Break the Status Quo: Inpatient Glycemic Management Care & Preparing for the Future


David Klonoff, MD | Diabetes Technology Society


Steven Edelman, MD | University of California at San Diego


Bruce Bode, MD | Atlanta Diabetes Associates


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[00:00:00] Robby Booth: All right. Welcome back. Once again, uh, my name is Robby Booth, I'm the Senior Vice President of Research and Development, and one of the founders here at Glytec, and we are honored to have, uh, some very distinguished guests with us today for our panel discussion. And so we're going to jump right into it.
I will briefly introduce each of them, uh, though, I suspect most of you are already familiar with our panelists. And we're going to start off with a question, uh, for each. We will have some time for open discussion and we'll be taking your questions in the second half of the session.

First, we have Dr. Bruce Bode, who is a Diabetes Specialist in Atlanta and on the faculty of Emory University as a Clinical Associate Professor in the Department of Medicine. And as many of you know, Dr. Bode was also one of the founders here at Glytec.

Dr. Steve Edelman is a Clinical Professor of Medicine at the University of California, San Diego, and the Veterans Affairs Healthcare System of San Diego. He's the Director of the Diabetes Care Clinic at the VA Medical Center and the founder and director of Taking Control of Your Diabetes.

Also want to welcome Dr. David Klonoff, who is an endocrinologist specializing in the development and use of, uh, diabetes technology. He is Medical Director, um, at the Diabetes Research Institute at Mills-Peninsula Medical Center in San Mateo, California, and a Clinical Professor of Medicine at UCSF. He is also the founder of the Diabetes Technology Society and the founder and editor in chief of the Journal of Diabetes, Science and Technology.

So welcome gentlemen. Uh, and as I mentioned, we're going to have time to take questions from the attendees later in this session. Uh, we do welcome your questions, so go ahead. And at any time you can enter those into the session Q and A, which is on the right side of the video. And we'll get to as many of those as we can.

And Dr. Edelman, we're going to kick this off with, uh, the first question to you and it's, uh, something I wanted to ask you, uh, about in particular, cause I know you've been a very strong advocate for, uh, patients living with diabetes. Um, you started a group, Taking Control of Your Diabetes, many years ago now, that helps educate and inspire, uh, people living with diabetes. And so I'm curious as you've traveled the country, uh, hosted meetings, heard directly from patients and their families. What do you hear about their experiences in the hospital? Uh, and what advice do you give them?

And, uh, Dr. Edelman, I think you're muted.

[00:02:48] Steven Edelman: Okay, how's that?

[00:02:50] Robby Booth: Very good.

[00:02:51] Steven Edelman: You'd think after almost two years of doing this, you'd get a system down, but, uh, well I thank you for the introduction. Um, yeah. And you know, the, all of our meetings over the past 25 years were primarily face to face. And the last two years doing large virtual conferences that have live Q and A and discussion sections.

And I would say the, the uniform response for most patients has been a disastrous experience in the hospital. Um, and we know that there are certain centers that are much better than others that have, uh, even our center at UCSD has a, has a hospitalist wing that focuses on diabetes, but it's pretty rare.

But most of the time, uh, the blood sugars become way out of whack, patients aren't allowed to even keep their, uh, either CGM or pump or both on during their hospitalization, even for hospitalizations that do not require NPO or surgery. Uh, and then you have, of course, the caregivers in the hospital. They do their best, they care, but the blood sugars control is not just out of whack, but dangerously out of whack. And then of course the timing of the insulin with the food, the nurses. It's, Robby it's, uh, it's the perfect storm for disaster. It really is.

[00:04:17] Robby Booth: Yeah. Thank you. Thank you for that. We are going to, and we have some follow-ups, um, we'll we'll tackle in the discussion portion.
Um, we're going to move on to, uh, Dr. Bode. And I think folks joining us today, you know, will know that you've been involved in, uh, pioneering inpatient glycemic management technologies for several decades now, including a lot of the early work and really getting out, uh, education on IV insulin protocols.

And I, as I've often heard you say, you know, the evidence for inpatient management of glucose has been around for a very long time. Um, and fortunately I think, you know, the tide is turning. Um, now with CMS, uh, is bringing forth, uh, you know, these measures, um, that were just released and, and, uh, the October rule, uh, for hospitals to start reporting on their glycemic metrics.

