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DM programming moves from the Internet to mobile phones for added impact

One of the primary keys to effectively managing chronic disease is getting patients to the point at which they take charge of their own health. But this is a tall order, especially with diseases as complicated and laborintensive as diabetes. Just getting people to test their blood sugar on a regular basis can be a huge challenge when they have busy jobs and lifestyles that require them to be constantly on the move.

For all of these reasons, several healthcare technology companies are focused on developing applications that can deliver core DM tasks via mobile phones. The capabilities of these new offerings range from being able to exchange data and other information with patients on an almost real-time basis wherever they are located to being able to use specially equipped mobile phones to actually test blood sugar and transmit those readings to a central location. And mobile phones are not just being used to manage diabetes; they are being deployed in weight-management clinics and asthma programs, as well as other settings.

Although many of these applications are already on the market, many more are in various stages of development and pilot testing, and healthcare analysts believe that the purely Internet-based DM programs will soon be looking to mobile phones for added power and reach.

Mobile phone applications draw interest

One organization that is keeping a close eye on developments with mobile phones is the Juvenile Diabetes Research Foundation (JDRF). The idea of arming youngsters and teens with cell phones equipped with glucometers or communications tools designed to help them track their sugar and manage their disease is immediately appealing, because younger diabetics are unlikely to resist the allure of a cell phone.

Further, any step toward easing the burden of managing a disease such as diabetes is worth exploring, explains Aaron Kowalski, PhD, the research director of JDRF's Artificial Pancreas Project, an effort focused on building a system whereby a continuous glucose sensor automatically triggers an insulin pump as needed without the patient having to intervene. Kowalski envisions that some of the technology needed for a so-called closedloop system could ultimately be consolidated onto a cell phone. "It is something that is high up on our radar screen," he says, noting that consolidation, convenience, and ease-of-use are very important with diabetics. "It falls under the umbrella of new technologies that we are interested in."

Although the JDRF has not yet funded any studies involving cell phone applications, a number of options are already on the market, and more will soon be available.

For example, by the end of this year, Palisades Park, NJ-based HealthPia America plans to introduce its GlucoPhone, a cell phone that is equipped with a glucometer so that patients can test their blood glucose levels wherever they are and then transmit the readings to a centralized Web location. "It is an automatic transfer to the Web site, so the patient doesn't have to worry about writing it down, or worry about [his or her] computer crashing, or whether [he or she] has the correct software involved," explains Kathi O'Neill, president of HealthPia America. O'Neill explains that patients have access to their individual data, but they can also give their providers access through the use of a user ID and password.

In addition to these capabilities, the company is currently pilot testing a program whereby HealthPia transmits a text message to a parent or guardian whenever new blood glucose data from the person's child reach the HealthPia Web site. And O'Neill points out that there is obvious potential in using the GlucoPhone system in payfor- performance programs in which providers are compensated for their management of chronic disease.

"Both employers and payers are looking to drive down their costs, and diabetes is obviously high on their list of chronic diseases because of the costs and crossover implications to other diseases and the amount of resources [it requires]," says O'Neill. "It consumes 2.4 times the resources of any other chronic illness."

New studies to focus on efficacy

Confidant, a software company based in Research Triangle Park, NC, is already on the market with mobile phone applications that can retrieve data from off-theshelf home-monitoring devices-such as glucometers, blood pressure cuffs, and scales-and then transmit those data to the company's server, where they are interpreted based on treatment regimen thresholds that have been set for the individual ahead of time.

"Then messaging comes back [to the patient] in virtual real time to help the person understand where they are in terms of managing their disease, as well as to give some positive reinforcement," says Tom Wall, MBA, vice president of business development and marketing for Confidant. "Essentially, it is using a mobile phone as a health coach and sort of the center of a support system."

Wall emphasizes that the messaging built into the software is designed not to tell patients the obvious-that their sugar levels are high, for example-but rather to give them some context that will help them change behavior patterns.

