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New diabetes devices improve connectivity, but patient, provider education needed

New data-sharing capabilities and increased connectivity are rapidly changing the way patients and providers work to manage diabetes, with new devices, applications and cloud-based platforms incorporating the latest wireless technology with the goal of improving glycemic outcomes.

The latest innovations, according to clinicians and diabetes educators, are addressing some key patient needs: smaller, more accurate meters, insulin pumps and continuous glucose monitors (CGMs) that are both user-friendly and interconnected, and new platforms that link data from multiple devices in a single accessible interface.

“The interest in developing technology and the capacity to develop is much, much greater than ever before, and the FDA has made it easier to develop technology in many ways,” Anne Peters, MD, professor at the Keck School of Medicine and director of Clinical Diabetes Programs at the University of Southern California, told Endocrine Today. “Device development has been at the starting gate for a long time, and now, we’re in the race. Things are happening fast, and we’re going to have a lot more.”

Anne Peters, MD, professor at the Keck School of Medicine and director of Clinical Diabetes Programs at the University of Southern California, discusses diabetes technology and the potential to change outcomes. Photo by Mark Harmel. Reprinted with permission.

But with new opportunities to share and receive data from the latest “smart” devices come a host of new concerns, including the potential of overwhelming not only the patient, but the caregiver and even the clinician, with numbers.

“The issue it comes down to with any technology in diabetes ... is that the primary user is the patient, and these are just tools to help them in their self-care,” Howard Wolpert, MD, director of the insulin pump and CGM programs at Joslin Diabetes Center, told Endocrine Today. “But it comes down to the patient using the technology effectively. CGM is a transformative technology, but patients need to know how to interpret the information.”

And, adds Anastasia Albanese-O’Neill, PhD, ARNP, CDE, assistant professor at the College of Nursing, University of Florida, new technology should demonstrate its worth with improved outcomes. “There’s the psychological piece where a patient might think, ‘Hey, I find this data really useful now,’ or possibly the concern of, ‘Uh oh, now I’m a little overwhelmed by all the data I’m getting real-time,’” Albanese-O’Neill said. “But there is the second piece of how do we make that data actionable for the patient? That’s the question of 2016 and beyond: How do we take that data and make it actionable in terms of improving glycemic outcomes?”

Diabetes management experts spoke with Endocrine Today about their favorite new features in meters, pumps and CGM, and the latest applications available to help manage available data safely.

Blood glucose meters

Self-monitoring blood glucose has improved, in part, due to smaller, faster and more accurate meters, with many offering new features, such as Bluetooth connectivity, to wirelessly transmit data. But what may work for one patient with diabetes may not be a good fit for the next.

“The best meter is one the patient will use and can afford,” Albanese-O’Neill told Endocrine Today. “In addition to accuracy, those are the two criteria that are most important. To the extent that the meter reduces the burden of managing diabetes, all to the better.”

For patients who take multiple daily injections to manage their diabetes, Albanese-O’Neill said a meter with a built-in insulin calculator, such as the Accu-Chek Aviva Expert (Roche), can help calculate doses accurately and avoid insulin stacking, which can lead to hypoglycemia. The meter calculates the amount of insulin needed based on the patient’s personal data, the test result, expected carbohydrate intake and past bolus doses, often referred to as “insulin on board.”

Anastasia Albanese-O’Neill

“If a parent is worried and wants an instant connection to a child on multiple daily injections who does not use a [CGM], they might try the Accu-Chek Connect,” Albanese-O’Neill said. The meter transmits blood glucose results to the app on the patient’s smartphone using Bluetooth technology, and auto-generates text messages with results that can be sent immediately to the caregiver’s cellphone.

“Of course, using these devices effectively requires education and clinical support,” Albanese-O’Neill said.

Other meters also offer instant connectivity. Livongo Health offers a cellular-enabled, connected blood glucose meter that uploads readings in real time to the company’s cloud system. The meter sends blood glucose readings along with important contextual information, such as time of day, the type of meal eaten, physical activity information and any symptoms a person may be feeling. The patient receives an instant feedback message and tailored educational messages from the American Association of Diabetes Educators curriculum.

