CLINICAL DIABETES
VOL. 18 NO. 4 Fall 2000


THE BUSINESS OF DIABETES


The Internet in Diabetes Care: The Wild Card for the Future


Steven B. Leichter, MD, FACP, FACE


In case you missed it, the Internet is coming to diabetes care. Just click on www.diabetesmanager.com   to see an example. Until now, World Wide Web sites related to diabetes have offered information for health professionals and consumers. Diabetesmanager.com suggests the advent of new capabilities on the Web. For that reason, consideration of the business implications of Internet services in diabetes may be important.

The Web as a Source of Information
The primary role of the Internet in diabetes care thus far has been as a growing source of information for both health professionals and consumers. Certainly, one of the most important resources for information on the Web is the site of the American Diabetes Association itself (www.diabetes.org). This site is a rich reference for lay information as well as all for the association's professional journals. Another key resource is the search engine of the National Library of Medicine, Internet Grateful Med (http://igm.nlm.nih.gov). Other health information search sites include Medline (www.allhealth.com) and QdOnline (www.qdonline.com). Specific medical journals, such as the New England Journal of Medicine (www.nejm.com) and the Journal of the American Medical Association (www.jama.com), also offer Websites. In addition, corporations involved in diabetes have their own Websites, which are additional sources of information. These include Eli Lilly Corporation (www.lillydiabetes.com), Bristol-Myers Squibb Corporation (www.bms.com/well/index.html), Roche Diagnostics (http://diabetes.roche.com), and many others.

The Web has offered individual providers an opportunity to interact with existing and potential patients. A number of physician groups or other provider organizations have Websites. Examples are www.endocrinologist.com, www.endo-consult.com, and www.tcoyd.org. This last site provides educational and community activities from a physician who also provides clinical care to patients with diabetes separately from the Web site.

All of these sites seek to engage readers with useful information hopefully geared to the interests of those individuals most likely to visit the specific site. The organizations that own such sites gauge their effectiveness in part by the number of visitors to the site per unit time, or the number of "hits." Obviously, the information presented on each proprietary site will be biased to meet the needs of each organization in forming concepts among consumers or health professionals. Nevertheless, these sites represent important opportunities for rapid and effective learning.

Business and Diabetes on the Internet
Another aspect of the application of the Internet to diabetes is its use as a vehicle for conducting business. Some retail organizations offer consumers the opportunity to purchase goods or services related to diabetes, just as other companies offer similar opportunities to consumers in all sorts of retail businesses. One example is PlanetRx, an online pharmacy that offers a specific site for its diabetes customers (www.diabetes.com). Another site specifically for diabetes-related products is www.diabetes-consult.com. This site serves as both a vendor of diabetes-related products and a local resource for diabetic people in the Colorado Springs, Colorado, area.

Other national vendors for diabetes supplies, especially those funded by Medicare, host Websites. On many of these, such as National Diabetes Pharmacies (www.rev.net/~ndp), patients can order supplies online.

Other retail items of interest to diabetic patients may be ordered through the Internet. There are sites for sugar-free foods (www.sugarfreeparadise.com), gift baskets for diabetic people (www.alldiabeticdelights.com), and even a site for ordering orthopedic shoes for diabetic patients (www.markellshoe.com). At present, there are no large vendors involved in Internet commerce in diabetes-related retail except for the few national vendors in Medicare-approved diabetes supplies. Interestingly, some large suppliers in this field do not have Websites.

Remote Diabetes Management
Perhaps the most thought-provoking application of the Internet to diabetes involves the remote management of diabetic patients. A few Websites have been established for such functions, such as diabetesmanager.com. These claim to assist patients and physicians in the management of blood glucose. Patients enroll in the program and communicate with the company via the Internet. This interaction is an example of the innovation arising through the use of the Internet. It also shows the potential for and raises questions about even greater Internet use in the future.

A primary concern is the degree to which it is practical or ethical to manage aspects of patient care by remote monitoring, such as through the transfer of blood glucose data via the Internet. Remote management of patients is an incipient concept that may grow on the Internet. There have been concepts to read retinal photographs by remote transmission of the pictures, for example. However, a search of three different search engines did not yield an active site for this technology at present. It is also possible to read remotely any other parametric data on patients, such as laboratory data, cardiographic data, and X-rays. These interventions do not entail active patient management.

Applying the Internet to the ongoing management of diabetes may be a further evolution of the use of the net. And it raises new questions. Companies may contract with managed care organizations to advise patients on blood glucose management by computer models or protocols. Companies may also contract with specific vendors, such as vendors of blood glucose meters, in a reciprocal arrangement. For example, the vendor of blood glucose meters might preferentially direct its customers to the diabetes management company for difficult questions about diabetes. In return, the diabetes management company would preferentially suggest the blood glucose meters of that vendor.

Whether this support to diabetes management will be a major addition to diabetes care is unclear because of practical issues in at least some states. One issue regards the confidentiality of patient information. Any Internet transfer of patient information would have to be secure or sent via encrypted transmissions. Hawaii recently passed a stringent confidentiality bill that might make encryption inadequate.1

Another issue is the management of patients in any way by physicians who have not examined or seen them. This matter is yet to be considered widely. A third question is whether any health professionals who participate in remote care have to be licensed in the state in which their patients reside. In unrelated questions, a number of state Boards of Medicine have upheld this requirement for any health services provided to people who are within the state at the time services are rendered.

Finally, the technology for diabetes products is not yet equal to other available technologies for Internet use. No major home glucose meter manufacturer has included the easy transmission of blood glucose data from their meter to other locations via e-mail or other Internet transmission. Other related technologies, such as the glucose sensor (MiniMed, Burbank, CA) can transmit files by Internet, but only to a remote computer that has the proprietary program from the manufacturer of the glucose sensor. The files cannot be imported into commercial office software for further manipulation and reporting. This may make them cumbersome to use.

Summary
Given the technological capabilities of the Internet, its applications in diabetes care are nascent. Remote management of patients is perhaps the most advanced concept, but its implemen-tation faces both technological and practical obstacles. Retailing in diabetes products is rather new compared to other forms of Internet retailing, but it is slightly more established than remote patient management. Of the three existing functions for diabetes on the Net today, the presentation of information is the most available and presently the most useful. However, the state of Internet business in diabetes today should be viewed with reference to what the existing technologies suggest is possible rather than limiting consideration to what currently exists.


REFERENCE

1Altonn H: Doctors fear new privacy law. Honolulu Star-Bulletin. July 2, 2000. http://starbulletin.com/2000/07/01/news/story2.html.  


Steven B. Leichter, MD, FACP, FACE, is the managing director of the Columbus Health Education and Research Foundation in Columbus, Ga., and a clinical professor of medicine at Mercer University School of Medicine in Macon, Ga.


Copyright 2000American Diabetes Association
Updated 10/00
For ADA Related Issues contact
CustomerService@diabetes.org

For Technical Issues contact webmaster@diabetes.org