What will the apps of the future in diabetes be?

Diabetes apps is a very interesting and well -thought topic can come in the most present future to be a great help for people with diabetes.Basically so that they take control of the disease in a determined way and can thus stop the dire complications that diabetes ends up triggering.

For this reason today we publish, in full, a very complete article that made us arrive Lluis Bohigas, Doctor of Economic Sciences and Master in Public Health and Director of Institutional Relations of Roche.

Before the summer I wrote a note about the situation of the apps for diabetes.There are currently more than 1000 specific apps for diabetes that, in 2013, were used by a million and a half people.In the previous note he analyzed to serve these apps, while in this note I reflect on the apps that will come in the future.

Current app and future evolution

The focus of the note is to analyze what is the usefulness of an app, since today's apps try to meet the current needs of diabetes patients, while those of the future should evolve to meet future needs.Current apps are mostly served to do things that we currently do with a paper and a pencil through the mobile phone.The purpose is to automate current activities, not make them different.It looks like the first step of computer science in the offices back in the 70s of the last century, whose objective was to mechanize the activities of the office.Years later the way of working of the office was changed thanks to the possibilities offered by computer science.

I hope that something similar happens in the future with diabetes and their apps, when patients and professionals get used to mobile health (Mhealth), then we will stop doing the same thing we do now to start doing different and more useful things.

The functionality offered by current apps for diabetes is to automatically do the "notebook" of diabetes, that is, registering patient's blood glucose measures.Is this the most important utility in the future?This summer an article has been published in the New England on the Bionic pancreas (1), an apparatus that replaces the pancreas just like the dialysis apparatus replaces the kidney.

A group of people with type 1 diabetes managed their diabetes for a week through an Apple iPhone 4 and could lead an almost normal life thanks to the MHEALTH.Each person had a continuous glucose meter, which sent the blood level data every 5 minutes to an iPhone.He made them through an algorithm (an app) and sent orders to two bombs that the patient had, one with insulin and another with glucagon.When the blood glucose was too high, the iPhone ordered the insulin pump to introduce insulin into the body, and when the blood glucose level was too under the order I went to the glucagon pump.

The patient should not do anything.The study baptized the meter assembly, the two pumps, the telephone and the app such as the bionic pancreas, since its function is to simulate the operation of a normal pancreas, although according to the definition of the European Union it can be considered as an application ofMHEALTH.(2)

The profits of the apps of the future

Diabetes apps profits will be:

1. Insulin dose calculation
2. Therapy monitoring
3. Patient formation
4. Complications monitoring
5. Life Style monitoring
6. Motivation and reminders
7. Socialization
8. Data analysis.

1.- Calculation of insulin doses

The bionic pancreas is actually an app located on a mobile phone that receives data from a continuous blood glucose sensor and emits orders to two insulin and glucagon pumps.It is an app that according to the definition of the FDA is medical and therefore must pass the same controls as a medication, that is, it must be valued in clinical trials with human beings.The article is the description of a clinical trial to assess that the bionic pancreas is better than the traditional way of managing diabetes.

The bionic pancreas, and the algorithm, still requires a lotSupport the supply of insulin that the patient needs, since this is the basic function of the organism that diabetes makes it difficult or prevents.

Currently, this functionality already exists in apps but very indirectly, it is called bowling calculator.Insulin pump patients should apply an extra amount, an insulin bolus, before each meal.To calculate the dose, glycemia are measured by means of a strip, they calculate the carbohydrates of the food and by means of an algorithm that can be customized, an insulin volume is recommended.

The bionic pancreas does the same but directly, not from carbohydrates
of the food that is going to be ingested, but analyzing the blood glucose that is really in the body.

2.- Therapy monitoring

The current function of the notebook is to monitor therapy, that is, monitoring therapy to see if it goes well or if it should be modified.The advantage of the app on the notebook is that it not only records the patient's glycemia but once digitized, curves and indicators can be calculated that give information elaborated both to the patient and their doctor about the evolution of blood glucose.

The function of monitoring therapy will continue to be an important function of the future of the app, but we find a dysfunctionality in the current diabetes monitoring system.Thus, while the patient with his notebook monitors blood glucose, instead the doctor uses the HBA1C monitoring criterion, glycosylated hemoglobin that is a laboratory analysis that the patient should do each quarter.The patient takes his notebook to the quarterly control of control, but observes with despair that the doctor ignores him and instead see if the hemoglobin is above or below 7% or of the figure that has been put as a goal.

