Improving Diabetes Care Efficiency: Glucose Meter Download Station in Medical Offices

INTRODUCTION

Despite advances in the knowledge of diabetes management and the advances in the treatment of diabetes it continues to be very challenging to manage. As there are more people with diabetes every year there is an increase in health care utilization and outpatient visits for these patients. While 1 in 9 Americans have diabetes today, it is projected to be 1 in 3 Americans by 2030.1 In family medicine the physician treats most if not all of the patients’ concerns and the increasing time needed for diabetes management has become a dilemma for the physician. It has been estimated that it takes 3 to10 hours per day of physician time to manage chronic diseases.2 The management of diabetes and its complications re- quires 4 diabetes-focused visits/patient/year. Improving the efficiency of these visits and enhancing pattern recognition to identify problems would shorten visit time and improve patient care. A glucose meter download station is one of those efficiency-enhancing mechanisms.

WHAT IS A DOWNLOAD STATION?

A download station is a clinic-equipped office space with the necessary tools to extract data directly from patients’ glucometers when they present to the clinic for their medical appointments. Most information can be organized and reports generated according to the provider’s preference. A download station can be easily set up in a typical office space (i.e. 6 feet x 6 feet) with a computer and a printer as the main components. Designated a medical assistant’s workstation can also function as a download station if it is equipped with the necessary software and hardware. The goal of a download station is to systematically generate a clear, preconfigured blood glucose report prior to the consultation, allowing providers to simplify their decision-making process.

WHY DO I NEED A DOWNLOAD STATION?

Successful management of diabetes mellitus greatly relies upon patients’ self-care behaviors. Self-monitoring blood glucose (SMBG) has become the standard of care in effective management of diabetes therapy.3 SMBG allows patients to better evaluate their individual responses to medications, dietary modifications, and physical activities with the aim to prevent hypoglycemia and make appropriate decisions on bolus insulin dosages (correlation scale and food coverage). Along with hemoglobin A1c, fasting and 2 hour post meal readings can help providers to safely and effectively manage diabetes, e.g., fasting and 2-hour post-prandial readings.

mia, hypoglycemia unawareness and those whose diabetes goals are not achieved with SMBG.7 Likewise, many insulin pumps available on the market are able to receive information from the sensor through the transmitter and are also able to store the patient’s CGM glucose levels. Hence, this paper aims to provide clinicians with more information on the technical details with regards to setting up glucose reading download station for the major products currently available in the market.

WHAT ARE THE NECESSARY SOFTWARE & HARDWARE NEEDED FOR THE DOWNLOAD STATION?

ARE THERE ANY UNIVERSAL DOWNLOAD SYSTEMS?

If you have a busy practice and have patients from many different insurers (who doesn’t), having many different download stations becomes a problem since each of the meters has their own software and downloading capacities. One way to handle this is to utilize those meters that are most represented in your practice. However, what many providers long for is a universal platform to download devices.

Several health management systems are working on being com-

Glooko: MeterSync Blue system enables patients to upload data via Bluetooth from over 30 glucose meters to Android and Apple apps. When a patient or provider wants to download data, they simply plug MeterSync Blue adapter into their meter, and results are sent wirelessly to the app. The MeterSync Blue adapter can be left plugged in continuously which essentially transforms those meters into 24/7 Bluetooth-enabled device. This device is not currently compatible with insulin pumps. This system also requires a subscription. We recommend that the patient buy the subscription

the clinic for evaluation, or they may not accurately reflect the

TABLE 1:

Abbot Freestyle® Glucose Meters

Glucose Meters	FreeStyle® Lite	FreeStyle® Freedom Lite	FreeStyle® InsuLinx	FreeStyle® Precision Neo	FreeStyle® Precision Xtra
Connection Cable	USB to 2.5mm stereo	USB to 2.5mm stereo	Micro USB	Mirco USB	USB with Strip Port
Other compatible meter(s)	FreeStyle® Freedom
FreeStyle® Auto-Assist	Supported	Supported	Supported	-	Supported
FreeStyle® LibreView TM	Supported
Software Requirements	FreeStyle CoPilot Health anagement System version 4.2.1 Adobe® Acrobat or Adobe® Reader For Mac OS® X Mountain Lion or higher Web Browser: - Safari (View-only; upload utility is not supported)			Microsoft® Windows® XP, Vista, or 7 Web Browser:
	2 GB free disk space or greater			512 MB RAM or greater
	Display with a minimum screen resolution of 1024 x 768 pixels			Mouse/Trackball
Hardware Requirements	Internet connection (if using internet download installation) CD-ROM (optional unless installing from disk)			Keyboard 1 free USB port
	Intel® Pentium® 3 processor 550MHz equivalent or higher			Black and white or color printer

