Diabetes Technology in 2018

Linking here to two resources I published recently:

First, my presentation at the April 2018 UCSF Diabetes CME course.  Those slides on a 2018 Update in Diabetes Technology are here:

Second, I wrote “A Clinician’s Guide to the Latest Diabetes Devices” for Medscape recently.  Here is the first section of that blog post:

This has been a huge year for technological advances in diabetes management. We are on a rapidly advancing path with continuous glucose monitoring (CGM) technology and finally approaching the holy grail of fully automated, closed-loop insulin delivery. Within a few years, patients with type 1 diabetes may never need to do another fingerstick or have another A1c test. For many clinicians, recent developments may seem to present an array of head-spinning options. Here, I’ll try to cut through the noise and focus on technologies that have the biggest implications for clinical practice and our patients.

CGM Data Directly to Your Smartphone

CGM technology has been advancing rapidly in accuracy, number of options, and ease of use, and the problem of inaccurate, painful, alarming, needy, and annoying CGMs feels long in the past. It is hard to believe that it was as recently as December 2016 that the US Food and Drug Administration (FDA) first decided that a CGM (the Dexcom G5®) was accurate enough to no longer require supplemental fingersticks for insulin dosing decisions.

In 2018, Dexcom released the G6 CGM, which is slimmer (and less likely to snag on clothing); requires no fingerstick calibration; and is the first to have the FDA indication of “interoperable,” meaning that it can “plug and play” in the future with other interoperable devices.

Medicare finally started covering CGMs in 2017, and in June 2018 agreed to stop blocking the ability of the Dexcom G5 (which is reimbursed by the Centers for Medicare & Medicaid Services) to transmit data directly to a smartphone, something most users of the G5 had already benefited from for a few years. This was a big deal, as I believe that the ability to view CGM data directly on a smartphone may be the technology advance that has most positively affected my patients with diabetes.

In the past year, billing codes for CGM improved to enable providers to be reimbursed for analysis and interpretation of CGM data. This brings diabetes management one step closer to population health, where a provider can review CGM data without an office visit; correspond with the patient over the telephone, by email, or by text; and be reimbursed for that work. I plan to try this out in my practice during the next few months, blocking off time every 1-2 weeks to review CGM data in web software and communicate recommendations to patients via our electronic health records portal or telephone, with no scheduled visit required.

Immediate Feedback, No Fingersticks Required

Of everything that has come out recently, Abbott’s FreeStyle® Libre Flash CGM has had the greatest impact on my practice. The Libre is a disk-shaped device worn on the back of the arm (see any recent photo of British prime minister Theresa May). My patients have been consistent in their appraisal that the Libre is relatively or even entirely painless to insert, nonintrusive on the arm, and stays on during activity or contact with water. Most important, it entirely changes their approach to diabetes management.

For more, please continue on to Medscape (free Medscape log-in required)

 

HIMSS 2018

Another HIMSS conference is in the books. Amidst the craziness that HIMSS can be, it is always a pleasure to spend time running into friends, collaborators, and former colleagues.  There have been lots of great pieces written about 2018 HIMSS, including by Chrissy Farr and by Lisa Suennen. Here are some of my thoughts and takeaways:

1 – Where’s the Peds?

HIMSS pretty much has a little something for anybody. However, walking the exhibition hall and seeing vendor booths, attending sessions, and talking with colleagues, there was a noticeable under-representation of anything having to do with pediatric care. I’m guessing this has something to do with $$, but I would love to see more attention paid to the specific needs of children, parent caregivers, pediatric care, and children’s hospitals.

2 – Cash and Flash

HIMSS had its usual plethora of vendor swag giveaways, plush carpeted booths, sponsored parties and happy hours, steak dinners, and other signs of the amount of money flowing through the system. One couldn’t help but wonder, if the biggest challenge facing American healthcare is one of cost and value, how could we be spending this much money on HIMSS while telling each other we were there to save money?

Some great tweets on this subject:

Screenshot 2018-03-12 10.20.56Screenshot 2018-03-12 10.20.33

 

3 – Interoperability’s Day Has Arrived

With many thanks to years and years of tireless work by Ken Mandl, Josh Mandel, Aneesh Chopra, Micky Tripathi, Graham Grieve, and so many others, there was a palpable sense that FHIR APIs are crossing from “early adopter” to “mainstream.” CMS announced “Blue Button 2.0,” an API containing four years of Medicare claims data for 53 million beneficiaries that allows individuals to allow third parties to receive that data via API. The VA announced its Lighthouse platform, which gives external developers access to data and tools from the VA in order to more easily build apps to serve the needs of veterans. This is happening.

