Diabetes Prevention

• Preventing Diabetes -- On AAA Home, the hyperlink beside the LESS Initiative hyperlink.

NOTE: That once this template has been closed, you must click on the "Screening Recommendations" hyperlink to return to the template. The pop up actives only on the opening of the Preventing Diabetes template.

• There are three categories of screening recommendations:
  
  
  1. Those who are >45 years of age are recommended to be screened
  2. Those who are >45 years of age and who have a BMI > 25 are required to be screened
  3. Those who are 25 and who have anyone of four risk factors -- hypertension, hypercholesterolemia, family history of diabetes, non-Caucasian -- are required to be screened.

• The template has another section entitled "How to Screen?"
  
  
  1. The first way is with a Fasting Blood Glucose (FBG), which requires a 12-hour fast
  2. The second way is with a 2-hour Oral Glucose Tolerance Test (OGTT).

• You can order the FBG, by clicking on the button, "Order these tests"
  
  
  1. When you click "Order these tests," a pop-up is launched which asks if the patient has been fasting for 12 hours.
  2. If the answer is, "yes,: the test is ordered and added to charge posting.
  3. If the answer is, "no," the test is sent to the Future Labs template.
  4. In order for the Future Lab function to work, you must then access the Future Labs template from AAA Home and complete the date and the provider information before e-mailing the Future Lab template to the laboratory and to charge posting.

Now that you have finished with the ordering of the screening test for diabetes, you can close the Screening Recommendations pop-up by clicking the OK button and review the other information on the Preventing Diabetes Template.

• The top section on the Preventing Diabetes Template has a series of eight hyperlinks which will be discussed below

• The second section of the template has a notation about the atherogenic nature of pre- diabetes, and the criteria for establishing diabetes, pre-diabetes and normal plasma glucose levels.

• The third section has the patient’s vital signs and lab values.
  
  
  1. There is a button for importing the most recent lab values.
  2. There is also the results of the Diabetes Mellitus Prediction Rule (see below). If the score of the Prediction Rule is 4 or higher, the patient has a high probability of having Impaired Glucose Tolerance (IGT) which is one of two pre-diabetic conditions (along with Impaired Fasting Glucose).

• The fourth section has treatment recommendations and methods for treating:
  
  
  1. Insulin Sensitivity
  2. Impaired Fasting Glucose (pre-diabetes)
  3. Hypertriglyceridemia
  4. Homocysteine
  5. hsCRP
  6. Endothelial Dysfunction

These conditions are found in patients with pre-diabetes and diabetes. There is also is a method in this section of the template for sending a referral for diabetes education in those who have pre- diabetes. All patients with Impaired Fasting Glucose and/or Impaired Glucose Tolerance should be referred to diabetic education classes. This is the first step in a serious effort to prevent them from progressing on to full-blown diabetes mellitus.

To access the referral template, double click just below the field labels but just above the horizontal scroll bar.

Click here to learn How to Complete a Referral

• The fifth section has links for treating the conditions discovered by this review:
  
  
  1. Insulin Sensitivity
  2. Hypertension
  3. Weight Management
  4. Exercise
  5. Lipids Management
  6. Metabolic Syndrome
  7. Smoking Cessation

The eight hyperlinks at the top of the Preventing Diabetes Template are:

1. Screening Recommendations – discussed above
2. Predicting Diabetes – This calculates the Diabetes Prediction Rule results and gives the objective, conclusion and interpretation of the study on the basis of which this rule was developed.
   
   
   1. The lab values and demographic data required are automatically displayed on this template.
   2. If the value is 4 or greater, then the patient has a significant potential of having Impaired Glucose Tolerance which is a pre-diabetic condition further along toward diabetes than Impaired Fasting Glucose.

3. Screening Insulin Resistance
   
   
   1. The first section on this pop-up is "The Following are factors which increase the likelihood of insulin resistance."
      
      
      1. Because the information is capture elsewhere in the EMR, several of the elements are automatically checked:
         
         
         1. age – demographic from EPM
         2. waist size – demographic from Nursing Template
         3. BMI – calculated on Nursing Template
         4. ethnicity – demographic from EPM
         5. family history of diabetes – demographic from Extended Family History at the bottom of the History Template
         6. hypertension – demographic from Extended Family History g.   CVD – demographic from Extended Family History
      
      
      2. Because the information is not captured elsewhere in the EMR, several of the elements are not automatically checked and must be noted by the nurse and/or healthcare provider:
         
         
         1. sedentary lifestyle
         2. history of gestational diabetes
         3. history of glucose intolerance
         4. history of CAD
         5. history of hypertension
         6. history of polycystic ovary syndrome
         7. history of acanthosis nigricans.

2. The second section is "The following are abnormalities of the insulin resistance syndrome." The four elements of this section are automatically completed:
   
   
   1. Triglycerides
   2. HDL
   3. blood pressure
   4. glucose level

3. The third section is "Based on the risk factors and abnormalities indicated above…".
   
   
   1. When the "Conclusion" button is clicked, a conclusion appears in the window which states whether or not this patient is likely to have insulin resistance or not.
   2. The presence of a high potential for insulin resistance places the patient at higher risk of developing type 2 diabetes.

4. IFG and IGT – the fourth hyperlink at the top of Preventing Diabetes gives the definitions and significance of:
   
   
   1. Impaired Fasting Glucose (IGF) and
   2. Impaired Glucose Tolerance (IGT).
   3. This pop-up is for information only.

5. Current Strategies – the fifth hyperlink at the top of Preventing Diabetes. This launches a pop-up entitled Current Strategies to Prevent Diabetes.
   
   
   1. There are four elements to this pop-up
      
      
      1. Preventing Diabetes Type 1 by preventing gestational exposure to rubella
      2. Encourage present feeding and minimize exposure to cow’s milk in first six months, particularly if a first-degree family member has type 1 diabetes.
      3. Do not stop insulin if type 1 diabetes goes into remission
      4. Low fat diet, active lifestyle and ideal body weight for those with relatives with type 2 diabetes.
   
   
   2. There is a box which when checked launches a document with more information on these four prevention strategies.

6. Could You Have Diabetes And Not Even Know It? Is the sixth hyperlink.
   
   
   1. In response to seven questions, a point total is calculated.
   2. The conclusion will tell if a person is at high or low risk of diabetes.

7. Reducing Your Risk is the seventh hyperlink. It identifies seven lifestyle and therapeutic measures which a person can undertake to decrease the risk for developing diabetes.

8. Low Risk of Developing Diabetes is the eighth hyperlink. This pop-up identifies eight characteristics of those who are known to have a low risk of developing diabetes.

Concluding the Diabetes Prevention Template

• The final step to completing the use of the Preventing Diabetes template is the creation of a note by single clicking the Document button.
  
  
  1. This will generate a document that can then be given to the patient to help them understand clearly how they can avoid diabetes.
  2. Remember: the best way to treat diabetes is still not to get it.

• There is also a list of 13 documents for patient education on diabetes prevention.
  
  
  1. There are three hyperlinks to the right of the document hyperlinks.
  2. The first hyperlink will auto print the first six documents.
  3. The second hyperlink will print the next three.
  4. The last hyperlink will print the next four.

• Then there are nine documents for provider education