Understanding patients’ burdens associated with diabetes management, pediatric endocrinologist Stephen Ponder, MD (pictured), is utilizing technology to help his patients save time and alleviate costs.

By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net

In recent years, there has been an explosion of technology including everything from continuous glucose monitoring systems to wireless devices to smart phone apps - all developed for the management of diabetes.

However, many people with diabetes are often not aware of or financially able to take advantage of some of these technologies.

Yet, one pediatric endocrinologist, Dr. Stephen Ponder, has become something of a technology advocate by embracing it for use in his clinical practice, and trying to circumvent patients’ utilization challenges and find solutions to have his patients embrace its use when possible.

For example, Dr. Ponder has practiced medicine in the four corners of his massive home state of Texas, and he is able to continue to see his patients from all over the state, via his telemedicine program, Diabetes Housecall. This program allows his patients to connect with him via computer webcam, and through a series of pre-visit responsibilities on the part of the patient, Dr. Ponder is able to conduct a full appointment - without the patient having to drive to his office at the Texas Tech University Health Sciences Center (pictured below, right) in the Permian Basin region in West Texas. For some of his patients this saves them driving hundreds of miles each way for a face-to-face visit.

Working with a health company in 2002, Dr. Ponder also helped to develop a wireless device called GlucoMON. This device allows people to upload patient blood glucose reports into easy-to-read formats for immediate review by the patient or family, and in effect, decreasing the amount of steps a person might have to do this online on a regular basis.

Having type 1 diabetes for 45 years, and practicing pediatric endocrinology for almost 25 years, Dr. Ponder truly knows diabetes, and he understands the financial and time burdens associated with the disease.

He does not believe technology is a panacea for clinical care, but it does have an important adjunctive role in its management. Conversely, Dr. Ponder also cautions that as technology becomes more sophisticated, it may mean the costs associated with devices and various technologies may become even more cost-prohibitive to many who suffer with diabetes, and could lead to a two-tiered or multi-tiered system of healthcare access.

DiabetesCare.net recently spoke to Dr. Ponder, and we discussed how he is using technology in his practice today, what type of role a futuristic technology like the artificial pancreas could play, and the barriers patients face for self-management education.

DiabetesCare.net: One of the biggest technology discussions going on right now in the type 1 diabetes arena is the artificial pancreas. Do you believe this device would really help the type 1 patient population greatly?

Dr. Ponder: I think the concept of the closed loop deliver system (artificial pancreas) is fantastic. It has been around for many years, and only recently has it gotten to the point where we have the technological capacity to implement it.

If you strip away all the involvement of the patient in their own self-care, and you have that empowered into a machine, it has the potential to improve the populations’ health overall. I think the biggest challenges will be cost, and how much effort is involved to do this. Some patients will put in an extraordinary amount of effort in and some will put in very little to their own self care. A lot of that is driven by their own understanding of their disease and how well they are supported by their family and the system as a whole. And the system is not only physicians, but the third party payers and scientific community as well.

I have had diabetes for almost half a century, and the idea of an artificial pancreas sounds very appealing to me, but I don’t sit up at night thinking is it going to happen tomorrow. I also know a lot of the hurdles involved with this, namely having quality sensor data, which is still one of the biggest challenges. I’ve worn a pump for 30 years and a sensor for the past 4 years. It shapes your attitudes about the technology and your own role in it.

Once they get past these sensor issues, there will be some pretty complex mathematics involved. I don’t think anyone has developed the ideal algorithms to be used for this. But what is out there is impressive. I imagine the device will adapt to its users’ behaviors over time.

Lastly, like most things in medicine, progress is going to be made with this technology incrementally.

DiabetesCare.net: Speaking of technology, for your work with the GlucoMON, you did a yearlong randomized clinical study using this device. What conclusions or results were demonstrated?

Dr. Ponder: We are writing up the paper right now. We did demonstrate significant improvement glycemic control without any involvement in a physician team. This device empowered families, especially the parents - who are more comfortable with blood glucose monitoring - and made it exquisitely easy to use, analyze, and read their own data.

The time and effort in collecting blood glucose data and documenting, charting, or logging it into the computer or punching it into some application is challenging for people to do and can take an hour of someone’s day.

