Building a Better Digital Health System for Diabetes

Outcomes from Type 2 Diabetes Mellitus in Singapore are not where they should be and Digital Health systems like SugoSure aim to drive a transformation of care delivery for chronic diseases.

Transformation is imperative for several reasons: the rising prevalence of chronic diseases, limited human resources to provide care, cost (diabetes is expected to cost the Singapore economy S$1.8 billion annually by 2050).

Addressing Overlooked Areas

SugoSure has been designed from the start to address areas which have been overlooked by the many diabetes app on the market.1 This has involved detailed discussions with our Medical Advisors and reviews of Clinical Best Practice.

Our protocols are designed to build patient engagement and adoption of self-management behaviours - which has been proven to lead to better outcomes.2

Our health coaches are diabetes-trained registered nurses who play a critical role in ongoing patient support and education.

The result? a better digital health system for diabetes.

Comprehensive, Coordinated Team-Based Care

Wiring diagram

Patient interactions are guided by SugoSure's alerts and analytics, powered by ConnectedHealth's cloud-hosted Clinical Data Platform.

This single platform also hosts SugoSure's diabetes EMR and assists coordination of Lifestyle and Clinical Plans. 

In this way SugoSure enables comprehensive, coordinated team-based care - a proven approach to improving outcomes in diabetes. 

Key Features of SugoSure's Design

Four key objectives underlie the principles of SugoSure's design.  Firstly, SugoSure was always intended to be a tool to help deliver Clinical Best Practice care.

SugoSure's Physician Portal guides the physician through a full and thorough patient review when SugoSure is initiated.  The physician receives rules-based decision support in relation to lab test results, medication and changes in monitoring frequency.

SugoSure's protocols are designed around Singapore Ministry of Health Clinical Practice Guidelines for Diabetes Mellitus3 and SugoSure is designed to help physicians comply with these best practices, despite their busy schedules.

From the outset we designed SugoSure to facilitate Coordinated Care Plans which comp-rise a Clinical Plan developed by SugoSure doctor and a Lifestyle Plan developed by health coach in collaboration with patient. 

Clinical Plans cover glycaemic control targets, activity and weight loss targets, diet type, medication, lab test frequency and approach to blood glucose monitoring.  Lifestyle Plans cover specific changes to diet, steps and exercise and a range of factors needed by the patient to improve self-management. 

These plans are coordinated between doctor, health coach and patient - representing a more carefully constructed care plan where medication is used in conjunction with lifestyle changes to improve glycaemic control.  (This is the official labelling for all diabetes medications although rarely fully implemented).

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A third aspect of SugoSure's design is that it Closes the Loop so that indicators generated from patient clinical data inputs are presented in a logical and easy-to-understand way which allows patients to learn about root causes of deviation from targets.  This feedback is supported by ongoing health coach discussions and physician Remote Reviews.

Managing diabetes well is largely about monitoring the right measures, interpreting the data generated and acting on conclusions drawn.  In traditional approaches the turnaround time to close the loop is 3 months (the time between patient consultations) since there is no mechanism to close the loop faster. 

Consequently, adjustment of Clinical Plans to reach a stable, well-controlled state is often slow, spanning months over which a patient's diabetic control may be very variable.  In contrast, SugoSure's approach to analysing patient data according to clinically-defined algorithms then providing alerts to patient, physician and health coach allows Faster Problem Resolution and course correction to optimal care.

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SugoSure assembles these features into a comprehensive tool for physicians and patients with coordinated health coaching.  The result is a system which is sophisticated and clinically-relevant yet easy to use.

This is the future of diabetes care:  Coordinated, data-driven and based on best clinical practice

 

References

1Jimenez G, Lum E, Car J. Examining Diabetes Management Apps Recommended From a Google Search: Content Analysis. JMIR Mhealth Uhealth. 2019;7(1):e11848. Published 2019 Jan 16. doi:10.2196/11848

Klonoff DC. Improved Outcomes From Diabetes Monitoring: The Benefits of Better Adherence, Therapy Adjustments, Patient Education, and Telemedicine support. J Diabetes Sci Technol. 2012;6(3):486–490. Published 2012 May 1. doi:10.1177/193229681200600301

3https://www.moh.gov.sg/hpp/doctors/GuidelineDetails/cpgmed_diabetes_mellitus