The Challenge of Sustainable Access to Telemonitoring Tools for People with Diabetes in Europe: Lessons from COVID-19 and Beyond

Assessing Cross-Border Telemedicine Data Exchange in the European Union: A Call to Action

Background: Telemedicine offers potential benefits for health care delivery. However, evidence of cross-border telemedicine data exchange within the European Union (EU) remains limited. The objective of this communication provides a brief outline of the regulatory framework, initiatives, and challenges associated with cross-border telemedicine data exchange in the EU, setting the stage for a comprehensive evidence assessment. Methods: We explore the current regulatory landscape (European Health Data Space), existing initiatives (the European Electronic Health Record Exchange Format), and interoperability challenges (e.g., legal, technical, semantic) facing EU cross-border telemedicine data exchange. Results: There is a need for thorough evidence assessment of cross-border telemedicine and related data movements. Conclusion: Understanding the current landscape of cross-border telemedicine is crucial. This article highlights the need for evidence assessment through a formal review to inform future research and policy initiatives in this domain.

HL7 Fast Healthcare Interoperability Resources (HL7 FHIR) in digital healthcare ecosystems for chronic disease management: Scoping review

BACKGROUND

The prevalence of chronic diseases has shifted the burden of disease from incidental acute inpatient admissions to long-term coordinated care across healthcare institutions and the patient's home. Digital healthcare ecosystems emerge to target increasing healthcare costs and invest in standard Application Programming Interfaces (API), such as HL7 Fast Healthcare Interoperability Resources (HL7 FHIR) for trusted data flows.

OBJECTIVES

This scoping review assessed the role and impact of HL7 FHIR and associated Implementation Guides (IGs) in digital healthcare ecosystems focusing on chronic disease management.

METHODS

To study trends and developments relevant to HL7 FHIR, a scoping review of the scientific and gray English literature from 2017 to 2023 was used.

RESULTS

The selection of 93 of 524 scientific papers reviewed in English indicates that the popularity of HL7 FHIR as a robust technical interface standard for the health sector has been steadily rising since its inception in 2010, reaching a peak in 2021. Digital Health applications use HL7 FHIR in cancer (45 %), cardiovascular disease (CVD) (more than 15 %), and diabetes (almost 15 %). The scoping review revealed that references to HL7 FHIR IGs are limited to ∼ 20 % of articles reviewed. HL7 FHIR R4 was most frequently referenced when the HL7 FHIR version was mentioned. In HL7 FHIR IGs registries and the internet, we found 35 HL7 FHIR IGs addressing chronic disease management, i.e., cancer (40 %), chronic disease management (25 %), and diabetes (20 %). HL7 FHIR IGs frequently complement the information in the article.

CONCLUSIONS

HL7 FHIR matures with each revision of the standard as HL7 FHIR IGs are developed with validated data sets, common shared HL7 FHIR resources, and supporting tools. Referencing HL7 FHIR IGs cataloged in official registries and in scientific publications is recommended to advance data quality and facilitate mutual learning in growing digital healthcare ecosystems that nurture interoperability in digital health innovation.

Challenges of using telemedicine for patients with diabetes during the COVID-19 pandemic: A scoping review

Background

Telemedicine has aided patients with diabetes during the COVID-19 pandemic in receiving better healthcare services. However, despite its numerous benefits, the use of this technology has faced several challenges. This study aimed to identify the challenges of using telemedicine for patients with diabetes during the COVID-19 pandemic.

Methods

This scoping review was conducted in 2024. Relevant articles published between 2020 and 2023 were searched in databases including PubMed, Scopus, Web of Science, ProQuest, and the Cochrane Library. Initially, 822 articles were retrieved, and after screening 21 articles were selected.

Results

The challenges of using telemedicine for patients with diabetes during the COVID-19 pandemic were categorized into the clinical, individual, organizational, and technical challenges. The clinical challenges included the lack of physical examinations and unavailability of patients' medical history. The individual challenges contained difficulties in using smart phones by patients and their low level of literacy. The organizational challenges were related to insufficient laws about obtaining patient consent and limited reimbursement for telemedicine services, and the technical challenges included limited access to the high-speed Internet services and inadequate technical infrastructure for telemedicine services. Most studies highlighted the role of individual and organizational challenges in using this technology.

