TY - JOUR
AU - USA, Jordan E. Pinsker, MC
AB - ABSTRACT The majority of telemedicine interventions for diabetes have failed to show objective improvements in outcomes. We describe the Real-Time Diabetes Monitoring System (RT-DMS), which augments our successful telemedicine system for pediatric patients with type 1 diabetes by allowing automated uploads of glucometer readings. The addition of automatic transfer of glucometer readings enables RT-DMS to improve patient compliance and increases monitoring by physicians. The system is scalable for use by both children and adults with all forms of diabetes and has the potential to significantly improve clinic workflow, allowing RT-DMS to serve as a model for managing chronic disease using telemedicine. INTRODUCTION Caregivers for pediatric patients with type 1 diabetes must be able to communicate effectively with their physician to facilitate quality medical care. We have previously reported on the effectiveness of the Pediatric Diabetes Education Portal (PDEP) website at our institution, showing that users of the PDEP website had a significant improvement in Hemoglobin A1c when compared to nonusers.1 PDEP is a secure, Health Insurance Portability and Accountability Act (HIPAA) compliant, asynchronous (store-and-forward) website for pediatric diabetic patients and their families that improves communication with their physicians. PDEP allows families to log on from home using a computer or smartphone, review clinic testing results, post comments and ask questions of their diabetes care providers. Patients and families can also review educational materials on the web site. A major limitation of PDEP, however, is that it requires patients to manually type in or upload scanned copies of their blood sugar readings for later review. Because of this, a significant amount of data captured by the patient (glucometer readings) is never transferred to the physicians for review. To address this, we have now deployed our Real-Time Diabetes Monitoring System (RT-DMS), an addition to the PDEP website that allows for automated uploading of glucometer readings to help pediatric patients with their diabetes care. Unlike previous systems described in the literature which required telephone calls, use of computer modems, potentially difficult interactions with websites, or downloading of devices that are sometimes challenging to connect to home computers,2,–5 RT-DMS allows for transparent uploading of glucometer readings with minimal patient and physician effort. THE REAL-TIME DIABETES MONITORING SYSTEM With RT-DMS, patients were given a MedApps HealthPAL device (MedApps, Scottsdale, Arizona) to connect to their glucometer as part of an institutional review board approved project at Tripler Army Medical Center (TAMC). The HealthPAL is a Food and Drug Administration approved device that plugs into a glucometer and was preconfigured for each patient's PDEP account. The device collects glucometer readings and securely transmits them via the cellular phone network to our existing PDEP website in real time. The HealthPAL uses 128-bit secure socket layer encryption and its transmissions meet all administrative requirements for full HIPAA compliance. Configuration of usernames, passwords, or other settings is unnecessary. Instead, the device is preconfigured and linked to the patient's PDEP account by the medical team. After transmission from the HealthPAL device, RT-DMS saves transmitted glucometer readings and aggregates them for posting on a weekly basis to PDEP, so there is no required time to plug in the device, emphasizing ease of use. A schematic representation of the system is shown in Figure 1. FIGURE 1. View largeDownload slide Schematic overview of the RT-DMS system. FIGURE 1. View largeDownload slide Schematic overview of the RT-DMS system. After posting weekly glucometer readings, diabetes care providers are immediately notified by email to log on to the HIPAA compliant, secure PDEP website where they can interpret the readings and send a response to the patient. As shown in Figure 2, the parents of a 5-year-old type 1 diabetic patient plugged in the HealthPAL device to their son's glucometer at home. No other intervention was needed, and now the patient's glucometer readings are automatically ready for review by the pediatric endocrinologist and appear as a detailed table on the website in the patient's PDEP account. The endocrinologist is able to respond, and the family is automatically notified by email to log on and read the response. One week later, new readings are automatically uploaded again. The parents, who were resistant to write down glucometer readings and who had previously been nonusers of the PDEP website, now become active participants and begin to post comments (Fig. 3). The physician response can refer to educational materials posted on the website, allowing patients to continually review relevant educational material as they encounter new problems. FIGURE 2. View largeDownload slide Example of a provider responding to the weekly automated glucometer upload. FIGURE 2. View largeDownload slide Example of a provider responding to the weekly automated glucometer upload. FIGURE 