A newer meter not yet available in the United States — the Abbott Freestyle Libre — functions like a CGM without finger pricking and has been in high demand in Europe, Peters said. The device is expected to be available in Canada in the next 2 years.

“The problem with meters is that ... you still have to prick your finger and ... just numbers don’t change anything,” Peters said. “Someone has to tell you what to do with the numbers, and the numbers have to be in the context of what you’re eating and doing. The patient would love to have something they could beam onto the food to figure out how many carbs, to figure out how much insulin to give. The key is trying to integrate numbers into action, so the devices are trying to become smarter, to give some sort of narrative with the data.

Howard Wolpert

“You want the most accurate meter,” Peters said. “Some are smaller, some are bigger, some are pinker, some are greener, but to me, getting the most accurate device is important, and the branded devices, unfortunately, are still more accurate.”

Insulin pumps

Newer insulin pumps in development, such as the Medtronic 640G pump, as well as the t:slim from Tandem Diabetes, are more user-friendly than pumps of the past, Peters said, because of full-color features, informative icons and brightly lit screens. But a pump with the latest features still requires a user who knows how to interpret the data.

“One of the big issues I see is insulin stacking, and the new Medtronic pump — and the t:slim pump does this too — is they show you clearly the insulin that is still on board,” Peters said. “You can see the screen easily at night, so it’s not as hard to look at. But that’s a subtle finding. It’s still just a pump.”

“When talking about the pros of the various pumps, a lot of patients like the touch screen pump on the t:slim,” Shannon Knapp, BSN, RN, CDE, manager of diabetes education at Cleveland Clinic, told Endocrine Today. “They like that it’s brightly lit, easy to read, it’s intuitive.”

Many patients with type 1 diabetes prefer the tubeless and wireless features of the OmniPod, which also offers a controller unit with a built-in meter, meaning patients can carry one less device around, Knapp said. Still, other patients prefer the Minimed, the Animus Vibe or the t:slim G4 because of their ability to connect with CGM.

For patients with type 2 diabetes, patch pumps, which are filled with insulin daily and worn on the body, are an option, Peters said. These offer a fixed basal rate and no electronic interface, so the fine-tuning of doses is not possible.

Shannon Knapp

“The simple patch pumps that they’re developing now will be for a longer period of time, but they’re still a slave to a basal rate,” Peters said. “Whether that’s going to be a game changer, I don’t know. I’ve always liked the idea of something like the OmniPod, but again, it’s about how technically advanced do they become, how does the interface change over time, and how does [the technology] make it easier to interact with the patient?”

“I’m always excited about the future of pump therapy, because it’s always advancing,” Knapp said. “I personally can’t wait to see what is around the corner, from more touchscreen pumps, to more tubeless pumps, to more CGM links.”

Continuous glucose monitoring

CGM devices continue to improve, with interfaces that wirelessly transmit data to smartphones or a cloud-based system. As an example, the Dexcom G5 mobile CGM helps caregivers to monitor their family members with diabetes and also allows physicians to monitor several of their patients at once, Peters said.

“CGMs, overall, are becoming more popular with patients, even patients that don’t have pumps,” Knapp said. “They’re starting to see the benefits of them. They’re starting to see the benefits of having access to more data, instead of just four blood sugar checks a day. They can see what’s happening between those times.”

Tandem Diabetes and Dexcom announced a development agreement, promising to work toward future integration of the next-generation t:slim insulin pump and Dexcom G5 sensor, eliminating the need for a separate CGM receiver.

“The CGM products are all becoming more accurate, and that’s good for patients,” David Klonoff, MD, medical director of Diabetes Research Institute, Mills-Peninsula Health Services in San Mateo, California, told Endocrine Today. “The companies are developing new software to make it easier for patients and doctors to use the information.”

Klonoff said implantable CGM systems, currently in development, could improve outcomes for patients.

David Klonoff

“With implanted devices, you put it in and it stays in place for a long time, so, that would be an advantage,” Klonoff said. “But, we don’t know how accurate they are going to be.”