Conclusions

Considering the numerous challenges experienced in using telemedicine for patients with diabetes during the COVID-19 pandemic, it seems that more attention should be paid to address each of these challenges to improve the actual usage, service quality, and user acceptance of telemedicine technology. This, in turn, can lead to saving costs and improving the health status and quality of life of patients with diabetes.

Cost-Effectiveness of a Home Telemonitoring System for Asian Adults with Type 2 Diabetes Mellitus

Background: Telemonitoring programs have been found to be effective in improving diabetic control by promoting patients' self-management of diabetes through medication adherence, dietary modifications, and exercise. Nonetheless, few studies have assessed the cost-effectiveness of telemonitoring for the self-management of diabetes based on real-world data. Methods: A randomized controlled trial entitled Optimizing care of Patients via Telehealth In Monitoring and Augmenting their control of Diabetes Mellitus was conducted among adults with Type 2 Diabetes Mellitus in Singapore. Individuals in the intervention group (n = 159) underwent a telemonitoring program comprising of remote patient monitoring, education, individualized health coaching, and teleconsultations, whereas individuals in the control group (n = 160) received regular care. Economic evaluation was conducted from health care system and societal perspectives in 2020 in Singapore dollars, using health outcomes and costs documented at baseline and at 6 month follow-up. One-way sensitivity analyses and bootstrapping to generate scatter plot on cost-effectiveness planes were done. Results: The adjusted reduction in HbA1c scores was greater in the intervention group by -0.41 (95% confidence interval [CI], -0.65 to -0.17), while the change in utility scores was higher in the intervention group by 0.011 (95% CI, -0.016 to 0.0378). From a health care perspective, the incremental cost-effectiveness ratio (ICER) of the telemonitoring program per unit improvement in HbA1c, per additional case of well-controlled diabetes, and per unit improvement in quality adjusted life years was SGD 580.44, SGD 9100.15, and SGD 21,476.36, respectively. From a societal perspective, the ICERs were SGD 817.20, SGD 12,812.02, and SGD 30,236.36, respectively. Conclusions: The Optimizing care of Patients via Telehealth In Monitoring and Augmenting their control of Diabetes Mellitus telemonitoring program was effective and potentially cost-effective for the management and control of diabetes among patients in primary care.

Continuous glucose monitoring for the routine care of type 2 diabetes mellitus

Although continuous glucose monitoring (CGM) devices are now considered the standard of care for people with type 1 diabetes mellitus, the uptake among people with type 2 diabetes mellitus (T2DM) has been slower and is focused on those receiving intensive insulin therapy. However, increasing evidence now supports the inclusion of CGM in the routine care of people with T2DM who are on basal insulin-only regimens or are managed with other medications. Expanding CGM to these groups could minimize hypoglycaemia while allowing efficient adaptation and escalation of therapies. Increasing evidence from randomized controlled trials and observational studies indicates that CGM is of clinical value in people with T2DM on non-intensive treatment regimens. If further studies confirm this finding, CGM could soon become a part of routine care for T2DM. In this Perspective we explore the potential benefits of widening the application of CGM in T2DM, along with the challenges that must be overcome for the evidence-based benefits of this technology to be delivered for all people with T2DM.

Insulin Pump Utilization in 2017-2021 for More Than 22,000 Children and Adults With Type 1 Diabetes: A Multicenter Observational Study

This large type 1 diabetes cohort study showed that insulin pump utilization has increased over time and that use differs by sex, insurance type, and race/ethnicity. Insulin pump use was associated with more optimal A1C, increased use of continuous glucose monitoring (CGM), and lower rates of diabetic ketoacidosis and severe hypoglycemia. People who used an insulin pump with CGM had lower rates of acute events than their counterparts who used an insulin pump without CGM. These findings highlight the need to improve access of diabetes technology through provider engagement, multidisciplinary approaches, and efforts to address health inequities.

