Abstract
Diabetes technology (DT) is a major pillar of modern diabetes therapy that enables many people with diabetes (PwD) to achieve optimal glucose control. Diabetes technology is also advancing at a high speed, which brings new challenges. In addition, the number of PwD continues to rise, while the number of health care professionals is declining. The use of DT requires a lot of specialized knowledge, including the handling and troubleshooting of various technological systems. This means that a considerable amount of effort is required to stay up to date with all relevant products. Additional training of certified diabetes specialists and diabetes counselors to become “diabetes technologists” can be an answer to this job description. Several aspects associated with such a position are discussed in this article.
Introduction
In recent decades, the importance of technology in medicine—especially in diabetology—has increased dramatically. There is now a wide range of systems that are used in diabetes therapy under the umbrella term diabetes technology (DT). These range from diagnostic systems, such as continuous glucose monitoring (CGM) systems and therapeutic applications, such as connected/smart insulin pens and insulin pumps to clinical decision support systems and image and temperature analysis software for predicting diabetic foot ulcers. By detecting biofeedback, a glycated hemoglobin (HbA1c) improvement can be achieved with the help of a CGM system, and with the combination of CGM systems and insulin pumps to form automatic insulin-dosing (AID) systems, the boundaries between diagnostic and therapeutic medical devices used in diabetes therapy are becoming blurred. These various “tools” generate data because they are increasingly communicating with each other and “growing” into a digital ecosystem that enables more and more people with diabetes (PwD) to achieve good and safe glucose control. At the same time, DT is advancing at an enormous pace, which brings new challenges.
Due to demographic (and anthropometric) changes, the number of PwDs continues to rise, while the number of health care professionals is declining. The use of DT should enable diabetes teams to organize their daily practice more efficiently and provide better care to more PwD in less time. The technology should be easy to use, allowing diabetes team members to focus on their core task of caring for PwD in face-to-face consultations. However, many diabetes teams perceive the situation differently: they currently spend a significant portion of their working time at the computer, dealing with the handling and troubleshooting of various DT systems. In addition, the use of DT is perceived as a complex task. The speed at which technical systems are evolving and the increasing number of providers and systems pose further and additional challenges. This means that a considerable amount of effort is required to stay up to date with all these products. In everyday practice, various “special situations” arise with PwD, such as specific occupational or sporting requirements that need to be addressed individually. Due to the expected acceleration in the development of DT—in particular through the use of artificial intelligence (AI)—it is hoped that many of the situations mentioned above in the everyday care of PwD and the associated demands on the diabetes team can be reduced.
How can optimal care be provided for diverse patient groups with individual DT requirements in everyday practice? Could additional training for certified diabetes specialists and diabetes counselors to become “diabetes technologists” be the ideal solution?
Who Could Become a Diabetes Technologist?
It would be useful and desirable for these two professional groups, which play central roles in diabetes teams, to develop expertise in the application, training, and use of DT. The current reality shows that this expertise lies primarily with counselors, who play a key, if not decisive, role in the care of PwD with DT.
Specific further training for members of the diabetes team with a focus on DT should enable them to become familiar with all relevant aspects and the clinical use of DT. In principle, all members of the diabetes team are eligible for such training, but in particular, diabetes counselors and assistants, as well as nurses and medical assistants with experience in specialized facilities for the treatment of PwD.
In practice, it is already common today for individual members of diabetes teams to focus on the use of DT in diabetes therapy due to a personal affinity. However, there are currently no structures or curricula for such a job with a suitable job description or qualification. In adiposiology, there is a distinction between adiposiologists and obesity counselors. Perhaps it would make sense for the DT field to do the same, both for medical and counseling specialist groups.
Tasks of the Diabetes Technologist
A diabetes technologist should take care of all aspects of data handling for blood glucose monitoring and CGM systems: instruction in the respective system, reading the data, and documentation and visualization. They should support the diabetologist in analyzing and interpreting the data and instruct PwD in the handling and optimal configuration of insulin pumps (conventional pumps or patch pumps) and AID systems from diabetes technologists. Such tasks are already largely performed by diabetes counselors. Important questions in this context are therefore:
Where does their area of responsibility end, and where does that of the diabetes technologist begin?
How should legal aspects be handled, and who is liable for treatment decisions?
