) examine theneed for all team members to have access to vital diabetes-relatedrole of virtual teams; and (iii) present a model for the integration ofdata; (ii) the availability of large amounts of patient-generatedthe virtual team in diabetes.electronic data; and (iii) a renewed focus on patient-centered care.Diabetes care has been characterized by a team approach for asThe removal of barriers (e.g. lack of access to important diabetes-long as 4 decades.[1] The teams have generally comprised health-related data) that prevented coordination of care and communica-

care professionals with the unique skills and expertise required fortion between team members presented an opportunity for equal

the comprehensive management of diabetes. The earliest multi-access to clinical information that was once the domain of the

disciplinary teams comprised an endocrinologist, a nurse, and aphysician and immediate team members. It had been known for

dietitian. Because of their close proximity, they were expected tomore than 2 decades that the care of the individual with diabetes

coordinate all care and maintain communications with the personwas principally under the management of multiple clinicians;

with diabetes, their family members, and consulting experts. Thehowever, central to this paradigm had been primary care physi-

original Federal legislation that transformed diabetes from a se-cians who accounted for the majority of health professionals

condary public health issue to a central concern of the US govern-managing diabetes. Despite many attempts to alter this paradigm,

ment specifically noted that the multi-disciplinary team was a keyit has remained relatively unchanged for the past several decades.

component of diabetes care.[2] It went further, to “require” thatIt is estimated that as many as 90% of individuals with diabetes

patient education, nutrition, psychosocial “issues,” and exercise be (type 1 diabetes ~70%, type 2 diabetes ~95%, and gestationaladdressed by research and included in the training of all health diabetes ~80%) obtain their management without reliance onprofessions. Soon after this landmark legislation was enacted, specialists.[2] Part of the rationale for primary care management ofthree major federal programs were created: the National Institutes diabetes is based on the lack of geographic distribution of special-of Health–Diabetes Research and Training Centers, the Public ists and on the multiplicity of co-morbidities that accompanyHealth Service–Indian Health Service Diabetes Program, and the diabetes. Management of hypertension, dyslipidemia, and obesityDiabetes Control Program of the Centers for Disease Prevention inevitably accompanies the management of diabetes and requiresand Control. Each of these programs, from their unique perspec- clinicians trained to address a multiplicity of co-morbidities; atives, addressed the multi-disciplinary characteristics of diabetes fundamental characteristic of primary care medicine. A secondcare. characteristic unique to diabetes is the need to coordinate care

During the ensuing 4 decades, the disciplines grew, not only in when other disciplines are involved. Once again, this is an impor-tant component of primary care. Consequently, approximatelythe numbers of health professionals, but also in the amount of16 million of the estimated 18–20 million people in the US withresearch and in the further clarification of each discipline’s contri-diabetes rely on primary care management. Their care requiresbutions to the understanding of diabetes, and the manner in whichimmediate access to large amounts of information, contact withcare would be delivered.[3-5] The roles and responsibilities ofspecialists, sharing clinical data, and communications with pa-healthcare professionals specifically trained in these areas becametients. Therefore, nowhere would the virtual team be betterclearer and broader. The definition of the multi-disciplinary teammatched than under the circumstances of primary care manage-evolved to encompass specialist and generalist physicians, nurses,ment; and nowhere is it less utilized.nutritional educators, psychologists, social workers, pharmacists,

and myriad health professionals directly or tangentially involved

in diabetes care. This expanded team was expected to maintain 1. Virtual Team Developmentcommunications and provide coordinated healthcare services. Si-

multaneous with this development were advances in diabetes There are many definitions of the virtual team. In diabetes it hasresearch, and consequently, diabetes management, that for the first come to mean the application of several disciplines towards thetime, enabled quantification of key data critical to diabetes man- common goal of improving care; specifically, restoring glycemicagement. Essential to this development was the measurement of control to prevent micro- and macro-vascular complications. Con-glucose by the patient. sequently, there is a need for rapid and efficient exchange of

© 2008 Adis Data Information BV. All rights reserved. Dis Manage Health Outcomes 2008; 16 (3)

