In the past, health care providers have often been puzzled by how best
to optimize treatment for diabetes and improve diabetes self-management for
patients. Now, with the exploding popularity of smartphones and increased
Internet access, some might say: “There’s an app for that.”
“Any software application that can be used on a mobile phone is now
being termed a mobile application. The advantage of mobile technology is that
it is anywhere and everywhere and is becoming ubiquitous to all socioeconomic
groups and all geographies,” Malinda Peeples, RN, CDE, vice
president for clinical advocacy at WellDoc, told Endocrine Today.
In the realm of diabetes care, this ubiquity allows providers to expand
their sphere of influence and maximize the results of their care, according to
Charlene C. Quinn, RN, PhD, assistant professor at the University of
Maryland School of Medicine.
Charlene C. Quinn, RN, PhD, of the University of Maryland
School of Medicine, said emerging research provides evidence that mobile health
interventions improve patient diabetes care.
“Physicians and nurse practitioners don’t have time to do
lifestyle coaching when they are seeing a patient. While these tools and
technologies cannot replace providers, they can serve as an adjunct to the
clinical therapies that they are providing,” Quinn said in an interview.
Mobile technologies, however, are only one area of exploration. Many
health care systems are now creating novel ways to incorporate Internet
technologies into clinical practice. For instance, some offer online patient
portals that provide patients with detailed information about previous visits
to their physicians, their glucose levels and more. Others are using websites
such as Skype to conduct counseling sessions, and telehealth remains popular
for diabetes education for patients and providers. Many manufacturers are
taking advantage of widespread connectivity to improve their devices, such as
allowing patients to download data from equipment onto computers.
Yet, integrating these new tools and technologies presents unique
challenges. There are reimbursement and regulatory issues, as well as concerns
about patients’ ability to access and use computers and cellphones or
smartphones. Organization, time and training are concerns for busy providers as
well, according to experts interviewed by Endocrine Today.
Even so, in the past few years alone, many providers have gone
paperless, going to texting and established web-based services.
“Look at all of this innovation and how far we have come in
medicine,” Marcia Draheim, RN, CDE, past president of the American
Association of Diabetes Educators and president of Draheim Dimensional
Presentations, said in an interview. “I have every confidence that we can
integrate these technologies into our practices. We just have to make up our
minds to do it. And we will.”
A wide variety of tools fall into the category of mobile health.
Development ranges from applications that provide health coaching to those that
focus on diagnosis, treatment and mitigation of the disease, according to
“Mobile health, or mHealth, is a term used for the practice of
medical and public health supported by mobile communication devices,” she
said during a presentation at the 2011 AADE Annual Meeting & Exhibition in
August. “It is a segment of e-health that includes applications that
collect community and clinical health data; deliver health care information;
and provide real-time monitoring of patient data and real-time direct
According to Quinn, these features can greatly improve existing
cornerstones of diabetes management, especially enhanced data collection.
“Patients have been doing logbooks for many years, but they may not
consistently collect information and the information also isn’t
consistently available to physicians or nurse practitioners, so it has not
really been useful for the providers or the patients,” she said.
In the same vein, Donna Tomky, MSN, RN, C-NP, CDE, current
president of the AADE, said these technologies offer patients information to
give them insight into management of their disease. Downloading the data from
glucose meters, for instance, allows patients to organize data and distinguish
patterns in their blood glucose levels. Other applications, such as Lose It! or
the Atkins Carb Counter, which are available through Apple’s iTunes store,
log caloric intake and physical activity and help patients track their diet and
exercise more closely.
“In the broadest sense, these technologies can really change our
behaviors,” B.J. Fogg, PhD, director of research and design at
Stanford University’s Persuasive Technology Lab, told Endocrine
Today. “They can help us create new habits in our lives by
triggering us to do new behaviors at the right time, often enough that those
new behaviors become habits.”
Nevertheless, consolidating this information alone may not lead to
behavior change, Peeples said. “We need to be able to take that
information, analyze it and present it to both the patient and the provider in
a distinguishable or an actionable way by providing reports, action plans or
In addition, Peeples said patients often leave physicians’ offices
with treatment plans that may be difficult to implement in their daily lives.