A key task for diabetes technologists is the initial and ongoing training of PwD in the use of complex technical systems, such as CGM or AID systems. Although training in DT can be very timely at the outset, it pays off significantly in the long run. The better PwD are trained, the more likely DT will be accepted as an integral part of diabetes therapy and successfully implemented in the long term. At the same time, psychological and educational aspects must be given sufficient consideration when using DT, as it is not just a matter of handling the products, but also of integrating and using them in everyday private and professional life, as well as in special situations.
Many diabetes counselors have the ability to view and address PwD holistically, taking into account all influencing factors—not just DT. Consideration must also be given to possible psychosocial problems associated with the use of DT, such as the visibility of the systems, their influence on body image, the occurrence of “alarm fatigue,” and similar problems. Such psychosocial components should be a core competence of diabetes technologists.
In connection with the use of DT, clinical studies are also being conducted by the manufacturers of the products used. If such studies are conducted in the respective practice or clinic, diabetes technologists can contribute their expertise as “study nurses,” not only in the practical implementation of the tasks involved, but also—based on their experience—by providing relevant feedback on the characteristics of the systems being investigated in the respective study.
The use of DT generates large amounts of data. These data must be transmitted, stored, analyzed, and interpreted. Smartphones and computers are primarily used for this purpose, which means that diabetes technologists should also have a thorough understanding of how to use them. The role of diabetes technologists is not that of an “IT specialist,” but they should be able to resolve any issues that arise at the interfaces between these communication systems.
Further Training and Education for Other Members of the Diabetes Team
Due to the rapid development of DT, diabetes technologists should also be the point of contact for training aspects for other members of the diabetes team/other colleagues within practices and clinics. The current “horror scenario” of a person with problems with their AID system arriving at the emergency room can be turned into a positive situation through consistent training of the staff there. Anesthesiologists would have a direct contact person who could answer questions at short notice during operations involving insulin pumps. Technological “problem cases” could be discussed in regular quality circles within local networks. In practices, continuing education assistants would receive excellent support as they take their first steps into the DT world.
It is certainly important that sufficient time is left for direct support for PwD and that this is prioritized over internal training. However, the coexistence of this must also be reflected in the framework of a possible remuneration system.
Workflows/Processes
To achieve the goal of efficient and high-quality care for PwD, it is important to coordinate and plan the position and work of diabetes technologists within the diabetes team. It is likely that the institutions already have approaches in place that are similar to those described here. However, it will be necessary to develop clear task, position, and process descriptions for diabetes technologists in team meetings, also to avoid discussions about competition and responsibilities. The “patient journey” needs to be structured in a more time-efficient manner that is suitable for all parties involved.
Training
To date, potential diabetes technologists learn very little about DT during their training and have to acquire the relevant knowledge through continuing education courses, conferences, and company training programs, often in their free time. To raise the level of training to the level envisaged here, it will be necessary to coordinate with all relevant organizations and structures. The German Diabetes Society has recently redesigned the content of the diabetes assistant and diabetes advisor training courses with a modular structure. 1 This redesign is referred to as “diabetes education.” The rigid division between diabetes assistants, who primarily support people with type 2 diabetes, and diabetes counselors, who primarily care for people with type 1 diabetes, is now obsolete. One reason for this is that the treatment of people with type 2 diabetes has become significantly more complex, and digitalization and DT are also having a considerable impact on the everyday work of diabetes professionals.
It is necessary to agree on how the content of training for diabetes technologists should compare with this and what a qualification might look like. Training as an assistant and then as a consultant should provide the basic requirements for becoming a diabetes technologist:
Practical Implementation
Once the first steps have been taken to implement the position of diabetes technologists in practices and hospitals, an evaluation should be carried out. This should not only evaluate the benefits of the work of such “experts,” but also look at what lessons can be learned to improve the job profile. A before/after comparison would be useful. For example, does the handling of AGPs or AID systems in institutions differ when a specialist is actively involved? Can complications be prevented? Has the quality of life of PwD improved? But also: Can costs be saved? A pilot project in clinics and, if possible, in surrounding specialist practices would be useful to include the aspect of trans-sectional care.
