Joslin and Glooko launch HypoMap software to identify and improve hypoglycemia unawareness – June 11, 2014

Today, Glooko and Joslin Diabetes Center announced the release of the Joslin HypoMap powered by Glooko, a jointly developed software module for identifying and improving hypoglycemia unawareness. HypoMap centers on a patient survey that will sit within the existing Glooko mobile app (see figure one below). After patients upload glucose data from any of the 27+ supported glucose meters using Glooko’s universal MeterSync cable, HypoMap will flag episodes of low blood glucose that have occurred within the past two weeks. Patients will then be prompted to enter contextual information about the hypoglycemia episodes – what symptoms were experienced, what they think caused the low, and how it was treated. On the backend, the data will be sent to three reports in Glooko’s web-based Population Tracker (launched in February), where providers can follow patients, identify those at high risk, and dive into particular hypoglycemia episodes.

HypoMap is only available to Joslin patients right now, though as Glooko scales up and expands from the current controlled launch, more providers will get access to the product. As we noted in our previous coverage, Glooko provides payers/health systems with Population Tracker in exchange for a monthly/per-patient fee – always great to see a business model in mHealth!

In speaking with Joslin’s very smart Dr. Howard Wolpert, he emphasized that a guiding philosophy for the entire system is to create “teachable moments” that can improve patients’ self-management and tailor clinical conversations to patient needs. Indeed, as shown in figure two below, we think Glooko and Joslin have done a terrific job of linking the patient-inputted survey data to a heat map that plots glucose levels against the symptoms experienced. One quick glance at the top left of the plot will quickly help providers identify whether patients are hypo aware or not (i.e., if they are experiencing autonomic symptoms at glucose levels >60 mg/dl). The heat map also allows patients to improve their hypoglycemia recognition by identifying their individual specific symptoms. The other reports are discussed below.

Of course, the key input to HypoMap is that patients must manually enter the contextual data surrounding a hypoglycemia episode, which gets more difficult as time passes between the event and the data upload (up to two weeks in HypoMap). Glooko has made excellent strides in making meter data upload fairly hassle free in the current system, and this will no doubt improve once the company launches its universal Bluetooth upload product – as we understand it, this will be on display in the ADA 2014 exhibit hall. Furthermore, we believe there is lots of potential for reminders and prompts to encourage patients to upload data more frequently.

Below, we enclose many further details on HypoMap, discuss how it fits into changing healthcare delivery, and highlight Glooko/Joslin’s plans for future improvements.

• Overall, we are optimistic about the product and approach and particularly like that the system can make both providers and patients feel more successful. For HCPs, HypoMap can simplify and enhance glucose data analysis, improve clinical efficiency, automate the process of identifying patients with hypoglycemia unawareness, and quickly identify high-risk individuals who need targeted guidance to prevent severe hypoglycemia. For patients, HypoMap is a tool to improve engagement and self-management skills – the contextual prompts will trigger patients to focus on the causes of glucose fluctuations and individual specific hypo symptoms. This should ideally result in fewer instances where patients make the same mistakes over and over again (e.g., skipping lunch) that result in hypoglycemic episodes.
  
  • We imagine HypoMap will be particular appealing to vertically integrated providers like Kaiser. Given the product’s focus on identifying high-risk individuals, it could potentially reduce severe hypoglycemia events – this is critically important in those very costly hypoglycemia unaware patients that recurrently end of up the hospital. An integrated system like Kaiser can roll a digital product like Glooko out to providers, and then see a return on investment linked to fewer in-hospital admissions.
• HypoMap will sit within the existing Glooko mobile app/web dashboard, but it will only be available to patients whose providers use the system (“ProConnect”). Right now, HypoMap is only available to patients and providers at Joslin. As a reminder, payers and health systems establish contracts with Glooko and pay a subscription rate based on the number of patients using Glooko’s system. Scripps and Joslin are the only two partnerships that have been publicly announced. Glooko is smartly undertaking a controlled launch of its entire data management system (mobile app, cable, web dashboard), and is currently looking to sign up some additional key opinion leader provider groups (particularly those who are ACO oriented).
• The HypoMap product is considered as part of Glooko’s FDA-cleared system. The company told us it follows relevant FDA guidance documents and quality system regulations for new features in order to be compliant. We assume the product does not need an additional FDA clearance, since it is not providing clinical decision support or therapeutic recommendations. Of course, the agency is always hard to predict.
• Aside from the HypoAwareness heat map (see figure two below), HypoMap includes two other reports intended to help providers and patients: HypoPatterns and HypoDay.
  