• Internet Explorer 10+

• Microsoft Edge

• Google Chrome release 37.0+

• Mozilla Firefox release 32.0+

TABLE 2:

Bayer Healthcare Contour® Glucose Meters

TABLE 3:

Lifescan OneTouch® Glucose Meters

Glucose Meters	OneTouch Ultra® 2	OneTouch UltraMini®	Verio®	Verio® Flex System	Verio® IQ
Connection Cable	USB to 3.5mm stereo	USB to 3.5mm stereo	Micro USB	Mirco USB	Mini USB
OneTouch Reveal® Mobile Application	-	-	-	Supported	-
OneTouch Reveal® Web Application	Supported
Software Requirements	OneTouch Reveal® Data Transfer Tool Microsoft® Windows® XP, Vista, or 7 Adobe® Acrobat or Adobe® Reader 10+ Web Browser: For Mac OS® - Mozilla Firefox® 11+ - Google Chrome™ 17+ Web Browser: - Internet Explorer® 9+
Hardware Requirements	Microsoft® Windows® 7, 8.1, or 10 Display with a minimum screen resolution of 1024 x 768 pixels Mac OS® X 10.9, 10.10, 10.11 Connection cables for other supported devices, please refer to: Internet Conncetion www.onetouchreveal.com/support/en_US/ Black and white or color printer

• Mozilla Firefox® 11+ - Microsoft Edge®

• Safari® 7+

TABLE 4:

Glucose Meters	TRUE METRIX®	TRUEresult®	TRUEtrack®	TRUEbalanceTM	TRUEread®
Connection Cable	-	-	USB to 3.5mm stereo	USB to 3.5mm stereo	USB to 3.5mm stereo
Docking Station	Supported	Supported	Supported	-	-
Software Requirements	TRUEmanager® Diabetes Management Software Adobe® Acrobat or Adobe® Reader Microsoft® Windows® XP, Vista, or 7
Hardware Requirements	USB cable and/or docking station Graphics card that supports 1024 x 768 or higher Mouse/Trackball Display with a minimum screen resolution of 1024 x 768 pixels Keyboard Black and white or color printer

1. GB of RAM or greater Intel® Pentium® 4 processor 2GHz equivalent or higher

2. GB free disk space or greater Internet connectivity (if using internet download installation) 1 free USB 2.0/3.0 port CD-ROM (optional unless installing from disk)

Nipro Diagnostics TRUEtrack® Glucose Meters

Glucose Meters	Contour®	BREEZE® 2	Contour® LINK	Contour® NEXT	Contour® NEXT EZ
Connection Cable	USB to 3.5mm stereo			Mirco USB	USB to 3.5mm stereo
Other compatible meter(s)	Contour® USB / Contour® NEXT USB / Contour® NEXT LINK
Software Requirements	GLUCOFACTS® DELUXE Diabetes Management Software version 3.10.08 Adobe® Acrobat or Adobe® Reader Mac OS® Operating System(s): Microsoft® Windows® Operating System(s): - Leopard, Snow Leopard, Lion, Mountain Lion, - XP (SP3), Vista (SP2), 7, 8, or 10 Mavericks, Yosemite, or El Capitan
Hardware Requirements	2 GB free disk space or greater Mouse/Trackball Graphics card that supports 1024 x 768 or higher Keyboard Display with a minimum screen resolution of 1024 x 768 pixels 1 free USB port Internet connection (if using internet download installation) Black and white or color printer CD-ROM (optional unless installing from disk

TABLE 5:

Roche Diagnostics Accu-Chek® Glucose Meters

Glucose Meters	Accu-Chek® Nano	Accu-Chek® Aviva	Accu-Chek® Aviva Expert	Accu-Chek® Compact Plus
Connection Cable	USB / Infrared (IR)	USB / Infrared (IR)	USB / Infrared (IR)	USB / Infrared (IR)
Other compatible meter(s)	Accu-Chek® Compact Accu-Chek® Spirit Insulin Pump Accu-Chek® D-TRONplus Accu-Chek® Active Accu-Chek® Smart Pix Reader Accu-Chek® Aviva Connect Accu-Chek® Combo System Accu-Chek® Go
Web-based Applications	Accu-Chek® Connect Online Diabetes Management System
Software Requirements	Accu-Chek 360° Diabetes Management System Microsoft® Windows® XP (SP3), Vista, 7, 8 or 10 Adobe® Acrobat or Adobe® Reader Web Browser: - Internet Explorer 9+ Mac® OS 10.10, 10.11 - Microsoft Edge 25+ Web Browser: - Firefox 45+ - Safari 9.0+ - Google Chrome 49+
	Intel® Pentium® processor 1 GHz equivalent or faster Keyboard
Hardware Requirements	Display with a minimum screen resolution of 1024 x 768 pixels 1 free USB port 5 GB free disk space or greater CD-ROM 512 MB of memory or greater Black and white or color printer
	Mouse/Trackball

