Information technology in DM
Effective management of diabetes requires multidisciplinary care and self-management by patients. Good management reduces the risk of developing complications, enhances health related quality of life and reduces hospital admissions. Conversely, poorly managed diabetes is associated with serious complications including stroke, blindness, heart disease, kidney disease, nerve damage, amputations, and death. This article introduces the reader to the use of information technology to support and enhance the management of diabetes.
Due to changes in population size, age distribution, and ethnic diversity, patients with diabetes often fail to receive the recommended care. Less than half of persons with diabetes meet the recommended levels of HbA1c, blood pressure and lipid control . Conversely, effective management can prevent or delay complications, and reduce the need for hospital admission . Effective communication is central to this process, and a growing body of literature suggests that the use of information technologies may improve diabetes care.
Information technology (IT) refers to the use of digital technologies such as computer, software, Internet, etc. to transmit, manipulate and store various types of information. The term eHealth is also used interchangeably to refer to IT in healthcare field. IT-enabled diabetes management (ITDM) have the potential to improve care process, and provide support to patients; which in turn may produce clinical and economic benefit. Recent reviews have evaluated the potential benefit of information technologies in diabetes management and found that IT use has been associated with a corresponding improvement in measures of diabetes care including HbA1c, blood pressure and lipids .
1. Technologies Used by Providers
National diabetes registry: This is an electronic database that allows identification and tracking of patients with diabetes to help providers overcome fragmented care and improve the consistency and quality of patient care. At the point of care, registries may provide clinicians with reports for analysing a patient’s key diabetes-related measures and help track a patient’s progress. Registries may also provide a rich source of data across the population that can be utilised for research, for example, to find the proportion of patients with diabetes who have acute and long-term complications or a list of patients with high blood-glucose level (HbA1c > 8%).
Clinical decision support systems (CDSS): A computer software designed to assist clinicians during a patient visit to enhance decision-making. Such systems use the latest medical knowledge along with patient data to generate case-specific advice allowing clinicians to make an informed decision. These tools include computerised alerts and reminders to care providers; clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support, and contextually relevant reference information, among other tools.
Electronic medical records (EMRs): Patient or population medical records in an electronic format that can be shared across different health care settings over secure networks. It contains the medical and treatment history of the patients besides the clinical administration system such as discharge/transfer orders, laboratory and radiology results, etc. It may also encompass ePrescribing and eBooking systems.
Electronic prescribing systems (ePrescribing): Generate and transmit the medical prescription electronically and aims to reduce the risk of errors and increase accuracy and safety.
Electronic booking systems (eBooking): Allow patients to schedule and arrange appointments online with aim to improve patients’ access and save time.
Telemedicine and telecare services: A range of assistive technology equipment and telecare products used to provide help and reassurance for people living with diabetes to live independently and safely in their own home. Telecare services mainly comprise three components: emergency response, environmental monitoring and lifestyle monitoring. Examples include: sensors and alarms; which can detect if there is a problem; linked to a monitoring centre, and medication dispensers and reminders.
Internet-based technologies and tools: Widespread and low cost internet access appears to be reducing geographic, demographic and economic barriers to obtaining medical assistant tools online. Use of internet-based tools among clinicians is common such as computerised reminders, medical calculators, and computerised advice on drug dosage, and eLearning materials.
Information retrieval systems: Provide clinicians with up to date knowledge about research conducted in the field, such as online databases and medical journals, digital libraries, and electronic guidelines.
2. Technologies Used by Patients
Any form of technology used to enable patient’s monitoring outside of clinical setting (e.g. at home) which frequently involves at least two-way communication, where patients capture and send healthcare providers information that is needed to facilitate diabetes management between scheduled clinic visits. These technologies allow clinicians to monitor patient’s control of diabetes between visits and to modify care plans accordingly. Four major systems have been used to monitor patients remotely and presented in box 1.
|Key diabetes remote monitoring systems.|
|A. Videoconference systems: Videoconferencing equipment (television, digital camera, webcam, videophone, etc.) is a useful technology for real-time applications such as doctor appointments, follow up, and consulting. It has been used to overcome time and location constraints of the patient and provider.|
|B. Telephone-based systems: Patients periodically submit data about their condition and they receive retrospective feedback and instructions all through regular telephone contacts performed typically by diabetes nurse for follow up or treatment adjustment. Telephone consultations as an alternative to clinic visits has been shown to be safe, convenient and increases access for clinician’s advice .|
|C. Internet-based systems: Uses interactive websites which accepts data uploaded directly from glucometers and other home devices; receive feedback and support at a time and place most convenient for them, and not limited to clinicians' office hours. These systems may also connect patients to provider email as an additional component within the technology to improve provider-patient communication.|
|D. Mobile-based systems: Mobile devices provide the mobility and flexibility so that care can be provided wherever a patient may be. The widespread use of mobile phones across socioeconomic, and age groups increase the access to healthcare; particularly for patients in remote areas and hard to reach populations such as elderly and disabled. Newer remote monitoring involves the use of mobile devices where patients with diabetes are given a glucometer that connects to a mobile phone to upload data instantly, and then all data stored can be transmitted immediately to their clinicians. Another utilised method involves the use of text or image messaging - SMS or MMS - to send data and receive prompt feedback, or possibly be used to consult with clinicians directly for individual recommendations; enabling remote monitoring and teleconsultation.|
Reinforcement strategies such as phone calls, text messages, and emails to promote patients adherence is associated with greater benefits. Remote monitoring technologies offer great opportunities to improve patient–provider’s interaction and feedback. Research has investigated the use of IT to promote access and engagement of people who live with diabetes and shown to increase the frequency of contact between patient and care team.