And we're going to hear more about that later today, but it's just, it's something that hospitals still really struggle with is hypoglycemia and severe hyperglycemia. Um, either, you know, either extreme. And so I wanted to ask you, how have you seen, over this time, how have you seen hospitals evolve when it comes to insulin management?

[00:05:32] Bruce Bode: Yeah. So, um, uh, for, you know, as far as evidence, uh, for managing diabetes in the hospital, it, if you can go back to, to 2001, when the Lubin, uh, did a blinded, double blinded study showing that if in the surgical ICU, it, it, it significantly decreases mortality as well as time, time in the ICU and so on. And so at that time, ADA and everyone, uh, recommended the, and the goal was 80 to 110 at that time.

And so, so the goal was trying to get as same as the DCCT trying to get your glucose to normal and then after that, uh, Nice Sugar came along and, and what happened with them is they and, they had an increase in, in, uh, in deaths, in people being, uh, getting, getting glucoses below 130 and the reason that they, and the reason they had these deaths is, was because of hypoglycemia. So, so then everybody then raised it to 140 to 180, and there's been several studies since then, including GLUCO-CABG done by Emory, Umpierrrez and his group, showing if in, in, in with CABG, uh, if your glucose is between 100 and 140 versus 140 to 180, you actually save each, each patient about $3,700. And it's, And the reason why controlling glucose is so important is, is, is it, it actually, uh, prevents, uh, um, uh, staying, staying too long in the hospital.

Uh, they have infections, multitude of other problems. And so, but now, as far as other hospitals, it's not easy to do. I've, you know, we've w we have, we have developed, uh, IV systems and SubQ systems, um, and Glytec is using those now. And it's, it's been very successful, but we only have about three to 500 hospitals in the system, in the US doing it.

Um, the reason why others don't do it, is, you know, to do this, it's not easy. Um, and it's not easy to do it, man, manually. You really need algorithms to do that. You know, fortunately in Georgia, we, we have more than half the hospitals are using systems now, same as in South Carolina and some in Florida and elsewhere.

However, the academic centers, uh, came and said, um, to, to me ma, several times we have to teach our residents how to manage diabetes and the only way they're going to do it is you're going to have to manage it in man, manually learn how to do it and, and that's very, it's, it's almost impossible. It's like doing hybrid closed loop is so much better, uh, using that in the outpatient, than, than not using it. So, so I think, why do hospitals, not many hostpitals are using systems. I don't really know, but it, it is not, it is not their priority.

However, coming up with CMS coming, uh, wanting to, um, not only look at hypoglycemia, but hyperglycemia, it's gonna, it's gonna make the hospitals to, to actually do do the right thing for the patients with hyperglycemia in the hospital.

So I'm hoping to see that will grow with this over, over the next few, um, uh, several months to maybe another couple years before everyone will be able to have euglycemia in the hospital, it might be using, uh, systems with CGM and so on, but and that remains to be seen.

[00:09:36] Robby Booth: Yeah. Thank you for that. Yeah. We've had a lot of questions about CGM and I know there's been a lot of interest, um, hospitals, um, Using CGM over the, over the past, uh, what, how many months into the pandemic are we? Uh, 18, 20 months, um, since the FDA had announced, uh, enforcement discretion for inpatient use of CGM, but that's definitely been something that's been of interest. Um, thank you, Dr. Bode.

We're going to move to Dr. Klonoff now. And, uh, as I mentioned in the intro, um, Dr. Klonoff founded the Diabetes Technology Society, uh, which has been, uh, the forefront of, uh, the development and collaboration of diabetes technology. And I think as folks are probably aware, Dr. Klonoff you, you also organize, um, the regular meetings, um, that are focused on diabetes technology and hospital diabetes and cybersecurity.

So I think we'd love to hear your perspective on what advice you would give hospitals to consider, um, as they now have this increasingly complex landscape of all sorts of, uh, diabetes technology, um, to think about.

[00:10:47] David Klonoff: Well, as Dr. Edelman said, there were problems and Dr. Bode said, uh, the problems are not always dealt with well. Uh, currently, uh, hospitals use blood glucose monitoring to control blood sugar, but we're going to see continuous glucose monitoring gradually, uh, take over for blood glucose monitoring. I think in the next 5 to 10 years, we're going to see almost all continuous glucose monitoring. And there's several advantages of continuous glucose monitoring over blood glucose monitoring.