TABLE 6:

Glucose Meters	ReliOn® Prime	ReliOn® Confirm	ReliOn® Micro	ReliOn® Ultima
Connection Cable	USB to 3.5mm stereo	USB to 3.5mm stereo	-	-
Other compatible meter(s)	GLUCOCARD® Expression GLUCOCARD® Vital		GLUCOCARD® 01 GLUCOCARD® Shine
Web-based Applications	Supported	Supported	-	-
Software Requirements	ARK Care® Real-Time Diabetes Management System Microsoft® Windows® 7, 8, or 10 Internet Explorer 10+
Hardware Requirements	1 free USB port CD-ROM Internet connection		Mouse/Trackball Keyboard	Display monitor Black and white or color printer

ARK CareTM ReliON® glucose meters

Tidepool takes data from most glucose meters, continuous glucose sensors, and insulin pumps and then consolidates that data into a single consolidated report. Tidepool is also working to develop the Tidepool Uploader, a web-based software that will connect with multiple devices and upload the data, eliminating the need for unique software for every single device. Tidepool is a 501c3 non- profit entity that intends to offer its software for free to patients and providers.

WHAT DO THE REPORTS LOOK LIKE?

Examples of what these downloaded results would look like can be seen on pages 26 - 28.

HOW DO I GET MY PATIENTS TO ENGAGE IN THIS TECHNOLOGY?

Printing the reports off to show patients is very helpful. They can see what you see and you can discuss the patterns that can help them. Often noted can be written on these pages to provide reminders and instruction for treatment modifications. This reinforces the importance of SMBG. Finally as patients become advanced we ask them to look at their trends and make adjustments even between visits. While only a few become this advanced it is a pleasure to see when patients can maximize disease self management.

CONCLUSIONS:

In order to obtain a useful blood glucose report at every office visit to guide diabetes management, the health care team will need to help patients integrate self-monitor blood glucose into their daily routines. A suggestion would be to remind patients to set alarms or reminders on their smartphones to include blood glucose monitoring as part of the treatment plan. Further troubleshooting with patients to overcome barriers on checking blood glucose levels at home is instrumental in empowering these patients to help them take charge of their disease. The SMBG data is for them not just for the physician. This is one of the many ways to encourage and empower patients to take control of their diabetes.

Educating patients on interpreting their own blood glucose trends on the reports is equally important, as some patients will need the information for insulin self-titration. In addition, from a safety standpoint, patients can self-identify low blood glucose readings and/or trends of hypoglycemia influenced by their diabetes regimens, fully utilizing the data gathered on a daily basis.

Key Recommendations:

1. Diabetes management takes time and efforts, so we should utilize practice efficiencies whenever possible.

2. A glucose meter download station is free and can save you tremendous amount of time.

3. Glucose meter downloads will organize data to allow you quickly see: how often the patients are checking their blood glucose levels, are experiencing severe hyperglycemia or hypoglycemia, and what the current glucose patterns are.

4. Ultimately, glucose meter downloads are intended to be helpful for patient self management. You can use glucose downloads as a patient education tool to enhance the existing tools that you have already shared with your patients to empower them taking control of their diabetes.

REFERENCES:

1. CDC 2014 Diabetes Fact Sheet. Available at https://www.cdc.gov/ diabetes/data/statistics/2014statisticsreport.html. Accessed 4/18/17.

2. Østbye T1, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005 May-Jun; 3(3): 209-14.

3. American Diabetes Association. Glycemic Targets. Sec. 5. In Standards of Medical Care in Diabetes - 2016. Diabetes care. 2016; 39(Supplement 1): S39-S46.

4. Kazlauskaite R, Soni S, Evans AT, Graham K, Fisher B. Accuracy of

   self-monitored blood glucose in type 2 diabetes. Diabetes technology & therapeutics. 2009;11(6):385-392.

5. Schenk RJ, Jr., Schenk J. Integration of remote blood glucose meter upload technology into a clinical pharmacist medication therapy management service. J Diabetes Sci Technol. 2011;5(1):188-191.

6. Nardacci EA, Bode BW, Hirsch IB. Individualizing care for the many: the evolving role of professional continuous glucose monitoring systems

   in clinical practice. The Diabetes educator. 2010;36 Suppl 1:4S-19S; quiz 20S-21S.

7. Blevins TC. Professional continuous glucose monitoring in clinical practice 2010. J Diabetes Sci Technol. 2010;4(2):440-456.

