Telemedicine as a tool for intensive management of diabetes: the DIABTel experience

Abstract

This paper presents the current features of the DIABTel telemedicine system and the evaluation outcomes of its use in clinical routine. This telemedicine system is designed to complement the daily care and intensive management of diabetic patients through telemonitoring and telecare services. The system comprises a patient unit (PU) used by patients in their day-to-day activities and a Medical Workstation used by physicians and nurses at hospitals. Both applications offer tools to collect, manage, view and interpret data and to exchange data and messages. The system was evaluated for usability, telemedical protocols, metabolic control and quality of life. This evaluation consisted in a 6-month cross-over pilot study with ten Type I diabetic patients. The results of the evaluation allowed assessment of the telemedicine protocols in terms of the number of communications/patient (21.6±7.7); days between communications (5.4±2.66); messages sent by physicians (118 text messages); and data and messages transmitted by patients (3524 blood glucose readings, 1649 day-to-day insulin adjustments, 24 exercise reports, ten diet modifications and 63 text messages). Physicians performed more therapeutic changes during the DIABTel period than in the control period. There was a trend towards HbA1c improvement during DIABTel use with no incidence in the number of hypoglycaemias. This pilot study demonstrates the feasibility of the DIABTel system in clinical routine use and its potential benefits for diabetes care: improving the availability of information necessary for therapy adjustments; offering new physician–patient communication tools; increasing patient empowerment and education; and showing a positive trend towards improving the metabolic control of patients. Further studies are needed to validate these findings and to promote telemedicine as an opportunity to better diabetes care.

Introduction

In Western societies, diabetes and its complications are still causing a tremendous amount of suffering in over 5% of the population. It continues to be a major health problem and amounts to as much as 8% of national spending in health care [1]. Diabetes is a chronic disease characterised by a sustained elevated blood glucose level, caused by a reduction in the action of insulin secretion where related metabolic disturbances generate severe, acute and long-term complications that are responsible for premature death and disability [2].

Nowadays, a well-treated Type I diabetic patient can expect to have an almost normal life span as the benefits of intensive management have been well established and include reduced long-term complications [3]. Nevertheless, the achievement of the therapeutic goals and current guidelines [4] implies a significant increase in the amount of patient data to be monitored, the need of a tight control of patients in their self-monitoring blood glucose levels and day-to-day insulin adjustment, requiring in many cases a better patient empowerment and education, increasing physicians and nurses workload and raising immediate health care costs. On the other hand, the inability of a large proportion of the population in the more affluent western societies to cope with the excess caloric supply together with a lack of physical exercise results in a greater prevalence of Type II diabetes. This fact can be seen in figures: at least 100 million people today suffer from Type II diabetes and by 2010, this will rise to 215 million [5]

During the last two decades, diabetes has been a major clinical focus for advances in information technology, telemedicine developments and intelligent systems [6]. Due to its multifactorial and systemic character, diabetes mellitus has been considered a paradigm of chronic disorders which has led to the application of information technologies in diabetes care [7]. Applications have been classified taking into account several approaches such as the system end-user, namely the patient or the physician [8] to provide them with tools to support their daily tasks in diabetes care, or under more general technological headings such as clinical databases, therapeutic algorithms, decision support systems [9], modelling and educational tools [10]. Telemedicine provides an integrated approach to those tools, which enhances co-operation between users and information sharing and knowledge (see Fig. 1).

Nowadays telemedicine is radically changing healthcare models particularly in the way healthcare is currently delivered [11]. It is transforming the relationships between healthcare administrations and companies, professionals and patients. Furthermore, Internet is changing the way patients gather information about diseases and drugs and is allowing them to communicate directly with their physicians. The need for more and better health care information is confirmed by the fact that health-related sites are among the most frequently accessed information resources on the Web [12], [13].

Earlier experiences of telemedicine in diabetes management aimed to improve communication and co-operation between patients and doctors [14] and in many cases only comprised the transmission of computerised blood glucose profiles by telephone modem-based home glucose monitoring equipment [15]. In some of these experiences, and as an extension of remote patient data monitoring, patients received advice over the telephone on insulin adjustments and food intake after transferring results to the clinical centre [16].

Over the last years the search for increasing the possibilities offered by telemedicine in diabetes care has led to a growing number of experiences covering several technological approaches and scenarios of care delivery [8]. For home care several approaches for therapeutic advice delivery to patients at home have been reported [17], [18], [19]. Recently, telemedicine is being applied in wide scale healthcare experiences as a main tool for the delivery of home care and diabetes education to patients [20].

This paper presents the current development of a telemedicine system, DIABTel, which complements the daily care of diabetic patients, and the pilot study conducted to evaluate the system usability and users acceptance, to characterise the telemedical protocols and to analyse the impact of the system use on the patients metabolic control and quality of life.