New diabetes apps, platforms

The newest devices make diabetes data more accessible than ever before — yet few patients and caregivers are reviewing the information retrospectively. According to a recent study of adults and caregivers of children with type 1 diabetes, published in Diabetes Technology & Therapeutics, just 31% of adults and 56% of caregivers reported ever downloading data from one or more devices, whereas 12% of adults and 27% of caregivers were considered routine reviewers of data, reviewing their data most of the time they downloaded it. Both routine reviewers and the children of routine reviewers had lower mean HbA1c levels when compared with participants who did not review their data (adults, 7.2% vs. 8.1%; P = .03; children, 7.8% vs. 8.6%; P = .001).

“Our study was a survey-based study that just scratched the surface of how patients use their data,” study researcher Jenise Wong, MD, PhD, of the Madison Clinic for Pediatric Diabetes at the University of California, San Francisco, told Endocrine Today. “Some obstacles to data review include not being aware and not perceiving that there is a need to even download data ... but what about that technology itself? Is it that the technology is not user-friendly enough? This is what drives further advances in technology — not just in the devices themselves, but in ways to collect, visualize and use the data from the device.”

To meet the growing need, developers have introduced several cloud-based platforms that allow the aggregation of diabetes data across different devices. Tidepool, a nonprofit company based in San Francisco, is currently building three applications, including the Tidepool Uploader, a Google Chrome extension that assists patients with uploading data from insulin pumps, CGMs and blood glucose meters to the platform. Blip, a Web-based application, streamlines data from a patient’s diabetes and related devices — insulin doses and carbohydrate consumption from pumps, blood glucose levels, and data from smartphones and wearable fitness devices — and makes those numbers viewable in one shareable interface. Nutshell, a mobile app, helps patients with diabetes to better manage the meals they eat and to properly dose insulin for them. The company has partnerships with multiple device makers to store their data on behalf of patients, and formed a partnership with JDRF in September 2014.

Jenise Wong

The Glooko platform offers a similar model. The company’s MeterSync technology can download diabetes data from more than 40 meters, pumps and CGMs directly to a smartphone, integrate food and activity data, and share results with caregivers or providers

“There are all kinds of new things always entering the market, and it’s data overload for providers,” Knapp said. “Having these, where it’s one platform to use, helps providers to make sense of the data and quickly read it. You just have to figure out what is the platform you want to use.

“The biggest issue is when patients are coming in and there are five different styles of download reports,” Knapp said. “You know where to look [for information] on one, but you have no idea where to find it on the other, and it takes you 10 minutes. And in these days, an office visit can be just 15 minutes. Providers don’t have time for that. You have to have what works for your office and encourage your patients to use those platforms.”

The next step, Wong said, will be devices and software with more sophisticated algorithms that can perform pattern recognition. The question, she said, is how well that type of advancement can work.

“I don’t know how automated the technology can be,” Wong said. “You can’t really practice medicine with technology alone, but you can point people toward the right direction. And there is a lot of power in that, in the technology being able to whittle [data] down to the important patterns and give both providers and patients a little bit of guidance. Device and software companies are improving their software for the most part, but it’s still overwhelming. There is no great solution right now, but part of ongoing research is understanding a little bit more about what people think of new developments, and really understanding what they want.” – by Regina Schaffer

Disclosures: Albanese-O’Neill, Klonoff and Knapp report no relevant financial disclosures. Peters and Wong report serving on the advisory board for Tidepool. Wolpert reports serving as a consultant for Abbott Diabetes Care, Becton, Dickinson and Company, Insulet Corp. and Novo Nordisk.

POINTCOUNTER

Will the availability of new technology be a game changer for diabetes self-management?

POINT

As diabetes devices become cloud-connected, patients stand to benefit from increased empowerment, awareness of their physiologies and ability to manage their disease.

Brandon Arbiter

Their families are already gaining peace of mind with real-time access to blood glucose values. Next, the diabetes “Internet of Things” will enable an ecosystem of software, including closed-loop systems, which may turn out to be the most significant transformation in diabetes self-management since home glucose testing.