Diabetes Technology Center/Automatic Insulin-Dosing Center
A consistent approach to the requirements outlined here can also be achieved by establishing a regional “Diabetes Technology Center” (or “AID Center”) that focuses on DT. This center would concentrate the necessary expertise to provide optimal PwD treatment with DT on an initial, long-term, or interim basis.
Patients with diabetes largely run “automatically” in everyday life, at least as long as you are not eating or exercising. However, there are always special situations and problems that require targeted and experienced care. Such time-consuming “services” cannot be provided by the diabetes team in a conventional practice or clinic, and certainly not by a general practitioner’s office, even if they are interested in using DT.
The possibility of cloud-based reading of AGPs enables telemedicine, making it conceivable that such “AID centers” could provide PwD not only regionally but also supra-regionally. Such centers can temporarily relieve the burden on regional specialist practices during the transition to DT-based therapy and provide selective support in therapy in the long term. Intermittent co-care is also conceivable. Such a center can provide telemedical support to the clinic, especially in situations where PwD are being treated on an inpatient basis. This requires good cooperation and communication between the AID center and the (regional) specialist practices/clinics.
Some of our European neighbors have already established comparable structures. 2 For example, there is “Diabeter” in the Netherlands and the Steno Diabetes Centers in Denmark. These are centers where diabetes teams focus on caring for people with type 1 diabetes and systematically use DT in this context. This is covered by the cost bearers in these countries. Only if such financial options are also available in Germany within the framework of billing will it be possible to obtain an additional designation and/or certification as a “Center for Diabetes Technology..”
Looking beyond the horizon, there are telemedicine heart failure and tele-cardiology centers that provide telemedical care to patients with pacemakers and defibrillators, as well as heart failure. Digitalization assistants are now needed in every modern practice that wants to meet the challenges of digital transformation, not only in diabetology or for the implementation of DT. This refers to a specially trained employee who implements and supports the transition from analog to digital processes in the practice workflow. This is primarily focused on telematics infrastructure and its applications, rather than on specialist digital solutions.
Basic Financial Requirements
The financial scope of statutory health insurance funds for innovative care concepts is limited. However, the basic prerequisite for establishing the structures envisaged here is the drafting of special contracts to cover the costs of particularly resource-intensive requirements. Can a practice or clinic even afford such an employee if they do not receive additional remuneration for this from the cost bearers (or the manufacturers of the medical devices used)? It is understandable that diabetes technologists want appropriate remuneration for their specialized work, but not all employers can cover the additional costs.
For diabetes teams, instructing PwD in the use of AID systems, for example, and supporting them in their everyday lives means a considerable amount of extra work for which the practice or clinic is not adequately compensated. From their perspective, they receive the same remuneration for caring for an older PwD with type 2 diabetes on monotherapy as for a young PwD with type 1 diabetes who is in frequent contact with diabetes counselors by phone to optimize the use of their AID system. This massive difference in the amount of care required is not reflected in the current remuneration system.
The consequence is that a practice or clinic will consider whether to offer AID systems to all PwD, or whether to try to avoid them altogether and refer such patients to other practices or clinics, or to focus only on a “simple” subgroup. In view of the increasing number of AID systems, it is questionable whether every practice or clinic can adequately cover all the different systems, both conceptually and in practical terms. However, the question also arises as to whether the optimal use of a rather cost-intensive technology without adequate support makes sense at all.
If the expertise provided by diabetes technologists in a practice or clinic (or even in an AID center) enables smoother care for complex PwD (see above), this can reduce the overall workload of the diabetes team. This team can then focus more on the procedures and processes involving all the other PwD that need to be managed, which can also free up financial resources to a certain extent.
To what extent would DT manufacturers contribute to the costs of diabetes technologists (and/or AID centers) if their products were specifically used for this purpose? With such a (so far purely hypothetical) contribution from manufacturers, would it still be possible to ensure that a PwD is offered the DT system that is best for them? One possibility would be for manufacturers to jointly fill a “pot” that could be used to finance AID centers, for example.
Necessity, Sub-specialization, and Minimum Requirements
The fact is that DT is the gold standard for people with type 1 diabetes. In Germany, more than 90% of people with T1D use a CGM system, and many use an AID system. Diabetes treatment for people with type 2 diabetes is also expected to develop in this direction in the coming years. In our opinion, this widespread use of DT justifies the need for diabetes technologists.