A systematic review and knowledge mapping on ICT-based remote and automatic COVID-19 patient monitoring and care

BACKGROUND

e-Health has played a crucial role during the COVID-19 pandemic in primary health care. e-Health is the cost-effective and secure use of Information and Communication Technologies (ICTs) to support health and health-related fields. Various stakeholders worldwide use ICTs, including individuals, non-profit organizations, health practitioners, and governments. As a result of the COVID-19 pandemic, ICT has improved the quality of healthcare, the exchange of information, training of healthcare professionals and patients, and facilitated the relationship between patients and healthcare providers. This study systematically reviews the literature on ICT-based automatic and remote monitoring methods, as well as different ICT techniques used in the care of COVID-19-infected patients.

OBJECTIVE

The purpose of this systematic literature review is to identify the e-Health methods, associated ICTs, method implementation strategies, information collection techniques, advantages, and disadvantages of remote and automatic patient monitoring and care in COVID-19 pandemic.

METHODS

The search included primary studies that were published between January 2020 and June 2022 in scientific and electronic databases, such as EBSCOhost, Scopus, ACM, Nature, SpringerLink, IEEE Xplore, MEDLINE, Google Scholar, JMIR, Web of Science, Science Direct, and PubMed. In this review, the findings from the included publications are presented and elaborated according to the identified research questions. Evidence-based systematic reviews and meta-analyses were conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework. Additionally, we improved the review process using the Rayyan tool and the Scale for the Assessment of Narrative Review Articles (SANRA). Among the eligibility criteria were methodological rigor, conceptual clarity, and useful implementation of ICTs in e-Health for remote and automatic monitoring of COVID-19 patients.

RESULTS

Our initial search identified 664 potential studies; 102 were assessed for eligibility in the pre-final stage and 65 articles were used in the final review with the inclusion and exclusion criteria. The review identified the following eHealth methods-Telemedicine, Mobile Health (mHealth), and Telehealth. The associated ICTs are Wearable Body Sensors, Artificial Intelligence (AI) algorithms, Internet-of-Things, or Internet-of-Medical-Things (IoT or IoMT), Biometric Monitoring Technologies (BioMeTs), and Bluetooth-enabled (BLE) home health monitoring devices. Spatial or positional data, personal and individual health, and wellness data, including vital signs, symptoms, biomedical images and signals, and lifestyle data are examples of information that is managed by ICTs. Different AI and IoT methods have opened new possibilities for automatic and remote patient monitoring with associated advantages and weaknesses. Our findings were represented in a structured manner using a semantic knowledge graph (e.g., ontology model).

CONCLUSIONS

Various e-Health methods, related remote monitoring technologies, different approaches, information categories, the adoption of ICT tools for an automatic remote patient monitoring (RPM), advantages and limitations of RMTs in the COVID-19 case are discussed in this review. The use of e-Health during the COVID-19 pandemic illustrates the constraints and possibilities of using ICTs. ICTs are not merely an external tool to achieve definite remote and automatic health monitoring goals; instead, they are embedded in contexts. Therefore, the importance of the mutual design process between ICT and society during the global health crisis has been observed from a social informatics perspective. A global health crisis can be observed as an information crisis (e.g., insufficient information, unreliable information, and inaccessible information); however, this review shows the influence of ICTs on COVID-19 patients' health monitoring and related information collection techniques.

Expanding the Role of Continuous Glucose Monitoring in Modern Diabetes Care Beyond Type 1 Disease

Application of continuous glucose monitoring (CGM) has moved diabetes care from a reactive to a proactive process, in which a person with diabetes can prevent episodes of hypoglycemia or hyperglycemia, rather than taking action only once low and high glucose are detected. Consequently, CGM devices are now seen as the standard of care for people with type 1 diabetes mellitus (T1DM). Evidence now supports the use of CGM in people with type 2 diabetes mellitus (T2DM) on any treatment regimen, not just for those on insulin therapy. Expanding the application of CGM to include all people with T1DM or T2DM can support effective intensification of therapies to reduce glucose exposure and lower the risk of complications and hospital admissions, which are associated with high healthcare costs. All of this can be achieved while minimizing the risk of hypoglycemia and improving quality of life for people with diabetes. Wider application of CGM can also bring considerable benefits for women with diabetes during pregnancy and their children, as well as providing support for acute care of hospital inpatients who experience the adverse effects of hyperglycemia following admission and surgical procedures, as a consequence of treatment-related insulin resistance or reduced insulin secretion. By tailoring the application of CGM for daily or intermittent use, depending on the patient profile and their needs, one can ensure the cost-effectiveness of CGM in each setting. In this article we discuss the evidence-based benefits of expanding the use of CGM technology to include all people with diabetes, along with a diverse population of people with non-diabetic glycemic dysregulation.