Taking the treatment plan and translating it into prompts for the patient
through messaging or reminders can supply the patient with the support needed
for successful diabetes self-management.
Another important aspect of mHealth, Quinn said, is the enhanced
connectivity between patient and provider. Neal Kaufman, MD, MPH,
founder and CEO of DPS Health, told Endocrine Today that Internet
services, mobile applications and text messaging aid in delivering the help,
support and information that a specific patient requires at that moment.
Furthermore, using cellphones or smartphones may be the best way to
reach a variety of populations. Peeples said many people, despite economic
circumstances, own cellphones or smartphones, which may have worldwide
implications as well.
“The mobile phone is becoming many people’s first
computer,” she said. “The scalability for this is not only domestic
— it is global for improving access and outreach. It offers an opportunity
to democratize health care and make it more available to everybody.”
A major benefit of mHealth and web-based programs is the ability to
tailor care to the individual patient, according to Draheim. First, she said,
these new platforms allow patients to choose how they would like to receive
“For the first time in our history, in the last few years, we have
actually been providing diabetes education to four different generations at one
time,” she said. “Of course there are the traditionalists, but many
Gen Xers, Millennials and the generations to come are going to be
extraordinarily tech-savvy and they are going to want information provided in
Draheim also said technology affords providers the opportunity to give
diabetes education in different formats that may be more effective for certain
patients. For example, written information could be provided on the Internet,
but a patient could click on an icon that reads the information aloud. This
system also easily allows translation into various languages so that
non–English-speaking patients could access the same information in the
same location. Or, also, physicians and diabetes educators could list
frequently asked questions to refer patients to other reliable resources if
they have questions about their diabetes care.
“If it was appropriate, we could even insert rich media so that you
could have an animation that would actually show or demonstrate to the patient
what he or she has just read,” Draheim said. “Also, if the
information is meant to have an emotional impact, music or other elements could
be incorporated as well.”
What is even more exciting, she said, is that it is available at any
time in any place. Patients can easily download this information or visit the
website using a computer, a smartphone, an Internet pad or any other form of
mobile technology. Moreover, certain items, such as quick response (QR) codes,
expand the amount of information that a person can receive. Because most
cellphones have cameras, a patient can easily scan a QR code placed on a piece
of paper or brochure and be taken to a website or link with more information.
In another sense, patients who are unable to receive diabetes education
in person may benefit from increased options for access, according to Draheim.
Often, patients work during the day and are unable to attend all classes
required for diabetes education. Therefore, offering the information online
through a distance learning program may be more convenient. She said some
people still may prefer to physically come to class or visit the physician, but
providing a patient with options increases the likelihood of success.
Kaufman said technology may eventually be able to identify which
interventions are most effective before initiating therapy. Although this is
not yet a reality, an instrument that accounts for a patient’s various
characteristics, such as age, sex, socioeconomic status, BMI or style of
learning, could modify the patient’s experience and aid physicians in
selecting the most effective course of treatment early on.
“These are the things now that we have to appreciate and start
looking at and thinking: Who is our consumer, what are their needs and how do
they want their information presented to them,” Draheim said.
Although these technologies present exciting opportunities, many
providers question their value. Because mobile health is a relatively new
field, few studies have examined its efficacy in depth. Nevertheless, research
In a 2008 study published in Diabetes Technology &
Therapeutics, Quinn and colleagues assessed HbA1c levels of patients who
used cellphone-based software (WellDoc) that provided real-time information on
patients’ blood glucose levels; displayed medication regimens; used
hypoglycemia and hyperglycemia treatment algorithms; and requested additional
data required for evaluation of diabetes management. Results indicated better
results in the intervention group, with these patients experiencing a 2.03%
decrease in HbA1c levels compared with a 0.68% decrease among control patients.
The health care providers of intervention patients also said the system
facilitated therapeutic decision-making.
