Abstract
Diabetes is a chronic disease that is often comorbid with cardiovascular disease, hypertension, kidney disease, and neuropathy. Its management is complex, requiring ongoing clinical management, lifestyle changes, and self-care. This article examines recent literature on telehealth and emerging technological tools for supporting self-management of diabetes and identifies best practices. The authors conducted a PubMed search (January 2008–2012) that was supplemented by review of meeting materials and a scan of the Internet to identify emerging technologies. Fifty-eight papers were reviewed; 12 were selected for greater analysis. This review supports earlier findings that the delivery of diabetes self-management and training (DSME/T) via telehealth is useful, appropriate, and acceptable to patients and providers. Best practices are emerging; not all technology is appropriate for all populations—interactive technology needs to be appropriate to the patient's age, abilities, and sensitivities. Telehealth is scalable and sustainable provided that it adds value, does not add to the provider's workload, and is fairly reimbursed. However, there are multiple barriers (patient, provider, health system) to remotely provided DSME/T. DSME/T delivered via telehealth offers effective, efficient, and affordable ways to reach and support underserved minorities and other people with diabetes and related comorbidities. The new generation of smartphones, apps, and other technologies increase access, and the newest interventions are designed to meet patient needs, do not increase workloads, are highly appropriate, enhance self-management, and are desired by patients. (Population Health Management 2013;16:169–177)
Introduction
Diabetes is a chronic disease that is often comorbid with cardiovascular disease, hypertension, kidney disease, and neuropathy. Its management is complex, requiring ongoing clinical management, lifestyle changes, and self-care. 2 Diabetes self-management education and training (DSME/T) imparts knowledge about the disease and empowers people with diabetes to adopt healthy behaviors that are essential for optimal health status and quality of life. 3 Payers cover DSME/T but the benefit is underutilized, in part because access is limited. 4 Health care providers and researchers have been seeking ways to use technology to expand access and improve monitoring, medication taking, healthy eating, and other components of diabetes self-management. Piette's 2007 article 5 recommended guidelines for subsequent studies looking at technological approaches to diabetes treatment, encouraged further study in this area, and emphasized the importance of collaboration among all those involved in developing such interventions: researchers, care providers, clinicians, health care managers, and people who have diabetes. 5 Our article examines recent literature on telehealth and emerging technological tools for supporting self-management of diabetes, thereby expanding upon Piette's work.
Background
Telehealth provides an opportunity to increase access and improve the current health care system, which has been criticized as being too structured around brief acute care office visits and is ill equipped for patients with chronic illnesses who need to understand and become involved in their own treatment plan. Telehealth is a broad term, but for the purposes of this article it is defined as the delivery of diabetes-related services and information via telephonic, Web-based, computer-assisted, and/or mobile technologies (real time, store-and-forward, or on demand). 6 Additional definitions are provided in Table 1.
PDA, personal digital assistant; SMS, short message service.
In 2007, Piette examined more than 300 research studies on the state of technological interventions related to diabetes. He found that interactive behavior change technology (IBCT) offers a solution to helping patients with diabetes and aligns with the chronic care model (CCM), which integrates all aspects of health care delivery and encourages providers to develop structured treatment plans and access to information so that patients can self-manage their condition once they leave the doctor's office. 5 Piette's review indicates that, when done correctly, technological tools and interventions can foster interactive behavior change and lead to improved patient health, and help to implement the vision of the CCM. Conversely, a recent National Institutes of Health-funded study of 205 older adults with a high risk of rehospitalizations for heart, lung, and kidney disease, and diabetes, reported no difference in hospitalization rates, emergency department visits, and hospital day rates between the group that used telemonitoring services and the control group; mortality was 14.7% and 3.9%, respectively. 7 These findings indicate that home-based monitoring might not be cost-effective in all instances and may not be useful for everyone. Piette agrees that technological interventions provide only a partial solution because of the diversity of those with diabetes and the presence of comorbid chronic conditions, noting that they are most effective when supporting human contact. 5
Many individuals who have used telehealth over the past 10 years have done so in pilot and research studies. Increasingly, technology-based health monitoring, education, and IBCT are being used by a growing number of people with chronic illnesses and are likely to be scalable to larger populations. According to a Pew Research Center 2010 Study, 59% of adults in the United States, across all age groups, used laptops and smartphones to access the Internet wirelessly, a 51% increase over the previous year. 8 The study also found the use of mobile apps to access the Internet, send or receive instant messages, and for other purposes, also increased significantly between 2009 and 2010. 8 A Nielsen Wire survey found that the highest users of mobile smartphones in the United States were ethnic and racial minorities as of year end 2010—45% of Asians/Pacific Islanders, 45% of Hispanics, and 33% of African Americans owned smartphones, while only 27% of whites said they owned smartphones. 9