The effect of education of patients with type 2 diabetes at risk of covid-19 on symptoms and some metabolic outcomes: A randomized controlled study

OBJECTIVE

Type 2 diabetes is one of the most common chronic diseases worldwide. It also has a high risk of morbidity and mortality in the covid 19 pandemic. Due to pandemic measures, disruptions have emerged in the care treatments of patients with type 2 diabetes. The present study aimed to determine the effects of telehealth monitoring and patient training on the symptoms and metabolic outcomes in the patients with type 2 diabetes who are at risk of COVID-19.

METHODOLOGY

The current study is in the design of a single-blind randomized controlled trial. Patients were randomized into intervention group (n=41) and control group (n = 44). The patients in the intervention group received diabetes training once a week for the first 4 weeks and every other week for weeks 5-12. No training was given to the control group. The data was collected using the socio-demographic information form, the questionnaire of diabetes treatment, the form of metabolic control variables, and the Diabetes Symptoms Checklist. The data was analyzed with Chi-square, independent samples t-test, and paired sample t-test.

RESULTS

The mean age of the patients in the control group was 56.86 ± 9.40, and the mean age of those in the intervention group was 54.12 ± 8.32. After the training, a statistically significant difference was found between the checklist averages of the groups in the subscale of hyperglycemia. However, a statistically significant difference was found between the subscales of neurology, cardiology, cognition, hyperglycemia, and the total checklist averages in the intervention group before and after the training (p < 0.05). In the control group, there was a statistically significant difference between the subscale of hyperglycemia and the total checklist averages at the beginning and 3 months later (p < 0.05).

CONCLUSION

It has been determined that the disease training given to the patients with diabetes via telehealth monitoring during the COVID-19 process has a positive effect on the diabetes control of the patients. Health education through telehealth methods can be an effective and cost-effective strategy to support patients with diabetes.

Improving the management of patients with chronic cardiac and respiratory diseases by extending pulse-oximeter uses: the dynamic pulse-oximetry

Respiratory and cardio-vascular chronic diseases are among the most common noncommunicable diseases (NCDs) worldwide, accounting for a large portion of health-care costs in terms of mortality and disability. Their prevalence is expected to rise further in the coming years as the population ages. The current model of care for diagnosing and monitoring NCDs is out of date because it results in late medical interventions and/or an unfavourable cost-effectiveness balance based on reported symptoms and subsequent inpatient tests and treatments. Health projects and programs are being implemented in an attempt to move the time of an NCD's diagnosis, as well as its monitoring and follow up, out of hospital settings and as close to real life as possible, with the goal of benefiting both patients' quality of life and health system budgets. Following the SARS-CoV-2 pandemic, this implementation received additional impetus. Pulseoximeters (POs) are currently used in a variety of clinical settings, but they can also aid in the telemonitoring of certain patients. POs that can measure activities as well as pulse rate and oxygen saturation as proxies of cardio-vascular and respiratory function are now being introduced to the market. To obtain these data, the devices must be absolutely reliable, that is, accurate and precise, and capable of recording for a long enough period of time to allow for diagnosis. This paper is a review of current pulse-oximetry (POy) use, with the goal of investigating how its current use can be expanded to manage not only cardio-respiratory NCDs, but also acute emergencies with telemonitoring when hospitalization is not required but the patients' situation is debatable. Newly designed devices, both "consumer" and "professional," will be scrutinized, particularly those capable of continuously recording vital parameters on a 24-hour basis and coupling them with daily activities, a practice known as dynamic pulse-oximetry.

Monthly video consultation for children and adolescents with type 1 diabetes mellitus during the COVID-19 pandemic

AIMS

To explore the impact of primarily telemedical care for children and adolescents with type 1 diabetes by monthly video consultations on metabolic control and parents' treatment satisfaction and disease-specific burden during the COVID-19 pandemic.

