Consumers turn to technology in their everyday lives to communicate, perform daily tasks, and find information. Likewise, they are increasingly using technology to log and share lifestyle data, track their health status, find health information, and become more active participants in their own care. Digital health, the convergence of health care and technology, has reached a tipping point and is leading to clinical care and practice remodeling.1 This article explores the rapidly expanding role of digital health in diabetes care, the evidence advocating its use, and the leadership opportunity for diabetes educators.
Digital health in diabetes
Chronic conditions such as diabetes that require ongoing self-management, regular follow-up, and therapy progression can benefit from the integration of technology-based tools. The anytime-anywhere nature of digital technology supports the delivery of automated, individualized, contextualized coaching by enabling patients to share data and connect with their diabetes care team between appointments.2
As value-based models of care and payment are becoming established, people with diabetes are increasingly demanding diabetes care and education services outside often underutilized hospital-based diabetes self-management education and support (DSMES) services.3 Health plan care coordinators, health system population health managers, patient-centered medical homes, and employer-based health coaching programs are expected to deliver diabetes care and education. The growing complexity of diabetes medication regimens and the extensive ongoing self-management support that people with diabetes require have led to a growing interest in digital health in these evolving care models to support health-care teams in effectively managing their diabetes population.
The American Association of Diabetes Educators (AADE) defines the diabetes ehealth ecosystem as the use of information and communication technologies for health (Figure 1). The ecosystem goes beyond diabetes devices to include personal health devices such as physical activity and sleep trackers, cloud-based monitoring systems, data management platforms, telehealth services, digital education, mobile apps, digital therapeutics, and social media platforms.
But is digital health effective?
It depends. While technology is poised to become a major part of the solution in transforming diabetes care, it is currently a rapidly expanding and confusing space. Many diabetes technology solutions offer the opportunity to track and visualize data related to daily diabetes care, including blood glucose, blood pressure, weight, food, physical activity, and medications, but most offer minimal data analysis, interpretation, or guidance to patients. They are categorized by the FDA as general health and wellness apps not requiring regulation.4https://www.diabeteseducator.org/
In contrast, a new category of therapy is referred to as digital therapeutics. A digital therapeutic must meet the following criteria5:
1. evidence- and theory-based data analysis and feedback is tailored to individual clinical needs, goals, and lifestyle;
2. connects the individual with his or her health-care team;
3. demonstrates safety and efficacy in published, peer-reviewed randomized clinical trials;
4. ensures safety and security of patient-generated health data;
5. obtained FDA clearance when used as a medical device and developed in accordance with appropriate quality standards; and
6. designed to be user-friendly and engaging.
According to a 2017 systematic review of 25 studies that evaluated technology-enabled DSMES, improvements in A1C ranged from 0.1 to 0.8 percent in 18 of the 25 studies.6 Four key elements were identified that were incorporated into the most effective interventions: two-way communication in a continuous feedback loop, analyses of patient-generated health data, tailored education, and individualized feedback. The authors described this as a technology-enabled self-management (TES) feedback loop (Figure 2), which connects people with their health-care providers.
Access to and review of patient-generated health data (PGHD) can lead to more timely changes to care by providing insights for shared decision-making and proactive patient-team communication and engagement. To be of value, digital therapeutics and the resulting patient-generated health data must be integrated into clinical practice. Due to the growing evidence that digital tools improve A1C and other diabetes-related outcomes, both the 2017 National Standards for DSMES7 and the 2018 American Diabetes Association (ADA) Standards of Medical Care8 encourage inclusion of technology-enabled solutions to deliver diabetes care and education.
Transforming the role of diabetes educators
An enterprising diabetes educator can utilize evidence-based digital health to increase access, reach, and effectiveness of diabetes education and care services, ultimately positioning the educator as the expert consultant in leading health-care transformation in evolving practice models. Why educators? Educators are recognized as the subject matter experts for diabetes care and are skilled in the use of PGHD from their experience in using blood glucose and continuous glucose monitoring data. The diabetes educator can mentor and lead other members of the health-care team in the use of the ever-expanding PGHD with the goal of connecting individuals with their care teams through a complete feedback loop to optimize diabetes self-management and treatment. Educators are trained and oriented to provide person-centered care, including empowering individuals in building diabetes self-management and problem-solving skills.9
Diabetes educators are preparing to navigate and lead within the continuously evolving digital health and payment landscape. Training will be needed to integrate evidence-based technology tools into practice, including how to use the resulting patient-generated health data to optimize individual care. Learning how to use aggregated population-level data to assess the overall health status of a population and support quality improvement and population health initiatives is key. Technology-enabled care facilitates the pivot to data-driven versus time-bound episodic encounters. New skills in providing remote (virtual) care and how best to leverage new and proposed remote monitoring codes in their practice situation are necessary.10 AADE launched the Diabetes Advanced Network Access (DANA), a hub for diabetes educators, other health-care providers, and industry to learn about the latest devices, medications, mobile apps, and technology focused research in 2017.
Also in 2017, a Digital Health Learning Network (DDHLN) was established collaboratively by AADE and the digital health company Welldoc. The ongoing intent of the network is to provide opportunities for diabetes educators to develop and share best practices for integrating a digital therapeutic in various practice settings. Educators are exploring how the use of technology enables them to take on new roles and how to position themselves as leaders in population health management. Educators mentor the care team in the timely use of patient-generated health data to identify and resolve self-care barriers and to collaboratively optimize care plans in a timely manner. The network is open to new participants and plans to expand to include other members of the care team. If interested, the reader can email [email protected].
Virtual care payment
As the use of technology in health care grows, both fee-for-service and value-based models of payment will increasingly cover virtually delivered diabetes health services. Medicare incentivizes remote patient care within its Merit-based Incentive Payment System (MIPS), including as one of the recognized MIPS improvement activities the use of digital tools to monitor patient-generated health data with clinically endorsed tools that include an active feedback loop providing actionable information to patients and their care teams.11
Starting in 2018, Medicare “unbundled” an existing Part B CPT code, 99091, now paying separately for remote patient monitoring by qualified providers, including physicians, nurse practitioners, physician assistants, and clinical nurse specialists. Providers can be paid approximately $58 for a cumulative time of 30 minutes per month to review biometric data the patient and/or caregiver digitally transmits and to communicate the findings and care plan recommendations to the patient and/or caregiver. Additional new remote monitoring codes are proposed for 2019, reflecting the growing potential of using connected health tools to better support health-care teams in population health services, including using technology to connect with their patients at home and gather data for care management and coordination.12
Technology is rapidly transforming health care. Opportunities are here for health-care teams to leverage these tools to improve diabetes outcomes for their diabetes population. Educators, with their extensive experience in the practical use of patient-generated health data, person-centered diabetes care, and self-management training, are uniquely positioned as valued team members to integrate evidence-based technology tools into clinical practice.
Access additional resources and practical information to enhance the care and treatment of your diabetes patients.
About our expert: Janice McLeod, MA, RDN LCN, CDE, Director of clinical innovation for WellDoc, maker of the BlueStar digital therapeutic for type 2 diabetes