Improving Diabetes Care
Treatment of diabetes, like most areas of medicine, has changed considerably over the years as a result of technological advances. From the discovery, purification, and mass production of insulin to the development of less painful ways to deliver it, the lives of people with diabetes have been improved — and sometimes greatly extended — by both diabetes-focused research and broader improvements in medical care.
Although it can be difficult to predict the impact of an emerging technology, there are several exciting developments on the horizon that may soon significantly change how people with diabetes receive medical care or manage the condition on their own. At least one relatively new innovation, the continuous glucose monitor, is already changing the daily routine for some.
This article examines several innovations that are likely to change — or are already changing — the way medical care is delivered and the way medical information is communicated. Not all assessments of medical technology are completely upbeat, however. Especially when it comes to electronic health records, many experts are either frustrated at the pace of progress or skeptical of how the technology will be used.
Electronic health records
Dr. Richard Hellman, who is past-president of the American Association of Clinical Endocrinologists and has an endocrinology practice in North Kansas City, Missouri, laments that although someone can get money from an ATM or use a credit card anywhere in the world, medical information often cannot be easily accessed when it is needed. “The tragedy is that information doesn’t move around to the benefit of the patient,” he says. “There is much too much information that can’t be transmitted.”
The problem is not a technological one. Electronic health records already exist in many forms. Medical practices and hospitals often keep records of patient visits on a computer system; these records may include lab test results, imaging studies, weight and blood pressure measurements, comments by doctors and nurses, and anything else that can be captured digitally. However, these records often cannot be easily shared with other practices or hospitals because of the closed nature of the computerized record systems. While it may be possible to send information by e-mail or to print it out and then send it by fax or regular mail, an enormous amount of time could be saved by an integrated system in which everyone’s records are immediately accessible to health-care providers who need to see them. Such a system would be particularly useful in emergency situations, and if implemented correctly, the records would not be subject to accidental destruction in cases of disaster such as floods and fires.
But while the technology exists to develop an integrated system, security concerns and competition have so far stymied its realization. “It needs to be secure so someone can’t hack into [electronic files], take the information, and sell it,” says Dr. Hellman. To overcome the other roadblock, competition, the tech industry would need to “agree on common protocols: some agreement that there are certain standards that have to be used.” There would also need to be agreement on financing the new system: who would pay for the software, equipment, training, and data entry as paper records are computerized and computerized records are converted to the new system.
But Dr. Hellman asserts that these should not be actual barriers, citing the financial industry, which has been sharing information for years without significant security or compatibility issues. Just as a bank card from Indiana can withdraw cash from an ATM in Europe within seconds, with an integrated record system, a hospital emergency room anywhere in the world would be able to look up someone’s health problems or drug allergies as soon as he is admitted. And, for that matter, a natural disaster such as Hurricane Katrina would not be able to destroy the medical records of thousands, which is what happened in 2005.
In fact, Health and Human Services Secretary Mike Leavitt told the Associated Press shortly after Hurricane Katrina: “There may not have been an experience that demonstrates, for me or the country, more powerfully the need for electronic health records…than Katrina.” At the time, Leavitt said the federal government’s goal was to have electronic medical records available for most citizens by 2015.
“The medical field is the most backward in terms of information technology,” says Dr. Hellman. “When that problem gets solved, it will have a huge impact on health care.”
Continuous glucose monitoring
But while Dr. Hellman is frustrated by his industry’s slowness to adopt information technology, he calls the burgeoning technology of continuous glucose monitoring “completely revolutionary” for its potential to change diabetes care.
Compared with relying on urine glucose test strips and a single blood glucose measurement at each visit to the doctor, home blood glucose monitoring and the HbA1c test (which provides information about the level of blood glucose control over the previous two to three months) have allowed a degree of blood glucose control that was unimaginable at their inception. Both, according to Dr. Hellman, “were revolutionary in their day. Continuous glucose monitoring is just another advancement…you can see what’s going on at all times. It’s changing the rules of what we use for control.”
Continuous glucose monitoring uses a sensor, inserted under the skin, to provide a glucose reading every one to five minutes (depending on the brand) that is displayed on a monitor. The monitor also shows whether the glucose level is rising or falling and can sound an alarm if it gets too high or too low. Numbers are stored and can be viewed as graphs, which lets the user see his glucose trends throughout the day or across several days.
Currently, there are several continuous glucose monitoring systems that have been approved by the US Food and Drug Administration: the DexCom G4 Platinum, the Medtronic Diabetes Guardian Real-Time, and the
Medtronic Diabetes MiniMed Paradigm Real-Time Revel, which is a combination continuous glucose monitor and insulin pump.
According to Dr. Hellman, being able to see if your blood glucose level is rising or falling “is extremely important,” and this may explain why a randomized controlled trial showed that using a continuous glucose monitor resulted in a lower HbA1c level among insulin pump users. “In its own way,” says Dr. Hellman, continuous glucose monitoring “will have a profound effect.”