METHODS

In this 12-month multicenter observational follow-up VIDIKI 2.0 study, 100 participants (3-18 years) received monthly video consultations, which partially replaced quarterly outpatient clinic appointments during the pandemic. The children's metabolic parameters as well as the parents' treatment satisfaction and diabetes specific burden were assessed at study entry and 12 months later.

RESULTS

During the study, 912 video consultations took place (mean 0.84 ± 0.23 / patient/month). The children's HbA1c remained stable, while mean sensor glucose level and glucose management indicator decreased. Simultaneously, parents' treatment satisfaction significantly increased, and their diabetes-specific burden and distress decreased.

CONCLUSIONS

Primarily telemedical care of children and adolescents with type 1 diabetes during the COVID-19 pandemic via monthly video consultations resulted in a significant improvement in parents' treatment satisfaction and their diabetes-specific burden and distress. It was associated with a slight improvement in mean sensor glucose and glucose management indicator, while HbA1c remained stable. Thus, video consultations offer great potential to enhance standard care for children and adolescents with diabetes.

Efficacy of the mHealth application in patients with type 2 diabetes transitioning from inpatient to outpatient care: A randomized controlled clinical trial

INTRODUCTION

No studies have assessed the efficacy of telemedicine using a platform for recording and adjusting insulin doses in patients with diabetes mellitus type 2 (DM2) transitioning from inpatient to outpatient care. This study aimed to assess, in a population of patients with DM2, discharged from a tertiary referral hospital, whether treatment based on the use of an mHealth application was associated with better glycemic control at the 3-month follow-up, than standard care.

METHODS

This open, randomized, controlled clinical trial included adult DM2 patients who were transitioning from inpatient to outpatient care. The efficacy and safety of patient management with and without mHealth was compared at the 3-month follow-up. The primary outcome was the change in the Glycosylated hemoglobin (HbA1c) levels. The secondary outcomes were the rates of hypoglycemic and hyperglycemic events and treatment satisfaction measured using the Insulin Treatment Satisfaction Questionnaire (ITSQ).

RESULTS

In total, 86 patients (41 using mHealth) were included in the clinical trial. HbA1c levels showed a significant decrease in both groups. The mean HbA1c level was significantly lower in the mHealth group. Patients using mHealth showed decreased incidence rate ratios of hypoglycemia 3.0 mmol/L [<54 mg/dl], hypoglycemia ranging from 3.0 to 3.8 mmol/L [54 to 70 mg/dl] and severe hypoglycemia. The level of satisfaction assessed using the ITSQ was higher in the mHealth group.

CONCLUSION

Using mHealth in patients with DM2 transitioning from inpatient to outpatient care improves metabolic control and may reduce the hypoglycemia rates.

The effectiveness of a televisit service for people with type 1 diabetes: An observational, retrospective, single center, one year follow-up study

The use of a televisit service complying with efficiency and safety regulatory parameters was effective in significantly improving HbA1c levels of people with T1D after a one-year follow-up period. No acute diabetes-related complications occurred. Patients were highly satisfied with the service. Televisit is a valid option for diabetes management.

Utilizing the New Glucometrics: A Practical Guide to Ambulatory Glucose Profile Interpretation

Traditional continuous glucose monitoring and flash glucose monitoring systems are proven to lower glycated haemoglobin levels, decrease the time and impact of hypoglycaemia or hyperglycaemia and, consequently, improve the quality of life for children and adults with type 1 diabetes mellitus (T1DM) and adults with type 2 diabetes mellitus (T2DM). These glucose-sensing devices can generate large amounts of glucose data that can be used to define a detailed glycaemic profile for each user, which can be compared with targets for glucose control set by an International Consensus Panel of diabetes experts. Targets have been agreed upon for adults, children and adolescents with T1DM and adults with T2DM; separate targets have been agreed upon for older adults with diabetes, who are at higher risk of hypoglycaemia, and women with pregestational T1DM during pregnancy. Along with the objective measures and targets identified by the International Consensus Panel, the dense glucose data delivered by traditional continuous glucose monitoring and flash glucose monitoring systems is used to generate an ambulatory glucose profile, which summarizes the data in a visually impactful format that can be used to identify patterns and trends in daily glucose control, including those that raise clinical concerns. In this article, we provide a practical guide on how to interpret these new glucometrics using a straightforward algorithm, and clear visual examples that demystify the process of reviewing the glycaemic health of people with T1DM or T2DM such that forward-looking goals for diabetes management can be agreed.

