Brave New World: Diabetes Technology Streamlines Clinical Care

November 30, 2016

Healthcare professionals caring for those with diabetes can lighten their workload and greatly improve their efficiency and patient outcomes if they embrace all available technology and use social media to their advantage.

This was the key message from UK doctors and nurses speaking about their various experiences at the Diabetes Professional Care meeting in London earlier this month.

Pediatric endocrinologist May Ng, MBBS (Hons), FHEA, FRCPCH, LLM, PhD, of Southport and Ormskirk Hospital National Health Service (NHS) Trust, United Kingdom, whose team has published research on and won awards for its use of what she terms "digital advocacy," explained how the adoption of a few key technologies together with targeted use of social media has greatly improved outcomes in her region.

And diabetes specialist nurses Caroline Atkinson and Maggie MacDonald told how their implementation of Diasend for downloading patient data from glucose meters, insulin pumps, continuous glucose meters (CGMs), and other devices in their West Hampshire Diabetes Service has greatly reduced their workload and been met with enthusiasm by all of their patients.

As Dr Ng observed, "We can't run away from it.…Healthcare online is not going to go away, it's going to expand; the people who just sit in the bubble and avoid social media and technology will lose out on the opportunity to engage."

Responding to Challenges in Pediatric Diabetes Care

Dr May Ng

Describing what her team did, Dr Ng noted that the United Kingdom has the highest number of children diagnosed with type 1 diabetes in Europe but the lowest numbers attaining good glucose control.

Audit figures show that less than 30% of pediatric patients, on average, achieve even the older HbA1c target of 7.5%, never mind the recently introduced tighter target of 6.5%, she noted.

Limited time to spend with each patient, complex patient issues, the difficulty of obtaining accurate information and/or ineffective review of data in a patient's diary within a limited time, and very high nonattendance rates among teenagers in the young adult clinic during "transition" all hamper the effectiveness of care, she said.

And this is all coupled with an increasing demand on services, with an estimated rise of 13.5% in the number of children with type 1 by 2030, which needs to be reconciled with increasing pressure to cut costs and improve efficiency.

So in 2012–2013, she and her team set out to try to effect change. By adopting a few key technologies — including an electronic diabetes information management system, called Twinkle (Hicom), and Diasend for patients to download data from their devices, as well as judicious use of social media, they managed to greatly improve outcomes.

Dr Ng noted that, at the time, her team was "the only pediatric diabetes team with its own Facebook page in the UK."

This is updated in conjunction with the healthcare trust's media officer, and she and her colleagues also set up their own WhatsApp group to aid communication among themselves.

"Now our monthly audit has become a 10-second job with, and Diasend was another game changer for us," she noted.

"All of this is really helpful when you are faced with the 30-minute clinic visit with children and their families." These tools helped them to identify patients with poor metabolic control, who were targeted for more intensive contact.

"Our aim is to help educate them and transfer skills to them. If we don't know how to interpret a continuous glucose monitor or 'flash' monitor, how can we teach our patients?"

And their hard work has paid off. By 2013, 27.9% of their patients were achieving HbA1c of <7.5% compared with 23.7% in 2011, while hospital admissions and length of stay were significantly reduced (BMJ Qual Improv Rep. 2015;DOI:10.1136/bmjquality.u209396.w3846; Arch Dis Child. 2014;99:1059).

Dr Ng's team were also the winners of the Diabetes Quality in Care award in 2015 and runners-up for the BMJ Diabetes Team of Year 2015.

Patients, Carers, and Staff All Overwhelmingly Positive

The diabetes team at Southport and Ormskirk Hospital NHS Trust

To gauge how patients and carers viewed the use of the new technology, Dr Ng's team performed a survey, for which they obtained a 79% response rate.

Of the responders, 81% said they benefited from the downloading of blood glucose readings in clinic or elsewhere, and 87% felt it enhanced patients' or parents' management decisions.

One important point to emerge was that patients now felt "there was no point putting in false numbers," Dr Ng said, referring to the tendency sometimes for patients to make their blood glucose readings seem better than they actually are when filling in their paper diaries.

Patients and carers also said it was "easier to see the trends" and "clinics are more informative…and educational and not judgmental."

And regarding the Facebook page, feedback was overwhelmingly positive: "It's great for getting updates."

Meanwhile one patient speaker at the London meeting, nurse Sue Wales, who was diagnosed with type 1 diabetes at the age of 18 and is now in her 50s, told of her 20-year struggle — which she termed "diabetes burnout" — to live a normal life without limitations and then explained how technology, in recent years, has helped her to move much closer toward this goal.

The simple acquisition of an insulin pump a few years ago has changed her life, she noted, while lamenting the fact that in the United Kingdom, often adult patients with type 1 diabetes have to be deemed "hypoglycemia unaware" before they can get a pump. And the addition of a relatively low-tech eye mask to sleep in (Noctura 400 Sleep Mask) has enabled her to significantly reduce the number of laser treatments she needs for her retinopathy, she noted.