A professional differentiation between the occupational groups “diabetes counselor” and “diabetologist” into subgroups can lead to problems in practices or clinics: Will this encourage newcomers to pursue this career path, or rather deter them? Will this mean that additional qualifications will also be required for other pillars of therapy in diabetology (or adiposiology)? Until now, one of the strengths of diabetology has been the combination of specialized—quasi-medical—and generalist (“general practitioner”) activities. Will a “split” weaken the professional image?
Sub-specialization has led to enormous advances in many areas of medicine, but it carries the risk of losing a generalist approach and skills. From a medical history perspective, individual disciplines have evolved in line with existing needs; the current spectrum of disciplines, from general medicine to urology, and the need for specialization are no longer questioned. The parallel existence of diabetes consultants and technologists, for example, in “diabetes units” in hospitals or in AIDS centers, may also be a sensible minimum requirement.
Further training as a diabetes technologist can significantly strengthen the position of diabetes counselors in clinics and practices, not least because it highlights their special expertise and importance in care. Diabetes counselors from clinics in particular should be better deployed for cross-sector, digital outpatient processes, for example, for virtual training courses, and so on. If suitably trained specialist staff work in practices, this can prevent PwD patients from being admitted to hospital simply because they need to be switched to an insulin pump/AID system, and the certified expertise of diabetes counselors in hospitals is required for this.
Outlook
Looking to the future, it is clear that DT will play an increasingly important role in the care of PwD. Conversely, this means that there is a need for diabetes technologists who can truly meet the needs of all PwD and their specific problems and situations.3,4 These are not a “luxury” for practices or clinics; rather, their work will, in all likelihood, improve care for all PwD. Better long-term outcomes should lead to cost savings through diabetes-related diseases, but above all to a reduction in the suffering associated with them.
The proposed further development of treatment structures for PwD can better solve many problems in acute care. However, diabetes technologists also act as multipliers in the working environment of a practice or clinic, not only in terms of continuing education and training for diabetes teams.
In view of the rapid development of DT, it is foreseeable that a willingness to engage with its content during and alongside everyday working life will remain a basic prerequisite for providing the best possible care for PwD. Against this background, one-off training and continuing education in connection with DT will not be adequate; rather, a continuous learning process will be required. Diabetes technologists can be provided with regular information and participate in targeted continuing education courses, with priority given to professional associations and manufacturers. Quality circles can also be used to pass on this expertise to general practitioners and medical assistants working in their practices as needed. Since much of the practical work with PwD in connection with DT is carried out by consultants and medical assistants, much can be achieved by establishing close communication between these professional groups.
A key challenge in this context is establishing remuneration options that adequately cover the costs associated with providing the best possible diabetes treatment for PwD patients. This should be implemented across the board, with no disparities between different regions or between urban and rural areas. The involvement of DT manufacturers in financing the necessary structures, together with the cost bearers, should be examined as an option. At the same time, there are other options for increasing the efficiency of DT. If there were uniform user interfaces for the various systems (e.g., as is the case in Denmark), this would represent a significant improvement in everyday practice.
There is a considerable need in practices and clinics for solutions to many questions, difficulties, and problems in dealing with DT, also with regard to inter-sectoral transitions. In our opinion, there is a need for the implementation of a diabetes technologist in both outpatient and inpatient settings. This need exists at the medical level as well as in educational professions. The future of humanity, and in particular the future of diabetes therapy/diabetology, will be “technologized..” Let us anticipate, discuss, prepare, and implement the necessary steps together in the best possible way!
Footnotes
Abbreviations
CGM, continuous glucose monitoring; DT, diabetes technology; PwD, people with diabetes
Declaration of Conflicting Interests
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: LH is a partner at Profil Institut Stoffwechselforschung GmbH, Neuss; Science Consulting in Diabetes GmbH, Düsseldorf; and diateam GmbH, Bad Mergentheim. He is a consultant for a number of companies developing new diagnostic and therapeutic options for diabetes therapy. Over the past three years, JL has received accommodation/travel subsidies and/or lecture fees from Abbott, Dexcom, DiGA manufacturers, among others, and acts as a consultant for companies in the field of diabetes technology.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