Creating the Virtual Team 147

electronic-based self-care and clinical information between the 2. Virtual Teams and Clinical Decision Makingdifferent disciplines, even though they are geographically and

Our research has identified four additional factors that need totemporally separated. This team interaction can take on severalbe addressed for the virtual team to complete its development and

forms. Ideally, the team members are located in the same facilityto assure improved clinical outcomes: organizational support, a

and use electronic media to communicate in a coordinated fashioncommon approach to diabetes care based on specific clinical

to assure that information is shared in a time-sensitive manner,protocols, ongoing measurement, and incentives. In our study of

following the logical sequence of treatment. This type of arrange-the development of diabetes programs at ten medical centers in the

ment is typical of large primary care multi-clinic practices with US, the use of virtual teams (connected by electronic communica-access to dietitians, nurse educators, and other health professionals tions) was sparse.[8] Where it was employed, the process of devel-who, although geographically separated in a central location, can opment required the same four steps as in the introduction of newcoordinate care through common access to electronic data. At the and/or innovative approaches to coordinated disease management.other end of the virtual team spectrum in primary care is the

uncoordinated sharing of information by health professionals in 2.1 Organizational Supportdifferent facilities. The information and communications occur

The first step required was to garner significant organizationalwithout regard to the orderly sequence of events in the manage-support to assure appropriate allocation of resources and thement of diabetes. This characterizes primary care in rural areas,commitment of the organizational leadership. This required thesmaller cities, and solo or small group practices in large urbanidentification of the virtual team ‘champion’ as well as the corecenters. It is suspected that this paradigm describes most primaryteam members. This initial group then had to assess the current

care where access to specialists is ‘desynchronized.’ In a 4-yearstate of diabetes care in the facility, demonstrate a need for change,

efficacy study[6] of virtual teams in diabetes management, theand identify the key personnel required to introduce the new

authors concluded that such an arrangement would lead to signif-initiative. Specific to utilization of a virtual team approach was the

icant failures in coordinated care that could ultimately be reflectedrequirement for a thorough evaluation of the infrastructure for

in poor clinical outcomes. Essentially, they argue that for virtual electronic communications. Critical to the process of obtainingteams to develop they need to be synchronized and, although in organizational support was determining how closely the idea of adifferent facilities, must undergo the same key steps as would be virtual team aligned with the organizational values and how well itundertaken in face-to-face team development. ‘fit’ within the scope of organizational policies and resources. The

Team development, especially for a virtual team, is a careful questions most often asked concerning values were related towhether remote communications were viewed as part of compre-process in which self-assessment, team building, and identificationhensive care within the vision and mission of the organization.of roles and responsibilities must take place before the teamIssues connected with ‘fit’ tended to involve the organization’sperforms. This process has been termed ‘forming, storming, norm-commitment of resources (e.g. electronic networking) to support aing, and performing’ in recognition of the stages of team develop-virtual team. An organization whose mission was to improvement and the importance of passing through each stage beforediabetes care, but whose means did not allow for remote commu-initiating the next.[7] Nowhere is this more important than wherenications would not be a good ‘fit’ for the innovations needed inthe team members are not at the same location. During the firstorder to employ a virtual team.stage, team members define the boundaries of their profession,

their own work, and the collective activities of the team members.2.2 Clinical Pathways

During the ‘storming’ stage, conflicts over roles and responsibili-

ties emerges. The ‘norming’ stage is a point in which the conflicts Once organizational support was obtained, it was necessary toare resolved and the routine inter-relationships of team members identify and ‘re-train’ the team members caring for patients withare determined. The ‘performing’ stage is defined by the ability of diabetes using a common approach to diabetes management thatthe team members to achieve their goals. This process requires could benefit from virtual connections. We developed such anagreement on care guidelines, goals and clinical pathways, open approach, termed ‘staged diabetes management.’[9] This system-access to the same data, patient participation, and, most important- atic, evidence-based approach utilizes both qualitative and quanti-ly, ongoing assessment of team activities and clinical outcomes. tative data to advance diabetes care (see figure 1).