First, it can tell you in real time, if the person has a problem, if their glucose is outside the target range, too low or too high. Second, you can get prediction information, and that can help avoid the kinds of situations that can lead to costly, dangerous complications. Uh, and, uh, the third is that continuous glucose monitoring uh, makes it much easier for hospitals to deliver care.

 Uh, the nurses don't have to spend time, uh, gloving and doing the blood glucose tests. There are estimates that it can take, uh, 10% of their time for every patient that they have that they're doing hourly blood glucose monitoring on. And, uh, also, uh, they don't have to spend as much time, uh, in contact with the patient.

To the extent that COVID is an issue. Hope, hopefully it will be less of an issue and patients will be the less contagious. And then it also saves on use of personal protective equipment if the nurses are not at the bedside, running the blood glucose tests. So there are advantages to having this information continuously and automatically.

Uh, as, uh, in the current time, there's a lot of evidence that a commercial software, uh, has better outcomes than a so-called homebrewed paper and pencil software. In most cases, there are some hospitals that have excellent large endocrinology services who can, uh, come up with very good, uh, orders for how to manage glucose.

Certainly for blood glucose. We're not sure how well they'll do with continuous glucose, but they do well with blood glucose. However, there are many hospitals that don't have very large expert, uh, endocrinology services and they, uh, sometimes aren't able to deliver the kind of care that that would be good.

Uh, Dr. Bode mentioned that there probably, this type of software would be good for every hospital. I agree. I think the main issue is cost. However, if there are fines from CMS that are going to be associated with these never outcomes, very low or very high glucose readings or too much time spent high or low, then the cost shifts and it may actually be worth it for a hospital to spend money, to avoid fines.

If a continuous glucose, my, if I would say when continuous glucose monitoring becomes established, uh, it will require that a hospital, uh, mobilize many different, uh, parts of the hospital that will all, uh, be involved in introducing continuous glucose monitoring. The clinical team, the administrative team, the legal team, the IT team. And everyone will have to get used to this new, uh, way of monitoring patients. But it's coming.

[00:14:04] Robby Booth: Yeah. Thank you for that. And I know that you often talk about, um, you know, the cybersecurity aspect of this and, um, you know, we know that hospitals are increasingly becoming targets of cyber incidents. And so that's definitely something to keep in mind as well when you look at adoption of technology.

 Um, we're going to, uh, open it up for, for a discussion. And I have a question here and we have a lot, actually, a lot of questions coming in from, uh, the attendees. Um, and, uh, we'll just throw it out and, and, and have you guys go around. Um, why don't we start with Dr. Edelman. And the question is, uh, what do you think, uh, best-in-class hospital management of diabetes is going to look like in the future?

[00:14:50] Steven Edelman: Yeah, I think that it'll be, obviously, a continuous glucose monitoring device that communicates not only with the nursing station and the healthcare providers who could check in from home, but also become part of the electronic medical records, take into account the trend arrows.
And so when the, they have the insulin algorithms for the adjustments for depending on the blood sugar, uh, that it also makes adjustments for the direction of the blood sugar as well. And of course, alerts and alarm for the nurses when, uh, when the blood sugar starts to get too low. So it's a totally automated system, as David mentioned.

And, uh, Bruce said it, it will save tons of time, improve patient care and, uh, and, and really make a big difference in terms of outcomes and potentially length of stay and cost and all those things that people pay attention to.

[00:15:45] Robby Booth: Yeah. Dr. Bode, your doctor.

[00:15:50] Bruce Bode: Yeah. So I think in the, obviously right now, if you're in, um, if you're going through major surgery, you need IV insulin.
And the only way to do that, to manage that, is you need to have feedback, um, with, with an algorithm. And, and, and so anybody that comes in that that is not con, that is not controlled in there, and you can't easily control these people normally. So you really need to use IV insulin, especially if you can't eat or drink.