The GlucoMON eliminated a lot of those steps. It was a one step procedure; just plug the meter into the GlucoMON and that was it. No PC needed or Internet access to upload data. Once the data was collected, it was distributed per the wishes of the user family. It went to the parents in the form of an e-mail with a single, unified color chart structure that everyone became familiar with and they took just a few seconds to look at that. Or, they could receive “real-time” alerts sent directly to the parent’s cell phone, or even an e-mail. One bonus feature was the instant, automatic updating of the meter’s internal clock when it was docked to the GlucoMON. This assured the data points were all properly timed and correct to the atomic clock. When they disconnected the meter from the device, it automatically shut the meter off.

Much of what we discovered was that the more steps you have in a process, the more likely you are going to have a fall off in monitoring adherence. While people will do something for a while, there is a fatigue factor with a lifelong disease like diabetes.

DiabetesCare.net: What is your take on smart phone apps? Are they going to continue to be a niche for a smaller portion of the diabetes patient population, or do you see them having a bigger footprint in terms of self-management and helping a great number of people with diabetes?

Dr. Ponder: As I have this disease 24/7, I don’t have the time to spend two hours a day collating the data. If you had an app and it could grab all the information from all your devices and send it to a unified form or application that the patients could look at like a dashboard of information. That is the type of intelligence I need from my technology.

I want a snapshot of what I am doing, and I want it now. An app like that would be remarkable. I don’t want to do a lot of work to get it. With many apps out there, the amount of time and effort it takes to use them will only have a very small amount of people stay with a particular app over time. I think apps are a niche until they become incredibly simple, as far as diabetes self care is concerned.

DiabetesCare.net: Do you see the development of your telemedicine program, Diabetes Housecall, as a kind of supplemental case management approach to those who might not otherwise have the ability to seeing a practitioner every few months?

Dr. Ponder: It is a source of primary care delivery for people that live across a large geographic area. I have patients who live in El Paso (to my west), Brownsville (to my south), the panhandle (to my north), and east Texas, who see me in their homes while I’m in my office. During the telemedicine visit, I can discuss all their issues while they are in a relaxed and safe environment. 

There is homework prior to these telemedicine visits. The patient collects their own data and they send it in advance of our appointment. They have to get a home-based A1c collection done a week or two before the visit. They also have to fill out a history form. And for all that homework, they bypass a several hour drive and whatever costs that entails.

For most of the patients who have stayed with the program, they have seen the value of it. In fact, one gentleman who travels 400 miles to see me for face-to face visits said it costs him $1,500 for time away from work, his child out of school, and gasoline. And this is versus the one tenth of the fee for service we charge.

We were able to discuss this with a major health insurance provider, Blue Cross Blue Shield, here in Texas who decided to compensate me for these visits as if the patients are in my office, and not the traditional telemedicine fees. Blue Cross monitored it for a while and they were happy with the results. The next step is to make it more widespread.

DiabetesCare.net: You wrote an article where you stated, “it is malpractice, in my opinion, not to be offered access to diabetes education.” Why do you think education access is a big problem being experienced in medical practices?

Dr. Ponder: There is a misconception by physicians that sending a patient to a diabetes education class allows them to check that box off. However, just getting education does not finish the two other steps in that process. Education has to turn into understanding and understanding has to translate into behavior. Somehow there is this leap of faith that just sending someone to a class is going to change behavior.

Diabetes is a lifelong educational experience. If you don’t refer your patients to education as often as they can get it paid for, then you are not doing your patients a good service. It comes back to that fallacy that doctors control their patients’ diabetes. The doctors don’t make the decisions the diabetic has to make everyday. I’ll give you an example: when the person with diabetes walks past that vending machine and they have to think about putting a dollar in and getting a coke or decide to walk on by - that’s a choice!

On the other side of that, we have a lot of people who have behavioral and mental health issues. And a lot of those people have diabetes too. That becomes a huge barrier to managing diabetes if you have some disordered thoughts.

Ninety percent of diabetes care is psychological and 10 percent is medical. Education plays a part in that, and if you feel empowered, you are more likely to make better self care choices. But if you deny someone education, you are usually setting the person up to fail.

I saw a patient today who was put on an insulin pump four years ago. No changes had been made to the pump setting, and the child has an A1c of 13.2. No one told the child he would outgrow the honeymoon phase. He was on a pump setting for someone who was making 20 to 30 percent of their own insulin. And he has gotten progressively worse, and no one lifted a finger to retrain him. He went through the pump and dump training where he got an hour or two and that was it. It is like going to first grade and expecting to graduate high school.

We, as doctors, are expected to get continuing education credits, but we, as doctors, don’t expect our patients to get continuing education? It just doesn’t make any sense to me.


Originally posted by DiabetesCare.net on July 15, 2011.