Technology is now part of a new science within diabetes care. As diabetes educators, we are partnering with people with diabetes (PWD) to support their efforts in using the digital interventions. I am very excited about the first systematic review of systemic reviews evaluating the existing evidence and best practice while using technology in diabetes care and education.  Deborah Greenwood, PhD, RN, BC-ADM, CDE, FAADE Chief Digital Research Officer-Diabetes Mytonomy, is one of the authors of "A Systematic Review of Reviews Evaluating Technology-Enabled Diabetes Self-Management Education and Support" that was published recently. This month, I am happy to share my conversation with Deborah about diabetes and technology.

1. Deborah, how and why do you have an interest in technology as a CDE?
   
   

   In my doctoral program, I focused all my elective courses in informatics and my independent study/internship opportunities in telehealth and diabetes. For my dissertation study, I conducted a randomized clinical trial using paired glucose checking in people with type 2 diabetes not on insulin supported by a technology-enabled remote monitoring system. The intervention group lowered A1C significantly more than the control group at 6 months. The study incorporated a complete feedback loop where PWD followed structured monitoring principles, shared their data with CDEs, were provided with feedback through the electronic health record and made behavior and medication changes. I witnessed firsthand the impact that technology can have when incorporated into the workflow of a disease management program. I am very hopeful that technology can increase access to diabetes self-management education and support, improve outcomes and also remove some of the burden of treatment to make life easier for PWD.

2. What components of technology combined with diabetes are most rewarding to you?
   
   

   The Joint Position paper on diabetes self-management education and support (DSMES) published by AADE, ADA and AND in 2015 identified the 4 key times a PWD should be assessed for a referral for DSMES: upon diagnosis, annually, when complicating factors arise and during transitions of care. Electronic health record technology can help implement these recommendations by using algorithms to identify when an individual meets these criteria and can generate an automatic referral. Or when a person at high risk leaves the hospital and are new to insulin, they can be seamlessly managed through technology solutions to connect them with remote monitoring, and digital education and support to learn new skills, have questions answered and stop them from falling through the cracks. Any opportunity to engage people early in the concept of self-management and then help them manage all of the data associated with diabetes in a “behind the curtains” way, so they can focus their energy on living a long and healthy life; this is the way I think technology can be a game changer.

3. What are the findings from your systematic review?
   
   

   We found that technology-enabled diabetes self-management solutions significantly improve A1C. The interventions that were the most effective incorporated all the components of a technology-enabled self-management (TES) feedback loop including: 2-way communication between the PWD and their health care team, analyzed patient generated healthcare data, tailored education based on data, and individualized feedback. This review included papers from 2011-2017, so pretty recent research, applying the most commonly used technologies—mobile phones and mobile apps. The paper will be Open-Access for the month of August, in association with the AADE annual meeting, and can be downloaded here http://journals.sagepub.com/doi/abs/10.1177/1932296817713506?journalCode=dsta

4. How can we best apply those findings to our daily practice as diabetes educators?
   
   

   Ideally diabetes educators and health systems that provide DSMES will identify opportunities to incorporate technology-enabled self-management solutions into their existing workflows and services. These solutions can reduce the barriers of travel time, cost, and time away from work or family while at the same time, individualizing and personalizing care.

   We know that diabetes management is complex and requires the PWD engage in long term health care tasks including taking medication, changing behaviors, self-monitoring, going to medical appointments, getting lab tests and much more. Hopefully technology will help the PWD achieve their goals and not add to the existing burden of treatment. We need to develop and use technology-enabled systems that can take away some of the work on both the person and provider side of the equation.

   An interesting finding from our study is that A1C levels were improved more in people with type 2 diabetes. Although we are not clear why this was the case, we hypothesized that more people with type 2 diabetes may have not participated in self-management education previously and may have had more opportunity for improvement. New technology solutions can engage people who may not have engaged in traditional settings.

5. What is the future of technology and diabetes?
   
   

   Health care is changing daily and it is a challenging to predict the future, but new models of care including value-based care models, population health and chronic disease management programs ideally will incorporate solutions with the TES feedback loop to individualize care and support PWD in their journey. I also think the role of the diabetes educator will evolve. Technology creates an opportunity to scale diabetes self-management education and support, beyond the capability of the resources of the limited number of diabetes educators employed today. Educators can expand their scope by leveraging technology within their practices and engage in these new models of care. I think the future is exciting and diabetes educators can help to shape that future with their vast knowledge of behavior change principles and their ability to analyze patient generated health data (PGHD). Although PGHD is a buzzword now, diabetes educators have been using PGHD since the glucometer was invented!

6. Anything else you would like to share?
   
   

   We hope the evidence from this systematic review will lead regulatory policy makers to review reimbursement regulations and incorporate reimbursement for technology-enabled self-management education and support services. With less than 7% of commercially insured people with diabetes accessing DSMES services in the first 12 months of diagnosis, we know there is a huge gap in helping people learn self-management skills while they are healthy, prior to developing complications. Engaging in DSMES services from the comfort of their own home, at a time that is convenient to them, focusing on the content that is important to them, along with the ability to virtually reach out to diabetes educators when needed or to have the technology-enabled solution preemptively reach out to the person after analyzing their data is the goal! There are many companies working in this space incorporating a TES feedback loop and their real-world outcomes are impressive. The next step is to determine how technology can decrease the work-load of managing diabetes so everyone will benefit.