  • The HypoPatterns report organizes hypoglycemia events by time of day and day of week – it is designed to help differentiate between random hypos and more predictable hypos that are linked to different daily and weekly life routines habits (e.g., high intensity exercise every Tuesday and Thursday; or consistently skipping lunch on weekdays). In speaking with Dr. Wolpert, he highlighted the clinical utility of this display, as many hypos are predictably tied to certain behaviors at similar times. The display is intended to overcome some of the limitations of current methods of looking at glucose data, which often make it hard to tease out these patterns.
  • The HypoDay report allows providers and patients to dive into specific episodes – the inputted contextual information from each hypoglycemia episode (i.e., symptoms, causes, treatment) is displayed along with glucose data for 12 hours before and after the episodes. This view is really intended to turn hypoglycemia events into teachable movements – for example, patients can see if they over-treated a low with too much orange juice.
• Dr. Wolpert shared with us how digital approaches like HypoMap can re-envision diabetes care – moving us from the traditional prescriptive approach to interactive self-learning targeting individual-specific problem areas. Ultimately, the move to a digital infrastructure should increasingly facilitate a change in the diabetes care model, something that is long overdue. Dr. Wolpert explained to us that the current model of regularly scheduled office visits (independent of need/urgency) doesn’t make any sense – boy is he right! In the future, office visit frequency should vary, depending on individual patient needs for training and support – patients who are engaged and doing well need less in-person contact, while those at high-risk should come in more frequently.
  
  • Ultimately, this is where diabetes care delivery must go, given the shortage of doctors and growing number of patients. The imbalance between supply and demand has only one logical solution in our view – patients must be prioritized in terms of risk, and simultaneously armed with the knowledge and tools to adequately care for themselves.
• Glooko and Joslin have a long list of future planned product enhancements – allowing patients to score their autonomic symptoms for research purposes (i.e., a trend over time to understand the hypoglycemia awareness impact of an intervention); digitizing the current standards of care/practice recommendations; providing patient-specific treatment prompts to minimize hypoglycemia risk; integration of activity tracker data; and predictive analytics.
  
  • For instance, clinicians and patients could be automatically prompted to do certain things based on pre-programmed settings. A type 2 patient on a fixed insulin regimen could be automatically flagged and the clinician would be prompted to discuss meal planning (i.e., integrating an ACCORD finding that a cause of severe hypoglycemia stemmed from type 2 patients on fixed insulin programs skipping meals). At the same time, the app could build in prompts to remind these type 2 patients to eat and check their glucose. In another scenario, integration with a Fitbit activity tracker could trigger an automatic prompt to patients based on their historical pattern of activity and hypoglycemia.
• The Glooko-Joslin partnership was announced in January 2014, meaning this product was developed in just six months! We’d note that the timing of HypoMap is right on par with the January press release, which estimated that a concept would be shown at ADA 2014 – great to see such fast movement.
• As a reminder, the Glooko system consists of three components: a universal MeterSync cable (compatible with 27+ meters and 29+ mobile devices, both Android and Apple), a mobile app, and a web dashboard. Glooko offers a kiosk version of its app for clinical practices, which is intended to simplify the workflow in the clinic. The company’s Population Tracker is the provider side of the web dashboard, allowing clinicians to follow their population of patients and stratify them based on recent risk for extreme hypoglycemia or hyperglycemia. Glooko also makes its software API available, allowing integration into EHRs (e.g., the Joslin EHR has a Glooko button).

Figure 1: HypoMap Survey in Glooko Mobile App

Figure 2: HypoAwareness Heat Map

--by Adam Brown and Kelly Close