Effects of Mobile Application Program (App)-Assisted Health Education on Preventive Behaviors and Cancer Literacy among Women with Cervical Intraepithelial Neoplasia

Objective: This study aimed (1) to study the effects of health education on preventive behaviors and cancer literacy among women with cervical intraepithelial neoplasia (CIN); (2) to compare the effects of mobile application program (App)-assisted health education with traditional book-form health education. Participants: A total of 132 women ages 20 to 69 years women. Methods: This prospective longitudinal study enrolled 132 CIN women who were evaluated three times. Propensity score matching was used by controlling subjects’ age strata, body mass index, education level, occupation, and type of surgery. Results: The influences of various educational tools were investigated. Four domains were assessed, including health behavior, attitude towards behavior change, self-efficacy of behavior, and cervical cancer (CCa) literacy. Significant improvements in behavior change and CCa literacy due to a health education program were observed (p ≤ 0.002). The App combined with a traditional booklet had the highest score for behavior change and was significantly greater than the booklet-only learning (p = 0.002). The App-assisted form, either App alone or combined with booklet, had a significantly better impact on health promotion when compared to the booklet alone (p = 0.045 and 0.005, respectively). App-only learning had the highest score of CCa literacy (p = 0.004). Conclusion: Health education interventions can have positive effects in terms of change of behavior and CCa literacy. App-assisted learning could be used as a supportive technology, and App learning alone or combined with a traditional booklet may be an innovative model of clinical health promotion for women with CIN.

Benefits of a Switch from Intermittently Scanned Continuous Glucose Monitoring (isCGM) to Real-Time (rt) CGM in Diabetes Type 1 Suboptimal Controlled Patients in Real-Life: A One-Year Prospective Study §

The switch from intermittently scanned continuous glucose monitoring (isCGM) to real-time (rt) CGM could improve glycemic management in suboptimal controlled type 1 diabetes patients, but long-term study is lacking. We evaluated retrospectively the ambulatory glucose profile (AGP) in such patients after switching from Free Style Libre 1 (FSL1) to Dexcom G4 (DG4) biosensors over 1 year. Patients (n = 21, 43 ± 15 years, BMI 25 ± 5, HbA1c 8.1 ± 1.0%) had severe hypoglycemia and/or HbA1c ≥ 8%. AGP metrics (time-in-range (TIR) 70–180 mg/dL, time-below-range (TBR) <70 mg/dL or <54 mg/dL, glucose coefficient of variation (%CV), time-above-range (TAR) >180 mg/dL or >250 mg/dL, glucose management indicator (GMI), average glucose) were collected the last 3 months of FSL1 use (M0) and of DG4 for 3, 6 (M6) and 12 (M12) months of use. Values were means ± standard deviation or medians [Q1;Q3]. At M12 versus M0, the higher TIR (50 ± 17 vs. 45 ± 16, p = 0.036), and lower TBR < 70 mg/dL (2.5 [1.6;5.5] vs. 7.0 [4.5;12.5], p = 0.0007), TBR < 54 mg/dL (0.7 [0.4;0.8] vs. 2.3 [0.8;7.0], p = 0.007) and %CV (39 ± 5 vs. 45 ± 8, p = 0.0009), evidenced a long-term effectiveness of the switch. Compared to M6, TBR < 70 mg/dL decreased, %CV remained stable, while the improvement on hyperglycemia exposure decreased (higher GMI, TAR and average glucose). This switch was a relevant therapeutic option, though a loss of benefit on hyperglycemia stressed the need for optimized management of threshold alarms. Nevertheless, few patients attained the recommended values for AGP metrics, and the reasons why some patients are “responders” vs. “non-responders” warrant to be investigated.