AADE Technology Summit

AADE Technology Summit 2019 October 21-22, 2019; Chicago, IL; Highlights - Draft

Executive Highlights

  • AADE gathered ~40 leaders late last month to discuss integrating diabetes technology into clinical practice. Two papers will ultimately be published in Summer 2020, synthesizing both days of panels and breakouts: (i) Position Statement – Educator role in recommending, onboarding and supporting technology for the person with Diabetes; and (ii) Practice Paper – Practice considerations for assessing practice readiness for including various technologies in the treatment and self-management of the person with diabetes. More translation on tech is desperately needed are improvements in care delivery and we salute AADE for taking on some very challenging work.   

  • We appreciated hearing more about The Helmsley Charitable Trust’s ongoing work to develop a “Virtual Specialty Clinic.” It’s starting with remote on-boarding of CGM (Jaeb/Cecilia Health study), and ultimately aims to add mental health, clinical decision support software as part of insulin dosing, and whole-person support. The small Wisconsin pilot (n=36) was completed in August, and data has been submitted as an abstract to ATTD 2020.

  • Representatives from Dexcom, Abbott, Medtronic, and Senseonics discussed barriers that prevent more widespread uptake of CGM: lack of awareness among healthcare providers, challenges with reimbursement, lack of knowledge about the differences among existing CGMs, and unrealistic expectations about what the technology is and isn’t.

  • Ochsner Health System shared intriguing outcomes from its own remote care program using connected BGMs – a 0.6% A1c reduction (baseline: 7.3%) and reductions in extreme diabetes distress. We are very much looking forward to seeing details on diabetes distress. Great to see health systems focused on new care models!

Greetings from Chicago! AADE’s first-ever Diabetes Technology Summit just wrapped up, and we’re bringing you our top four highlights below.

Top Four Highlights

1. Helmsley’s “Geek Squad” Study – Data at ATTD 2020? Goal to create a “Virtual Specialty Clinic” to support whole person, including mental health

During a Q&A session, reps from the Helmsley Charitable Trust mentioned that pilot results from the Jaeb/HCT/Cecilia Health “Geek Squad” study may be publicly presented for the first time at ATTD 2020 (assuming the abstract is accepted). As of ADA 2019, the pilot of remotely onboarding CGM (prescription, shipment, education) had included primarily MDI users from Wisconsin (n=36), with intentions to expand to 200-300 people from 5+ states in late 2019 or 2020. In a subsequent email exchange, HCT told us its ultimate goal is the creation of a “Virtual Specialty Clinic” – “a telemedicine care model” – that will remotely onboard and support people with diabetes, giving access to specialty clinic care and expertise irrespective of geography. Excellent! The Virtual Specialty Clinic ultimately aims to add mental health screening and support. As of June, the “Geek Squad” had averaged 14 check-ins with each participant – far more than in clinical practice. (One participant expressed that he’d never even “had the idea of someone just focusing on me.”) Assuming this can scale and the business model is sustainable (see below), we see fantastic potential here for increasing uptake of CGM, improving touchpoints, and modernizing care delivery – most people with diabetes get ~15-60 minutes per year with a healthcare provider face-to-face (~1-4 check-ins) and hardly any interaction outside of that. A Virtual Specialty Clinic could also address geographic barriers impacting access to care (a big focus of HCT’s broader efforts in rural healthcare), educate people on the different types of CGMs on the market, and help primary care physicians cope with the fast pace of technology. We wonder if the clinic will use some of the existing connected care technology from industry – Livongo, mySugr, Omada, Onduo, One Drop, Fitbit Care, etc.

  • The program aims to operate under a sustainable business model, offering benefits to payers, CGM companies, and people with diabetes. The table below provides a further breakdown of the constituents (see previous coverage for further reference).

Stakeholder

Benefit

Patient

Access to specialty care, technology, and coaching without location constraints

CGM Company

Expands market outside of brick-and-mortar special clinics, reduces customer service burdens, and improves patient CGM retention

Insurance

Taking care of the full person especially starting with mental health saves money, improves long-term patient retention, and makes the investment more cost-effective

Virtual Clinic

Various revenue streams from proof of concept, people with type 2 that will eventually need insulin, and CGM companies

2. Barriers to CGM Adoption: Continued lack of awareness among HCPs, not enough clarity on CGM’s clinical value, and reimbursement issues

A 45-minute panel on barriers to CGM adoption captured insights from Abbott, Dexcom, Medtronic, and Senseonics reps. The panelists (and audience) all agreed that clinics need a CGM “champion” that advocates for utilizing the technology. Absent that, there remains a need for education about the clinical value of CGMs, education on the differences among existing CGM products, assistance with securing reimbursement, and setting proper expectations (e.g., HCP conversations with new-to-CGM patients).

  • Many healthcare providers still lack education and resources on the cost and clinical value of CGMs, which prevent onboarding new patients. Dexcom’s Ms. Keri Leone (Director of Professional Education) suggested that primary care physicians need to be familiar setting up the technology in the office, analyzing the data, providing coaching, and understanding reimbursement. Of course, most PCPs probably don’t even know about CGM (or have not kept up with the latest systems), let alone have time to optimize its use in the context of 10-15-minute appointments. Medtronic’s Ms. Laurie Jung (Senior Regional Clinical Manager) highlighted HCP knowledge on reimbursement as a continued barrier. Despite CGM being well reimbursed by commercial payers for type 1 diabetes, there are widespread misunderstandings about how insurance coverage works. An article in this month’s DT&TCurrent Eligibility Requirements for Continuous Glucose Monitoring Coverage Are Harmful, Costly, and Unjustified by Dr. John Anderson, Dr. James Gavin,  and Ms. Davida Kruger – puts the barriers into perspective. Ms. Jung likewise mentioned that if a provider is not comfortable with CGM and does not have education about its value, then there is no incentive to use it (or presumably there will be no successful use). Ms. Leone summarized the challenge in one phrase: “Tech must be a philosophy for the practice.”