The shift to a network of connected diabetes devices has begun in force. Dexcom’s G5 glucose sensor, worn on the body, transmits data directly to the user’s smartphone! The data don’t stop there. For iPhone users, glucose readings can be stored by Apple Health, which enables an ecosystem of apps to integrate patient glucose data, providing a variety of unique user experiences. Medtronic recently enabled customers to bypass the CareLink data download process with its new Bluetooth-to-smartphone Minimed Connect uploader ($99 as of January 2016). Tandem and Insulet have also indicated their intention to provide smartphone connectivity via Bluetooth in their upcoming models. Diabetes newcomer Bigfoot Biomedical recognizes that Bluetooth connectivity is table stakes. Bigfoot has its eyes set on delivering an Internet of Things–enabled closed-loop system that has one point of user interaction: the smartphone. No buttons on the pump!

Smartphone app stores are redefining the way people create and access useful tools. They offer a safe, open mechanism for software developers to publish connected apps. They’ve sparked an app-driven renaissance that is changing the world around us, but until now, it has passed over the world of diabetes because diabetes data weren’t online.

Let’s face it — manually logging was never going to take off beyond a minority of users. But Bluetooth connectivity is making device data available to our smartphones automatically, removing the user burdens of glucose logging and data downloads, which have been major barriers to software adoption in diabetes self-management. Platforms like Apple Health (and soon Tidepool) are making these data available to patient-authorized third-party apps, which in turn make the data intuitive and actionable, and provide the delightful user experiences we’ve come to expect from our nondiabetes software.

Apps from MySugr, Glooko, Databetes and OneDrop are already integrating data from the cloud. And months before the proper platforms were in place, we started seeing signs of what was to come through the impacts of Nightscout, OpenAPS and the #WeAreNotWaiting movement.

With the shift to the Internet of Things and the adoption of open data platforms like Apple Health and Tidepool, device makers are creating a secure mechanism to put data into patients’ hands, which will result in more user-friendly technologies and may lead us to a more empowered generation of patients, more efficient clinic visits and the better outcomes we know are within arm’s reach.

Brandon Arbiter is vice president for product and business development at Tidepool, a San Francisco-based nonprofit organization. He lives with type 1 diabetes. Disclosure: Arbiter reports no relevant financial disclosures.

COUNTER

User-friendliness, patient education and access are key.

Nicholas Argento

For technology to be a diabetes game changer, patients have to trust it. They have to believe the data are accurate and that they don’t have to double-check everything.

The perception that a device is difficult to use can keep highly motivated patients from trying technology that could otherwise help them. If patients find they have to call tech support to get a device to work, then forget it, they’re not going to bother. But as technology has improved for smart insulin pumps, meters and continuous glucose monitoring (CGM), the threshold for most patients has gotten lower. No diabetes device can help if it stays on the shelf. Patients must believe that their effort is worth it. I think we are seeing a big transition in this area now.

The bigger problem now for patients with CGM is that they have to be willing to put effort into learning the technology and then pay a lot of attention to it. There are not a lot of patient-friendly guides on what to do with the information. Figuring out how to act on the data is the hard part. In the past, what a patient could get out of, for example, the Medtronic CareLink system for patients, was not as useful as the professional version, and I find most of my patients will not use it between visits. Dexcom has made an effort on this front with its Clarity software, which has simplified the presentation of data. I have type 1 diabetes and I’m actually not fully satisfied with the current program because I liked some of the more complex data from the prior system. However, I’m finding that patients really like the simpler system because it can display specific examples such as rebound highs or lows.

The next step is helping the average patient to figure out how to use this information to change their day-to-day management. Education is key. At the end of the day, people have to perceive that the money and effort they put into new technology make their life better, and that can vary from one person to another. If they perceive improvement, they’ll vote with their feet. They’ll use the technology, as long as they have access.

What will really get people, doctors and, hopefully, payers on board are devices that they trust and that take the patient out of the loop — that is, a closed-loop system.

Nicholas Argento, MD, CDTC, is the diabetes technology director at Maryland Endocrine in Laurel, Maryland. Disclosure: Argento reports consulting and working on promotional programs for Animas and Dexcom, serving on the advisory board for Eli Lilly and Co., and receiving speaker’s fees from Boehringer Ingelheim, Eli Lilly, Janssen, Novo Nordisk and OmniPod.