In the September issue of Diabetes Care, Quinn and
colleagues reported similar results for the Mobile Diabetes Intervention Study,
one of the first cluster randomized clinical studies of mobile health reported
to date. The intervention included mobile- and web-based self-management
patient coaching and offered decision support to providers (WellDoc).
Automated, real-time educational and behavioral messaging was delivered to
patients via cellphone according to blood glucose values, diabetes medications
and behaviors. After 12 months, HbA1c levels decreased by 1.9% in the
intervention group compared with 0.7% in the usual care group, according to
information in the study.
Michael A. Harris
Likewise, preliminary results from another study being performed by
Michael A. Harris, PhD, director of psychology in the Child Development
and Rehabilitation Center at Oregon Health Sciences University, using Skype
— the free website that allows people to communicate over the Internet via
webcam — to replace or supplement clinic visits among adolescents with
diabetes has also produced positive results. Compared with adolescents
receiving face-to-face care in a clinic, the patients using Skype had
comparable improvements in diabetes management and metabolic control, Harris
said at the American Diabetes Association’s 71st Scientific Sessions in
As this area of health care grows, more studies are being conducted and
many are still in progress, according to experts interviewed by Endocrine
Today. For example, the AADE has recently partnered with the US
Department of Health and Human Services’ Office of Minority Health and
AT&T to evaluate the use of mobile devices to deliver diabetes
self-management training within an underserved minority community in Dallas.
“There is an emerging science of mobile health, providing evidence
that mobile health interventions work. Providers and patients will need to know
not only if a mobile intervention works but also how it works,” Quinn
Although technology has the potential to revolutionize the health care
system, the rapid development and introduction of these new tools and resources
has left many trying to catch up, including the FDA. The agency recently issued
guidance addressing the possible regulatory issues related to mobile health
applications. A major question is determining at which point a mobile app or
program becomes a medical device. Currently, the FDA is proposing that mobile
apps that connect to a FDA-regulated device or an application that transforms a
mobile platform into a medical device, such as an app that turns a smartphone
into an electrocardiogram machine, require review. The agency, however, will
not finalize the guidelines until after the public comment closes on Oct. 19.
Reimbursement remains many providers’ chief concern, Kaufman said,
because mobile health technologies are not yet considered reimbursable
expenses. Nevertheless, as research confirms their benefits, insurers may
likely realize that these tools actually save money.
“There is major return on investment when you help people improve
their behaviors, such as quitting smoking, losing weight, practicing safe sex,
and so on, because they will become healthier. So, currently, the problem is
that mobile health isn’t paid for, but in the future, it will be,” he
Quinn said she is concerned about literacy as well. As more information
becomes available to patients through patient portals, electronic health
records or logbooks, it will be essential that providers ensure that patients
understand what they are reading. Otherwise, they could easily misinterpret
facts or data.
According to Tomky, the digital divide is an emerging issue. Although
many providers are embracing these technologies, others have difficulty
learning to use an application, program or system or figuring out how to
implement it effectively into their practices. In addition, some patients may
be reluctant to use technologies in which they are unfamiliar. Moreover, even
though cellphones are commonplace, some patients may not be able to keep up
with payments. If mobile health becomes standard of care, it will be more
challenging to maintain a connection with these populations, she said.
Despite these problems, Draheim said addressing these issues as they
arise is part of progressing to the next level in health care. Instead of
focusing on the current limitations, providers should continue to think outside
“We shouldn’t think about how we can’t do something
because it is difficult to learn or it is too much money,” she said.
“Instead, I say, ‘Be visionary.’ We have the science of health
care, but hidden in the vision, that is where the art of health care comes
from. And I believe there needs to be a balance between the art and the
science.” – by Melissa Foster
For more information:
- Harris MA. Technology and behavior change across lifespan.
Presented at: the American Diabetes Association’s 71st Scientific
Sessions; June 24-28, 2011; San Diego.
- Kaufman N. F31. Presented at: the American Association of Diabetes
Educators Annual Meeting & Exhibition; Aug. 3-6, 2011; Las Vegas.
- Quinn CC. Diabetes Care. 2011;34:1934-1942.