  • Long-term benefits from CGM will only come if patient expectations about the product are set in the beginning. Ms. Leone mentioned that starting CGM requires setting expectations around “what it is, what it will do, and what it will not do.” (Part of this, in our view, requires educating users about the inaccuracy within BGMs – many patients have never been told fingerstick accuracy can vary by ±15% or more, with some meters performing far worse that factory-calibrated CGM.) Healthcare providers can also identify a patient’s number one concern and make a device recommendation based on that preference. As part of that process, Senseonics Ms. Patty Haney (Director of Clinical Education and Training) noted that HCPs must be familiar with what the different products offer – a tall order, especially as devices change quite a bit from year to year.

  • Patient perspectives should guide the development of future CGMs. Abbott’s Nitin Duggal (Senior Marketing Director) noted that this guided the FreeStyle Libre development process – e.g., the most powerful message for uptake was “no fingersticks.”

3. Ochsner Connected Diabetes Care Program Pairs Patients with Coaching: A1c Improves by 0.6% (Baseline: 7.3%); Lower Stress, High Satisfaction

Susan Montz presented six-month data from an Ochsner Health System (Louisiana) study testing connected diabetes care and remote support. A1c declined by 0.6% (baseline: 7.3%) at six months, and the percentage experiencing extreme distress from diabetes declined from 9% to 6%. Information on the number of participants involved and comparison to a control group were not provided. The program uses a connected BGM (iHealth) and blood pressure cuff, an app (iOS or Android), and a remote care team consisting of a health coaches (exact role not specified), pharmacists, and physician assistants. The care team proactively reaches out and intervenes if needed, along with support through phone calls, in-app messaging, and monthly progress reports. Feedback takes into account individual factors like behavioral patterns, healthcare access, environmental exposure, social circumstances, and genetic predispositions to certain illnesses. The program also makes use of a “mobile O-bar” vehicle that visits specific clinics in the Baton Rouge area on scheduled dates to help patients onboard through assistance with device set-up, virtual scheduling, and enrollment support. IN essence, this seems like a health system’s approach to what many industry players (Livongo, mySugr, One Drop, Onduo, etc.) are doing – nice!     

  • The program has seen impressively high satisfaction –  Net Promoter Score is 78, well ahead of 68 (Netflix) and 72 (Amazon). Ms. Montz emphasized the purpose of this program was to create a personalized support system where patients had a team accountable and responsible for their care. Through continuous monitoring and active feedback, individuals felt a sense of agency in their diabetes management.

  • During Q&A, Ms. Montz mentioned that while the initiative is obtaining “a lot of data on blood glucose,” there were no specifics on onboarding patients with CGM. The program is currently in progress from expanding from twelve hours on five days of the week to 24/7 monitoring.

4. AADE’s “Position” and “Practice” Papers Expected Publication in Summer 2020; Tentative Outlines for Both Papers Brainstormed

The conference concluded with two breakout sessions where participants attempted to organize the “position” and “practice” papers that AADE intends to write and publish by Summer 2020. The position paper will examine the “educator role in recommending, onboarding, and supporting technology” while the practice paper will assess practice “readiness for including various technologies” for those managing diabetes. We primarily covered the “position statement” breakout, where discussion centered around identifying the scope of the paper. Questions centered on the specific type of provider involved (e.g., physician, CDE, pharmacist), the type of technology (e.g., BGM, CGM), the need for making data understandable, and effective ways of making recommendations were all mentioned. Members from the “practice” breakout session advocated for specific quality indicators, mechanisms for self-assessment, efficient workflow, open communication, and willingness to change. Participants at both sessions brainstormed by writing thoughts on post-it notes and sticking them on poster paper.

  • The paper writers and reviewers include quite an all-star cast:

    • Position Statement: Deb Greenwood (Lead); Fran Howell; Gretchen Youssef; LaurieAnn Scher; Malinda Peeples.

    • Practice Paper: Diana Isaacs (Lead); Anastasia Albanese-O’Neill; Carla Cox; Kathleen Eubanks-Meng; Tamara Oser; Mary Jo Mason; Kathy Schwab

    • Reviewers: Starlin Haydon-Greatting; Jackie LaManna; Janice MacLeod; Jane Seley; Kathleen O’Neil (AADE); Shiv Patil (AAFP); John Kennedy (AMGA).

  • While the initial outlines discussed will likely change, there was consensus around a few concepts which these papers will likely address: (i) there is a lack of a systemic approach to technology integration in healthcare today; (ii) systems and roles need better definitions as the ad hoc approach to technology introduction, implementation, and ongoing support is unsustainable; (iii) there is an opportunity to improve quality of care and safety by better defining individual roles and systems during diabetes technology usage; and (iv) Diabetes Care & Education Specialists can play a significant role in supporting both patients and the healthcare team when it comes to technology.

 

--by Ani Gururaj, Adam Brown, and Kelly Close