At least 1 private health care insurer has embraced telehealth tools to assist members to make informed decisions about their health care; the insurer sends educational text messages to people with diabetes with tips on healthy behaviors and reminders about screenings and tests. 10 Although technology involves some cost, depending on the types of tools being used, those costs are likely to be significantly less than the costs of surgeries, emergency care situations, and hospitalizations. 11 The reach of the Internet is global and access is immediate, with virtually unlimited possibilities for information in print, audio, or visual formats. As Cutler and McClellan have argued, the cost of technology is worth the expense if outcomes are improved and overall costs are reduced. 12
Literature Review
With the aim of identifying best practices that have emerged since 2007, the authors conducted a PubMed search in January 2012 that was supplemented by a review of meeting materials and a scan of the Internet to identify emerging technologies. Fifty-eight papers were reviewed; 12 were selected for greater analysis and discussion (9 of which are listed in Table 2) because they are most relevant to current thinking about the delivery of IBCT and DSME/T delivered via telehealth. These articles generally reinforce Piette's views about what does and does not work in technology interventions for diabetes self-care. The authors looked at the components of these studies that were successful and those components that were not successful. In addition, we considered information about emerging technology that is likely to have an impact on individuals with diabetes in the future.
Applicability of telehealth for self-management education
Several recent studies demonstrate successful outcomes in studies using multiple approaches. 13 Davis et al found positive outcomes in the Diabetes Telecare program for African Americans in rural communities. 14 This program consisted of multiple technologies—provided group and individual sessions, both in person and online; interactive videoconferencing; mobile and landline phones; a fax line; and a telehealth-enabled retinal camera. Interactive video sessions were offered by a dietician and nurse/certified diabetes educator from academic health centers to patients at primary care clinics. Participants set goals and kept logs of blood glucose, diet, and physical activity. 14
Carter et al reported positive results in a program where participants were provided laptops in their homes, Internet access, and peripherals that included a wireless scale, a blood pressure cuff, a glucometer, and a camera attached to the laptop, along with instruction on how to use the equipment. 15 Participants also had access to different modules of intervention, including a self-management module for tracking personal health information and developing behavior-change strategies, and an education model. An 8-week pilot conducted by Stuckey et al provided participants with a smartphone, blood pressure monitor, glucometer, and pedometer. Phones sent measurements survey results to a database, enabled interactions with the clinical team, and enabled self-monitoring. This study also reported positive results. 16 Similarly, Hurling used accelerometers with success; compared to controls, the group using accelerometers had an average increase in moderate physical activity of 2 h 18 min per week and lost a higher percentage of body fat. 17
As an older example, Cherry et al demonstrated positive outcomes in a program that offered daily contact between participants and providers via a Web-based patient interface. 18 The program offered access to immediate interventions when participants experienced health crises. Carter et al offered twice monthly video interaction with a nurse to provide regular reinforcement and contact with patients. 15 In their review of research, Eakin et al noted that regular ongoing telephone contact was a key feature of studies with successful outcomes. 19 Regular contact, for example, may help motivate patients to increase physical activity and improve their diets.
Factors associated with positive outcomes
Ease and immediacy of communication matter. The review of the literature by Fjeldsoe et al found that interactivity in short message service (SMS) messaging led to successful outcomes. 20 Carter et al reported success with extensive interactive communications for minorities. 15 McIlhenny et al offered access to reliable health information via the Internet that enabled patients to learn successful self-management skills; as compared to the control group, monitoring behavior improved and disease knowledge increased, as measured by a standardized test. 21 Cherry et al found that patients like being able to receive care and attention from the comfort and convenience of their homes. 18 Carter et al conducted home visits to provide patients with a laptop and peripherals as well as instruction on use (and access to the Internet) to ensure they were comfortable with and able to use the technnology. 15
Several studies address the need to tailor the approach and content to participant characteristics and demographics. McIlhenny et al found that older patients liked personal interactions with nurse educators but did not like using the Internet via a computer that was located in an isolated room in the doctor's office and intended for independent use by participants. 21 Likewise, Fjeldsoe et al noted in their review of mobile phone interventions that tailoring of SMS content was a key component of intervention success. 20 The success reported by Carter and Davis for minorities was associated with study designs that offered culturally appropriate materials and action plans. 14,15 Specifically, Davis et al modified diet and lifestyle change components to suit a low literacy South Carolina participant group. 14 Carter et al found improved outcomes, extended provider access, and reduced costs as a result of coordination. 15 Coordinated delivery models support the CCM and are being tested to assess whether they save money, improve care, and add to patient satisfaction. 22
