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NAVIGATING THE SEA OF

DIABETIC MANAGEMENT

TOOLS TO CREATE BETTER

HEALTH OUTCOMES

Part II – mHealth Webinar

Series

Jumping into Wellness:

A Brief Swim in the Pool of Wellness Apps

Sponsored by BettrLife

Les Jebson MHA, FACHE, FACMPE, LHRM

The University of Florida – College of Medicine jebsolr@ufl.edu

Kyle Ziegler ,BHS

The University of Florida –Diabetes Institute

12/5/2014

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FINANCIAL AND/OR CONFLICT

OF INTEREST DISCLOSURE

� Neither presenter receives or has received any

compensation at all from today’s webinar sponsor

� Neither presenter has any financial interest or

formal financial relationship with today’s webinar

sponsor

OBJECTIVES

� Overview of mobile Health (mHealth)

� The Diabetes Market from a US Healthcare Standpoint

� Considerations in Selecting a good Diabetes App

� Security and other issues regarding App Adoption

� Share objective resources for further independent investigation, and

add to your knowledge base

� Provide time for any interactive dialogue/open questions

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HEALTH / WELLNESS PLATFORMS

� There are a broad array of standalone mobile

technologically driven solutions, ranging from fitness

trackers, to remote home telemonitoring

� For our discussion, focus on ways of integrating

mobile (mHealth) solutions into healthcare system

and management of diabetes

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BY DEFINITION…

� mHealth (also written as m-health) is an abbreviation for mobile

health, a term used for the practice of medicine and public health

supported by mobile devices. The term is most commonly used in

reference to using mobile communication devices, such as mobile

phones, tablet computers and PDAs, for health services and

information, but also to affect emotional states.[1] The mHealth field

has emerged as a sub-segment of eHealth, the use of information

and communication technology (ICT), such as computers, mobile

phones, communications satellite, patient monitors, etc., for health

services and information.[2] mHealth applications include the use of

mobile devices in collecting community and clinical health data,

delivery of healthcare information to practitioners, researchers, and

patients, real-time monitoring of patient vital signs, and direct

provision of care (via mobile telemedicine).[3]

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K9 Many have failed to live up to expectations because of their lack of integration into clinical care and poor

sustained patient engagement

Kyle, 12/3/2014

K10 Mobile phones (smart and not smart) offer a promising platform for engaging patients in chronic care

because most patients (95M Americans) own and regularly use smartphones for healthcareKyle, 12/3/2014

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BEYOND THE CLINICAL ENCOUNTER

� Providers: Looking for ways to increase revenue and deliver higher quality more efficient care.

� Government Agencies: Looking for ways to reduce costs.

� Consumers: Looking for means to more easily navigate the healthcare system and stay healthy.

� 4 of 5 Top chronic conditions U.S. have direct application to mHealth

MHEALTH:

PRIMARY USES & APPLICATIONS

� 1) Collection of Health Data

� 2) Delivery of Healthcare Information

� 3) Real Time Monitoring of Patients Vitals Signs,

or other Variables

� 4) Direct Provision of Care (Telemedicine,

Remote Monitoring, Wellness-Management)

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� Technology Adoption

� Smartphone adoption projected to be 81% by end of 2015

� 95M Americans use smartphones for healthcare

� Remotely-monitored patients expected to grow to 1.3M by 2017

� Shifting Accountability

� Penalties for readmissions within 30 days of discharge

� Explosion of ACO’s from 59 in 2012 to 626 in 2014

� Physician Buy-In

� ~89% would recommend a mobile health app

� ~93% see value in connectingmobile health apps to EHR’s

� Patient Buy-In

� ~44% would use mobile health app if prescribed by physician

� Large players entering the market

� Samsung (S Health); Apple (HealthKit); Google (Google Fit); WebMD (Health Target)

THE EMERGING LANDSCAPE

THE DIABETES LANDSCAPE /

US HEALTHCARE

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� Afflicts 29.1 million people in the U.S. — 9.3% of the population;

392 million people globally

� 7th leading cause of death in the U.S.

