Diabetes in Real Life

Diabetes clinicians, educators must keep current with telehealth trends

In this issue, Susan Weiner, MS, RDN, CDE, CDN, talks with immediate past president of the American Association of Diabetes Educators, Deborah A. Greenwood, PhD, RN, BC-ADM, CDE, FAADE, about harnessing the power of digital technology and online communities in diabetes education.

How did you become interested in researching telehealth in diabetes and encouraging diabetes clinicians and educators to engage?

Susan Weiner

Greenwood: In my doctoral program my emphasis was in informatics — clinical, consumer and nursing. As I started to engage in this field, I presented at several conferences focusing on telehealth and informatics. I quickly learned that a substantial quantity of research and business development was focused on diabetes management and education, yet there was a paucity of diabetes educators in attendance, either as members of the association, presenters or simply attendees of the meetings. My goal in 2015 as president of the AADE was to raise awareness of telehealth and informatics with diabetes educators, but also to promote recognition of diabetes educators as key individuals ready and able to support the evolution of this nascent field. AADE’s strategic plan and our most recent annual meetings have incorporated a strong telehealth message, as evidenced by AADE’s technology road map, which is in production and scheduled to be published in early 2017.

The telehealth field is so vast. Can you summarize the different opportunities in diabetes?

Greenwood: Telehealth in the diabetes space is a very broad field encompassing everything from telemedicine, defined as the use of telecommunication and information technology to provide clinical health care from a distance, to digital health, defined as the convergence of the digital revolution with health, health care, living and society. A key feature of telehealth is the goal of increasing access to care that is delivered in the right place, at the right time, at a lower cost; telehealth engages people with diabetes in their care. Digital health broadens the scope of services by incorporating smartphones, wearable devices, mobile applications and social networks, and increases personalized care. The inclusion of the e-community within AADE’s spheres of influence framework in its 2016-2018 strategic plan acknowledges that people with diabetes are engaging in self-care with support from others affected by diabetes during the 99% of the time they are not engaged with the health care system (www.diabeteseducator.org/about-aade/governance/2016-18-strategic-plan). Often, these engaged, empowered people enabled by the internet are referred to as “e-patients.” Many helped to create the diabetes online community — or the DOC — where people are educated, supported and most importantly “never feel alone.” This social media domain is increasing rapidly and will change the landscape of health care in the near term.

Deborah A. Greenwood

Do you think the DOC should be prescribed for people with diabetes?

Greenwood: Definitely and absolutely, yes! We know through recent research that diabetes self-management education and support (DSMES) is vastly underutilized. While Medicare and most insurances cover DSMES, we know that some people have limited access, whether from living in a rural location, lack of insurance, or barriers due to transportation or child care. The DOC is available 24 hours a day, 7 days a week, when people with diabetes need answers to questions or simply need to reach out and discuss a concern with another person who understands their experiences. Even individuals who attend DSMES programs can benefit from between-visit education and engagement via the DOC. A one-page free resource can be downloaded to share with people with diabetes and clinicians that describes the DOC and identifies some quality social networking resources to recommend (www.diabeteseducator.org/docs/ default-source/legacy-docs/_resources/pdf/general/Social_Media_Handout.pdf ).

You often discuss the importance of a complete feedback loop in diabetes. What are the important elements?

Greenwood: In a recent publication, Perry M. Gee, PhD, RN, CPEHR, and I, with co-authors, adapted the Chronic Care Model for improving chronic illness care to incorporate an enhanced e-health model. One of the key features of this enhanced model is the inclusion of the complete feedback loop. For productive interactions to occur, clinicians must have access to patient-generated health data, then use those data and partner with people with diabetes to make health decisions, including treatment and behavior changes. Telehealth supports this ongoing interaction by incorporating remote monitoring, digital health, patient portals into the electronic health record, text messaging and the internet of things. A complete feedback loop is an essential feature of successful telehealth interactions — researchers have shown that passive monitoring is not as effective as engaging patients in their own self-management. The complete feedback loop supports the ongoing problem-solving requirements of diabetes management essential to improving outcomes, including HbA1c, quality of life and self-efficacy.

What excites you the most about the future of digital health and technology?

Greenwood: The do-it-yourself movement is revolutionizing diabetes management and creating a whole new breed of e-patient. There are two simultaneous factions at work. One is the Nightscout Project (nightscout.info), where people with diabetes or family members with software and technology skills learned how to “hack” continuous glucose monitoring (CGM) data and enable a DIY remote monitoring system. These volunteers communicate via a Facebook group and established a CGM in the cloud network where they share software code to enable others to hack their own devices. Some people display their CGM data on smartwatches or on smartphones and use their data to trigger alerts for hypoglycemia or hyperglycemia. Their social media hashtag #WeAreNotWaiting signifies their intent to make the lives of people with diabetes easier by having access to their own data. The second innovative project called #OpenAPS (open source artificial pancreas system) is an extension enabled by access to CGM data. This technologic revolution by founder Dana Lewis creates a DIY artificial pancreas system utilizing older model Medtronic insulin pumps and algorithms designed to interpret CGM data that automate changes in insulin delivery. The overnight CGM tracings of people with diabetes using OpenAPS are remarkable and have provided these early adopters with a unique version of diabetes management not yet available. Although OpenAPS is a hybrid closed loop and the user still must manually meal bolus, they are able to create temporary basal rates to prevent hypoglycemia and/or hyperglycemia based on glucose trend data. The software does require monitoring and updates, and there are several essential hardware pieces to carry with them, but ongoing enhancements are making this system smaller and smaller.

Disclosure: Greenwood reports being an employee of Sutter Health. Weiner reports no relevant financial disclosures.