Current apps have nothing to do with glycosylated hemoglobin because it is a laboratory analysis whose result is directly to the medical history without the patient having to do anything but put the blood.Apps allow automating the glycemia registration function, but if the doctor continues to use another parameter to monitor the patient, the app can lose its usefulness.

The patient collects a series of data on the evolution of parameters: weight, blood glucose, etc., which could be integrated into their medical history, which would allow the health professional to easily find and use this information.The introduction in the medical history can be done electronically, which would allow remote monitoring and perform virtual control visits.

3.- Patient formation

The most important patient training is what your doctor or nurse does.This
training is complemented by group formation and in some cases with the training offered by a
Expert patientThe patient can read books, online information or talk to other patients.

Apps to train the patient complete and complement these various channels.They can also serve to mark a curriculum, which will allow the educator to indicate that trainingThe patient needs for each level of development.Education varies according to the patient's knowledge, its involvement in disease management and technology available.In the future the evolution of technology will require updates in education.

4.- Complications monitoring

A key objective of the patient's periodic visits to the health center is to monitor the appearance of complications and be able to treat them early.Each complication requires a specific exam.In the case of macular degeneration, the use of the non -midriatic chamber has been extended that allows a photo of the patient's eye and sending it to a hospital specialist.

An app could help the patient to self -control the appearance of the most frequent complications.

5.- Monitoring of changes in Life Style

In diabetes control it is very important to adopt a healthy lifestyle, both in food and in exercise.Especially on the subject of the exercise, many wellness apps have been developed that allow the steps or km that walk or run a patient.These apps keep the data on the patient's mobile, but in the future they could send information to the medical history so that the doctor can verify that the patient follows their indications.

6.- Motivation and reminders

The patient is the best located to control diabetes, but this is a full -time task and sometimes motivation falters.Apps dedicated to patient motivation can include games, challenges, reminders, etc.There are many apps that serve to play, but using games in the management of a chronic disease can help patients, both children and adults, to manage the disease in a fun way.Adhesion is a problem in all chronic treatment, so the reminder function to take medications, to measure glycemia, to go to the doctor's visit is an important function.Apps that try to influence emotional and behavioral aspects of the patient can have a lot of development in the future.

7.- Socialization

Diabetes is a disease in which patients share their problems, emotions and doubts, that is, there are communities of people with diabetes that exchange information, opinions,
feelings, frustrations, etc.These communities serve to foster solidarity and self -help, give confidence, etc.A functionality of the apps that will be developed in the future is to contact the patient with diabetes with other patients, or the parents of children with diabetes, etc.

8.- Data analysis

Each of the above functionalities produces data, especially those dedicated to the
monitoring that will be analyzed by the same app, to discover trends and predict future evolution.But there is still another analysis opportunity crossing the information of a functionality, for example the monitoring of blood glucose with food and exercise information.This crossing of variables will allow the patient to better know and better customize treatment.This analysis at the individual level can also be done at the group level, for example we can analyze all types type1 as their blood glucose reacts to a certain type of food.

What will the future apps be?

The above functionalities will help the patient and health professional to improve diabetes care, but it is also very important to see how this will be possible.I do not know if in the future all these functionalities will be in a single app or will be several tailored to the needs of each patient.

It is possible that some apps are incorporated into the devices that the patient uses:Meter, pump, etc.while others are on the mobile, but in this case the data introduction must be automatic to prevent the patient from having an extra job because of the app.The transmission of data from the patient to the equipment that attends is a fundamental aspect to be able to make a distance monitoring or to be able to analyze the patient's data.

Some apps simply collect information while others use information to give
Recommendations.This last group qualifies as a medical app according to the definition of the FDA and therefore requires that it be evaluated by this agency.In Europe these apps will require quality CE marking.As soon as the data leave the patient's app and travel to other places it will be necessary to preserve the confidentiality of health data.

A crucial issue is the way in which apps will reach the patient.Will it remain a free market like the "App Store" or will they be prescribed by the doctor or the nurse?

(1) Russell and others, Outpatient Glycemic Control With a Bionic Pancreas in Type 1 Diabetes, N English J Med, June 15, 2014.
(2) The European Union gives the following definition of Mhealth: Mobile Health (hereafter "Mhealth") Covers "Medical and Public Health practice supported by Mobile Devices, Such as Mobile Phones, Patient Monitoring Devices, digital staff Assistants (PDAs), andother Wireless devices. ”IT Also Includes Applications (Hereafter "Apps") Such as Lifestyle and Wellbeing Apps That May Connect to Medical Devices or Sensors (E.G. Bracellets Or Watches) As Well As Personal Guidance Systems, Health Information and Medication Reminders Provide By Sms and Telemedicine Provided Wireless.