Creating a device that would regulate blood glucose levels on its own, in effect creating an artificial pancreas, has long been a goal of diabetes researchers. Now, however, such devices are actually being built and undergoing testing. The advent of continuous glucose monitoring has been crucial to this process, since an artificial pancreas is basically the marriage of an insulin pump, a continuous glucose monitor, and a computer program that calculates how much insulin the user needs at any moment based on his blood glucose level.
But, Dr. Hellman says, “There are things that you and I would know about ourselves,” such as how stress and activities affect blood glucose levels and insulin needs, that cannot be determined by a piece of mechanical equipment, no matter how sophisticated. Artificial pancreases, he believes, “will always be imperfect,” requiring the entry of some information by the people who use them.
While electronic health records, continuous glucose monitors, and the artificial pancreas are at the top of Dr. Hellman’s list of important emerging technologies for people with diabetes, the lives of many will also be affected by other developments in medical technology.
Long-distance patient care
Soon, you may not need to live in or travel to a major city to receive big-city medical care. The American Telemedicine Association paints a picture of having your blood pressure read while you’re at home and the nurse is in the office, of a radiologist reading your medical images from his home in another town, even of a surgeon operating on you from 300 miles away.
This isn’t a dream: It’s happening right now.
An essay in the February 16, 2006, edition of The New England Journal of Medicine noted that in the past, “to examine the heart, the cardiologist could be no farther from the patient than his or her stethoscope allowed, and data gathering required face-to-face discussions with patients and sifting through paper files. But as health care becomes digitized, many activities, ranging from diagnostic imaging to the manipulation of laparoscopic instruments, are rendered borderless.”
What does this mean for you? It may lower the cost of your care, or even save your life.
Say you’re in a serious accident in the middle of the night. Your life depends on having the correct diagnosis fast, and the diagnosis involves having a radiologist read your x-rays. However, there is no radiologist available in the hospital you’ve been taken to, and calling one in would take too much time. Luckily for you, the hospital has a relationship with a radiologist in another part of the world where it’s the middle of the day, so the doctor is in. The image (taken by a technician) is transmitted to the radiologist by computer, and he reads it and sends back the findings.
Telemedicine may also provide more opportunities for people with a chronic illness or condition, such as diabetes, to interact with medical professionals. This, in turn, may lead to improved outcomes: A recent study of people with heart failure, published in the journal Telemedicine and e-Health, showed that patients who received follow-up attention by telephone or videotape after hospitalization had a significantly lower hospital readmission rate than those who received no such follow-up. (For more on how telemedicine is changing the face of diabetes care, check out “Telehealth Meets Diabetes.”)
The first step in long-distance robotic surgery was taken on September 7, 2001, when surgeons in New York removed the gallbladder of a 68-year-old woman in France using a high-quality telecommunication system and a three-armed robot. One arm held a camera, and the other two held laparoscopic surgical instruments. Surgeons were on hand in France to take over in case a problem arose.
In an article about the surgery that appeared in the online publication National Geographic News, surgical team member Michael Gagner, then chief of the Division of Laparoscopic Surgery at Mount Sinai Medical Center in New York City, was quoted as saying, “As the technology evolves and becomes available and wiring is more widespread, it will be useful for…performing rare surgery that requires different expertise. A smaller city could have the help of an expert surgeon just by being connected.”
As the technology becomes portable, the article noted, “it should also be possible to perform complex surgery even at remote disaster sites and battlefields, when response time is critical, and in developing countries that have few or no surgeons.”
On a more local level, many operating rooms now have robots that are manipulated by surgeons on-site. This form of robotic surgery is useful to perform minimally invasive procedures, since robots can perform smaller tasks with more precision than any human can.
Don’t be surprised, either, if some day in the future, you’re visited in your hospital room by a robot.
Some people who had laparoscopic gastric bypass surgery in a Baltimore hospital between January 2004 and July 2006 were visited by a six-foot-tall robot with a flat-screen monitor for a “face,” two other high-resolution monitors, and a microphone. The robots used a videoconference system to allow more frequent communication between patients and surgeons. More than three-fourths of those who were visited by the robot (and by human care providers) were discharged the day after surgery, versus nobody in another group who had human visits only. Of the latter, 77% were discharged on the second day.
The study was reported in the July 2007 issue of the Journal of the American College of Surgeons. Researchers said that robot-assisted close monitoring by the surgeons helped anticipate the types of adverse events that often cause longer hospitalizations.
Keeping your own electronic records
Until Dr. Hellman’s dream of worldwide access to medical information is realized, there is something you can do: Put your pertinent information on a flash (or “thumb”) drive and carry it with you in case of emergency. These small devices are about the size of a pocket knife, and many can be attached to a key chain. According to Dr. Kayur Patel, chief medical officer at Regional Hospital in Terre Haute, Indiana, information can be entered in plain text or using a word-processing program such as Microsoft Word. For suggestions on what to include in your record, see “Personal Electronic Health Records.”
Another option is to buy a flash drive made specifically for medical records, such as MedicTag (for Windows operating system). This may make entering and saving data easier, and the device will be recognizable in emergency situations. If you’d rather not use a flash drive, services such as MedicAlert provide 24-hour emergency access to your health information and give you an identifying medical tag that can be worn as part of a bracelet, necklace, or watch.