In this issue, Susan Weiner, MS, RDN, CDE, CDN, talks with immediate past president of the American Association of Diabetes Educators, Deborah A. Greenwood, PhD, RN, BC-ADM, CDE, FAADE, about harnessing the power of digital technology and online communities in diabetes education.

How did you become interested in researching telehealth in diabetes and encouraging diabetes clinicians and educators to engage?

Susan Weiner

Greenwood: In my doctoral program my emphasis was in informatics — clinical, consumer and nursing. As I started to engage in this field, I presented at several conferences focusing on telehealth and informatics. I quickly learned that a substantial quantity of research and business development was focused on diabetes management and education, yet there was a paucity of diabetes educators in attendance, either as members of the association, presenters or simply attendees of the meetings. My goal in 2015 as president of the AADE was to raise awareness of telehealth and informatics with diabetes educators, but also to promote recognition of diabetes educators as key individuals ready and able to support the evolution of this nascent field. AADE’s strategic plan and our most recent annual meetings have incorporated a strong telehealth message, as evidenced by AADE’s technology road map, which is in production and scheduled to be published in early 2017.

The telehealth field is so vast. Can you summarize the different opportunities in diabetes?

Greenwood: Telehealth in the diabetes space is a very broad field encompassing everything from telemedicine, defined as the use of telecommunication and information technology to provide clinical health care from a distance, to digital health, defined as the convergence of the digital revolution with health, health care, living and society. A key feature of telehealth is the goal of increasing access to care that is delivered in the right place, at the right time, at a lower cost; telehealth engages people with diabetes in their care. Digital health broadens the scope of services by incorporating smartphones, wearable devices, mobile applications and social networks, and increases personalized care. The inclusion of the e-community within AADE’s spheres of influence framework in its 2016-2018 strategic plan acknowledges that people with diabetes are engaging in self-care with support from others affected by diabetes during the 99% of the time they are not engaged with the health care system (www.diabeteseducator.org/about-aade/governance/2016-18-strategic-plan). Often, these engaged, empowered people enabled by the internet are referred to as “e-patients.” Many helped to create the diabetes online community — or the DOC — where people are educated, supported and most importantly “never feel alone.” This social media domain is increasing rapidly and will change the landscape of health care in the near term.

Deborah A. Greenwood

Do you think the DOC should be prescribed for people with diabetes?

Greenwood: Definitely and absolutely, yes! We know through recent research that diabetes self-management education and support (DSMES) is vastly underutilized. While Medicare and most insurances cover DSMES, we know that some people have limited access, whether from living in a rural location, lack of insurance, or barriers due to transportation or child care. The DOC is available 24 hours a day, 7 days a week, when people with diabetes need answers to questions or simply need to reach out and discuss a concern with another person who understands their experiences. Even individuals who attend DSMES programs can benefit from between-visit education and engagement via the DOC. A one-page free resource can be downloaded to share with people with diabetes and clinicians that describes the DOC and identifies some quality social networking resources to recommend (www.diabeteseducator.org/docs/ default-source/legacy-docs/_resources/pdf/general/Social_Media_Handout.pdf ).

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You often discuss the importance of a complete feedback loop in diabetes. What are the important elements?

Greenwood: In a recent publication, Perry M. Gee, PhD, RN, CPEHR, and I, with co-authors, adapted the Chronic Care Model for improving chronic illness care to incorporate an enhanced e-health model. One of the key features of this enhanced model is the inclusion of the complete feedback loop. For productive interactions to occur, clinicians must have access to patient-generated health data, then use those data and partner with people with diabetes to make health decisions, including treatment and behavior changes. Telehealth supports this ongoing interaction by incorporating remote monitoring, digital health, patient portals into the electronic health record, text messaging and the internet of things. A complete feedback loop is an essential feature of successful telehealth interactions — researchers have shown that passive monitoring is not as effective as engaging patients in their own self-management. The complete feedback loop supports the ongoing problem-solving requirements of diabetes management essential to improving outcomes, including HbA1c, quality of life and self-efficacy.

What excites you the most about the future of digital health and technology?

Greenwood: The do-it-yourself movement is revolutionizing diabetes management and creating a whole new breed of e-patient. There are two simultaneous factions at work. One is the Nightscout Project (nightscout.info), where people with diabetes or family members with software and technology skills learned how to “hack” continuous glucose monitoring (CGM) data and enable a DIY remote monitoring system. These volunteers communicate via a Facebook group and established a CGM in the cloud network where they share software code to enable others to hack their own devices. Some people display their CGM data on smartwatches or on smartphones and use their data to trigger alerts for hypoglycemia or hyperglycemia. Their social media hashtag #WeAreNotWaiting signifies their intent to make the lives of people with diabetes easier by having access to their own data. The second innovative project called #OpenAPS (open source artificial pancreas system) is an extension enabled by access to CGM data. This technologic revolution by founder Dana Lewis creates a DIY artificial pancreas system utilizing older model Medtronic insulin pumps and algorithms designed to interpret CGM data that automate changes in insulin delivery. The overnight CGM tracings of people with diabetes using OpenAPS are remarkable and have provided these early adopters with a unique version of diabetes management not yet available. Although OpenAPS is a hybrid closed loop and the user still must manually meal bolus, they are able to create temporary basal rates to prevent hypoglycemia and/or hyperglycemia based on glucose trend data. The software does require monitoring and updates, and there are several essential hardware pieces to carry with them, but ongoing enhancements are making this system smaller and smaller.

Disclosure: Greenwood reports being an employee of Sutter Health. Weiner reports no relevant financial disclosures.