Lawrence General Hospital

Eduardo Haddad

This may appear to be intuitive to every health care provider but it is in fact an elusive goal not necessarily discussed or much less emphasized on day-to-day management of diabetes at the primary care sites.

Cardiologists, vascular surgeons, neurologists and nephrologists are usually engaged at a later stage when organ damage has already occurred and may be permanent.

Endocrinologists and diabetologists are in short supply and tend to be referred the hard to control patients in need of better blood sugar control and frequently type 1 diabetics or type 2 patients of longer vintage.

This leaves a vast population of individuals who carry a clear and powerful risk for the development of vascular disease with manifestations such as stroke, heart attack, loss of limb kidney failure and premature death.

We are now in a new era with pharmacotherapy available and validated in randomized studies as being capable of altering the trajectory of these very poor outcomes including agents that stimulate the action of upper intestine peptides called incretins, agents that impede the reabsorption of glucose in the renal tubule and a specific blocker of the mineralocorticoid receptor.

In my view the digital medical record should serve as an instrument to make use of these agents' part and parcel of the discussion around sugar control and a mandatory reminder of missed opportunities regarding interventions solely aiming at improved outcomes sometimes dissociated from blood sugar control.

Primary care providers are inundated with too much data as they are the repository of information coming from all sources in formats that are not at all conducive to finding the main message. The end result is to concentrate on what is palpable and address the more immediate needs of the patients.

Patients alike fall trap to blood sugar control being the main goal not recognizing that they are only the tip of the iceberg in type 2 diabetes. It is all about the A1C!

This topic should be very familiar under the umbrella of artificial intelligence, however here it would be more like wearing the right prescription glasses to correct a refraction defect that does not allow you to see far.

There are many formulas validated by specialty societies that will calculate cardiovascular risk. Current suggested use is for the prescription of statins for lipid control.

Type 2 diabetes as well as chronic kidney disease are multipliers of cardiovascular risk of greater magnitude than lipids alone but they are only taken into account as variables in some of those formulas.

It should be the goal of the digital record to remedy this.

There is no disagreement in medicine regarding the importance of those metabolic derangements.

A graded color bar of a numerical score equivalent could be derived from diagnostic codes validated by the principal provider of care with continued enhancement as patients progress longitudinally in their lives accumulating additional risks.

The capture of an aggregate of BMI, fasting blood sugar, microalbuminuria and blood pressure should be fertile ground to start building a foundation of risk edifice with additional structures rising from it as they become available in the medical record.

This would make the invisible a glaring red or orange facilitating care in the primary setting and also alerting patients of their risks allowing time to intervene before specialty care becomes inevitable or worse before an irreversible complication occurs. We are now reliant on informatics more than ever, no longer conflicted about its value or labor intense tool simply used for documentation. It is time to elevate it to the level of your additional brain, always there to remind you of the fundamentals of optimal medical care.