What about using a Web-based health records program, such as those being offered by Google and Microsoft? Dr. Hellman cautions against it, as do the authors of an article in the April 17, 2008, edition of The New England Journal of Medicine.
While Dr. Hellman’s main concern is a lack of knowledge among some people about what should be included in the record, the article’s authors believe that personally controlled health records “are a disruptive innovation that inverts the current approach to medical records in that they are created by and reside with patients who grant permission for their use.” If it becomes the norm, this new approach, according to the authors, could disrupt studies that (anonymously) examine medical records. While they voice some concerns about privacy, the main problem that the authors have with personally controlled electronic records, as they currently exist, is that they’re not very useful. Without “broad agreement on standard data formats,” there are limits to what a patient can do with his records on such a system.
So until a universal format is adopted, it’s probably best to keep your records whichever way is easiest for you, and to make your basic health information available separately in case of an emergency.
Whether or not you carry your personal health information on a flash drive or make use of some other system, you can take advantage of the electronic records that are kept by virtually all pharmacies these days. First, by buying all of your drugs from one pharmacy, you can benefit from the pharmacy’s ability to quickly check your prescription records for potential drug interactions or allergy issues. Second, if you get your drugs from a pharmacy that’s part of a nationwide chain, it’s likely that a pharmacist at any of its locations can access your prescriptions from the company’s central database. This can be a huge help if you’re traveling and get partway across the country before realizing that you’ve left behind something vital (such as insulin) that you can only get with a prescription. And it can be a lifesaver in the event of a natural disaster that requires you to leave your home.
If you’re traveling and don’t normally get your medicines at a pharmacy with a national presence, or you’re going to an area that doesn’t have the chain pharmacy you use, follow the old-fashioned method: Take paper copies of your prescriptions with you.
If you have a computer, there’s no need to take a ragged, blood-spotted record of your blood glucose measurements with you when you see your doctor: Just upload the data from your meter to a computer program provided by your meter manufacturer or available online. You can then print out charts or graphs to bring to your doctor. Many online programs even let you give your doctor access to your profile over the Internet, but of course this requires his cooperation.
It may also be advisable to keep a backup record on paper and to look at your blood glucose trends between doctor visits. If you notice an upward or downward trend in your numbers at a particular time of day, call your health-care provider for advice.
You can also help your health-care provider by providing him with your family history. Don’t know what to include? The Department of Health and Human Services makes it easy for you through its Family History Initiative. Because some diseases and conditions — both common and rare — can run in families, it’s helpful for your doctor to know what to watch out for when it comes to your health.
Go to www.hhs.gov/familyhistory to learn more and to download a Web-based family health portrait that you can fill in and take to your doctor. You may also want to share the information with family members.
Technology is also poised to improve diabetes education, especially for young people. In a 1997 study, kids ages 8–16 who were assigned to play a diabetes-themed video game called Packy & Marlon had 77% fewer diabetes-related urgent care and emergency room visits over six months than those not assigned to play the game. “The [study] demonstrated that a well-designed diabetes self-management game could change health behaviors and outcomes,” says Debra Lieberman, a coauthor of the study, which was published in the journal Medical Informatics. (Packy & Marlon, for Super Nintendo, can still be bought used at www.ebay.com and www.amazon.com.)
Highly rated diabetes education computer games that are widely available include dbaza’s Diabetes Education for Kids, a CD-ROM for Windows operating system, and It’s Time to Learn About Diabetes, a CD-ROM for both Windows and Mac. Two more graphically complex nutrition-themed video games, Escape From Diab and Nanoswarm: Invasion From Inner Space, are set to be released this year. Both were developed through a partnership between Archimage, Inc., and the Children’s Nutrition Research Center at Houston’s Baylor College of Medicine. A variety of free online games can also be found at the American Diabetes Association’s Youth Zone, located at www.
Educational computer programs aren’t just for kids. In 2008, Spectrum Health, Cerner Corporation, and Microsoft announced a collaborative effort to develop a device for patients in hospitals called the Cerner Care Console. The goal is to create a user-friendly system that can educate patients about their care by showing treatment plans and lab results, lets them communicate with their health-care team, and also gives them entertainment options including music, movies, and video games.
Another tool for adults that can be used online or downloaded to a personal computer is the AIDA “diabetes simulator.” If you’d like to know how a change in your diet, exercise, or insulin regimen would affect your blood glucose level, you could just make the change and see what happens — or you can test your plan on a virtual person at www.2aida.net. There are 40 preset “people” with varying characteristics to choose from; you can also modify a “person” or enter your own information. The Web site maintains that it is “not meant for individual patient blood glucose prediction or therapy planning,” so it’s still a good idea to talk to your health-care provider before making any changes in your diabetes treatment plan.
With so many new technologies coming into existence, diabetes care has the potential to become a distant relative of what it was even a decade ago. All signs are that technological developments will continue and probably even accelerate, given the expected increase in the number of people with diabetes. While a miracle cure is unlikely, advances in medical technology — both directly and indirectly related to diabetes — can make diabetes control easier, more convenient, and more accurate for everyone. Just think: One day, your grandchildren may ask you what a blood glucose meter was.