� 3 out of 10 adults with type 2 diabetes remain undiagnosed;

Annals of Internal Medicine 2014

� Due to the severity and number of complications from diabetes,

self-care behavior is critically linked to clinical outcomes

� Diabetes prevention is key: 5 surprises in the cost of obesity

BURDEN OF DIABETESK1

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6 ASPECTS OF DIABETES SELF-CARE

� Blood glucose monitoring

� Risk Reduction (i.e. Foot care)

�Engaging in physical activity

�Healthy diet (i.e. carb counting)

�Medication management and adherence

�Problem Solving

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K1 A study in Diabetes Care found health and other costs associated with diabetes care in the U.S. grew 48%

in recent years, to $322 billion yearly. Data also showed the cost of prediabetes care increased 74% and

expenses for undiagnosed diabetes grew 82%. Kyle, 12/3/2014

K15 At the University of Florida, researchers helped lay the groundwork by providing one of the very first

estimates on projecting the national economic burden of type 1 diabetesKyle, 12/3/2014

K2 Diabetes is one of the best examples of a condition where self-care behavior is linked to clinical

outcomes.

Research in this space can have applicaiton to other chronic disease states.Kyle, 12/3/2014

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K7 Outcomes for patients with type 2 diabetes are largely determined by the activities they engage in during

the 5,000 walking hours of the year, include taking medication, eating healthful food, engaging in

physical activity, and monitoring symptoms.Kyle, 12/3/2014

K8 A key challenge remains the healthcare delivery system, which is organized around doctors and hospitals

instead of patients and communitites. Fewer healthcare resources are available for self-care Kyle, 12/3/2014

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Almost always see glucose monitoring in research (HbA1C) measured

others not listed: lipds, blood pressure, body mass indexKyle, 12/3/2014

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3 BEHAVIOR CHANGE CONSTRUCTS

Health Beliefs

• Perceived Susceptibility

• Perceived Severity

• Perceived Barriers

• Perceived Benefits

Self -Efficacy

• Mastery Experience

• Social Persuasion

• Physiological Factors

Social Support

• Social Support

• Enacted Support

• Social Integration

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SELECTION OF A MHEALTH PHONE

APP

FOR DIABETES MANAGEMENT

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K5 Some of these effects are also hypothesized to be bidirectional: self-management modifies health beliefs

by reducing the perceived barriers to diabetes care and also increases self-efficacy through mastery

experience.Kyle, 12/3/2014

K6 The idea of meaningful monitoring begins with an improvement in the physician–patient relationship,

according to the experts.

Health care providers (HCPs) can educate patients about the available pragmatic technological resources

for the management of their diabetes

Kyle, 12/3/2014

K4 Area of research in psycholoy

Major area of research in psychology. If you are an app developer, something you may want to think

about: how do we engage users to make a change?

show them that it is easy to do

Help improve knowledge, attitudes and accountability for their conditionKyle, 12/3/2014

K3 feeling overwhelmed by the demands of living with diabetes

feeling like they are failing with diabetes regiments

Unfamiliar with mobile apps

diabetes already well-managedKyle, 12/3/2014

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� A smart phone app for diabetes is defined as an

app that specifically provides functionality and

offers services to better manage the disease.

� Apps that inform about the disease or promote a

lifestyle or nutrition specifically for diabetics are

also part of the diabetes app market segment.

� General fitness or medical apps that could be

used to support the treatment of a diabetic but

are not specifically designed for them are not

part of the diabetes app market.

BY DEFINITION…

"Apps don't replace your doctor," said Shelley Wishnick,

a diabetes educator and registered dietitian with the

Friedman Diabetes Institute at Beth Israel Medical

Center, in New York City.“ You still have to understand

the disease process. You have to understand your

diabetes. An app can't replace your education.“

Wishnick said she doesn't have a lot of patients who rely

on diabetes apps yet -- or those who do don't bring it to

her attention.

However, there are a number of apps, such as iBGStar,

OneTouch Reveal, OnTrack Diabetes, Glucool, Glooko

and Glucose Buddy, that can help you track your blood

sugar levels, she said.

