Feedback Loops and Teachable Moments: The Future Diabetes Care Paradigm

The current paradigm of office visits every three months for PWDs (people with diabetes) is not the right model (nor is it for other similar chronic conditions).  The management of diabetes requires a patient to make dozens of daily self-management decisions.  “How much insulin should I give for this slice of pizza?  Do I need to eat a snack to prevent my blood sugar from going low before I go for a jog?”  Diabetes related questions and issues do not occur on an every-three month basis in synch with this current model for office visits.  They are predictably unpredictable.  Accordingly, to best serve our patients, our system must be flexible and nimble.

In the current model, I see a PWD in my office and let’s say, for example, that we decide together to make a change to his insulin to carbohydrate dosing ratio.  He then leaves my office and we wait three months to reconvene and see if that dosing plan change is working or not.  It’s not that it takes three months to decide.  We could probably know within a week or two if the change is working.  It’s just that healthcare isn’t set up that way.  Our entire world now, in every industry and facet of life, is about data, analytics, and metrics.  Other industries have learned that rapid feedback loops are effective.  Adjusting a PWD’s insulin to carbohydrate dosing ratio should be no different.  By the time he comes back to my office three months later, the opportunity for learning may already have been lost.  Neither one of us has gotten timely and relevant feedback about our decisions.  We may have lost the opportunity for a teachable moment.  Healthcare needs to develop a new model where these feedback loops are much tighter and much faster, actually capitalizing on opportunities for teachable moments.  (Sidebar: One doctor who realized this years ago was Dr. Jordan Shlain, who founded HealthLoop)  Research studies show that PWDs are more successful and confident with managing their diabetes when they feel like they have the backup and support of their clinical providers looking over their shoulders to make sure things are going ok.  If we were to design the system from scratch to accomplish these goals, we probably would not have built it to rest on the concept of office visits every three months.

So, what should be the future model of a Diabetes and Endocrinology clinical practice?  Here’s what I imagine my practice looking like in the (hopefully near) future.  Instead of having 16 office visit slots per day of 30 minutes each, I imagine myself seeing 5 patients a day for 45-60 minutes each, allowing us to take our time working together in person and truly addressing the needs and goals of the patient.  These longer visits are essential for a patient new to my practice, a patient with a complicated or unknown diagnosis, a patient with complications or a major change in their disease state, or for discussing major changes in therapeutic course or strategy.  The rest of my day will be spent using a dashboard to do remote population management, looking for trouble spots among my patient population and focusing in on those, and doing telemedicine, connecting with patients through video-chats to make more minor adjustments and to do brief “check ins.”  Ten minutes spent with a patient at the point where there is a teachable moment like a low blood sugar from walking the dog might be more effective than a standard 30 minute office visit every three months.  We’ll have to test this hypothesis, of course, but we must try it.

This is why I’m brimming with so much enthusiasm and excitement about working with the non-profit, Tidepool, who is building an open data platform and a new generation of software applications for the management of type 1 diabetes.  Tidepool will provide us with the technology infrastructure to reach this vision of more frequent feedback loops and teachable moments.  I’m also very excited about the work that my UCSF colleagues, Drs. Ralph Gonzales and Nat Gleason, are doing to pilot the use of telephone visits and e-visits with patients in place of office visits.  Their work is paving the way toward demonstrating efficacy of e-visits, helping to achieve payer reimbursement so that such a model can take root.

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OneTouch Verio IQ meter

I won’t review this meter, since I haven’t tested one, and there is a very thorough review already here at DiabetesMine.  I do want to draw attention to it, however.  The draw of this meter is that it purports to find patterns in a user’s glucose data and to then give the user feedback and recommendations about how to make changes based on those patterns.  In theory, this sounds wonderful.  Give feedback to a patient during a “teachable moment,” ie at the moment when the feedback is relevant and someone is most likely to learn from it.  Unfortunately, according to the DiabetesMine review, the actionable recommendations are actually contained in a separate paper book that you have to request.  This would significantly detract from the usefulness of the feedback given by the meter.

There is significant medical literature about decision support and how to make it successful.  One BMJ systematic review from Kawamoto et al in 2005 noted that four key features are that “(a) decision support provided automatically as part of clinician workflow, (b) decision support delivered at the time and location of decision making, (c) actionable recommendations provided, and (d) computer based.”  It sounds like the Verio IQ meter tries to achieve these goals but still falls short…

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