3. View largeDownload slide Example of a family and physician discussing the automated glucometer upload. FIGURE 3. View largeDownload slide Example of a family and physician discussing the automated glucometer upload. DISCUSSION Automated transfer of glucometer readings allows patients and their families to effortlessly engage their diabetes care provider with objective data for review. Although many systems have attempted to link medical devices to “health vaults” of medical information online, patient use was often limited because of difficulties sending data to the system and the lack of readily available feedback once the data was uploaded. In fact, previous studies show regular communication and feedback are linked to higher use of such systems.6 By linking seamless uploading of glucometer readings to an educational website that can provide patient-specific feedback, we hope to improve patient care beyond what we have shown previously. Although we have not used the system long enough to formally assess the impact of such a device on changing objective outcome parameters of care (such as Hemoglobin A1c or the frequency of hypoglycemic events), we offer a description of RT-DMS to show how it can improve clinic workflow. This is because despite the extensive funding of the development of telemedicine systems over the last few years, results of many telemedicine and mHealth projects have not consistently shown definitive improvements in objective outcomes of care.7,–9 Instead, it has been postulated that the greatest gains may come from simple increases in clinic efficiency and use of time.10,11 Automatic email notification of new postings and the asynchronous nature of the system allows families and providers to post messages at any time they want, with no need to interrupt other activities. For patients using RT-DMS, we no longer have to review faxed or emailed copies of glucometer readings and then call back patients to explain recommended changes in insulin doses, saving time and effort that can now be used elsewhere. And by using billing codes specifically designated by the Department of Defense (DoD) for telemedicine encounters, pediatric endocrinologists at TAMC are able to bill for their time and capture workload using an integrated billing form that connects with the Armed Forces Health Longitudinal Technology Application (AHLTA) workload module. In the case described above, we used an approved Current Procedural Terminology code for collection and review of data electronically transmitted from the patient (Current Procedural Terminology Code 99091, bottom of Figs. 2 and 3). In this case, we were able to bill 1.1 physician work relative value units that are paid to our military treatment facility from the DoD's military healthcare system. All of this done using the integrated billing module in RT-DMS that simply requires checking a box on the web page after submitting comments back to the patient. This improves clinic workflow by decreasing time spent on telephone consults and faxes; time that is often not billed appropriately in AHLTA. It has been our experience that in many cases this type of data is never reviewed between appointments because patients find it too cumbersome to use fax machines or secure email to send the relevant data. In addition, providers using AHLTA do not want to spend the time needed to enter the appropriate codes and supporting documentation in such a cumbersome system that suffers from poor usability. It is also important to note that providers outside of the DoD's military healthcare system may choose to require the patient to return to clinic to review data that could otherwise be easily transmitted electronically. This is because Medicare does not currently reimburse for this procedure code, and will again change reimbursement codes for version 10 of the International Classification of Diseases, making it very difficult for providers to support such a system outside of a military treatment facility. A number of web-based and mobile applications currently exist to enhance diabetes management. The Medtronic Carelink system is one of many programs that allows patients to upload readings from their glucometers and insulin pumps to a centralized database on the internet, where physicians can download the results. Use of the Carelink system has been associated with improved glycemic control in children with type 1 diabetes on insulin pump therapy.12 Yet Carelink and similar systems do not automatically notify physicians that new results are available for review. Instead, they require patients to click on a button and type in their health care provider's email address for each report they wish to send. In addition, they neither offer physicians the ability to send educational feedback to patients, nor do they link to a hospital billing system. These restrictions limit their suitability for use by physicians seeking these features. Similarly, there are now numerous mobile applications available for patients with diabetes. Analysis of these mobile applications has shown that although clinical guidelines widely refer to the importance of personalized education, this remains an underrepresented