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SELECTING THE RIGHT DIABETES

APP ---MANY HAVE JUDGED!, EVEN

US…

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Diabetes WaveSense (iPhone): Diabetes WaveSense tracks carbohydrate intake, blood glucose levels and insulin doses. It also includes a notes section for users. The app was rated as the most user-friendly in a recent study. Results are easy to share and data ranges from 7 to 90 days can be shared with clinics and hospitals.

iBGStar (iPhone): This app can track carbohydrate intake, blood glucose levels, exercise, and insulin dose. It contains a notes section where people can tag blood glucose readings with notes. It can also integrate with the Sanofi iBGStar meter and records can be emailed. You can read Co-Managing Editor Adam Brown’s test drive of the iBGStar here.

dLife (iPhone): The dLife app allows users to track blood glucose levels, carbohydrate intake, insulin doses, and exercise, and includes a food database and notes section. AADE speaker Ms. Molly McElwee (University of Virginia, Charlottesville, VA) stated, “I love this app” because it allows specification for exercises and insulin type. It is also unique because it has a Q&A section that links to an online support community.

Diabetes Pal (Android and iPhone): Diabetes Pal can track blood glucose levels, A1c levels, nutrition, medication, weight, and analyzes blood pressure. Ms. McElwee called this app “fantastic,” and it works with the Telcare meter with no extra entry (read our test drive in diaTribe #41).

My Glucose Buddy (Android and iPhone): This app can track blood glucose levels, medication, food, and exercise, although the drawback is that it has more pop-ups than the typical app, which may be annoying for users. However, the app has the added benefits of weight and blood pressure tracking.

Medisafe (Android and iPhone): Medisafe is an app designed to help people keep track of their medications, by creating reminders and alerting family members when the user has not taken their medication. People with diabetes represent the largest group of users on Medisafe, followed by people using hypertension and cholesterol medications. More information is in this issue’s new now next.

AADE Diabetes Goal Tracker (Android and iPhone): The AADE Goal Tracker allows users to set, share, and track their goals in seven different areas of diabetes management - healthy eating, being active, blood glucose monitoring, taking medication, problem solving, healthy coping, and reducing risks. It also contains information and resources about diabetes and self-management.

Others

Ms. McElwee, RN, CDE recommended a few more apps, which are condensed below:Pancreum IOB calculator (iPhone)

Pancreum Insulin to Carb Ratio (iPhone)

MedSimple (Android and iPhone)

MedCoach (Android and iPhone)

AADE PRESENTS THE LATEST AND GREATEST IN SMARTPHONE

APPS FOR DIABETES MANAGEMENT

Apps to Consider

Some of the choices reviewed by Washington State University were:

Diabetes Buddy (Krodzone Technologies). It takes only a few keystrokes to enter data

such as glucose readings, time spent exercising, carbohydrate intake, and water consumption.

Users also can add personalized recipes to calculate the carbohydrate content per serving. It's

not difficult to send the data you record through e-mail, but the computer or device must have

external spreadsheet software in order to display the information.

Diabetes Pilot (Digital Altitudes). The insulin calculator tells you the number of insulin

units you will need to reach your targeted blood glucose level based on what you eat. However,

the calculator doesn't consider how much you exercise, your previous dose, and other factors

that could affect how much insulin you actually need. And there's an extra cost for the

software required to synchronize recorded data and food information to a computer.

Glucose Buddy (SkyHealth). This app records and monitors your glucose levels,

medications, carb intake, and A1C. You can easily synchronize this information to the Glucose

Buddy Web site. The app lets you set reminders to check your blood glucose and take your

meds. You can also get updates through Facebook and Twitter and chat with other users.

You'll need a separate app called CalorieTrack to manage your daily carbohydrate intake,

however.

iDiabetes (iHealthVentures). This is a good choice if recording blood glucose values is the

only function you're seeking. It doesn't have a specific section for recording each diabetes-

related medication. There is an option to manually log your meds, but the list provided

includes only injectables, no oral medications.

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1. Compatibility (EHR)

2. Security (HIPAA/Risk)

3. Broad Adoption Factors (Patients)

Additional factors considered:

HERES WHAT WE THINK!

MHEALTH PHONE APP ESSENTIAL

CRITERIA

� Cost?

� Android and Apple Store Ratings?

� Uploading meter reading data?

� food and nutrition tracking?

� Fellow patient interactions/communications?

� Weight, waterintake, bp tracking?

� Direct clinician interactions?