"What we do is look for trends in the data, so, for instance, what a diabetic may not know is that they have a pattern of readings at a certain time of the day," Wall says. "In some cases, they don't remember when they last tested, let alone what their last reading was, so rather than reporting that they just posted a 300 reading, we would say that they are consistently high in the mornings, or that they have issues around weekends." In addition, Wall points out that the software facilitates graphic representations of trends, so that patients can view their data in any number of ways.

Although the patient is getting regular feedback, the caregiver-which may be a provider, DM company, case manager, or payer representative-will receive notices if the patient falls out of certain parameters that have been established ahead of time. In response, Wall notes that the caregiver can send a text message to the patient or give him or her a phone call with specific instructions.

The company is working with a variety of DM companies, payers, and provider groups that are interested in using the phone applications to stay in close touch with chronically ill patients and help them better manage their disease. For example, the company just announced that it is working with Honolulu-based Ho'okele Personal Health Planners, a company that offers a suite of services designed to help chronically ill patients better manage their disease and navigate the complicated healthcare system. Other customers include a weight-management clinic in North Carolina that is using Confidant applications to stay on top of patients once they have left the clinical setting. "They have participants who come to their campus, spend two to four weeks, and lose a considerable amount of weight, but their issue is that when the patients go back to their routines at home, they lose that structure," says Wall. "They are using our product in conjunction with some other service offerings they have so that, when people leave the campus, they can take our product home with them and stay connected."

To date, Confidant has completed several small trials and pilot studies that have been mainly focused on usability and comfort with the technology. However, Wall explains that the company is now in the process of implementing larger pilots that will compare patient groups that have access to the Confidant applications with control groups engaged in usual care. The focus of these studies will be to establish not just comfort with the technology, but also efficacy in terms of clinical outcomes and financial impact.

Patient engagement is critical

San Francisco-based BeWell Mobile Technology offers services that are somewhat similar to Confidant's, although rather than communicating directly with other devices, BeWell's programming relies exclusively on patient-reported information. Established in 2004, BeWell offers two main products: its Diabetes Assistant and Asthma Assistant programs-software applications that are customized to address the needs of a particular patient population.

"Our job is to figure out what the clinical team is trying to do clinically so that we can then support that with our technology," says Peter Boland, PhD, business development director at BeWell. "So it really gets down to understanding what are the underlying drivers, the underlying symptoms, and the underlying triggers that relate to [the condition and population.]"

By mapping out all of the various symptoms and issues that are important to a clinical team to monitor and manage in a given population, Boland says BeWell can then design the software so that it regularly prompts patients to provide feedback about these matters of concern.

Once the patient has inputted his or her responses, the data are transmitted to the BeWell server, where they are analyzed according to parameters that have been established ahead of time by the clinical team. The analyzed data are then transmitted to the caregiver server so that care managers can see which patients are most at risk for exacerbations and therefore require priority attention.

"This gives the nurse case manager information on how to organize [his or her] day and [his or her] time and what needs to be done in terms of intervention," says Boland. In addition to keeping caregivers apprised of the clinical matters that they have stipulated, patients receive almost instantaneous feedback every time they submit answers to questions, says Boland. This information ranges from motivational messaging and education about their condition to trend reports that provide a graphic representation of the data that have been collected for the past week or month.

"What we are really trying to do is get people to self-manage their disease. That is the real key, and that means they have to have more information about their illness and what they can do about it, and they have to be motivated," says Boland. "We are not just talking about avoiding the ER but [making sure that patients] are on top of their illness, managing their condition, and leading full and productive lives. There are very tangible rewards."

Although BeWell has customers already using both of its initial applications for patient care as well as for research purposes, Boland acknowledges that the pathway to reimbursement is a continuing challenge.

"We are in discussions with some very large DM vendors, and what it comes down to is the ROI," he says. "They just don't have the sense yet of just how powerful this ubiquitous technology can be in healthcare. We are trying to amass the documentation to answer those questions."