But however, if you're in, however, if you're able to eat and drink, then I, I agree, you're gonna then need to have both basal and bolus plus a correction. And the whole goal is you want to prevent any blood sugar below, um, 80, really. Uh, but, but definitely below, uh,anything below 70 or below 54 and you want to be in a reese reasonable between 70 to 180 over, over the time.

And that would be ideal. And hopefully the average would be about 120 or 130.

[00:17:05] Robby Booth: Very good. Yeah. Dr. Klonoff?

[00:17:08] David Klonoff: Um, you mentioned, uh, my interest in cyber security after I spoke last time. And, uh,
Through Diabetes Technology Society, we created the first cyber security standard for any type of medical devices, for diabetes devices. We have since then turned it over to IEEE and UL who are co-managing the standard.

It's almost through the process. It will be called IEEE 2621 by early next year. And it's a method for a company that has a wireless data transmission. For example, blood glucose monitor, continuous glucose monitor, insulin pumps, smart pen, closed loop system, or even some future product that we don't know about yet, to demonstrate that they have sound cybersecurity.

Currently products will, let's say to get cleared, go to the FDA and they'll demonstrate what they did to um, show that they have security. Many security experts feel that, uh, some of the products on the market aren't as secure as we'd like them to be. And a 2621, when it's completed, DTSec currently sets a certain level of security. It's not going to keep a nation state out, but it will keep most hackers out of most devices. And if a manufacturer is compliant with the standard, that will provide assurance to the regulators, to the doctors, to the patients, that the product has a certain level of security. And I, whenever I talk with manufacturers, I encourage them to go out and have their product certified, according to today, DTSec, and by early next year, 2621 IEEE. That will provide assurance and that can be a market differentiator for a product.

[00:18:57] Robby Booth: Yeah, . Thank you. Um, I, uh, I do want to follow up, um, the, uh, Dr. Edelman, you mentioned, uh, the potential for CGM and being able to, um, check, uh, glucose levels, uh, remotely. And we know that, um, particularly during, during COVID, um, there was a considerable uptick and folks trying to do a remote inpatient consults and trying to leverage CGM.
Um, for that, your thoughts?

[00:19:26] Steven Edelman: Yeah. Well, it has, it has been accomplished. Um, there were a few hospitals in New York City that had an algorithm that, um, allowed doctors, uh, either at home or outside of the ICU where they would not have to gown up to see the CGM values in real time. Uh, at UCSD, where I'm at San Diego, we borrowed that algorithm and have been using it, but, you know, it's, it's a rare hospital that has that system.

And as you know quite well, the N, the national, uh, people that run the, the guidance for using CGM in the hospital are still in the, in their own learning phase. And it's quite, uh, disappointing and frustrating that we cannot institute that in a hospital setting right now, through, throughout the country. So it can be done, it is being done, but it's going to take some coordination. Uh, where a lot of different hospitals can utilize the same system, just like we use Epic, you know? So it's it CGM in hospitalized patients is in its infancy. Unfortunately, and if you think about it, CGMs can get going in one to two hours.

And I do think that the cost of a CGM will, will be far worth it when it comes to the overall cost of a hospital stay. And even, uh, some of the hassles that occur. I'll just mention this briefly, but being an expert witness in a few medical legal cases. Um, most of the cases that I see, I should say a lot of them, are disasters that occur in the hospital, primarily, uh, hypoglycemia where there was a severe outcome and then a lawsuit.

So, I mean, just the money saved on one lawsuit could pay for a lot of good care for people who need it.

[00:21:11] Robby Booth: Yeah. On that same thought I'm being flooded with questions here. Um, we have a question coming in, how difficult is it to start CGM for an inpatient? Which patients should be prioritized, um, and which patients should be considered, um, you know, uh, candidates for, for CGM in terms of reliability? Um, would one of the three of you like to tackle that one?

[00:21:36] Bruce Bode: Yeah, this Bruce Bode. Right now, it's it, it is, it is not approved in the hospital. During COVID, they allowed people to come in because you have to go in the room to prick their finger. And if you're gonna use IV insulin, they, they, and they thought it would be easier, but getting a lot more data with the CGM is.

You, you can manage it very well with a finger stick every hour. However, during COVID, people didn't want to go in the room every hour. They, in, however, the nurse is in there anyways, and there with COVID and you're intubated, you're on pressors, the nurses are in there all the time. And, and so, so my, my feeling right now is, the FDA is not going to allow CGM in the hospital until it's approved.