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HbA1c <8%FPG <200 mg/dLCPG <250 mg/dL

At presentation HbA1c reduction

Medical nutrition and activity therapy stage

HbA1c 8−9%FPG 200−250 mg/dL

CPG 250−300 mg/dL Insulin sensitizer (metformin or thiazolidinedione)Insulin secretagog (sulfonylurea, nateglinide, repaglinide)or α-glucosidase inhibitor

HbA1c 9−11%FPG 251−300 mg/dL

CPG 301−350 mg/dL

Combination oral agent stage + medical nutrition and activity therapy

Insulin stage + medical nutrition and activity therapy(± oral agents)

HbA1c >11%FPG >300 mg/dL

CPG >350 mg/dL

1%

1−2%

2−4%

unlimited

Basal insulin (insulin glargine) + oral

agent(s)

Basal/bolus insulin[rapid-acting insulin in the

morning, at midday, and in the afternoon, insulin glargine at

bed-time ± sensitizer(s)]

Mixed insulin[rapid-acting insulin and NPH in the morning and afternoon ± sensitizer(s)]

Oral agent stage + medical nutrition and activity therapy

Fig. 1. Type 2 diabetes mellitus Master DecisionPath. This Master DecisionPath represents the overall clinical pathway for the treatment of type 2diabetes, and is customized by the virtual care team. The Master DecisionPath lays out the sequence of therapies, the criteria for starting each therapy,and the expected results. Specific DecisionPaths that detail starting dose, adjustments, and maintenance of therapy are published in the Staged DiabetesManagement QuickGuide™.[10] This assures that all team members are aware of the approach to diabetes care customized to their clinical setting. Note:(i) This DecisionPath is bi-directional; patients may move in either direction between therapies; (ii) insulin sensitizers may be considered for use with insulintherapies; (iii) monthly improvement in self-monitored blood glucose (SMBG) of 15–30 mg/dL and/or improvement in glycosylated hemoglobin (HbA1c) of0.5–1.0 percentage points is considered clinically relevant improvement; (iv) patients should be referred for diabetes and nutrition education at time ofdiagnosis and annually thereafter. Rapid-acting insulin includes insulin glulisine, insulin lispro, and insulin aspart. CPG = casual plasma glucose level;FPG = fasting plasma glucose level; NPH = neutral protamine Hagedorn insulin (insulin suspension isophane).

Based on the employment of common clinical pathways, all process, which is the selection of sentinel indicators that would beteam members use the same guide for the detection and treatment used to evaluate the team’s performance. Once measurement toolsof diabetes and its complications. These pathways constitute the are in place, the final step is to identify the organizational and teamcommon language by which all health professionals communicate members’ incentives for participating in this innovation. In ourwith each other and the person with diabetes. The use of clinical study, pay-for-performance rewards, mandated by state govern-pathways assures that both quantitative and qualitative data are put ments, were among the incentives identified as being critical tointo a format that can easily be communicated among the various encouraging organizations to adopt innovative approaches to man-team members. It lays out in detail the approach to diabetes care to aging diabetes that would ensure existing community standards ofassure continuity. As part of its implementation, all team members care were met or surpassed. An equally important incentive wasare required to participate in its customization for application to recognition. Many medical facilities were trying to meet Nationaltheir clinical settings. This process of customization enables each Committee for Quality Assurance’s (NCQA) Diabetes Physicianteam member to clarify their roles and responsibilities around very Recognition Program (DPRP) care and outcome criteria, believingspecific tasks. that the NCQA might become the basis for setting Federal govern-

ment reimbursement policies.[11] While this did not materialize as2.3 Measurement and Incentives

Federal policy, it did establish the outcomes (e.g. glycosylated

hemoglobin [HbA1c], blood pressure, lipids, microalbuminuriaClinical pathways have an additional function, which is toscreening, annual eye and foot examinations) that would beidentify the key quantitative variables that can be periodically re-targeted, and for which goals would need to be met, in community-assessed to ensure that clinical goals are being established and

met. Essentially, the clinical pathways define the third step in the wide standards of care.