4 – 2018 HIMSS Word Cloud

AI. Cloud. Interoperability. Security. Provider Burden. API. Connected. Engaged. Consumer. Coordinated…… and Blockchain

4b – My favorite 2018 HIMSS pitch

Started off with the company saying, “even though all our founders come from an AI-background, and all our competitors use AI, we do not use AI in our product.”

5 – From EHR Implementations to Pilots to Mainstream Digital Health

Lots of thought and effort is going into thinking about how to scale innovation and move digital health into the mainstream. How can we create the infrastructure, processes, and tools to try things out, iterate, and scale innovations to get beyond the pilot trap? You can still feel the tension as people try to move past the era of EHR implementations to actually using their EHRs as an underlying platform to achieve care delivery goals like patient engagement, population health, and precision medicine. How can we best use EHRs as a platform on top of which we can integrate novel apps, analytics, and decision support?  To me, solving this at scale is the key question and challenge of the next several years.

 

 

What’s the Health IT Buzzword of 2015? (Full post at Medscape.com)

Note: This is an excerpt from my first column at Medscape.com.

While walking my dog one recent evening, I listened to a podcast in which two Internet pioneers suggested that there are only two ways to make money: via “bundling” or “unbundling.”[1] They described everyday examples, such as the music industry, which started out by bundling individual songs into record albums. The music industry then turned to unbundling, when iTunes® sold individual songs for 99 cents, then bounced back to a bundling phase with such services as Spotify® or Rhapsody® that bundle entire music libraries to sell for a monthly fee.

A similar ebb and flow occurred with television. Cable TV channels have long bundled individual channels to be sold as a package. However, we are now seeing unbundling, with such services as HBO GO® selling individual channels to consumers.

Remember browsing the never-ending connections of the Internet on the World Wide Web using your desktop browser? The Web has also been unbundled. We all now have dozens of smartphone apps that offer unique, distinct, and generally siloed functionalities.

Bundling and Unbundling Digital Healthcare

Healthcare has experienced similar trends. Before the era of electronic health records (EHRs), the typical physician’s office had its own paper chart for each patient. Every chart was its own silo, unseen and inaccessible to other physicians’ offices. I can still remember working in my primary care clinic and having to ask my patients what their specialist had said in consultation, because I had no access to their consult note. Lab information systems, pathology systems, radiology systems, and billing systems were all separate.

Today, at medium-sized to large healthcare organizations, the enterprise EHR has facilitated the integration of these systems. Hundreds or thousands of physicians across an organization share a single chart for a patient, which includes the patient’s lab results, radiology results, pathology results, and billing functionality, providing a unified and accessible medical record for each patient at each healthcare institution.

At the same time, these institution-wide EHRs include potentially unwanted or unneeded functionalities, much like that bloated cable TV bundle at home. In some cases, EHRs contain some inferior modules that must be used simply because they came with the package, and they lack other capabilities that the organization really needs.

Entrepreneurs have seized this opportunity, filling these functionality gaps and creating thousands of digital health apps. Each app attempts to offer a slice of functionality to consumers or to the healthcare system that is either unique or of higher quality.

We are not yet able to allow healthcare organizations to create mix CDs

The trouble is that most apps create siloed data and siloed functionalities. Although the EHR is the centerpiece of clinical workflows, most apps do not easily interact with the EHR. Most apps do not exchange data with the EHR. Nor do most apps even interact with each other, allowing free flow of data between them.

This is “unbundled” digital health. It is the iTunes era. We are not yet able to allow healthcare organizations to create mix CDs, where there is an intentional order and flow from track to track. Instead, we remain in the era of “come and buy your favorite songs à la carte for 99 cents, stick them all on your iPod Shuffle, and hit ‘play.'”

Click here for the rest of the blog post.

Can 3D Sculpture Help Patients ‘Grasp’ Diabetes Data? (Full post at Medscape.com)

Note: This is an excerpt from my most recent column at Medscape.com (full post at Medscape).

Recently, I was given a first look at a fresh take on BG monitoring, created by artist and technologist Justus Harris. Justus is an artist and technologist based in Oakland, California, and Chicago who was diagnosed with type 1 diabetes at age 14 years. He is blazing a new trail by bringing together personalized health data and the tactile world, creating 3-dimensional (3D) data visualization sculptures.

Often the most exciting innovations happen at the intersection of disciplines, such as the intersection of art, technology, and medicine. Sitting at this crossroads, Justus created an object that can be viewed through many different lenses. As an art gallery piece, it is a form of self-expression for someone struggling with a chronic disease, using art to humanize the BG numbers that he lives with on a daily basis. As a medical education tool, it is a very creative method that connects a patient with his BG data in a 3D, tactile, and visual fashion. This approach could even become a way for someone with low health literacy to rapidly understand whether his diabetes is in good or poor control, beyond what glycated hemoglobin conveys.

To read the full post, please go to the article at Medscape.com (note: you will need to sign in to Medscape to access it)