feature in these applications.13 This is reflected in studies that show improvements in the frequency of blood glucose monitoring in adolescents using mobile diabetes applications,14 but studies that track objective outcomes of care (such as reduced hospitalizations and emergency department visits) note that involvement from multiple parties is needed for successful outcomes.15 Usability issues have limited the adoption of systems designed to integrate all aspects of diabetes care.13 Our system is designed to easily integrate all of these elements of care, with a focus on ease of use for all parties involved. RT-DMS is currently limited by the cost of each HealthPAL device, limiting the number of devices in use. With more devices we plan to expand RT-DMS to serve remote locations served by TAMC, such as other countries in the Pacific Rim that have access to cellular and internet technology but who, otherwise, have limited host nation resources. This will increase access to care for all of our patients. We also plan to add real-time alerts to the system for very high or low glucose readings, with an adjustable per patient threshold for when to alert physicians and family members by either phone call or text message. We are also beginning work on phase 2 of the RT-DMS project, which was recently funded by the Army Medical Department's Advanced Medical Technology Initiative. Phase 2 will allow for a smartphone app to communicate with glucometers and insulin pumps, replacing the need for extra hardware such as the HealthPAL. We hope to deploy this smartphone app for patient use early next year. CONCLUSION By using the cellular technology embedded in the HealthPAL device, RT-DMS allows pediatric diabetic patients and their families to effortlessly transmit glucometer readings to their physicians. Pediatric endocrinologists can more effectively monitor patients and improve the quality of diabetes care with near real-time feedback when needed. We hope RT-DMS can serve as a model for managing chronic disease using telemedicine, and we are interested in joining other centers in expanding our outreach in caring for children and adults with both type 1 and type 2 diabetes. In addition to improving the quality of medical care we can provide, it is our hope that long-term use of RT-DMS and similar systems will show significant costs/benefits related to improved clinic workflow. This will allow us to more effectively advocate for the creation of a standardized national billing model for telemedicine encounters. ACKNOWLEDGMENTS The authors thank Eludrizza Tabisola-Nuesca, RN, CDE and Debora Chan, PharmD for their assistance in setting up the TAMC RT-DMS. Resource support for this project was provided by the U.S. Army Public Health Command (formerly the U.S. Army Center for Health Promotion and Preventive Medicine) through the Health Promotion and Prevention Initiatives (HPPI) program. REFERENCES 1. Pinsker JE, Nguyen C, Young S, Fredericks GJ, Chan D A pilot project for improving paediatric diabetes outcomes using a website: the Pediatric Diabetes Education Portal. J Telemed Telecare  2011; 17: 226– 30. Google Scholar CrossRef Search ADS PubMed  2. Bellazzi R, Larizza C, Montani S, et al.   A telemedicine support for diabetes management: the T-IDDM project. Comput Methods Programs Biomed  2002; 69: 147– 61. Google Scholar CrossRef Search ADS PubMed  3. Biermann E, Dietrich W, Standl E Telecare of diabetic patients with intensified insulin therapy. A randomized clinical trial. 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Corriveau EA, Durso PJ, Kaufman ED, Skipper BJ, Laskaratos LA, Heintzman KB Effect of Carelink, an internet-based insulin pump monitoring system, on glycemic control in rural and urban children with type 1 diabetes mellitus. Pediatr Diabetes  2008; 9( 4 Pt 2): 360– 6. Google Scholar CrossRef Search ADS PubMed  13. Chomutare T, Fernandez-Luque L, Arsand E, Hartvigsen G Features of mobile diabetes applications: review of the literature and analysis of current applications compared against evidence-based guidelines. J Med Internet Res  2011; 13: e65. Google Scholar CrossRef Search ADS PubMed  14. Cafazzo JA, Casselman M, Hamming N, Katzman DK, Palmert MR Design of an mHealth app for the self-management of adolescent type 1 diabetes: a pilot study. J Med Internet Res  2012; 14: e70. Google Scholar CrossRef Search ADS PubMed  15. Katz R, Mesfin T, Barr K Lessons from a community-based mHealth diabetes self-management program: “it's not just about the cell phone”. J Health Commun  2012; 17( Suppl 1): 67– 72. Google Scholar CrossRef Search ADS PubMed  Footnotes 1 This article was presented as part of a larger oral presentation on Diabetes and Telemedicine, BIT World Congress of Diabetes, Beijing, China, June 2012. Reprint & Copyright © Association of Military Surgeons of the U.S.
TI - Emerging Technology in Diabetes Care: The Real-Time Diabetes Monitoring System
JF - Military Medicine
DO - 10.7205/MILMED-D-12-00317
DA - 2013-02-01
UR - https://www.deepdyve.com/lp/oxford-university-press/emerging-technology-in-diabetes-care-the-real-time-diabetes-monitoring-FbmflkU6Z6
SP - 218
EP - 221
VL - 178
IS - 2
DP - DeepDyve
ER -