As part of incentives, the study considered cost-effectiveness diabetes management was considered (endocrinologist, dietitian,analyses and reviewed the type of data that would be required. A exercise physiologist, or educator), knowing the glucose level wascost-effectiveness analysis would result in the ratio of the cost of a critical. Consequently, evidence from SMBG of the relationshipvirtual team less the cost of current care to the benefit of the virtual between blood glucose levels and complications was expected toteam with regards to a particular outcome (such as a reduction in increase our understanding and become fundamental to diabetesHbA1c) over that provided by current care. The result would be the care. Verifiable, accurate, and reliable capture of this informationincremental cost for the additional benefit. We noted that ‘cost revolutionized diabetes management.effective’ and saving money are not synonymous. The key is toplace a cost on the outcome (e.g. does lowering blood glucose 3.1 Electronic Self-Monitored Glucose Datanecessarily produce a marginally better financial outcome?). Asthe complexity of this issue was beyond the scope of the study, SMBG was founded on the principle that diabetes managementfurther analysis was not undertaken. required ongoing clinical decision making which, in turn, required

The rationale for virtual team development at some study sites coordinated care between the team members and the patient. Inwas also related to limited resources, inaccessibility of experts, 1984, the Ambulatory Glucose Profile (AGP) computer programand recognition of poor coordination of care amongst several care was introduced at the Diabetes Research and Training Center,providers. These deficits in the process of care can be addressed by Albert Einstein College of Medicine, New York, USA, to enhanceelectronic communications among various experts without requir- team management and clinical decision making.[12] AGP analysising their physical presence. Clearly, the underlying motivation for collapsed several weeks of all patient-generated SMBG data into aadoption of the virtual team is to improve diabetes outcomes. To single day and presented these data in a continuous fashion toachieve this, the virtual team, more than any other type of team, enable rapid assessment of the clinical status of the patient by therequires a common, evidence-based approach to diabetes care, the physician, nurse educator, and dietitian. Since the data were in andevelopment of a database that enables easy communications electronic format, AGPs were designed to be shared by multiplebetween providers and measures outcomes, and incentives (such team members at different locations, as well as with the patient.as pay for performance and peer recognition) to maintain motiva- However, glucose monitoring device manufacturers chose not totion for health professionals to remain committed to this innova- accept a common format, and each meter was downloaded by ation in diabetes care. different program, each producing its own distinctive report. Con-

sequently, the significance of self-monitoring for the evolution ofthe virtual team was not fully realized.3. Electronic Media and Clinical Decision Making

Over the past 5 years, the search for a more reliable means ofobtaining sufficient patient-generated verifiable glucose data hasDiabetes care presents an excellent model for the developmentled to the development of devices that continuously monitorof virtual teams in chronic disease management because of itsglucose; once again, improving the potential for shared data bymulti-disciplinary characteristics and reliance on patient-generat-virtual team members. Invasive glucose monitoring methods ored data. Fundamental to the virtual team is the sharing of quanti-continuous glucose monitoring (CGM) use electrochemicaltative data that contributes to clinical decision making. Central to(amperometric) monitoring in the subcutaneous fluid to providethese data are glucose measurements. Until the late 1970s, thecontinuous glucose values over periods extending from 3 tomeasurement of glucose levels was an inexact science dependent7 days. The continuous data from these systems can be aggregatedupon episodic laboratory measurement of fasting blood glucoseby AGP and subjected to higher levels of analysis than SMBG,levels and home measurement of urinary glucose levels and there-with the advantage of nocturnal and diurnal continuous data (seefore, the importance of glucose was equivocal. However, with thefigure 2). These data provide vital information about glycemicadvent of capillary blood glucose monitoring (enabling self-moni-control sufficient to improve clinical decision making, especiallytoring of blood glucose levels [SMBG]) and the abandonment ofif they are linked to a common clinical pathway (such as stagedurine testing, the importance of glucose levels in diabetes manage-diabetes management [SDM]) that depends upon these data forment became more apparent. The ability to monitor blood glucoseclinical decision making.levels at home, work, school, and essentially anywhere was expec-

ted to change diabetes management and put self-care at the core of The accessibility of CGM data for members of the virtual teamdiabetes treatment. Regardless of the perspective from which presents myriad opportunities for interaction. Because of the na-