• 43,700 healthcare applications on Apple Store alone

• 31% are intended for clinical use (>13,000)

Too Much Noise

• Primarily B2C applications

• Lack integration into corporate wellness or clinical plans

• Lack a portal for health coach interaction

Simplistic

• Not HIPAA-compliant

• Incapable of integrating into EHR’s

Not Clinic-Ready

MANY CURRENT APP PLATFORMS ARE

INADEQUATE

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� Mobile phones have shown some positive effect in

the diabetes self-management space

� Simplicity of use

� Consumers see benefits of mobile platforms that

collect and store their health information

� Diabetes apps are being constantly rated as the

therapeutic area with the highest business potential

for mHealth apps- ongoing growth of people with

diabetics that are addressable with an app

PROVEN UTILITY OF DIABETES

APPS

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K19 A significant number of diabetes app publishers developed their solution based on their personal

experience with the disease.  For most of the top players the initial motivation to publish a diabetes app

was to make life easier for themselves, relatives or friends – developing a products only came second.

Too simplistic? This has led to an overemphasis on innovation that targets “low-hanging fruit”—for

example, tools that track dietary intake or help people find doctors—and less attention to technologies

that could substantially improve the safety, effectiveness, and efficiency of care delivery.Kyle, 12/3/2014

K20 Crisp, clear, visually appealingKyle, 12/3/2014

K18 Most evaluated through written questionnaires- results suggest use of mobile phones leads to improved

A1C and self-management in diabetes care

many have relied on text alertsKyle, 12/3/2014

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ALIGNING FINANCIAL INCENTIVES

� Traditional healthcare payers and providers have not started yet to integrate diabetes apps into their reimbursement schemes:

- Quality

- Total Download �

- User Numbers�

� The race to a comprehensive app-connected combined experience, (i.e. CGM) is still in the early stages.

� Chances for a major market breakthrough have improved.

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K11 How do we engage users to participate? Kyle, 12/3/2014

K16 The quality of the numerous existing clinical studies is not good enough to justify the expenditure.

Prevent new innovators complying with the best practice standards for diabetes app publishing to enter Kyle, 12/3/2014

K22 Providers and payers should not wait for broad national payment reforms to align financial incentives for

mHealthKyle, 12/3/2014

K23 The lack of clear guidelines and regulations concerning provider-to-patient communication in mHealth

makes healthcare organizations less likely to develop innovative programs in this areaKyle, 12/3/2014

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A BRIEF LOOK AHEAD

� Over the course of the next five years the market environment for diabetes apps

will improve. The usage of diabetes apps within the addressable market will

reach 7.8% in 2018. (Addressable market is defined as diabetics owning a

smartphone or tablet). 31 million global diabetes population will actively use

diabetes apps to manage their health condition in 2018.

1. A steadily growing number of people with diabetes (1 in 3 by

2050) will be reachable via a mobile app

2. Increasing number of diabetes apps = higher quality level.

Diabetes apps will adopt best practices from other app models.

3. Diabetes apps will develop from a stand-alone product to a

bundle product. Thus the mobile app will be a tool to sell

devices like plug-in glucometers/ wearable sensors, or services

like remote monitoring/ consultation.

4. With app costs being reimbursed by traditional payers in

countries with high yearly treatment costs for a diabetic

patient competition, app publishers will increase.

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A FEW OBJECTIVE RESOURCES

� Taking Digital Health to the Next Level; www.commonwealthfund.org

� A Systematic Review of Type 2 Diabetes Management Mobile Applications: Use of

Behavior Change Theory and Evidence-Based Medicine, World Social Marketing

Conference 2013, Kitty Harding, MPH

� Nundy S, Dick JJ, Chou CH, Nocon RS, Chin MH, Peek ME. Mobile phone diabetes

project led to improved glycemic control and net savings for Chicago plan

participants. Health Aff (Millwood). 2014 Feb;33(2):265-72.

� xyz

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K12 Entire U.S. diabetes population could fit into the # of people anticpated using appsKyle, 12/3/2014

K17 Need to go from a stand-alone to a bundle product that integrates with other technology  (e.g. plug-in

glucometers and wearable sensors) and services (e.g. remote monitoring and consultation)Kyle, 12/3/2014

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Les Jebson MHA, FACHE, FACMPE, LHRM

The University of Florida – College of Medicine

Kyle Ziegler ,BHS

The University of Florida –Diabetes Institute