Cloud Management Will Help Bring Diabetes Care into the Future

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Dr. William Hsu studies a new app aimed at helping patients to better manage their diabetes

Over the past five years countless smartphone applications have been introduced to make navigating the day-to-day aspects of life a little easier. But until recently, one area has remained largely untouched by the promises of technology – healthcare.

More specifically, the management of chronic conditions. Surgeries and medical imaging technologies have been evolving since their developments allowing for better and better care. “But the specialties that have no surgical procedures remain pretty much the same as decades ago,” says Will Hsu, M.D., Vice President, International Programs at Joslin Diabetes Center.

“I think our current model of care is really not adequately set up for recurring chronic illness that have no cure,” says Dr. Hsu.

Diabetes is a prime example. People who have to manage their blood sugar get no break from their disease. Currently, it’s recommended that they see a doctor every few months but that leaves weeks at time when they are unsupported. “Diabetes is a 24/7 disease,” says Dr. Hsu. “It does not wait until the next medical visit for patients to get the information they need.”

A new mobile application explored by Dr. Hsu in a recently published study aims to fix this problem. Three years ago, Dr. Hsu began a collaboration with John Moore, M.D., Ph.D., founder of Twine Health. Thanks to a meeting facilitated by Aldo Rossini, Mary K. Iacocca Visiting Scholar at Joslin Diabetes Center and Harvard Medical School and
Professor Emeritus at University of Massachusetts Medical School, they began working together on creating an app that would help bridge the gap.


Dr. Moore, who was then working on his Ph.D. at MIT, had ceased practicing medicine when he became frustrated with his inability to provide his patients care between office visits.

“The world was moving at a pace to really allow individuals to participate in a lot more, whether it’s their financial management or their travel or other things. But when it came to health they were totally at the mercy of the healthcare system,” says Dr. Moore.

“We live in an era when people need to have problems solved instantaneously,” says Dr. Rossini. “A person with Type 1 diabetes may have a sick day and requires a prompt recommendation to adjust the insulin regimen, for example. Another issue may be related to taking the fast acting insulin instead of the long acting insulin.”

With Dr. Hsu’s assistance, Dr. Moore developed and tested an application that has evolved into his business, Twine Health. They employed the concept of cognitive apprenticeship, the idea that patients would begin to learn more about their health through subtle coaching provided through the app.

All of the study participants were Joslin patients with type 2 diabetes who were about to start insulin therapy. They randomized the participants into two separate groups. Both would start using insulin, but one would get traditional office-based care while the other would be supported through this mobile application.

The application interface showed the patients their medications, including insulin, and allowed them to input the dosages for each day. They could also input their blood glucose level, either manually or by linking up a smart glucose meter. The app would chart that data, allowing them to visualize what was happening to their blood glucose in response to medications.

As they started using the app, the patients were given insulin dosing suggestions by a certified diabetes educator (CDE), who had access to all of the patients’ inputs.

“Over time, what happened was they’d shift that responsibility over to the patients through this study,” says Dr. Hsu. “So the patients begin to make dosing decisions with the CDEs support. And then in the end what happened is the CDEs faded away. Patients made decisions on their own insulin dose, and they would send their suggestions to us and then we would approve it. It’s collaborative decision making”

Transferring of responsibility was the crucial idea behind the success of the app. Through use of this cognitive apprenticeship, the CDEs taught the patients how to think about their health needs and react accordingly. The CDEs and Drs. Hsu and Moore were allowing them to take ownership of their diabetes, becoming experts in their own conditions.

“We try to help people actually develop confidence and self-efficacy,” said Dr. Moore. “We see that that’s what really makes a difference.”


In fact, it made a huge difference. The group that received support through traditional means saw a decrease in HbA1c of two percentage points.

“Anybody would say that’s great,” says Dr. Hsu. “But in the intervention group, [the ones using the application,] it was three percentage points, plus.” The team behind the study accounted for any forces outside the application that could have accounted for the difference in A1C drop. Both groups used the same amount of insulin on average. Both groups ended the study at similar average weights. Both groups reported the same amount of hypoglycemia.

The key difference, they thought, was that people in the intervention reported significantly higher levels of satisfaction with their care. They asked the intervention participant how they felt about using the application, and they received a wave of positive feedback. One of Dr. Hsu’s favorites? “[One patient said] ‘I really look forward to seeing what my blood glucose is going to be,’” he shared.

Not only was the intervention group happier, they saved more time and money as compared to the group who came in to see the physicians regularly. In the end, the control group had 81.6 minutes of interaction time with their CDEs, versus only 65.9 minutes in the intervention.

“While all the other interventions [such as medications] that are coming out have marginal gain and cost a ton of money, our coaching actually saves money and produces dramatically better results,” says Dr. Moore. Twine Health is currently providing this app-based service, no longer exclusively in diabetes, by partnering with healthcare providers that are reimbursed on a per-patient basis, rather than a per-service basis, which is a trend that needs to increase if this system is to be widely implemented.

Dr. Hsu suggests such a major shift in healthcare delivery can only be made possible through interdisciplinary solutions. “The business folk have to help us come up with a business model so there is money to provide this kind of care, policy makers have to allow reimbursements in a different structure, and the hospital leadership has to embrace the changes in innovation,” he says.

But he is hopeful that once this is implemented, we will see a huge improvement in the care of people with chronic illnesses.

“Patient support is best when it’s provided in small doses in increased frequency rather than in one big jolt and not having a follow-up until the next time,” he says. People who need frequent visits would still have access to them, but people who are able to manage their conditions on their own would be able to enjoy a new ease of care.

Dr. Rossini believes this app and other like it have tremendous potential. “There is an explosion of technology but that alone is not the solution. The technology is an extension of care.” he says. “As John Steinbeck said: What do I want in a doctor? A friend with special knowledge. We need to make sure that we have knowledgeable health care providers who can coach patients through their crises. Telemedicine will assure that the health care provider will have quality time with the patient, to answer the questions that the patient believes are important.”

“Hopefully this will improve the productivity of society, where patients don’t have to take half a day or a whole day off to come drive in, park, traffic, wait for the doctors, see them for a few minutes then turn around and repeat the same thing, do this a couple of times a year. Wouldn’t that be nice?”

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