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Fig. 2. The ambulatory glucose profile (AGP). The AGP superimposes on the individual data points (collapsed to 24 hours) five smoothed frequency curvesthat represent the underlying glycemic pattern. The center solid line is the median, the two outer solid lines represent the 25th and 75th percentiles and arethe boundaries of the inter-quartile range (IQR). The dotted lines depict the 10th and 90th percentiles (accounting for outlier values). The statisticalsummary contained in the AGP report is customizable. This example includes calculation of percent of values within pre-set targets, total and hourlyglucose exposure (measured using the area under the median curve), and summary statistics related to the five curves.

ture of these data, pharmacological interventions, diet, activity, enhance and make transparent the process of selecting, initiating,and adjusting medications to achieve specific glucose goals withinand other key variables associated with glycemic control can bea set timeframe.closely evaluated. Since the virtual team relies on the expertise of

its diverse membership, their interpretation of the same data set4. Role of the Person with Diabetes Mellitus in thepresents opportunities for advances in clinical decision makingVirtual Teamthat were previously impossible to achieve. Access to the same

database by all virtual team members assures a broader under- More than 4 decades ago, with the recognition that individualsstanding of the characteristics of glycemic control. Overall glucose with diabetes were central to the long-term management of theirexposure, variability following meals, and stability in glycemic condition, multi-disciplinary teams integrated care with educationcontrol can be measured from CGM outputs analyzed by AGP. to ensure that the patient had the ability to collect important self-This understanding enhances communications, improves efficien- care data, manage diabetes without constant physician surveil-cy, and lays a foundation for assuring a common approach to lance, and ultimately contribute to clinical decisions. This centraldiabetes management. The virtual team relies on input from each role on the team was further advanced with the advent of electron-team member. Using a common database presented in a common ic data collection. From the patient’s perspective, the ability toformat supports the integration of information from diverse measure SMBG (or use CGM) and electronically transmit thesesources. Because the data are in an electronic format, they can also data to the physician enhances clinical decision making. Thebe linked to laboratory and other clinical measures. This would development of the electronic medical (health) record (EMR)



moved the patient from a tangential to a pivotal place on the team. scribed; and the primary care physician did not have access to the

The virtual team best exemplifies this transition. From the pa- ophthalmologist’s report or the dietitian’s recommendations. Thetient’s perspective, geographic diffusion, temporal dysynchroniza- patient could not retrieve any of this information.tion, and dissonance among the varying team members were

The character of diabetes care should change when an integrat-probably characteristic of routine care for diabetes prior to the

ed electronically-based virtual team is involved. The patient theo-introduction of the EMR. Clinic visits were too short to review

retically moves to a pivotal position alongside the primary careSMBG data, obtain necessary laboratory measures (such asphysician. The EMR allows access by all team members at allHbA1c), integrate data from other team members, and make the

times. The geographic separation may no longer be a barrier, andnecessary appointments for follow-up care. Typically, SMBG data

were reviewed from logbooks, which are subject to reporting the temporal dysynchronization may be overcome by permittingerror, rather than analyzed in an electronic format; HbA1c testing the patient and team members timely access to self-care, labora-was ordered and the results were received days after the clinic tory, physical examination, and patient history data. Patientvisit, appointments with dietitians and ophthalmologists were

SMBG or CGM data are downloaded to the EMR and integratedmade weeks after the visit, and the information from these health-

with laboratory findings. Primary care providers have access tocare professionals was unlikely to be integrated into the clinical

these data along with dietitian recommendations and the results ofrecord. The dietitian did not have access to SMBG or HbA1c dataophthalmologic examination. Most importantly, the patient canupon which to make recommendations; the ophthalmologist was

access these records and thus fully participate in care decisions.uncertain as to the medications that the patient had been pre-

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Person with diabetes mellitus

Endocrinologist Educator

Primary care physician

Visit Date Gender Age Height Weight BMI Dx Onset Duration Treatment Total Basal Bolus3/24/2006 Female 66yrs 62in 125lbs 20.30 Type 1 1978 28yrs CSII 57units 27units 30units

N %ABOVE %WITHIN %BELOW MEAN SD MAX MIN AUCmd DAY NIGHT3935 180 70 33.1 61.2 5.7 156.2 61.9 355.0 28.0 3629.5 2412 1217.5