New data-sharing capabilities and increased connectivity are rapidly changing the way patients and providers work to manage diabetes, with new devices, applications and cloud-based platforms incorporating the latest wireless technology with the goal of improving glycemic outcomes.

The latest innovations, according to clinicians and diabetes educators, are addressing some key patient needs: smaller, more accurate meters, insulin pumps and continuous glucose monitors (CGMs) that are both user-friendly and interconnected, and new platforms that link data from multiple devices in a single accessible interface.

“The interest in developing technology and the capacity to develop is much, much greater than ever before, and the FDA has made it easier to develop technology in many ways,” Anne Peters, MD, professor at the Keck School of Medicine and director of Clinical Diabetes Programs at the University of Southern California, told Endocrine Today. “Device development has been at the starting gate for a long time, and now, we’re in the race. Things are happening fast, and we’re going to have a lot more.”

Anne Peters, MD, professor at the Keck School of Medicine and director of Clinical Diabetes Programs at the University of Southern California, discusses diabetes technology and the potential to change outcomes. Photo by Mark Harmel. Reprinted with permission.

But with new opportunities to share and receive data from the latest “smart” devices come a host of new concerns, including the potential of overwhelming not only the patient, but the caregiver and even the clinician, with numbers.

“The issue it comes down to with any technology in diabetes ... is that the primary user is the patient, and these are just tools to help them in their self-care,” Howard Wolpert, MD, director of the insulin pump and CGM programs at Joslin Diabetes Center, told Endocrine Today. “But it comes down to the patient using the technology effectively. CGM is a transformative technology, but patients need to know how to interpret the information.”

And, adds Anastasia Albanese-O’Neill, PhD, ARNP, CDE, assistant professor at the College of Nursing, University of Florida, new technology should demonstrate its worth with improved outcomes. “There’s the psychological piece where a patient might think, ‘Hey, I find this data really useful now,’ or possibly the concern of, ‘Uh oh, now I’m a little overwhelmed by all the data I’m getting real-time,’” Albanese-O’Neill said. “But there is the second piece of how do we make that data actionable for the patient? That’s the question of 2016 and beyond: How do we take that data and make it actionable in terms of improving glycemic outcomes?”

Diabetes management experts spoke with Endocrine Today about their favorite new features in meters, pumps and CGM, and the latest applications available to help manage available data safely.

Blood glucose meters

Self-monitoring blood glucose has improved, in part, due to smaller, faster and more accurate meters, with many offering new features, such as Bluetooth connectivity, to wirelessly transmit data. But what may work for one patient with diabetes may not be a good fit for the next.

“The best meter is one the patient will use and can afford,” Albanese-O’Neill told Endocrine Today. “In addition to accuracy, those are the two criteria that are most important. To the extent that the meter reduces the burden of managing diabetes, all to the better.”

For patients who take multiple daily injections to manage their diabetes, Albanese-O’Neill said a meter with a built-in insulin calculator, such as the Accu-Chek Aviva Expert (Roche), can help calculate doses accurately and avoid insulin stacking, which can lead to hypoglycemia. The meter calculates the amount of insulin needed based on the patient’s personal data, the test result, expected carbohydrate intake and past bolus doses, often referred to as “insulin on board.”

PAGE BREAK
Anastasia Albanese-O’Neill

“If a parent is worried and wants an instant connection to a child on multiple daily injections who does not use a [CGM], they might try the Accu-Chek Connect,” Albanese-O’Neill said. The meter transmits blood glucose results to the app on the patient’s smartphone using Bluetooth technology, and auto-generates text messages with results that can be sent immediately to the caregiver’s cellphone.

“Of course, using these devices effectively requires education and clinical support,” Albanese-O’Neill said.

Other meters also offer instant connectivity. Livongo Health offers a cellular-enabled, connected blood glucose meter that uploads readings in real time to the company’s cloud system. The meter sends blood glucose readings along with important contextual information, such as time of day, the type of meal eaten, physical activity information and any symptoms a person may be feeling. The patient receives an instant feedback message and tailored educational messages from the American Association of Diabetes Educators curriculum.

