MILITARY MEDICINE, 178, 2:218, 2013

Emerging Technology in Diabetes Care: The Real-Time

Diabetes Monitoring System
CPT Anthony Recupero, MC USA*; LTC C. Becket Mahnke, MC USA†;
MAJ Jordan E. Pinsker, MC USA†

ABSTRACT The majority of telemedicine interventions for diabetes have failed to show objective improvements
in outcomes. We describe the Real-Time Diabetes Monitoring System (RT-DMS), which augments our successful

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telemedicine system for pediatric patients with type 1 diabetes by allowing automated uploads of glucometer readings.
The addition of automatic transfer of glucometer readings enables RT-DMS to improve patient compliance and
increases monitoring by physicians. The system is scalable for use by both children and adults with all forms of
diabetes and has the potential to significantly improve clinic workflow, allowing RT-DMS to serve as a model for
managing chronic disease using telemedicine.

INTRODUCTION that are sometimes challenging to connect to home com-

Caregivers for pediatric patients with type 1 diabetes must
be able to communicate effectively with their physician to
facilitate quality medical care. We have previously reported
on the effectiveness of the Pediatric Diabetes Education
Portal (PDEP) website at our institution, showing that users
of the PDEP website had a significant improvement in
Hemoglobin A1c when compared to nonusers.1 PDEP is a
secure, Health Insurance Portability and Accountability Act
(HIPAA) compliant, asynchronous (store-and-forward) website
for pediatric diabetic patients and their families that improves
communication with their physicians. PDEP allows families
to log on from home using a computer or smartphone, review
clinic testing results, post comments and ask questions of their
diabetes care providers. Patients and families can also review
educational materials on the web site.
A major limitation of PDEP, however, is that it requires
patients to manually type in or upload scanned copies of their
blood sugar readings for later review. Because of this, a signif-
icant amount of data captured by the patient (glucometer read-
ings) is never transferred to the physicians for review. To
address this, we have now deployed our Real-Time Diabetes
Monitoring System (RT-DMS), an addition to the PDEP
website that allows for automated uploading of glucometer
readings to help pediatric patients with their diabetes care.
Unlike previous systems described in the literature which
required telephone calls, use of computer modems, potentially
difficult interactions with websites, or downloading of devices
*Department of Pediatrics, Uniformed Services University of the Health
Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.
†Department of Pediatrics, Tripler Army Medical Center, 1 Jarrett White
Road, Honolulu, HI 96859-5000.
This article was presented as part of a larger oral presentation on Diabetes
and Telemedicine, BIT World Congress of Diabetes, Beijing, China, June 2012.
The views expressed in this manuscript are those of the authors and do
not reflect the official policy or position of the Department of the Army, the
Department of Defense, or the U.S. Government.
doi: 10.7205/MILMED-D-12-00317
puters,2–5 RT-DMS allows for transparent uploading of
glucometer readings with minimal patient and physician effort.
THE REAL-TIME DIABETES MONITORING SYSTEM
With RT-DMS, patients were given a MedApps HealthPAL
device (MedApps, Scottsdale, Arizona) to connect to their
glucometer as part of an institutional review board approved
project at Tripler Army Medical Center (TAMC). The
HealthPAL is a Food and Drug Administration approved
device that plugs into a glucometer and was preconfigured for
each patient’s PDEP account. The device collects glucometer
readings and securely transmits them via the cellular phone
network to our existing PDEP website in real time. The
HealthPAL uses 128-bit secure socket layer encryption and its
transmissions meet all administrative requirements for full
HIPAA compliance. Configuration of usernames, passwords,
or other settings is unnecessary. Instead, the device is precon-
figured and linked to the patient’s PDEP account by the med-
ical team. After transmission from the HealthPAL device, RT-
DMS saves transmitted glucometer readings and aggregates
them for posting on a weekly basis to PDEP, so there is no
required time to plug in the device, emphasizing ease of use. A
schematic representation of the system is shown in Figure 1.
After posting weekly glucometer readings, diabetes care
providers are immediately notified by email to log on to the
HIPAA compliant, secure PDEP website where they can
interpret the readings and send a response to the patient. As
shown in Figure 2, the parents of a 5-year-old type 1 dia-
betic patient plugged in the HealthPAL device to their son’s
glucometer at home. No other intervention was needed, and
now the patient’s glucometer readings are automatically
ready for review by the pediatric endocrinologist and appear
as a detailed table on the website in the patient’s PDEP
account. The endocrinologist is able to respond, and the
family is automatically notified by email to log on and read
the response. One week later, new readings are automati-
cally uploaded again. The parents, who were resistant to