HbA1c SBP (mmHg) BP Dias (mmHg) 10th 25th 50th 75th 90th IQ Range NORM NORM NORM7.7 125 70 90.8 114.2 151.4 191.6 233.5 77.4 151.22917 160.8 135.3

TARGETS (mg/dL)

10th 25th 50th 75th 90th IQ Range90.8 114.2 151.4 191.6 233.5 77.4

Changes in therapy:Increase overnight basal rate by 0.1 uIncrease pre-breakfast bolus by 1 u

Decrease mid-afternoon basal rate by 0.2 u

Fig. 3. Virtual team in action showing the integration of virtual team members (including the person with diabetes mellitus) employing electronic media forcommunications. The specialist, primary care physician, and educator are viewing the ambulatory glucose profile (AGP) of the patient and sending arecommendation for therapeutic changes. This assures a synchronized response, enables automated documentation of changes in therapy, and providesthe underlying evidence (AGP) for the alteration in treatment regimen.


152 Mazze

5. Implications and Future Directions clinical decision making, allows for review and further analysis.When patients and providers review the data together, the variousinputs permit the virtual team members to learn from one another.The creation, organization, and implementation of virtual teamsThese inputs can be codified so that they can be accessed at a laterdepends on several inter-related factors. The ideal model (figure 3)date and applied to the same patient or to a different patientpermits synchronized communications between team members soshowing the same AGP characteristics. Over time, a library ofthat timely decisions can be made in a transparent manner, ena-profiles based on the type of diabetes, treatment, and other impor-bling the person with diabetes to fully participate in the decision-tant clinical factors could be accumulated and shared. The long-making process. From a structural perspective, the team needsterm benefit would clearly be to associate these profiles withorganizational support, common care protocols, a means of mea-clinical outcomes.suring performance (including, but not limited to, outcomes), and

The virtual team in diabetes is an evolving concept. A perspec-incentives for all participants. From a functional perspective, thetive on the virtual team that needs further understanding is thehealthcare team (including the patient) requires technologies thatpotential ‘perils’ of internet-based interventions. One study ofenable easy access to clinical data, whether this data has beenindividuals with type 1 diabetes cautioned that internet use must fitobtained from the laboratory, during an office visit, or has beenwithin the current care models for diabetes, address individualself-generated by the patient. These data need to be integrated inneeds, and may not be suitable for everyone.[13] At the other end ofsuch a manner as to clarify their significance and, when needed,the continuum is that virtual teams mark a significant change in thecompel the healthcare team to take action. The ease of access toapproach to diabetes management, essentially not fitting intoinformation through the use of common formatting of data (usingcurrent care patterns. Relying principally on internet-based com-one nomenclature) and reporting systems, are key elements of amunications, they focus on open access to information, rapid yetvirtual team. Central to this process is the continued developmentdistant real-time interaction, large amounts of data, and employ-of computer-based technologies that enable the virtual functions ofment of analytic tools for clinical decision making. Both perspec-the team at levels that equal or surpass traditional face-to-facetives have merit and thus deserve our attention.team interaction. The ability of the patient to access clinical data,

communicate with various team members, and, most importantly,participate in clinical decision making are fundamental to the 6. Conclusionsvirtual team approach to diabetes care. Similarly, the ability of theprimary care provider to share clinical data simultaneously with The team approach to disease management is in constant flux.the specialist and educator creates greater assurance that a com- Its ideal formulation is yet to be discovered. As an integratedmon approach, consistent with evidence-based medicine will be group of individuals with a common purpose, the diabetes health-applied. ‘Virtual’ implies utilization of new computer-based tech- care team faces major logistic problems. The team is reliant onnologies, such as CGM, to enhance the exchange of information several sources of information, most of which is patient generated,between team members and patients despite distance. and which must be integrated and acted upon in a consistent,

