Case Study: Information Technology Enhances Diabetes Team Care in Hawaii

Joe Humphry, M.D., FACP


Ms. FR is a 54-year-old Ilocano (Filipino dialect)-speaking female living in Lana’i City on the island of Lana’i in Hawaii with her husband, her adult daughter, her daughter’s husband, and her two grandchildren. She has had diabetes for 10 years and associated hypertension and hyperlipidemia. She is under the care of her health care team at the rural community health center.

Team Members

Her team includes the patient and her family, her family nurse practitioner/primary care internist providers, a community health worker (CHW), a dentist, a pharmacist (telehealth), a nutritionist (telehealth), the health center exercise program, a behavioral health specialist, and an eye specialist (telehealth).

Community Health Care Services

Ms. FR is currently enrolled in the health center’s home blood pressure (BP) monitoring program. Due to her work schedule, she has home BP visits by the CHW who currently works with her on lifestyle changes, reviews her medications, and uploads the BP readings into the Chronic Disease Management Program (CDMP). She follows a strict protocol to obtain morning BP readings and has been under good control for 6 months. The health center is transitioning over to a Bluetooth-enabled BP cuff, enabling her to share her BP readings by transmitting them through her cell phone.

She has been on two oral agents, and her A1C has recently elevated to 9.8 percent. Based on the health center’s treatment protocol, developed in conjunction with the pharmacist, she will be starting insulin. She has an office visit with her nurse practitioner and CHW, who start insulin therapy and develop a treatment plan with shared decision making, adjustments to diet instructions, and training on insulin administration and initial training related to hypoglycemia. She also receives a Bluetooth-enabled glucose meter, allowing her to provide the team with frequent uploads and adjustments in insulin doses.

She is also scheduled for her annual retinal exam using the tele-ophthalmology non-mydriatic camera at the health center, with the images read by an eye specialist in Honolulu.

A week after the office visit, the CHW makes a home visit. CHWs carry tablets with internet access, and, with the change in treatment, the CHW asks the patient to take the Diabetes Distress Survey to help assess the impact of additional insulin administration and increased dietary requirements on the already complex routine of managing diabetes. The patient has successfully uploaded the glucose readings to CDMP, and the CHW reviews the results using the graphics built into CDMP to help the patient interpret her performance. The majority of the readings are above target, and the CHW sets up an immediate brief telehealth video conference (HIPAA-compliant, cloud-based service) with the primary care internist to get recommendations on insulin adjustment. The patient also had a 3-pound weight gain. The CHW, using the patient education library built into CDMP, brings up the YouTube video in Ilocano produced by the health center showing simple ways to calculate portion size. There are very few diabetes-related videos in lesser spoken languages, and the visual education is effective in the population that has limited health literacy in the written Ilocano language.

The CHW records the content of her visit in CDMP and revises the care plan that will be reviewed by the nurse practitioner. The CHW schedules a follow-up visit in 2 weeks, makes certain that the patient and the family have the URL for the Ilocano educational material on YouTube, asks that the patient upload to CDMP the BP and glucose readings weekly, and tells the patient that she will be reviewing the results of the Diabetes Distress Survey with the behavioral health specialist, as the patient had high levels of distress in two categories.

Information Technology and Communication Technology

The health center uses a certified electronic health record (EHR) and is essentially paperless. The EHR passes clinical and financial information into the health center’s data warehouse that has a unidirectional interface into CDMP for clinic information. The data warehouse has advanced population reporting capabilities, allowing for frequent monitoring of clinical and financial metrics. In the first year of the hypertension program, BP control improved for 57 percent to 70 percent of the hypertensive population. CDMP is cloud-based, providing access to lab and other clinical information to the pharmacist, who is on another island, and to the eye specialist, who reads the retinal image. The entire team has access to the care plan, patient-generated data including BP readings, self-monitoring blood glucose, weight, survey results, and patient reminders. CDMP has a patient portal with secure email and access to the patient education library, the care plan, and lab results.

Insurance Coverage

Health plans do not cover community- and home-based services for patients who are not homebound. Some states have laws covering video-conferencing to the home and store and forward technology. (Tele-ophthalmology has a CPT code and is covered by Medicare and some health plans.) The services provided by the CHW and the many brief communications between team members are not covered, but some of the services are captured as “enabling services” by the community health center.


The cultural competency and communication skills of the CHW, coupled with the effective use of communication technology, allow Ms. FR to rapidly bring her blood glucose readings into control. She works in the hospitality industry with traditional low salaries and frequently irregular hours. The home-based care allows her to significantly limit the time off work, manage her diabetes, and reduce the distress of diabetes. The CHW was able to arrange a telehealth session with the BP specialist from her home, which allows for a better understanding of the distress and the ability to better communicate with her family and initiate learning relaxation techniques. She is also making progress on dietary adherence.

This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. The NIDDK translates and disseminates research findings through its clearinghouses and education programs to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by the NIDDK is carefully reviewed by NIDDK scientists and other experts.