Telemedicine Allows Army, Indian Health Service to Expand Range of Diabetes Care

by U.S. Medicine

November 13, 2016

By Annette M. Boyle

Dwight D. Eisenhower Army Medical Center and Blanchfield Army Community Hospital launched the Army's first pilot Telehealth primary care services within BACH's Emergency Center earlier this year. In this photo, Spc. Nathan Dye prepares 1st Lt. Maxx Maumla as Gen. Daniel B. Allyn, the Vice Chief of Staff of the Army observes. Army Medicine photo by Laura Boyd

Dwight D. Eisenhower Army Medical Center and Blanchfield Army Community Hospital launched the Army’s first pilot Telehealth primary care services within BACH’s Emergency Center earlier this year. In this photo, Spc. Nathan Dye prepares 1st Lt. Maxx Maumla as Gen. Daniel B. Allyn, the Vice Chief of Staff of the Army observes. Army Medicine photo by Laura Boyd

FALLS CHURCH, VA—To reach the growing number of individuals in their care who have diabetes, both the Army and the Indian Health Service have aggressively adopted telemedicine, with excellent results. Their efforts have increased in importance with the dramatic rise in the number of Americans diagnosed with diabetes.

For the Army, telemedicine is making a difference in the lives of soldiers with diabetes as well as those whose dependents have the disease. While the number of active duty soldiers with diabetes has fallen from 249 to 186 in the last five years, a combination of improved treatments and better access to care means a diabetes diagnosis is no longer the career-ending event it was a few decades ago.

Telemedicine has been a major factor in improving access to care for soldiers and their families, whether stationed in the U.S. or abroad. “One of the benefits of telemedicine is the ability to provide the best health care Army Medicine has to offer, wherever the provider and the patient are,” said Colleen Rye, PhD, chief, Army Virtual Health.

Army Medicine spends more than $10 million annually on telemedicine, according to Rye. That investment “has built an integrated global system of telemedicine/virtual care covering our beneficiaries in over 30 countries and territories, 18 time zones and in over 30 clinical specialties,” she told U.S. Medicine.

Remote health monitoring (RHM) addresses one of the major concerns with managing diabetes among active duty personnel: How does it affect readiness?

A retrospective study of a telemedicine clinic at the Womack Army Medical Center, Fort Bragg, North Carolina, published in the Journal of Telemedicine and Telecare, tackled that question. It found that with remote monitoring,  very physically active patients with Type 1 diabetes “could attain acceptable [hemoglobin] A1c targets without compromise of military duties. Furthermore, through advanced monitoring techniques, we were able to verify that participation in extreme forms of activity was safe.”1

The range of activities studied included military deployments, airborne operations, high-altitude low-opening parachute jumps, 400-mile cycling events, and ultra-marathons as well as airborne and jumpmaster training programs.

The 51 soldiers in the study had an initial intake visit with a diabetes educator followed by three one-hour weekly training sessions on intensive diabetes management. Soldiers were offered insulin pump therapy, though not all chose it, and continuous glucose monitoring.  They were then managed almost exclusively through telemedicine, according to the study authors.

Soldiers transmitted data daily or more often during periods of intense physical activity. Those with A1c above 8.0 transmitted data weekly, while those with lower levels did so less often. Over a mean time in study of 17.1 months, average A1c values dropped from 9.8 at baseline to 7.3 at three months and 6.9 at the end of the study. Results did not vary significantly between those who were newly or previously diagnosed or those who used an insulin pump or multiple daily injections. 

“For Type 2 diabetic patients, RHM enables greater situational awareness for both patient and provider through improved self-health management and earlier intervention,” Rye said. “Proactive and preventive chronic care management has been shown to reduce likelihood of disease exacerbation, thereby improving health outcomes and quality of life.”

To further assist soldiers with Type 2 diabetes with management of their disease, the Army Medical Department is currently fielding a pilot at Madigan Army Medical Center, Join Base Lewis McChord. The pilot uses secure mobile health monitoring software tools and smartphones to provide both automated feedback and coaching on health statues, according to Rye.

Telemedicine can also help dependents with diabetes, while expanding the number of posts to which servicemembers can move with their families. “If a soldier’s or family member’s condition can be appropriately treated or managed via telemedicine, then this sometimes expands options for soldier postings,” Rye said.

The Med Apps HealthPAL device, which provides real-time diabetes monitoring for patients with Type 1 diabetes, for instance, could provide remote access to care at Tripler Army Medical Center in Hawaii for dependents with diabetes in Pacific Rim nations that have limited medical care.2

IHS Telemedicine

While the Army deals with a relatively small number of patients with diabetes, the condition is twice as common among American Indians and Alaska Natives (AI/AN) as among non-Hispanic whites, according to the national Centers for Disease Control and Prevention. In addition, the vast rural areas in which many AI/AN patients live makes regular clinic visits for disease management challenging.

In 2012, 15.5% of AI/AN adults had a diagnosis of diabetes, compared to the 9.3% rate seen in the general population. To reach the large number of patients, the Indian Health Service has stepped in to provide remote care via telemedicine.

Since 2001, the IHS has offered retinal screenings for individuals with diabetes via teleophthalmology. To date, more than 130,000 total examinations have been performed remotely in more than 100 clinics in 25 states. In 2015 alone, the IHS program provided 20,000 retinal examinations, said April Hale, IHS spokesperson.

In late September, the IHS announced a new contract for $6.8 million to provide telemedicine services in the Great Plains Area service units, which serves approximately 130,000 American Indians and Alaska Natives, Hale said.

The new service will enable “IHS facilities to offer additional specialty services and appointments to ensure patients have the fastest possible access to the health care they need,” including critical diabetes services, Hale told U.S. Medicine.

“Given the range of specialties that will become accessible through the new telehealth contract, patients with diabetes will have increased access far beyond teleophthalmology, which is important since patients with diabetes experience higher rates of cardiac, renal, and dermatologic complications,” Hale said.

  1. Choi YS, Cucura J, Jain R, Berry-Caban C. Telemdicine in U.S. Army soldiers with Type 1 diabetes. Journal of Telemedicine and Telecare. 2015. 21(7):392-395.
  2. Malasanos T, Ramnitz MS. Diabetes Clinic at a Distance: Telemedicine Bridges the Gap. Diabetes Spectrum 2013 Nov;26(4):226-231.

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