Managing diabetes, both type 1 and type 2, takes daily, if not hourly, vigilance: checking blood sugar, taking medications or the right amount of insulin, thinking about what foods to eat. Even people who have had diabetes for years and are doing relatively well can struggle with the routine. Just one miscalculation about how much insulin to take before a meal can lead to a dangerous low blood sugar, or a very elevated one that can leave them feeling terrible for hours.
Shantanu Nundy, MD, a clinical instructor of medicine at the University of Chicago Medicine, calls this constant struggle the “daily-ness” of diabetes.
“A lot of people with diabetes do well for a while and then they slip up,” he said. “We don’t have a systematic way of getting people to really buy into their diseases. We just say, ‘Here’s some medicine,’ but we don’t really have a mechanism for teaching people the idea of what it really means to have this disease and have it every day for the rest of your life.”
Nundy and his colleagues in the section of general internal medicine have developed a system to help diabetics manage their daily routine through a device they already have in their pockets: cell phones. They built a system to send text messages that remind patients to take medications and check their blood sugar, provide tips about diet and exercise, and ask them questions about how they are doing.Science Life spoke to Nundy in 2011 when he launched a pilot study that tested this approach with a small group of patients. The program has since expanded to employees of the University of Chicago, the medical center and their families who are enrolled in the university’s health plan. After six months of running the program at a larger scale, he and his colleagues are learning about how mobile technologies can be used to help patients manage chronic diseases.
The system uses software that can send up to 800 different messages. When patients first enroll, they speak to a nurse on the phone who asks them a series of questions to customize which ones they should receive based on their habits and lifestyle.
Nundy said the initial setup could have easily been done with a form on the internet, but a key component of the program is having patients develop a relationship with a nurse who monitors their case. Some of the messages ask questions about how a patient feels, or how often they’ve been checking their blood sugar. If a response raises a red flag, like answering “No” when asked if they’ve been taking their medication, the nurse calls to check in to see how she can help. Patients can also respond to adjust what types of messages they receive, and how often.
At the time the program started in May 2012, everyone on the university health plan was offered a chance to enroll in the program, which is free of charge. Of those eligible, about one in five signed up. Nundy recently published a paper about the initial phase of the program in the International Journal of Telemedicine and Applications, along with Jonathan Dick, a Pritzker School of Medicine graduate now at Columbia University who helped start the pilot project, Marshall Chin, MD, MPH, and Monica Peek, MD, MPH, from the department of medicine, and colleagues from the University of Chicago Health Plan and the University of Illinois at Chicago.
As the first group of patients completes six months in the program, doctors will be able to look at their blood test results to see the impact it’s had on their overall diabetes control. Nundy said he’s encouraged by feedback from patients, but it clearly isn’t for everyone. It’s clear that different personality types respond to different parts of the program. Analytical types who are looking to track blood sugar readings down to the hour and fine-tune their insulin regimen may find it too simplistic. Older, retired patients with more time on their hands may benefit more from regular face-to-face appointments or phone calls with a nurse instead.
The sweet spot seems to be for people busy with work and family commitments who may need a little nudge to help with their diabetes, or to learn about health plan benefits they may not have been aware of. However, there is no ideal patient for this model. It’s a combination of lifestyle, habits and personal preferences. Finding the right mix will be a continual work in progress. “That’s the million dollar question,” Nundy said.
The project presents an interesting opportunity to extend health care delivery beyond traditional in person appointments and scheduled checkups. It’s a different take on personalized medicine like the 1200 Patients project Science Life covered recently, where treatments are tailored to a patient’s genes.
“What I think about is personalized health care delivery,” Nundy said. “Instead of ‘The doctor will see you know,’ I think of it like ‘How do you want the doctor to see you now?’ When we’re dealing with diseases that patients manage mostly on their own, I think this piece about how you want to be taken care of is so critical.”