Emerging technology for self-management
People with diabetes have used technology to create data logs and share health information with their providers. 23 Emerging technology also allows people with diabetes to obtain information, track activity, view charts of their data over time, request immediate assistance, ask questions, and alert care providers of crises or concerns without first rushing to an emergency room or waiting for a doctor's appointment. One wireless health care application (Macaw, US Preventive Medicine, Jacksonville, FL) includes a 7-question health risk assessment that generates a diabetes well-being score, tracks diet and activity, monitors biometric readings, and connects with other wireless devices (eg, pedometer, wireless scale). 23 Smartphones now can serve as portable platforms for mobile medical monitoring devices. When combined with capabilities offered by downloadable apps, people with diabetes can use the iBGStar device to check their blood sugar levels using their iPhone or MP3 player and then store, share, track, and analyze the data. 24 Security and validity of information are, however, of prime importance. Providers and patients want to be assured that their personal health information is secure and that they have access to reliable information. Health Insurance Portability and Accountability Act (HIPPA) requirements ensure that technology does not compromise patient privacy. The transition to the HIPAA 5010 code set increases emphasis on privacy of patient data content in provider transactions by ensuring that only the “minimum necessary” personal health information is used. 25,26
Effective vs. ineffective approaches
The literature indicates that technology increases access to information, expands contact with providers, and makes it possible to share information. When best practices are applied, as summarized in Table 3, telehealth allows people to monitor their blood pressure, glucose levels, and weight effectively, and to improve their general health status. In addition to identifying best practices, the authors asked, “What does not work?” The literature indicates that simply making technology available, without connecting it to the larger context of the DSME/T intervention, does not lead to behavior change and improved outcomes. McIlhenny found a high dropout rate among older people with limited Internet and computer experience, despite training in the doctors' offices and information about where public computers could be found. 21 Graziano's review of research on isolated phone interview interventions found that those generally were not effective. 27
The studies in Table 2 demonstrate that well-designed technology and telehealth interventions for diabetes patients can: increase the availability of services; improve the overall health of diabetes patients; extend care provider access to patients; reduce the number of hospitalizations, leading to healthier patients; teach patients how to self-manage their diabetes; foster more positive attitudes towards health care; and enable effective chronic disease management, even in underserved communities. On the other hand, stand-alone technology or communication that is used for 1-time outreach may be used successfully to gather health information but does not positively impact behavior change or enhance outcomes.
Discussion
The rapid growth of mobile phone ownership in the United States and elsewhere—particularly smartphones that can access the Internet, send and receive texts and emails, and use applications that enable sensors and other devices to transmit data (eg, glucose levels, blood pressure) to care providers—may be a boon to the remote delivery of DMSE/T. Additionally, the largest growth of cell phone ownership in the United States is among racial and ethnic minorities, the same populations that have the highest percentages of diabetes and that are less likely to have convenient access to health care.
Use of telehealth technology for the delivery of care to people with diabetes aligns with the “Triple Aim” for improving and redesigning health care proposed by Donald M. Berwick, MD, MPP—to (1) improve the population's health; (2) enhance the experience of care for patients in terms of access, reliability, and quality; and (3) reduce or control the cost of care per patient. 28 Several recent studies add to Piette's work and generally indicate that diabetes care and support can be effectively provided via telehealth; the technology, however, is not appropriate for all populations in all instances. IBCT should not (1) increase demands on providers' time; (2) be expected to serve all diabetes patients (many diabetes patients have other chronic diseases, including dementia or depression, and are not likely candidates for technological interventions because diabetes is not their main concern; some patients with diabetes do well without additional interventions); or (3) be driven by the alluring capabilities of technology, but rather focus on what patients need and are able and willing to use. 5
Although practice guidelines are available for the care and management of people with diabetes, multiple factors impede the effective management of diabetes and its co-morbidities, including limited access to self-care and treatment resources. 29 –32 Physicians have limited time to see patients and there are a limited number of diabetes educators. Many diabetes patients are members of racial or ethnic minorities in rural or urban areas that are medically underserved. Although these individuals are eligible for DSME/T, it remains a significantly underutilized service. Lack of ongoing care and self-management leads to complications and increased costs—many people with diabetes only receive treatment when they are in a health crisis and need to be hospitalized, adding to the cost and illness burden. Telehealth improves care coordination and increases access by providing access to care and health information. 30 Twenty-four hour, 7-day-a-week access to Web-based programs, smartphone apps, and devices for education and self-monitoring empower people with diabetes to better self-manage their illness.
