Supporting Self-Management of Diabetes

Interview with:

Neal Kaufman, MD, Professor of Pediatrics and Public Health, University of California, Los Angeles, and CEO, DPS Health, Los Angeles, CA

Using information technology, health, and public health

At the intersection of personal and public health are questions of efficiency and individualization. This is well illustrated in the setting of chronic diseases such as diabetes, which requires activated, informed patients and practices that can support them. The question about how best to bridge the gap between the healthcare system and the larger community may best be answered with new applications of information technology.

Information technology and the chronic care model

The chronic care model considers healthcare to be one of the many interconnected aspects of a person’s life. One of the first proponents of the chronic care model was Ed Wagner, who noted that to be effective, healthcare systems must incorporate the following components:

• A clinical information system that allows patients and clinicians to gather and share information
• Decision support to help patients make informed decisions related to their health and disease management
• A system of delivering care that allows clinicians and patients to interact effectively and efficiently
• Self-management support

Information technology and self-management support

In an era of high-speed Internet, Youtube, and smartphones, interactive programs may seem like an obvious answer, but lower-tech versions can be very effective. In one successful program in South Africa, low-income women (many of them illiterate) were given low-cost cell phones for peer-to-peer support. With the wide-scale availability of basic cell phones, that model could be used in many settings worldwide.

Challenges of rapidly changing technology

A randomized trial can take more than two years before it is published, at which point the technology being studied likely will be dated if not obsolete. Evidence should be based not on a particular technology or a particular interface, but on the core principles of self-management support interventions. As technology evolves, these principles are transformed into different delivery mechanisms, with the lessons learned from each incarnation (hopefully) furthering the next.

Basic principles of self-management support

• Knowledge: Although critical, knowledge alone is not enough to change behavior. To be effective, the program needs to address patients’ knowledge, attitudes, and skills so that they can then change their behavior.
• Incremental improvement: Rapid improvement is not typically sustained, but incremental improvement becomes a habit.
• Goals and motivation: It is important to set goals that are measurable and specific and can be attained within a reasonable period of time. Motivation is best when it is internalized, but external sources of motivation also can be helpful.
• Measurability: Patients need to be able to assess their progress and identify when they meet their goals.
• Feedback: Personalized feedback helps patients understand which interventions and behaviors were effective and why. It also helps them to recognize incremental changes and associated benefits.

Technology: Improving diabetes management

Technology often begets more technology. The introduction of glucose meters, for example, revolutionized diabetes management. Not long thereafter, continuous glucose monitoring (CGM) provided even more information and benefits to patients. Once CGM was in use, it became evident that the ability to upload BG data to share with clinicians or to track over time would prove valuable — and the evolving technology soon met those needs.

Diabetes self-management education and support may not seem to drive technology in the way that glucose monitoring or insulin delivery does, but information technology is advancing at a very fast pace, allowing patients and clinicians to interact in ways that were not possible a few years ago.

Clinically linked lifestyle intervention programs

A major focus of information technology-based interventions is lifestyle — that is, providing information and support to help people make healthier choices. Numerous online programs are available, but most do not operate within a clinical context, and there is little evidence that they are effective. Newer clinically linked programs, which connect patients and clinicians via e-mail, online chat, and instant messaging, seem to be more effective.

Individualization

Technology-based systems can be modified to better target their audience. Color schemes, voice qualities, and other characteristics can be changed to create different experiences for different individuals. In the future, the specific information and educational messages also could be personalized based on various characteristics of the user.