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Apps You and Your Patients With Diabetes Should Know
The trend toward real-time digitization of primary disease management continues to increase. Major reasons for this trend are that digitization can enable increased awareness of current patient health status, adherence to a treatment plan, and closer patient follow-up. Nowhere has this trend been more embraced than in the management of diabetes. Mobile applications (apps) have evolved to play a meaningful role in chronic disease management. Moreover, as diabetes-focused foot care is essential to helping people with diabetes avoid common and preventable complications such as wounds and lower extremity amputations (LEAs), a growing number of foot health-specific apps can aid in the management of this population.
The focus of this article is to present the key shifts in the technological capability of apps and their utilization applicable to primary prevention of diabetes and secondary and specialty prevention of advancing lower limb disease.
Exploring Medical Device Digitization
Even in our lifetimes, we can see the evolution of medical devices from analog to digital. How many can recall taking a temperature with mercury-filled thermometers? Inspired by a desire to make temperature recording practical and timely, Gabriel Fahrenheit invented the first “bedside” thermometer in 1714. It was not until 1984 that Dr. David B. Phillips evolved the device to the infrared-based digital thermometer, so ubiquitous today.1
Here we see an example of how new and emerging technologies can advance the “job” of monitoring temperature in a practical and timely way. Likewise, smartphones have revolutionized the way we live. Where once the cord of a rotary phone tethered us, today mobile devices are part of our daily lives. Their ever-increasing capabilities, portability, and affordability contribute to developing innovative smartphone-based health care applications.
Consider the multitude of built-in sensors to the smartphone that can be exploited as health sensors for different intelligent medical applications (see figure above). Add to that the fact that typical mobile device has more computing power than what it took to get to the moon.1
The built-in capabilities of the smartphone continue to evolve at a rapid pace. Further realizing this capability are peripheral attachments (eg, cameras, digital stethoscope) or wearable connected devices, enabling a sensor-fusion approach to monitoring health status.
With thoughtful user-centered interface design and evidence-based innovation driving development, many applications have emerged as powerful tools to capture or monitor readings from physical/physiological measures and convert them to useful health and wellness parameters.2 The mobile platform facilitates development of new interactive sensing and communication capabilities, which, combined with artificial intelligence and machine learning, hold promise for creating new and different ways to decrease the burden of disease and improve outcomes. However, how can these advances help improve chronic disease management?
Digitization of Primary Prevention: Using an App in Diabetes Care
Chronic diseases such as diabetes continue to place a high burden on the US health care system. Thirteen percent of all US adults age 18 and older live with diabetes, and 34.5 percent have prediabetes based on their HbA1C levels.3 Incorporating technology aids patients with both diabetes and prediabetes to remain as healthy as possible, often extending the reach and impact of the provider. From connecting more seamlessly and collaborating more effectively - and from monitoring progress to supporting and encouraging behavior change - the digitization of diabetes management offers a new medium for patient and provider engagement, with a shared goal to improve patient health outcomes. The findings of a systemic review in 2019 showed strong evidence for the efficacy of mobile phone apps for lifestyle modification to reduce diabetes complication risk.4 Meanwhile, an article in Diabetology and Metabolic Syndrome concluded that diabetes management improved with mobile phone apps’ user-centered features aimed at improved diabetes self-management.5
Livongo® is a digital health company whose initial aim was reducing HbA1c levels. Founded in 2014 by Glen Tullman (former Allscripts Healthcare Solutions CEO), Livongo offers a data-based health coaching program that enables patient “members” to share blood glucose records via the cloud with Certified Diabetes Educators. Its flagship diabetes management system was comprised of a connected glucometer (sensor), an app, and a Certified Diabetes Educator “health coach” to engage with the patients when the app records a suboptimal reading. It was one of the earliest successes in digital health,6 and also linked to cost-savings for patient care.7
Livongo is one example of the digitization of diabetes trend, and how combining data from sensor-enabled devices, apps, and a health advocate can help improve health outcomes. There are various apps that can facilitate the use of sensor-enabled capabilities to improve the treatment and care of those with diabetes. Six of the most-utilized smartphone app foci aimed at improved diabetes self-management with some examples of related apps are listed below.8
• Nutrition apps: These incorporate databases where users can look up carbohydrate, fat, protein, and energy content; support meal planning; and/or support insulin or oral medication dose adjustment (Carbs and Cals, CarbControl, Foodily).
• Physical activity apps: These allow users to track their activity, count calories, and set goals for exercise and weight management (My Fitness Pal, Nike + Running, Track 3).
• Glucose-monitoring apps: These log lab result data (eg, daily glucose level), typically from an external device that measures glucose, and graphically display glucose levels to assist the patient and health care providers (Dexcom share, Tidepool Mobile).
• Insulin titration apps: These integrate bolus calculators with traditional blood glucose meters to help people with diabetes requiring insulin to calculate their basal, prandial, and correction insulin doses (WellDoc Blue Star, Voluntis Insulia, Sanofi MyDose Coach).