So Dexcom is doing the studies to do that. Abbott is not ready at this time and neither is Medtronic, but, but eventually Dexcom is going to try, you know, they're there, they're doing studies right now to be able to get approved. How long will that take? It would be another six months, year, maybe two years ,it all, all remains.

We've done work in the ICU and obviously Dexcom is not going in the ICU right now because it's not accurate right now to be able to use in the ICU. But if they're going to use it on the floor, and with that, you can clearly prevent hypoglycemia wearing this sensor because you can have arrows going down, you can have it alerted to the nurses and so on.

 So that's feasible, but the whole goal in the long run is the FDA has to approve this and then, then you need to have protocols and how to manage it. So in the outpatient with, uh, wearing CGM with pumps, it's all hybrid closed loop. That's what it's going to be in the hospital potentially.

Or you could do manually looking at the trend of the CGM, you could easily manage with Basal/Bolus, uh, by, without pricking the finger, it would, would be very easy to manage people in the hospital without any hypoglycemia.

[00:23:54] Robby Booth: Yeah. Sort of, to be determined, stay tuned. There's a lot of good, um, evidence and studies, uh, coming out on, um, uh, crit, critical care use and, and, and non-critical care use.

Um, we have another question. Uh, how can I convince my leadership team that spending money on an endocrinologist, why would anyone do that, right? Uh, will pay in the long run?

[00:24:21] Steven Edelman: What what's what's that question there? They're trying to convince their leadership to hire an endocrinologist?

[00:24:27] Robby Booth: Yeah. Hospital leadership team that spending money on an endocrinologist will pay in the long run.

[00:24:32] Steven Edelman: Well, I, I mean, I'll just jump in there. You, you have to obviously design a financial model of how much money they could save.
Uh, and so I can't go through those details now, but it's all about money. Um, and if you could design a program that, what you could save. Let's say revolving door with patients that are readmitted for diabetes out of control, you know, within a few days of being discharged. Maybe utilizing the keeping track of referrals to other specialties like cardiology, vascular surgery, nephrology, those can really help, uh, uh, support a salary for, you know, a very good endocrinologist. Perhaps a fellow coming out of their practice that likes hospital medicine.

So. It's all about money. You know that,

[00:25:21] David Klonoff: um, Michael Zilberman at Johns Hopkins in Bethesda, uh, suburban hospital has created a endocrinologist hospitalist program, which not only delivers excellent care, the type that Dr. Edelman's talked about, but has saved money for the Johns Hopkins system. And they're expanding it to other hospitals.
And the way he saves money is first, he's been able to show that there are fewer of these expensive complications when there's an endocrinologist on the case. But second, perhaps surprisingly, the endocrinologist sees patients and is able to bill for those services. And often it's providing care that just wouldn't be provided.

So the combination of money saved plus money brought in through billing far exceeds the cost of the endocrinologist.

[00:26:10] Bruce Bode: Uh, also going further, clearly you need to have a, either a diabetologist, an endocrinologist that knows how to manage diabetes, and then you higher NPs and PAs. In, in our system, we have three full time PAs and nurse practitioners, and we have one endo. We see about 90 patients a day in our hospital. We're a tertiary hospital.

We have transplants. We, we have a lot of, uh, uh, cardiovascular surgery and everything else, and it works very well and, and the hospital doesn't have to pay for it. So right now, it doesn't have to pay for it cause where we're charging our, whenever we see a patient, we, we charge them about 30%. Have no, have no, uh, insurance. And we, and we just write it off you know, not, nothing you can do.

 But it works. But, but the, but the one thing you need, we can't do it without algorithms. You have to have algorithms. You have to have IV insulin without question. We have 15, 18 people every day on IV insulin. You can't manage it with, you know, in, in the ICU, you need IV insulin.. It's very, and even on the floor, we use the IV insulin for DKA or, or any, any other major problem that, that you can't get them to normal.

Fortunately you, what you want to do is prevent all low blood sugars and you, do, you want to prevent anybody getting readmitted. And if you keep getting readmitted, what we're doing now, is we're giving them insulin for free and teaching and following them for up to a month to make sure they don't, mean, they don't come back and into the hospital.