218 MILITARY MEDICINE, Vol. 178, February 2013

 The Real-Time Diabetes Monitoring System
FIGURE 1. Schematic overview of the RT-DMS system.
write down glucometer readings and who had previously
been nonusers of the PDEP website, now become active
participants and begin to post comments (Fig. 3). The physi-
cian response can refer to educational materials posted on
the website, allowing patients to continually review relevant
educational material as they encounter new problems.
DISCUSSION
Automated transfer of glucometer readings allows patients
and their families to effortlessly engage their diabetes care
provider with objective data for review. Although many sys-
tems have attempted to link medical devices to “health
vaults” of medical information online, patient use was often
limited because of difficulties sending data to the system and
the lack of readily available feedback once the data was
uploaded. In fact, previous studies show regular communica-
tion and feedback are linked to higher use of such systems.6
By linking seamless uploading of glucometer readings to an
FIGURE 2. Example of a provider responding to the weekly automated glucometer upload.
MILITARY MEDICINE, Vol. 178, February 2013
educational website that can provide patient-specific feed-
back, we hope to improve patient care beyond what we have
shown previously.
Although we have not used the system long enough to
formally assess the impact of such a device on changing
objective outcome parameters of care (such as Hemoglobin
A1c or the frequency of hypoglycemic events), we offer a
description of RT-DMS to show how it can improve clinic
workflow. This is because despite the extensive funding of
the development of telemedicine systems over the last few
years, results of many telemedicine and mHealth projects have
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not consistently shown definitive improvements in objective
outcomes of care.7–9 Instead, it has been postulated that the
greatest gains may come from simple increases in clinic effi-
ciency and use of time.10,11 Automatic email notification
of new postings and the asynchronous nature of the system
allows families and providers to post messages at any time
they want, with no need to interrupt other activities. For
patients using RT-DMS, we no longer have to review faxed
or emailed copies of glucometer readings and then call back
patients to explain recommended changes in insulin doses,
saving time and effort that can now be used elsewhere. And
by using billing codes specifically designated by the Depart-
ment of Defense (DoD) for telemedicine encounters, pediatric
endocrinologists at TAMC are able to bill for their time and
capture workload using an integrated billing form that con-
nects with the Armed Forces Health Longitudinal Technology
Application (AHLTA) workload module. In the case described
above, we used an approved Current Procedural Terminology
code for collection and review of data electronically transmit-
ted from the patient (Current Procedural Terminology Code
99091, bottom of Figs. 2 and 3). In this case, we were able to
bill 1.1 physician work relative value units that are paid to our
military treatment facility from the DoD’s military healthcare
system. All of this done using the integrated billing module in
RT-DMS that simply requires checking a box on the web page
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 The Real-Time Diabetes Monitoring System
FIGURE 3. Example of a family and physician discussing the automated glucometer upload.
after submitting comments back to the patient. This improves
clinic workflow by decreasing time spent on telephone con-
sults and faxes; time that is often not billed appropriately
in AHLTA.
It has been our experience that in many cases this type of
data is never reviewed between appointments because patients
find it too cumbersome to use fax machines or secure email to
send the relevant data. In addition, providers using AHLTA do
not want to spend the time needed to enter the appropriate
codes and supporting documentation in such a cumbersome
system that suffers from poor usability. It is also important to
note that providers outside of the DoD’s military healthcare
system may choose to require the patient to return to clinic
to review data that could otherwise be easily transmitted
electronically. This is because Medicare does not currently
reimburse for this procedure code, and will again change
reimbursement codes for version 10 of the International