Clearly, there are benefits of the virtual team that already coherent, and cohesive manner. The use of a virtual team in whichsurpass face-to-face teams. They fall into two key categories: data communications are not face to face and actions may not bemanagement and continuing education. Because a substantial pro- synchronized, presents a major challenge. The virtual team re-portion of virtual team communications is based on computer quires a common, proven approach to diabetes care, a databaseutilization, recording of data can be instantaneous and permanent, that enables easy communications between providers and mea-significantly reducing error. When laboratory data, physical exam- sures outcomes, incentives to maintain motivation for health pro-ination information and self-monitored glucose values are reported fessionals (so that they remain committed to improved diabetesby electronic media, they are automatically recorded. This care) and organizational support.removes a fundamental step in current diabetes management, themanual transfer of data. Automation and record keeping open up a Acknowledgmentssecond avenue for data retrieval: automated analysis. Programssuch as AGP enable the clinician to obtain data in a format that No sources of funding were used to assist in the preparation of this review.supports rapid decision making. They have an additional function: The author has no conflicts of interest that are directly relevant to the contentthey promote learning. Sharing data, especially as they relate to of this review.



11. American Diabetes Association and National Committee for Quality Assurance.ReferencesDiabetes Physician Recognition Program (DPRP) standards and guidelines.

1. Etzwiler DD. Chronic care: a need in search of a system. Diabetes Educ 1997; 23:Chicago (IL): American Diabetes Association and NCQA, 2006

569-7312. Mazze R, Lucido D, Langer O, et al. Ambulatory glucose profile: representation of

2. Centers for Disease Control and Prevention. Team care: comprehensive lifetimeverified self-monitored blood glucose data. Diabetes Care 1987; 10: 111-7

management for diabetes [publication no. NDEP-36]. Atlanta (GA): US De-13. Armstrong N, Hearnshaw H, Powell J, et al. Stakeholder perspectives on thepartment of Health and Human Services, Public Health Service, Centers for

development of a virtual clinic for diabetes care: qualitative study. J MedDisease Control and Prevention, National Center for Chronic Disease Preven-Internet Res 2007, 9 (3); e23tion and Health Promotion, 2001

3. Von Korff M, Gruman J, Schaefer J, et al. Collaborative management of chronicillness. Ann Intern Med 1997; 127: 1097-102

About the Author: Roger Mazze was formerly Professor and Director of the4. National Institute of Diabetes and Digestive and Kidney Diseases. Metabolic

Diabetes Research and Training Center, Albert Einstein College of Medi-control matters: nationwide translation of the diabetes control and complica-cine. He and his team developed the first reflectance meters with a memorytions trial. Analysis and recommendations [NIH publication no. 94-3773].

Bethesda (MD): US Dept HHS, 1994 and the computer software to capture SMBG data. He is currently Head of5. Ray MD. Shared borders: achieving the goals of interdisciplinary patient care. Am the WHO Collaborating Center of the International Diabetes Center and

J Health Syst Pharm 1998; 55: 1369-74 Clinical Professor at the University of Minnesota Medical School. The6. Lapidos S, Rothschild S. Interdisciplinary management of chronic disease in principal author of Staged diabetes management, Dr Mazze has been visiting

primary practice. Manag Care Interface July 2004; 17 (7): 50-3professor and consultant to numerous university medical centers and7. Tuckman B. Developmental sequence in small groups. Psychol Bull 1965; 63:government organizations. He is also the principal developer of Ambulato-384-99ry Glucose Profile. His research focuses on the translation of research8. Mazze R, Pearson J, Powers M, et al. Partners in Advancing Care and Education

Solutions (PACES): two-year multi-site study of Diabetes Physicians Recogni- findings into clinical practice and applications of computer technologies totion Program (DPRP). Diabetes 2005; 54 Suppl. 1: A302 diabetes care.

9. Mazze R, Strock E, Simonson G, et al. Staged diabetes management: a systematic Correspondence: Dr Roger Mazze, International Diabetes Centre, Park Ni-approach. 2nd ed (revised). West Sussex: Wiley and Sons, 2006

collet and University of Minnesota Medical School, 3800 Park Nicollet Blvd,10. Mazze R, Strock E, Simonson G, et al. Staged diabetes management quick guide:Minneapolis, MN 55416, USA.prevention, detection and treatment of diabetes in adults 4th edition revised.

Minneapolis (MN): International Diabetes Center, 2007 E-mail: [email protected]


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