November is Diabetes Awareness Month. More than 37 million U.S. adults live with this chronic condition, which can cause a variety of complications, such as stroke, kidney disease, heart disease and blindness.

To help address this epidemic, Dr. Sos Mboijana argued in a recent interview that providers should incorporate remote patient monitoring (RPM) into the standard of care for diabetes. Dr. Mboijana is a primary care physician and the assistant chief medical information officer at Kaiser Permanente’s Mid-Atlantic medical group.

Kaiser launched its RPM program for diabetes care in 2017 in California, and it has since spread to the health system’s other regions.

Dr. Mboijana asks all his patients with diabetes to participate in the program. He gives them a Bluetooth-enabled glucometer (a handheld machine that measures their blood sugar) and ensures that they sign up for the “KP Health Ally” app. As patients measure their blood sugar daily, the glucometer transmits their blood sugar data to the app and to their care team.

“It’s a mechanism for us to reach into the patient’s home and connect them to the healthcare team,” Dr. Mboijana said. “It further allows us to coordinate care, adjust care and adjust medicines.”

When treating chronic conditions like diabetes, having access to a continuous flow of patient data is critical, according to Dr. Mboijana.

When a patient is newly diagnosed with diabetes, their treatment plan will usually involve a new medication, often Metformin. Medication types and quantities often change for diabetic patients across the course of their life, so it’s rare that a patient will stick with the exact same prescription they received on Day One forever. With a continuous flow of blood sugar data, a patient’s care team can sooner figure out which adjustments need to be made to the care plan.

“When I started practicing initially, the standard for a patient with a new diagnosis was to collect all the data that we can, assign them for diabetic education, and then maybe a follow up with a month or a few weeks. And then we get into this cadence of about every three months. Essentially, what I would get is a snapshot in time of what’s happening with the patient. But diabetes is a dynamic clinical condition, and it’s a chronic medical condition. Things go up and down,”  Dr. Mboijana explained.

About 40,000 patients are enrolled in Kaiser’s RPM program for diabetes. Dr. Mboijana said that providers across the country should create similar programs, as he thinks it’s “integral to the whole care package that we should be offering patients.”

He also pointed out that diabetes can often lead to a host of complications. For example, diabetic retinopathy is the leading cause of blindness in working-age U.S. adults. Because RPM improves providers’ ability to intervene with diabetic patients’ care plans sooner, it can play a huge role in decreasing the amount of complications that occur.

“If we can track diabetes, in terms of chronic disease management, and improve on that from a population health standpoint — not just cast Kaiser Permanente patients, but everybody — the upside is dramatic,” Dr. Mboijana said.

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