That's a big problem. They, they, they go out, but then they don't have any insulin, they don't have the insurance and the next thing they're back in the hospital in five days, even two days.

[00:28:08] Steven Edelman: One day.

[00:28:10] Bruce Bode: One day. Yeah.

[00:28:12] Robby Booth: And Dr. Bode, you mentioned, you mentioned algorithms. I think it's particularly important when it comes to CGM data and you think about, you know, operationalizing that in the hospital and having to make sense of, of all of that.
I know it's something that we're working on and, you know, we hope to be ready to, uh, to support CGM data in the hospital once it's available. Um, but uh, definitely, definitely something to think about. Dr. Edelman, you have a big fan in the audience, uh,. They say I am a big fan of TCOYD. Type one myself. Um, do hospital clinicians have any resistance to switching to an automated, uh, dosing system,the AID, for the inpatient setting?

[00:28:53] Steven Edelman: Yeah, I, well, hello, whoever you are. Um, I, I think that, unfortunately there are a lot of ignorant physicians that do not know about hybrid closed loop AID systems. And once again, you know, you asked me in the very beginning, what do I tell patients? I never got to that part of the answer, but you, you have to be your own advocate.

You have to push for keeping, uh, staying on the equipment that has kept you under good control. And I do think that with uh good communication skills, uh, getting the physician and the teams together and showing them how these systems work, you can not only educate them for future patients that come in, but also have them be. Uh, all,allow you to use your devices while in the hospital. So it's, you know, the problem is there's just a lot of ignorance out there and it's, it's up to all of us to sort of educate them.

[00:29:50] Robby Booth: We do have, uh, we have another question, maybe Dr. Bode, you want to address this one, um, about, uh, you know, what the future may hold for use of, uh, oral antihyperglycemic medications in the hospital? Um, a lot of new research coming out, um, suggesting the potential for DPP-4s um, and mild, mild hyperglycemia, and, uh, the cardio renal benefits for SGLT2s that are being looked at for, in particular, cardiovascular surgery patients. Um, but of course, you know, um, this makes it a little bit more complex to determine which patients are appropriate for which therapy and, um, any thoughts on what the future might look like in terms of, uh, hospital use of these medications

[00:30:39] Bruce Bode: Yeah. So uh, Guillermo had developed, uh, using DPP-4 inhibitors in the hospital. Once, uh, when he started his, they normally start with MDI, and then if it looks like they were type 2, and they're coming down and they're managing it, they don't need much mealtime insulin, they'll give him something like Januvia and then continue the basal. And they showed it was relatively effective in clearly type 2 that are fairly easily controlled, and that made it easier instead of giving injections, uh, per each meal. Um, and then now, recently the SGLT2s have coming in and the reason why they're coming in is because they really prevent, they, they treat heart failure. That's their main thing. They also protect the kidney.

Uh, the only negative problem with SGLT2s in the hospital is if you, and if you're in NPO and you, aren't getting full fluids, you, you can easily get ketonic. You can cause acute kidney injury and there's a disaster there. And so if you're gonna ever use SGLT2s, you've got to make sure that if you're not, if you're not eating your NPO, you have to stop it immediately. And then you probably might have to give, give, uh, IV fluids. So the reason, what we do is when they're starting to leave, um, in the next two, one or two days we, we will start in the SGLT2 where, whether it's for preventing heart failure or if it's, uh, protecting the kidneys, either one, um, those are the reasons you're using SGLT2s.

The other thing that would be very good because, most of these people coming in the hospital with diabetes are obese, and what they really need to go home on is a GLP-1 that has been proven to be effective to decrease cardiovascular events, especially strokes and heart attacks. And those should be also considered going,going home on that.

Uh, you could also use it in the hospital, but not many have done that at this time, because most people have trouble coming out of surgery and they can't eat much. And they have nausea in starting a GLP-1 that also has symptoms of nausea and vomiting. You, you want to really start slowly and, give it when they're able to eat.

[00:33:12] Steven Edelman: Yeah. And I'll just add one quick thing, you know, is the hospital the best place to get education for, uh, risk mitigation against DKA as an outpatient? You know, I've heard people say, it's it's too, it's not the right place for learning, and this is something obviously that's pretty important.

