Professional CGM management workflow

We often face the challenge of helping patients whose insulin needs are not clearly evident by routine intermittent finger-stick measurements and HbA1c testing. Professional continuous glucose monitoring can help many of these patients.

Jay Watsky

Dawn Dluge-Aungst

Data from studies demonstrating the benefit of this emerging technology are limited, but Schiaffini and colleagues documented that identifying unrecognized hypoglycemia with professional continuous glucose monitoring (CGM) can effectively guide changes in insulin therapy. Professional CGM can help identify and monitor patients whose diabetes is characterized by dangerously low overnight blood glucose levels, high blood glucose levels between meals or early morning spikes in blood glucose. The professional CGM device and its ability to display trends in blood glucose levels across several days helps clinicians precisely evaluate the effect of food, diet and exercise; insulin dosing; and other variables.

A critical factor for success in providing professional CGM services is matching patient demand with practice resources of staffing, provider time, clinical space and available professional CGM devices. We recognize that finding this balance hinges on creating an efficient workflow.

Patient selection

Optimal workflow starts with patient identification. The practice’s protocol should list key indicators of patients most likely to benefit from professional CGM. These may include:

• Hypoglycemic unawareness;
• Gastroparesis;
• Discordant HbA1c and finger-stick data;
• Pregnancy;
• Dawn phenomenon;
• Postprandial hyperglycemia;
• Nocturnal hypoglycemia; and
• Noncompliance (with self-monitoring of blood glucose).

Communicating orders to staff

Notifying support staff of new CGM patients is best done while the patient is still at the practice. Quick notification helps initiate the scheduling of patients for CGM insertion; device removal and data download; and communication of results.

In our practice, we use an electronic medical record but still create a paper fee ticket. After identifying a patient for whom professional CGM is indicated, staff makes a notation on the fee ticket. Front office staff acts on this notation when patients are checking out by scheduling three CGM appointments: the insertion; the removal; and the visit to discuss the results.

Scheduling

A medical practice must pay careful attention to organizing the scheduling of professional CGM. We have determined the following factors for success:

• Scheduling CGM insertion appointments with trained clinical support staff;
• Matching patient demand, such as the number of patients scheduled for the day’s CGM insertion session, with the supply of available devices;
• Identifying unmet capacity quickly when devices are needed for same-day orders;
• Tracking the volume of planned and actual insertions;
• Generating charge tickets for scheduled appointments;
• Facilitating charge capture;
• Confirming appointments; and
• Tracking missed appointments.

To make the most efficient use of resources, we adhere to this protocol: Insertion takes place on specific days, followed by removal 3 days later. We schedule a face-to-face encounter to review the results on the same day the device is removed and downloaded.

Device insertion

The time span between the initial order for professional CGM and the patient’s first visit can be a matter of days — or minutes. Ideally, the interval should not be less than what is required for our administrative staff to reliably complete what is often a critical task: obtaining required prior authorization from the patient’s insurance carrier.

Scheduling CGM-insertion patients in focused sessions is an effective means of matching available resources to capacity. Careful timing maintains a cycle of insertions and removals that allows the devices to be with patients most of the time. Intermingling appointments for insertions and removals during the same session can lead to inefficient use of staff time and poor patient service, forcing patients to endure long waits, since the devices must be cleaned and recharged before the next insertion.

Device removal and data download

A practice can schedule CGM removals either as individual patient appointments or in a timeframe that allows patients to walk in within, for example, a 2-hour window on the appointed day. We schedule the Monday insertion patients to return Thursday morning for device removal, with more patients scheduled for insertions on Thursday afternoon. The Thursday insertion patients return for removals the following Monday morning. Whatever schedule you select, you must ensure adequate staffing to complete the proper logging, downloading and cleaning of devices in time for the next set of patients.

Setting a cutoff time for a morning device-removal clinic allows staff enough time to get the devices ready for the next set of insertions, which might be later in the afternoon. Training multiple employees to perform removals and clean devices helps ensure that patients are not kept waiting for insertions.

A dedicated computer and printer for professional CGM help reduce delays in device removal and interpretation. You can decrease equipment costs by placing a laptop or personal computer securely on a rolling cart that can be moved from room to room during device removal sessions. This mobile, dedicated CGM workstation should have all cables and other supplies needed to complete the task.

Staff members who are performing removals must be responsible for logging the devices immediately after their removal and obtaining signed confirmation from patients that the devices were returned.

Data interpretation

Various individuals can perform professional CGM interpretation. In our practice, an endocrinologist may interpret the results; however, the protocol is to schedule the visit with either our physician assistant or nurse practitioner, both of whom carry a certified diabetes educator credential and have extensive experience in diabetes management and patient counseling. They provide a summary report to the referring physician later the same day.

The interpreting clinician notes the completion of this step on a CGM order tracking form or a patient list. It only takes a quick look to see that interpretations were performed for all device removals and that all devices were returned and accounted for.

Alternative communication

Our preference is to counsel patients about the results of CGM face-to-face. Patients gain a great deal in seeing the graphs during the discussion. However, the CPT code for the interpretation of CGM does not require an in-person meeting. The provider can discuss results with a patient by phone or by secure electronic communication. We believe that a face-to-face visit is the best way to engage patients in the process.

Professional CGM can provide clinical insights not possible with HbA1c measurement and finger-stick alone. We believe that this technology helps patients and providers alike gain insight into factors influencing glucose fluctuation. An efficient process on the provider side allows both to gain the greatest value from this technology. A recent consensus statement from the American Association of Clinical Endocrinologists endorses the value of professional CGM, stating that it is an emerging technology that can improve the lives of those who incorporate it into a comprehensive management plan.

Jay Watsky, MD, FACE, is partner and practicing endocrinologist, and Dawn Dluge-Aungst, RPA-C, CDE, is an associate specializing in endocrinology, diabetes and metabolism, both at The Endocrine Group, LLP, in Albany, N.Y.

For more information:

• AACE Continuous Glucose Monitoring Task Force. Endocr Pract. 2010;16:730-745.
• Schiaffini R. Diabetes Metab Res Rev. 2002;18:324-329.

Disclosures: Dr. Watsky and Dluge-Aungst report no relevant financial disclosures.

The authors have written a detailed, practice-oriented viewpoint on the how, why and who of CGM usage in the office-setting. In the absence of compelling, prospective, randomized studies that point to who benefits, how to maximize the benefit, and just as importantly the lack of any consensus as to best interpretation and translation of data to clinical action, the authors’ personal experience is particularly valid and useful to all clinicians. Inertia exists in caring for patients with diabetes who are unable with current technology to achieve the goals of safely or capably lowering blood sugars to target.

While CGM has held great hope and promise for the diagnosis and treatment of diabetes care issues, it has failed to become standard of care in the treatment of all patients with diabetes, precisely because of the continued failure of studies to elucidate the standards that should apply to best clinical practice of in-office CGM. What is urgently needed is a coordination of all parties involved in CGM technology and its interpretation, including manufacturers, insurers, clinicians and allied health care professionals, including registered dietitians, to develop understandable educational and clinical standards and to coordinate their validation by prospective randomized studies that compare their benefit to that of self-monitored blood glucose. Unfortunately, we as clinicians may optimistically envision generalized population benefits, but these improved outcomes can only accrue to patients on an individual basis without there existing a standardization of all aspects of the application of any technology.

– Alan O. Marcus, MD, FACP

President, South Orange County Endocrinology, Laguna Hills, Calif.

Disclosure: Dr. Marcus reports no relevant financial disclosures.
He is a former medical adviser for Medtronic.