A newer meter not yet available in the United States — the Abbott Freestyle Libre — functions like a CGM without finger pricking and has been in high demand in Europe, Peters said. The device is expected to be available in Canada in the next 2 years.

“The problem with meters is that ... you still have to prick your finger and ... just numbers don’t change anything,” Peters said. “Someone has to tell you what to do with the numbers, and the numbers have to be in the context of what you’re eating and doing. The patient would love to have something they could beam onto the food to figure out how many carbs, to figure out how much insulin to give. The key is trying to integrate numbers into action, so the devices are trying to become smarter, to give some sort of narrative with the data.

Howard Wolpert

“You want the most accurate meter,” Peters said. “Some are smaller, some are bigger, some are pinker, some are greener, but to me, getting the most accurate device is important, and the branded devices, unfortunately, are still more accurate.”

Insulin pumps

Newer insulin pumps in development, such as the Medtronic 640G pump, as well as the t:slim from Tandem Diabetes, are more user-friendly than pumps of the past, Peters said, because of full-color features, informative icons and brightly lit screens. But a pump with the latest features still requires a user who knows how to interpret the data.

“One of the big issues I see is insulin stacking, and the new Medtronic pump — and the t:slim pump does this too — is they show you clearly the insulin that is still on board,” Peters said. “You can see the screen easily at night, so it’s not as hard to look at. But that’s a subtle finding. It’s still just a pump.”

“When talking about the pros of the various pumps, a lot of patients like the touch screen pump on the t:slim,” Shannon Knapp, BSN, RN, CDE, manager of diabetes education at Cleveland Clinic, told Endocrine Today. “They like that it’s brightly lit, easy to read, it’s intuitive.”

Many patients with type 1 diabetes prefer the tubeless and wireless features of the OmniPod, which also offers a controller unit with a built-in meter, meaning patients can carry one less device around, Knapp said. Still, other patients prefer the Minimed, the Animus Vibe or the t:slim G4 because of their ability to connect with CGM.

For patients with type 2 diabetes, patch pumps, which are filled with insulin daily and worn on the body, are an option, Peters said. These offer a fixed basal rate and no electronic interface, so the fine-tuning of doses is not possible.

PAGE BREAK
Shannon Knapp

“The simple patch pumps that they’re developing now will be for a longer period of time, but they’re still a slave to a basal rate,” Peters said. “Whether that’s going to be a game changer, I don’t know. I’ve always liked the idea of something like the OmniPod, but again, it’s about how technically advanced do they become, how does the interface change over time, and how does [the technology] make it easier to interact with the patient?”

“I’m always excited about the future of pump therapy, because it’s always advancing,” Knapp said. “I personally can’t wait to see what is around the corner, from more touchscreen pumps, to more tubeless pumps, to more CGM links.”

Continuous glucose monitoring

CGM devices continue to improve, with interfaces that wirelessly transmit data to smartphones or a cloud-based system. As an example, the Dexcom G5 mobile CGM helps caregivers to monitor their family members with diabetes and also allows physicians to monitor several of their patients at once, Peters said.

“CGMs, overall, are becoming more popular with patients, even patients that don’t have pumps,” Knapp said. “They’re starting to see the benefits of them. They’re starting to see the benefits of having access to more data, instead of just four blood sugar checks a day. They can see what’s happening between those times.”

Tandem Diabetes and Dexcom announced a development agreement, promising to work toward future integration of the next-generation t:slim insulin pump and Dexcom G5 sensor, eliminating the need for a separate CGM receiver.

“The CGM products are all becoming more accurate, and that’s good for patients,” David Klonoff, MD, medical director of Diabetes Research Institute, Mills-Peninsula Health Services in San Mateo, California, told Endocrine Today. “The companies are developing new software to make it easier for patients and doctors to use the information.”

Klonoff said implantable CGM systems, currently in development, could improve outcomes for patients.

David Klonoff

“With implanted devices, you put it in and it stays in place for a long time, so, that would be an advantage,” Klonoff said. “But, we don’t know how accurate they are going to be.”