[00:33:31] David Klonoff: A technology that we're going to see in the future will be continuous ketone monitoring. It's now possible to put a wire, and, under the skin that looks like a continuous glucose monitor wire, that measures beta-hydroxybutyrate, which is a ketone. Uh, very little, uh, clinical work has been done to date and it's certainly not FDA cleared, but I think that people who were at high risk of ketoacidosis, be they people with recurrent DKA or people using a drug like an SGLT2 inhibitor, uh, people like that will probably eventually be encouraged to use a continuous ketone monitor.

[00:34:08] Steven Edelman: David, you're always ahead of your time. How do you do that?

[00:34:19] Robby Booth: Uh, Dr. Klonoff, I do want to follow up, but we have more questions coming in about telemedicine. And I do remember at, um, now at a couple of the Diabetes Technology Society meetings, um, we've seen folks present, uh, about doing remote inpatient consultations and, um, you know, have you, uh, have you seen any, any activity on, um, in regards to that and, and CGM and what folks are, are thinking about?

[00:34:45] David Klonoff: Uh, USCSF has a very good, uh, in-patient, uh, remote monitoring system that was created by Dr. Robert Rushakoff, and he's published this and I think we'll see other hospitals doing it. Uh, more and more medicine is being handled remotely. If it's a, a communication between a doctor and a patient, that's telehealth, and if it's review of data that a patient is wearing from a sensor, that's digital health. And, um, we're entering the, the digital era. The whole world is becoming digitalized, which means that information is not so much by something that we can measure with our eyes or with a ruler, with our hands, but it's being measured electronically.

That's going to get into the hospitals. So I do think that, uh, a lot of the information that requires a doctor to be on site to look at will lend itself to, uh, remote monitoring, but something I want to say about remote monitoring also. You know, we're, we're here to talk about software, that's one of the purposes of this meeting.

And I think that if you run a hospital and you want to set up your own software, you have to be aware that there could be security risks. You've got to have a good IT person who has the time, not just the knowledge, but the time, because the, IT, people are very stretched with lots of devices. And you have to, uh, make sure that it's constantly checked.

 Uh, with commercial software, the downside is you spend a lot of money on it. The good side is you save a lot of money, but also you have a, a dedicated IT team looking at it and if there's changes that are necessary for the software, they automatically push those into the system. When I hear about a Hospital A borrowing software from Hospital B, I'm concerned.

What if, uh, there's some problem with Hospital B's software and Hospital A doesn't know about it, who's liable? Uh, when you, when you purchase software from a commercial vendor, the vendor is liable. Hopefully you don't see those problems because the vendor generally has much more dedicated staff working on maintaining that software than a university hospital does.

Um, one of the big problems that the, uh, that the hospitals have, is, uh, making sure that all the devices are on the network. Uh, at many universities, I mean, I can take, including UCSF, uh, scientists will come up with a device that helps them in a research and put it on the UCSF network and don't tell the IT team. If there's a problem with that device, it can be risky for the whole team.

So what I would say is that if you're using software that's homebrewed, make sure that your IT team is checking it regularly.

[00:37:31] Robby Booth: Yeah. No, thank you. That's a very good point. Um, we do, uh, we talked a lot about the future of diabetes management at the hospital. Um, you have a question. What is, what is something that hospitals are doing now that they won't be doing in 5 or 10 years? And I ask you to think carefully, because we said 10 years ago, that sliding scale was going away.
Uh, and we're still, uh, but what is, what is something you think that hospitals are doing now that they won't be doing?

To be optimistic maybe.

[00:38:11] Steven Edelman: Gosh,

[00:38:16] Bruce Bode: Unfortunately, I think I'm not sure how much change will happen unless CMS forces it, which I think they will. I think, I think you'll have better algorithms coming in to help manage diabetes. There's no question about that. And and that's going to be there and you need to pay attention. And also you want to make sure if they, if they do have poorly controlled diabetes in the hospital, you need to manage it and make sure that they don't come back in, in the first 30 days cause otherwise you're, you're gonna get, you know, obviously that's a penalty. So I think you need, uh, obviously, uh, using algorithms and making sure when you go home that, that you at least have the, the methods to manage your diabetes, whether it's insulin, meal dose or basal. Is it going home on a sensor even to make sure, because they aren't going to prick their finger and then you could follow them remotely.