Add to this use of calorie counting apps and hypoglycemia-awareness courses online, and a picture begins to emerge, she said, appealing to the audience: "Please find out anything and everything you can about technologies for your patients."

Dr Ng's staff also embraced the technological changes they made, commenting that the use of Twinkle and Diasend meant that "there's always blood glucose readings even if there is no diary," she noted, and saying they liked the fact that they could jointly uncover trends and patterns in blood glucose response to difference circumstances with their patients and carers.

Thus, they felt that it was "a collaborative effort to solve problems together."

Dr Ng stressed to Medscape Medical News that it was the overall combination of changes they made such an impact: "It wasn't one factor — we did many things — a multitude of change in behavior as well as employing every digital tool we could.

"Information technology and social media can significantly improve patient outcomes and are easily adapted into any pediatric diabetes service," she said, while stressing that this does require the support of the IT department and healthcare organization.

There's an App for That: Website Peer-Reviewed Apps for Diabetes

One of the recurring issues that came up at the Diabetes Professional Care meeting was how difficult it is for healthcare professionals and regulatory authorities to keep pace with technological changes and identify which of the multitude of tools out there are reliable.

For example, Mark Grumbridge, senior clinical advisor, medical devices division at the Medicines and Healthcare Products Regulatory Agency (MHRA, the UK equivalent of the FDA) described how the "biggest part" of the agency's time is currently spent trying to tackle a flood of counterfeit devices, including all of the technology commonly employed by diabetes patients.

"People think they are getting a bargain on Amazon," but little do they know that the product has been imported from China and rerouted via a "fulfillment warehouse," where it is repacked and reposted as coming from the United Kingdom, he noted.

"Make sure the device has a CE mark," he stressed to both patients and physicians. "Otherwise, the device is unregulated and it's buyer beware."

He urged doctors to report anything untoward under the "yellow card" scheme: device failures prior to use, in use, or those causing harm to patients, as well as those in which instructions are just not clear, or devices about which they have general safety concerns.

Apps are also regulated as medical devices and therefore also come under the auspices of this agency, and he noted that new guidance was issued by MHRA in August 2016, detailing five categories of apps.

"The biggest problem we have is that we are playing catch-up. We are not against apps, but our key message is to make sure they are regulated," Mr Grumbridge stressed.

And because they are regulated as devices, the best way to ensure an app is reliable is to make sure it has been awarded a CE mark.

But Dr Ng acknowledged that it is often difficult for healthcare professionals, patients, and their carers to easily ascertain whether an app has a CE mark or not, noting that the onus is on the developer of the app to apply for this.

This is one of the issues that drove the setting up of a new type 1 diabetes resources website, for which Dr Ng is a volunteer reviewer.

Every app included on the website has been peer-reviewed "to give them some sort of credibility,"she noted; they are all CE marked, and the site also provides a basic guide to what social media is and how it can be used, as well as detailing useful websites and blogs.

"We don't discourage use of apps — we provide our own education for the patients [or doctors/nurses] to be aware about which apps could be useful. It's the same as Googling a condition — you might get a whole range of answers. It's about educating people how to use healthcare online properly. The team needs to support and educate the patient," Dr Ng said.

Social Media: A New Frontier, but Don't Be Afraid

Regarding social media in particular, Dr Ng's overall message to physicians, nurses, and other healthcare professionals is "not to shy away" from it, because it "is an opportunity to be engaged," a fantastic tool to help promote communication between healthcare professionals and their patients and carers.

However, she stressed that it is important to "maintain boundaries." adding that for those who are unaware, the General Medical Council (GMC) and the British Medical Association (BMA) in the United Kingdom do have guidance on this issue.

Other organizations that have similar recommendations include the American Medical Association, the Canadian Medical Association, and their counterparts in Australia and New Zealand as well as the Mayo Clinic in the United States.

For example, it is not recommended to become a personal "friend" on Facebook with a patient, Dr Ng noted. But rather than ignoring a "friend request" from a patient or carer, a healthcare provider should explain this to their patient so that they understand the boundaries.

"Healthcare providers in the UK are very risk averse," she noted. "But if you look at GMC social-media guidelines and BMA guidance, if you read it, you wouldn't be scared to develop anything in a form of social-media engagement."

Ultimately, social media provides healthcare professionals with the opportunity to contribute to good information online, Dr Ng stressed.

Whether it be in the form of Twitter posts, an official Facebook page, or blogs, doctors and others can "recommend websites, and good articles and blogs on topics you see often, or questions you answer often," she noted.

Doctors now face "a generation with internet technology readily available," she stressed, adding that "healthcare online will become part of our clinical practice.

"Know the risks and behave accordingly, but do not be so risk averse that you do not participate."

Dr Ng is on Twitter: @mayng888.

Follow Lisa Nainggolan on Twitter: @lisanainggolan1. For more diabetes and endocrinology news, follow us on Twitter and on Facebook.


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