• Insulin delivery apps: These are for insulin pumps and smart pens to collect and display data. This category includes bolus calculators, data downloaders, and firmware update apps, including patient and/or health care provider decision support modes (Companion Medical InPen, Dexcom Clarity, Medtronic Sugar.IQ).
• Autonomous Insulin Delivery (AID) apps: These consist of a continuous glucose monitoring (CGM) system, insulin infusion pump, and a computer-controlled algorithm (for do-it-yourself AID systems involving a smartphone app) to allow communication between the CGM system and insulin pump on the patient (Medtronic MiniMed 670G/Guardian Sensor 3).
Digitization of Secondary and Speciality Prevention With a Focus on Diabetic Foot Care
Reducing complications such as wounds and lower extremity amputation in people with diabetes remains a priority among interdisciplinary team members managing foot disease. Estimates cite that the lifetime risks for people with diabetes to experience preventable wounds in their lifetime is 34 percent.9 Diabetic limb disease accounts for nearly 80 billion US dollars spent each year, which is roughly one-third of the direct costs in diabetes.10 These are sobering statistics, only made worse by the COVID-19 pandemic.
Since preventive measures aimed at reducing the risk for foot complications are considered essential for diabetic management, podiatrists play a crucial role in a team approach to the medical management of people with diabetes. The “next generation” of app development - while nascent - is beginning to focus on clinical care issues specific to the podiatry field.
Sensor-enabled apps can augment/automate elements of a foot assessment to identify abnormalities and disorders. Poor blood circulation, lower extremity neuropathy, foot deformity, and an increased likelihood of wound infection (that can result in the need for lower extremity amputation) are all potential complications that require podiatric intervention. Identifying, educating, and mitigating (or modulating) risk factors predisposing patients to ulceration or infection is vital to preventing worsened health status/disability.
Additionally, sensor-enabled apps that can help monitor critical physiological parameters of foot health, such as localized or diffuse skin temperature changes (a proxy for inflammatory conditions), activity “dosing,” adherence to offloading devices and/or the presence of high pressure/shear forces at the plantar surface.11 In this way, apps can provide visibility into subclinical changes and/or patient behaviors which may delay wound healing or contribute to the onset of a new ulcer.
As focused specifically on podiatric care, the following are five apps applicable in the monitoring and treatment of patients with diabetes (see table on page 46 for a sampling of specific apps currently or soon to be available in the marketplace):
• risk-based foot assessment apps;
• temperature-monitoring apps;
• pressure-monitoring apps;
• wound-measuring apps; and
• off-loading device adherence apps.
Apps such as these can further categorize into those primarily provider-utilized (for monitoring and/or intervention) or primarily patient-utilized (for monitoring and/or intervention). Besides their usefulness in providing actual foot health surveillance and/or clinical decision support, incorporation of such apps as described above can enable better patient risk stratification to predict whether current patients will require more frequent podiatric appointments (and more intensive podiatric care) or referral to other team specialties.
As medical stakeholders compete on better outcomes, lower costs, greater efficiency, and improved patient satisfaction, the use of these apps can facilitate the shift to precision medicine and personalization of care. A key to personalized medicine is to “deliver the right treatment to the right patient at the right time, based on individual diagnostics.”12
Whether capturing data during a patient visit or remotely, Podiatrists can play a significant role in helping patients make sense of what information foot health apps can deliver. Podiatrists are, after all, the patient’s best foot health advocate and will still provide the information about their patient’s foot health, but now the information is objective, personalized, and accessible.
Health Insurance Incentivizing of Diabetes Complication Prevention
Reimbursements by public insurers such as Medicare/Medicaid and inclusion in private Preferred Provider Organization (PPO) networks are increasingly being linked to health prevention such as diabetes complication prevention. Notably, the Centers for Medicare and Medicaid Services’ (CMS) current implementation of the outpatient provider Merit-Based Incentive Payment System (MIPS) includes diabetes management as a payment criterion.13 For podiatrists, this can impact annual revenue maintenance/growth potential. Therefore, preventing a patient with diabetes who experiences a small cut on the foot from progressing to the development of an infected foot wound can affect the financial viability of a podiatric practice dependent upon insurer prevention-related policies. This is yet another reason why utilizing emerging technologies (such as foot health-related apps) to improve provider capacity to monitor, educate, and provide care for those with diabetes makes excellent sense.
In Conclusion
Health care providers, including podiatrists, now have access to technological solutions that allow real-time and actionable insights about patient foot health (including monitoring diabetic foot health) both remotely and in the clinic. Consequently, podiatrists can engage patients with more timely and relevant foot-care information/recommendations tailored to their specific needs. As aptly noted in an article in Diabetes/Metabolism Research and Reviews in 2020, “a shift in priority in care and research in diabetic foot disease was needed.”12 The utilization of apps promotes the capacity of podiatrists to offer better care to their patients inclusive of those at risk for – or living with – diabetes.
Ms. Cantu is an executive in digital health. She is a Certified Wound Specialist, a Fellow of the American College of Clinical Wound Specialists, and a Diplomate of the American Professional Wound Care Association. She discloses she is the Founder and CEO of Revealix.
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