That's hopefully the future. It's not there now, but I think in the future, you should be able to control everybody in the hospital very easy with, uh, systems, but it's um, but it's, but it's going to be, it's going to be algorithms. They have to be FDA, FDA approved, and CGMs have to be approved and so on.

[00:39:45] Steven Edelman: Yeah. I, in 10 years, maybe that we will not have fingerstick measurements in the hospital anymore. Everyone that comes in, will get, uh, inexpensive, accurate, easy to use CGM that integrates with the EMR. How's that?

[00:40:03] David Klonoff: Um, I agree with, uh, both Dr. Edelman and Dr. Bode. What I would say is that we won't be seeing as clear of a distinction between the inpatient and outpatient environment.

Uh, more and more we'll have value based medicine, which means that the healthcare system is responsible for the patient, whether they're in a building called a hospital, or whether they're in another building called their house. And they will provide, the, the system will provide excellent care for people who have been recently discharged.

We may not even see a 30 day readmission issue because the hospital is on the hook, whether the person comes back in one day or 60 days. And, uh, we're just at the early stages now of seeing, uh, healthcare systems develop plans to monitor people that have been recently discharged to prevent readmission.

But I think that's going to become really important. And these people who are discharged will get very close care as much as they need to keep them out of the hospital. Not just at 30 days, but indefinitely.

[00:41:06] Robby Booth: Yup.

All all very good. I, uh, I think you're onto something. Uh, the, uh, I think. Hopefully, uh, you know, if we look at 5 to 10 years, most hospitals will be using an EGMS, um, as well, because as you mentioned, you have the complexity with CGM, um, different therapies, um, and just as we get more complexity, um, it just really drives home the point that, um, you do need, uh, you know, an FDA cleared, uh, decision support, uh, solution to help you manage all of the therapies.

Um, so, uh, it's getting more and more complex.

[00:41:44] David Klonoff: I think another trend that we're starting to see is direct to consumer telehealth. What this means is that you can sign up with the plan, maybe it's Amazon, maybe it's a virtual diabetes clinic, that is strictly virtual. It doesn't have a brick and mortar location in your neighborhood.

And people increasingly be getting their care from these places. We know that in retail, people buy products now electronically, not from a local store, but from an electronic virtual store. I think we're going to see healthcare do that. And, uh, healthcare professionals at so-called brick and mortar institutions, be they universities, or doctor's offices or hospitals, are going to have to compete and deliver just as good or better care.

The, in the established facilities have an advantage because there are times when the patient wants to talk to their doctor in person, the virtual programs can't do that. On the other hand, the virtual programs tend to invest in very good electronics, very good systems and databases and in some cases, even better than what the local hospitals and healthcare can deliver.

So I think, I think we're going to see a shift. And just like in many places, uh, uh, Uber was putting, uh, taxis out of business and the taxi drivers ended, end up now working for Uber. We could see that direct to consumer telehealth companies may start putting certain medical practice out of business just as we see shopping centers closing because of e-commerce.

And it could be that some of the healthcare professionals now, who are either independently employed, or who work for a local organization, may end up eventually working for a large virtual network. So I'd keep, keep an eye out on that.

[00:43:27] Steven Edelman: I'm going to get a job at Amazon, David. When they start doing that.

[00:43:30] David Klonoff: They've started getting into healthcare bit by bit.

[00:43:35] Robby Booth: Right. Any, any final note? I know we're running short on time. They're giving me the signal.

All right. So, uh, it looks like we are coming up on time. So I think we can, uh, we can close it off here. And, uh, of course I wanna thank, uh, Dr. Bode and Dr. Edelman and Dr. Klonoff for taking the time to be here. And, um, I think I speak for everyone when I say this has been a very interesting conversation and you've given us all a lot of good insight, um, about the future of glycemic management in the hospital.

Um, and, uh, on behalf of Glytec, I'd like to also thank the attendees for joining today's session and hope you enjoy the rest of the conference. All right. Thank you.

[00:44:26] Steven Edelman: Thanks everyone. Appreciate it.

[00:44:28] David Klonoff: Nice to see you both. Bye Bruce.


[00:44:30] Bruce Bode: Bye Steve.