- Quinn CC. Diabetes Technol Ther. 2008;10:160-168.
Disclosure: Drs. Fogg, Quinn and Kaufman and Mses. Draheim and
Tomky report no relevant financial disclosures. Ms. Peeples is an employee of
Where should funding for
technology in diabetes management be distributed?
Funding in diabetes prevention and management should go toward mobile
technology and personal health records (PHRs) that support collaboration of
consumers/patients with clinicians to improve health. Several examples of
innovative research on these technologies from Robert Wood Johnson
Foundation’s Project HealthDesign (projecthealthdesign.org) are:
- A computer-based personal health application for diabetes
self-management that provides customized recommendations.
- A chronic disease medication management system that uses a cellphone
application for people with diabetes to record their blood glucose levels,
blood pressure, diet and exercise, and quickly upload these readings via a
cellphone to their health care provider.
- iN Touch: an iPhone/iPod Touch application for youth with obesity and
depression to track food; exercise; mood and socializing; conduct analysis; and
communicate with a health coach, all in real time, and share summary reports
with their physicians and nurses.
While electronic health records (EHRs) are important for aggregating and
analyzing data for clinicians, they are not adequate for collecting data from
and delivering data to consumers/patients. The EHR is most often populated with
data from labs, clinics, physician offices and hospitals but not from patients
themselves. However, life is lived in between clinical visits. A comprehensive
data set for preventing and managing diabetes, which might include blood
glucose, food, exercise, weight, medication use and mood, is produced on a
daily basis by patients. Data are also required over time so that patients can
see patterns and trends and adjust their self-management strategies. The
ability to capture and review information in real time also allows clinicians
to offer guidance to patients and alter treatment plans quickly. Mobile
technology can be cost-effective to develop, making mobile a good platform for
designing targeted data collection applications, integrating that data in real
time with PHRs and EHRs, and delivering targeted interventions. Funding for
mobile and PHRs would help us close the gap in data, communication and
collaboration between consumers/patients and clinicians to improve the
prevention and management of diabetes.
Katherine Kim, MPH, MBA, is professor in residence at the
Health Equity Institute at San Francisco State University and principal
investigator for iN Touch and Project HealthDesign.
Disclosure: Ms. Kim reports no relevant financial disclosures.
Robert A. Vigersky
Efforts and funding for technology in diabetes management should go
toward improving the provider’s ability to take care of the patient. I am
not convinced that giving patients better technology is going to overcome the
basic issues regarding adherence to diet, taking medication, exercising and
performing blood glucose testing as recommended. These are all issues that are
integral to the psychology of living with a chronic illness, the denial that is
often associated with it and the lifestyle choices people make.
On the other hand, when providers see patients, they not only have to
deal with these psychosocial issues, but also must consider various medical
issues related to diabetes, as well as select the best treatment from a wide
variety of medications. At the same time, during this short visit, providers
also have to address patients’ other health complaints that often arise,
such as, ‘Oh, by the way, I have chest pain or a sinus problem, and then
the diabetes-related issues get put on the backburner. All of these contribute
to management inertia resulting in a failure to intensify hypoglycemic therapy.
Various technologies could help tremendously with this problem by creating
efficiencies in the care setting. These include decision support systems that
integrate relevant data from the laboratory, the pharmacy, a patient’s
medical history and blood glucose data uploaded from the patient’s home or
cellphone to the provider that would help guide the decisions that inevitably
have to be made.
On the patient side, technology that would offer some type of computer-
or cellphone-based decision support based on blood sugars and lifestyle
behaviors may be helpful. Nevertheless, only a minority of patients will pay
attention to it. In many respects, my experience is that the patient who takes
advantage of these kinds of systems is already someone who is motivated and
knows what to do. The ones who are not motivated, however, most likely would
never use these programs or systems, regardless of how exciting, effective or
easy to use they are.
Robert A. Vigersky, MD, is colonel in the medical corps of the
US Army and director of the Diabetes Institute of the Walter Reed National
Military Medical Center in Washington, D.C.
Disclosure: Dr. Vigersky reports no relevant financial