As shown in Table 3, best practices identified in this analysis include daily contact with participants, the use of mobile phones and other types of technology to provide interactive communication, and a team approach. People with diabetes have been receptive to remotely delivered education that is individually tailored, interactive, multifaceted, and offers frequent contact. Best practices continue to emerge, and studies are being undertaken to build the evidence for which approaches increase access to effective care. A study launched in March 2012 is implementing a number of these practices by establishing multifaceted teams that include medical providers (physicians, case managers, diabetes educators, medical assistants, physician assistants, and community health workers) and the participants' caregivers. 34 The goals are to: (1) enable diabetes education teams to extend their reach to a greater number of patients by focusing on those in need, and (2) provide a model for a scalable program that could be implemented nationwide. 35 The study of English- and Spanish-speaking medically underserved communities, coordinated by the American Association of Diabetes Educators, provides mobile phones to diabetes patients who have been identified as being at high risk for costly interventions (A1c levels>7.5). Participants will be monitored daily and will receive assistance to manage and control their diabetes, with scheduled real-time interventions as needed.
In summary, this review of the literature since 2007 supports Piette's earlier findings and indicates that the delivery of IBCT and DSME/T via telehealth is useful, appropriate, and acceptable to patients and providers. The studies that were reviewed indicate that people with chronic illnesses, such as diabetes, are open to using technology in the context of disease self-management under the right conditions. Best practices are emerging, especially in regard to the provision of DSME/T that will help people with diabetes manage their disease and achieve optimal health outcomes (Table 3). Not all technology is appropriate for all populations—interactive technology must be appropriate to the patient's age, abilities, and sensitivities. Isolated technological interventions have not proven to be successful tools for diabetes education; technological tools for behavior change and self-management must be used within a broader context of communication that supports contact with the health care provider. Telehealth for DSME/T is scalable and sustainable provided that it adds value, does not add to the provider's workload, and is fairly reimbursed. However, there are multiple barriers (patient, provider, health system) to remotely provided DSME/T. 33
Barriers
Patient-level barriers such as literacy, comfort-level with technology, security of personal health data, and accuracy of information have been addressed and are largely manageable. 37 Provider-level and health system barriers, however, pose larger concerns. 35 –40 Medicare's efforts to extend reimbursement to diabetes self-management training (DSMT) provided via telehealth is limited in its scope, covering DSMT provided only in accredited diabetes education programs that bill using Healthcare Common Procedure Coding System codes G0108 and G0109 with a modifier (GT or GQ). 36 As illustrated in Table 4, Medicare requires that DSMT be provided by an approved provider (but a diabetes educator is not designated as an approved provider) and be conducted via real-time interactive telehealth technology to underserved beneficiaries with diabetes. The requirements eliminate the use of alternative but effective approaches (eg, SMS messaging) that could have a positive impact on a broader population, such as school children with type 1 diabetes who are highly responsive to electronic media. The key Medicare coverage requirements for DSMT do not appear to be congruent with the way care can most effectively, efficiently, and safely be delivered by technology.
Limitations
The body of literature concerning the delivery of DSME/T via telehealth is still being developed. There are a limited amount of quantitative data available and considerable variability among the peer-reviewed papers, making comparisons difficult. Because this was not a formal systematic review or meta-analysis, some relevant studies may have been overlooked. The findings may be subject to some unintended bias.
Conclusion
DSME/T delivered via telehealth offers effective, efficient, and affordable ways to reach and support minorities and other people with diabetes and related comorbidities. Telehealth also supports care coordination and enhances the patient experience in multiple ways. The new generation of smartphones, apps, and other technologies increase access, and the newest interventions are designed to meet patient needs, do not add to the providers' workloads, are highly appropriate, enhance self-management, and are desired by patients. Payers (including Medicare) are encouraged to examine their coverage policies so as to align coverage requirements for DSMT with the way care can most effectively, efficiently, and safely be delivered by technology. Additional research will help to develop a stronger theoretical base and further describe best practices, especially for minority populations who are disproportionately affected by diabetes and tend to have reduced access to care.
Footnotes
Author Disclosure Statement
Dr. Fitzner and Ms. Moss disclosed the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article. This article was developed from a brief presentation that was prepared for the Driving Behavior Change at the Patient Level: Effective Healthcare Solutions for Patients With Diabetes meeting that was held in Washington DC on January 24, 2012. Funding for that meeting was provided by Sanofi.
The authors declared that no funding was provided for the development of the manuscript.
Acknowledgment
The authors would like to thank Jan Johnson, PhD, University of Hong Kong, and Elizabeth Heckinger, MAT, FHConsultants, for their review and comments.