Diabetes self-management has been defined as “the process by which a person develops the skills to manage their condition”. Attempts to leverage IT in diabetes self-management go back to the late seventies and have shown promising outcomes. Numerous ITs have been found feasible, applicable, and effective for self-management in diabetes care . Five key self-management components specific to diabetes care and living with diabetes include: education, monitoring, medication, exercise, and diet. Successful self-management requires patient education on self-care, and thus, patients should be provided with the information and tools that allow them to become active participants in their own care. IT-based education and support such as interactive educational programs on computers, online diabetes-management resources, and social networks for peer support groups are becoming vital components of quality diabetes care. Such method can be operated in the home or without location restriction.
For self-monitoring technologies, patients are given access to personalised self-management tools with data gathering mechanisms for managing their own care between provider visits. As the main goal for diabetes self-management is often to try and keep blood glucose level within the target range, monitoring blood glucose level is the core function in most technologies. There has been an increase in technology-based interventions, and based upon the current evidence, self-monitoring of blood glucose has been shown to reduce in HbA1c levels . These interventions may be placed broadly into two categories according to their platform:
- Web-based tools
- Mobile-based tools
The internet is one of the most common technologies where the self-management websites which facilitate patient’s daily diabetes care. The patient can access their information, input their data, and track their progress. Alternatively, mobile phones are increasingly being used by patients with diabetes to gain access to relevant information about diabetes and obtain immediate assistance with monitoring their own diabetes. Apps may provide better opportunities for self-management, although limited evidence is available on their effectiveness .
Self-management mostly involves the adjustments of diet and exercise and the use of medication or insulin to control blood glucose. The increased emphasis on control of lifestyle factors for people with diabetes has boosted technologies that have been applied to a wide number of behaviours, such as promotion of physical activity, diet adherence, and medication adherence. Internet and mobile applications offer variety of tools such as electronic diaries, medication reminders, calculators for insulin dose adjustment or carbohydrate counting, food databases for nutrients optimisation at meals, and tracking of physical activity.
In summary, implementation of IT in diabetes care has significant potential for improving patients’ care, preventing development of diabetic complications, and generating cost savings. Barriers of adoption may relate to IT characteristics, individual or professional or organisational level. Important barriers to using IT in diabetes care include privacy and confidentiality concerns, lack of time and anxiety about change, inadequate funding, workforce shortages, and lack of or inadequate training . However, using IT for self-care is highly dependent on the individual’s motivation; without the patient’s willingness to be an active participant in their care; IT implementation will likely fail.
^ Perez, C.M., et al., Are adults diagnosed with diabetes achieving the American Diabetes Association clinical practice recommendations? P R Health Sci J, 2012. 31(1): p. 18-23.
^ Diabetes UK, Improving supported self-management for people with diabetes. 2009. http://www.diabetes.org.uk/Documents/Reports/Supported_self-management.pdf
^ Siriwardena, L.S., et al., A review of telemedicine interventions in diabetes care. J Telemed Telecare, 2012. 18(3): p. 164-8.
^ El-Gayar, O., et al., A systematic review of IT for diabetes self-management: are we there yet? Int J Med Inform, 2013. 82(8): p. 637-52.
^ Verhoeven, F., et al., Asynchronous and synchronous teleconsultation for diabetes care: a systematic literature review. J Diabetes Sci Technol, 2010. 4(3): p. 666-84.
^ Sutcliffe, P., et al., Systematic review of communication technologies to promote access and engagement of young people with diabetes into healthcare. BMC Endocrine Disorders, 2011. 11(1): p. 1.
^ Tao, D. and C.K. Or, Effects of self-management health information technology on glycaemic control for patients with diabetes: a meta-analysis of randomized controlled trials. J Telemed Telecare, 2013.
^ Frazetta, D., K. Willet, and R. Fairchild, A systematic review of smartphone application use for type 2 diabetic patients. Online Journal of Nursing Informatics (OJNI), 2012. 16(3).
^ Gagnon, M.-P., et al., Systematic Review of Factors Influencing the Adoption of Information and Communication Technologies by Healthcare Professionals. Journal of Medical Systems, 2012. 36(1): p. 241-277.