New diabetes apps, platforms

The newest devices make diabetes data more accessible than ever before — yet few patients and caregivers are reviewing the information retrospectively. According to a recent study of adults and caregivers of children with type 1 diabetes, published in Diabetes Technology & Therapeutics, just 31% of adults and 56% of caregivers reported ever downloading data from one or more devices, whereas 12% of adults and 27% of caregivers were considered routine reviewers of data, reviewing their data most of the time they downloaded it. Both routine reviewers and the children of routine reviewers had lower mean HbA1c levels when compared with participants who did not review their data (adults, 7.2% vs. 8.1%; P = .03; children, 7.8% vs. 8.6%; P = .001).

“Our study was a survey-based study that just scratched the surface of how patients use their data,” study researcher Jenise Wong, MD, PhD, of the Madison Clinic for Pediatric Diabetes at the University of California, San Francisco, told Endocrine Today. “Some obstacles to data review include not being aware and not perceiving that there is a need to even download data ... but what about that technology itself? Is it that the technology is not user-friendly enough? This is what drives further advances in technology — not just in the devices themselves, but in ways to collect, visualize and use the data from the device.”

To meet the growing need, developers have introduced several cloud-based platforms that allow the aggregation of diabetes data across different devices. Tidepool, a nonprofit company based in San Francisco, is currently building three applications, including the Tidepool Uploader, a Google Chrome extension that assists patients with uploading data from insulin pumps, CGMs and blood glucose meters to the platform. Blip, a Web-based application, streamlines data from a patient’s diabetes and related devices — insulin doses and carbohydrate consumption from pumps, blood glucose levels, and data from smartphones and wearable fitness devices — and makes those numbers viewable in one shareable interface. Nutshell, a mobile app, helps patients with diabetes to better manage the meals they eat and to properly dose insulin for them. The company has partnerships with multiple device makers to store their data on behalf of patients, and formed a partnership with JDRF in September 2014.

PAGE BREAK
Jenise Wong

The Glooko platform offers a similar model. The company’s MeterSync technology can download diabetes data from more than 40 meters, pumps and CGMs directly to a smartphone, integrate food and activity data, and share results with caregivers or providers

“There are all kinds of new things always entering the market, and it’s data overload for providers,” Knapp said. “Having these, where it’s one platform to use, helps providers to make sense of the data and quickly read it. You just have to figure out what is the platform you want to use.

“The biggest issue is when patients are coming in and there are five different styles of download reports,” Knapp said. “You know where to look [for information] on one, but you have no idea where to find it on the other, and it takes you 10 minutes. And in these days, an office visit can be just 15 minutes. Providers don’t have time for that. You have to have what works for your office and encourage your patients to use those platforms.”

The next step, Wong said, will be devices and software with more sophisticated algorithms that can perform pattern recognition. The question, she said, is how well that type of advancement can work.

“I don’t know how automated the technology can be,” Wong said. “You can’t really practice medicine with technology alone, but you can point people toward the right direction. And there is a lot of power in that, in the technology being able to whittle [data] down to the important patterns and give both providers and patients a little bit of guidance. Device and software companies are improving their software for the most part, but it’s still overwhelming. There is no great solution right now, but part of ongoing research is understanding a little bit more about what people think of new developments, and really understanding what they want.” – by Regina Schaffer

Disclosures: Albanese-O’Neill, Klonoff and Knapp report no relevant financial disclosures. Peters and Wong report serving on the advisory board for Tidepool. Wolpert reports serving as a consultant for Abbott Diabetes Care, Becton, Dickinson and Company, Insulet Corp. and Novo Nordisk.

PAGE BREAK

POINTCOUNTER

Will the availability of new technology be a game changer for diabetes self-management?

POINT

As diabetes devices become cloud-connected, patients stand to benefit from increased empowerment, awareness of their physiologies and ability to manage their disease.

Brandon Arbiter

Their families are already gaining peace of mind with real-time access to blood glucose values. Next, the diabetes “Internet of Things” will enable an ecosystem of software, including closed-loop systems, which may turn out to be the most significant transformation in diabetes self-management since home glucose testing.