TABLE 7:

Insulin pump / Continuous Glucose Monitor (CGM)

Manufacturer	Abbott Diabetes Care	Animas Corporation	Dexcom	Insulet Corporation	Medtronic	Roche Diagnostics	Tandem Diabetes Care
Insulin pump / CGM	FreeStyle® Libre Pro	Animas® Vibe OneTouch Ping®	Dexcom G4® Platinum Dexcom G5® Mobile	OmniPod® + PDM Omnipod® + Dexcom G4	MiniMed® 530G + Enlite MiniMed® 630G + Enlite MiniMed® Paradigm®REAL-Time RevelTM MiniMed® 670G + Guardian® sensor 3	Accu-Chek® Combo system Accu-Chek® Spirit insulin pump	t:flex® Insulin Pump t:slim X2TM Insulin Pump t:slim G4TM Insulin Pump
Connection Cable	Micro USB	USB / Infrared (IR)	Micro USB	Mini USB	CareLink USB or Contour® NEXT LINK	USB / Infrared (IR)	Micro USB
			Dexcom® STUDIO Software to open .doc files Software to open Excel files Adobe® Acrobat or Adobe® Reader	FreeStyle® CoPilot Health Management System (Refer toTable 1) Adobe® Acrobat or Adobe® Reader PC or Mac® Web Browser: Internet Explorer Safari			Operating System:
Software Requirements	FreeStyle® Libre Pro Reporting Software Windows® 7, 8, 10 Mac OS X (El Capitan) (Refer to table 2)	Operating System: Microsoft® Windows® XP or later Mac® OS X 10.6.8 or later	Mac® OS X 10.8+ Web Browser: Safari 6+ Google Chrome Mozilla Firefox Microsoft® Windows® XP (SP3), Vista (SP2), 7 (SP1), 8, 10 Web Browser: Internet Explorer 9+ Microsoft Edge Google Chrome Mozilla Firefox		CareLink® Pro Therapy Management Adobe® Acrobat or Adobe® Reader Microsoft® Windows® 7, 8, or 10 Mac® OS 10.5+ Web Browser: Internet Explorer 10+ Mozilla Firefox 38+ Safari 4+	Accu-Chek 360° Diabetes Management System (Refer to Table 5)	Mac® OS X® Mountain Lion, Mavericks, or Yosemite Microsoft® Windows® XP, Vista, 7, or 8; Web Brower: Google Chrome 15.0+ Mozilla Firefox 7.0+ Safari 5.1+
							BG Meters:
Other Compatible Systems	Major Glucose Monitors from: Abbott Bayer Lifescan Roche	Major BG meters and CGMs*	Dexcom G4® CGM System Dexcom G5® CGM System	OmniPod® + PDM only† Major BG meters, insulin pumps, and CGMs‡	Major BG Meters and Insulin Pumps^	(Refer to Table 5)	OneTouch® Verio® IQ OneTouch® UltraMini OneTouch® Ultra2 Accu-Chek® Aviva Accu-Chek® Compact Plus FreeStyle® Lite FreeStyle® Freedom Lite
Web-Based Applications‡ * ¥	LibreView® Diasend® Web application	Diasend® Web application Tidepool® Uploader	Dexcom® CLARITY Diasend® Web Application Glooko Web App Tidepool® Uploader	Diasend® Web application Glooko Web App Tidepool® Uploader	CareLink® Personal Therapy Management Glooko Web App	Accu-Chek® Online Diabetes Management System Diasend® Web application	t:connect® Diabetes Mangement Application Diasend® Web application Tidepool® Uploader
Hardware Requirements (Additional to basic computer setup)	Dual-core 1.6GHz processor or faster 2 GB RAM or higher 1 free USB port Internet connectivity (for internet download installation)	Internet connectivity USB cables for BG meters (if planned to upload information from meter)	1 free USB port CD-ROM (if installed from CD) Internet connectivity Windows® OS: 1.3 GHz processor equivalent or greater 1 GB RAM 100 MB free disk space	Internet connectivity 1 free USB port USB cables for BG meters, insulin pumps, or CGMs USB Hub for Mac® OS X El Capitan	Internet connectivity 1 free USB port USB cables for BG meters or insulin pumps	(Refer to Table 5)	x86 compatible 1.6 GHz processor or faster Internet connectivity (for internet download installation) 1 GB RAM
	(Refer to Table 2)			(Refer to Table 1)			1 GB free disk space 1 free USB port
			Mac® OS:
			2.3 GHz processor equivalent or greater
			4 GB RAM
			100 MB free disk space

PDM = Personal Diabetes Manager

† = For OmniPod® + Dexcom G4, please refer to information listed for Dexcom in table 6.

‡ = For more information on complete list of compatible devices, please refer to https://www.glooko.com/compatibility

* = For more information on complete list of compatible devices, please refer to https://www.diasend.com/us/patient

^ = For more information on complete list of compatible devices, please refer to https://www.medtronicdiabetes.com/download-library

¥ = For more information on complete list of compatible devices, please refer to http://tidepool.org/products/tidepool-uploader/#devices