Classification of Diseases, making it very difficult for pro-
viders to support such a system outside of a military treat-
ment facility.
A number of web-based and mobile applications cur-
rently exist to enhance diabetes management. The Medtronic
Carelink system is one of many programs that allows
patients to upload readings from their glucometers and insu-
lin pumps to a centralized database on the internet, where
physicians can download the results. Use of the Carelink
system has been associated with improved glycemic control
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in children with type 1 diabetes on insulin pump therapy.12
Yet Carelink and similar systems do not automatically notify
physicians that new results are available for review. Instead,
they require patients to click on a button and type in their
health care provider’s email address for each report they
wish to send. In addition, they neither offer physicians the
ability to send educational feedback to patients, nor do they
link to a hospital billing system. These restrictions limit their
suitability for use by physicians seeking these features.
Similarly, there are now numerous mobile applications
available for patients with diabetes. Analysis of these mobile
applications has shown that although clinical guidelines
widely refer to the importance of personalized education, this
remains an underrepresented feature in these applications.13
This is reflected in studies that show improvements in the
frequency of blood glucose monitoring in adolescents using
mobile diabetes applications,14 but studies that track objec-
tive outcomes of care (such as reduced hospitalizations and
emergency department visits) note that involvement from
multiple parties is needed for successful outcomes.15 Usability
issues have limited the adoption of systems designed to inte-
grate all aspects of diabetes care.13 Our system is designed to
easily integrate all of these elements of care, with a focus on
ease of use for all parties involved.
RT-DMS is currently limited by the cost of each
HealthPAL device, limiting the number of devices in use.
With more devices we plan to expand RT-DMS to serve
MILITARY MEDICINE, Vol. 178, February 2013
 The Real-Time Diabetes Monitoring System
remote locations served by TAMC, such as other countries in
the Pacific Rim that have access to cellular and internet
technology but who, otherwise, have limited host nation
resources. This will increase access to care for all of our
patients. We also plan to add real-time alerts to the system
for very high or low glucose readings, with an adjustable per
patient threshold for when to alert physicians and family
members by either phone call or text message.
We are also beginning work on phase 2 of the RT-DMS
project, which was recently funded by the Army Medi-
cal Department’s Advanced Medical Technology Initiative.
Phase 2 will allow for a smartphone app to communicate
with glucometers and insulin pumps, replacing the need for
extra hardware such as the HealthPAL. We hope to deploy
this smartphone app for patient use early next year.
CONCLUSION
By using the cellular technology embedded in the HealthPAL
device, RT-DMS allows pediatric diabetic patients and their
families to effortlessly transmit glucometer readings to their
physicians. Pediatric endocrinologists can more effectively
monitor patients and improve the quality of diabetes care with
near real-time feedback when needed. We hope RT-DMS can
serve as a model for managing chronic disease using telemed-
icine, and we are interested in joining other centers in expand-
ing our outreach in caring for children and adults with both
type 1 and type 2 diabetes.
In addition to improving the quality of medical care we
can provide, it is our hope that long-term use of RT-DMS and
similar systems will show significant costs/benefits related to
improved clinic workflow. This will allow us to more effec-
tively advocate for the creation of a standardized national
billing model for telemedicine encounters.
ACKNOWLEDGMENTS
The authors thank Eludrizza Tabisola-Nuesca, RN, CDE and Debora Chan,
PharmD for their assistance in setting up the TAMC RT-DMS. Resource
support for this project was provided by the U.S. Army Public Health
Command (formerly the U.S. Army Center for Health Promotion and Pre-
ventive Medicine) through the Health Promotion and Prevention Initiatives
(HPPI) program.
MILITARY MEDICINE, Vol. 178, February 2013
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