The shift to a network of connected diabetes devices has begun in force. Dexcom’s G5 glucose sensor, worn on the body, transmits data directly to the user’s smartphone! The data don’t stop there. For iPhone users, glucose readings can be stored by Apple Health, which enables an ecosystem of apps to integrate patient glucose data, providing a variety of unique user experiences. Medtronic recently enabled customers to bypass the CareLink data download process with its new Bluetooth-to-smartphone Minimed Connect uploader ($99 as of January 2016). Tandem and Insulet have also indicated their intention to provide smartphone connectivity via Bluetooth in their upcoming models. Diabetes newcomer Bigfoot Biomedical recognizes that Bluetooth connectivity is table stakes. Bigfoot has its eyes set on delivering an Internet of Things–enabled closed-loop system that has one point of user interaction: the smartphone. No buttons on the pump!

Smartphone app stores are redefining the way people create and access useful tools. They offer a safe, open mechanism for software developers to publish connected apps. They’ve sparked an app-driven renaissance that is changing the world around us, but until now, it has passed over the world of diabetes because diabetes data weren’t online.

Let’s face it — manually logging was never going to take off beyond a minority of users. But Bluetooth connectivity is making device data available to our smartphones automatically, removing the user burdens of glucose logging and data downloads, which have been major barriers to software adoption in diabetes self-management. Platforms like Apple Health (and soon Tidepool) are making these data available to patient-authorized third-party apps, which in turn make the data intuitive and actionable, and provide the delightful user experiences we’ve come to expect from our nondiabetes software.

Apps from MySugr, Glooko, Databetes and OneDrop are already integrating data from the cloud. And months before the proper platforms were in place, we started seeing signs of what was to come through the impacts of Nightscout, OpenAPS and the #WeAreNotWaiting movement.

With the shift to the Internet of Things and the adoption of open data platforms like Apple Health and Tidepool, device makers are creating a secure mechanism to put data into patients’ hands, which will result in more user-friendly technologies and may lead us to a more empowered generation of patients, more efficient clinic visits and the better outcomes we know are within arm’s reach.

Brandon Arbiter is vice president for product and business development at Tidepool, a San Francisco-based nonprofit organization. He lives with type 1 diabetes. Disclosure: Arbiter reports no relevant financial disclosures.

COUNTER

User-friendliness, patient education and access are key.

Nicholas Argento

For technology to be a diabetes game changer, patients have to trust it. They have to believe the data are accurate and that they don’t have to double-check everything.

The perception that a device is difficult to use can keep highly motivated patients from trying technology that could otherwise help them. If patients find they have to call tech support to get a device to work, then forget it, they’re not going to bother. But as technology has improved for smart insulin pumps, meters and continuous glucose monitoring (CGM), the threshold for most patients has gotten lower. No diabetes device can help if it stays on the shelf. Patients must believe that their effort is worth it. I think we are seeing a big transition in this area now.

The bigger problem now for patients with CGM is that they have to be willing to put effort into learning the technology and then pay a lot of attention to it. There are not a lot of patient-friendly guides on what to do with the information. Figuring out how to act on the data is the hard part. In the past, what a patient could get out of, for example, the Medtronic CareLink system for patients, was not as useful as the professional version, and I find most of my patients will not use it between visits. Dexcom has made an effort on this front with its Clarity software, which has simplified the presentation of data. I have type 1 diabetes and I’m actually not fully satisfied with the current program because I liked some of the more complex data from the prior system. However, I’m finding that patients really like the simpler system because it can display specific examples such as rebound highs or lows.

The next step is helping the average patient to figure out how to use this information to change their day-to-day management. Education is key. At the end of the day, people have to perceive that the money and effort they put into new technology make their life better, and that can vary from one person to another. If they perceive improvement, they’ll vote with their feet. They’ll use the technology, as long as they have access.

What will really get people, doctors and, hopefully, payers on board are devices that they trust and that take the patient out of the loop — that is, a closed-loop system.

Nicholas Argento, MD, CDTC, is the diabetes technology director at Maryland Endocrine in Laurel, Maryland. Disclosure: Argento reports consulting and working on promotional programs for Animas and Dexcom, serving on the advisory board for Eli Lilly and Co., and receiving speaker’s fees from Boehringer Ingelheim, Eli Lilly, Janssen, Novo Nordisk and OmniPod.