In November 2014, electronic health record vendor Cerner announced it was forming a partnership with Livongo for Health, a remote care platform developer based in Chicago and Palo Alto, Calif., on a real-time diabetes care ecosystem. The system includes Livongo's cellular-enabled monitoring device and analytic "smart cloud," which the companies say will enable primary care providers and Livongo's virtual care team alike to deliver optimal real-time to the system's patients. Livongo CEO Glen Tullman and Cerner President Zane Burke explained how the system will work to Health Data Management via an email question-and-answer exchange.

HDM: Could you explain the basic technical architecture of a typical interaction between a Livongo-equipped patient at home and his or her primary care provider?

Burke: Cerner’s CareAware platform connects information from Livongo’s smart cloud, where the data is stored, to our population health system, HealtheIntent, and our Millennium EHR.

Tullman: Patients who are part of the Livongo for Diabetes program use the In Touch blood glucose monitoring system to check their blood sugar. Every time they check their blood sugar, they are asked personalized, contextual questions (for example, if the check was taken before or after eating and how the patient felt at the time) and then the reading is transmitted to the cloud. Since the Livongo device also contains a pedometer, activity information can also be transmitted real-time.  Once in the cloud, the data is analyzed in combination with all of the other information the patient has shared and the rules engine, the inference engine, and the communications engine kick into action, providing helpful suggestions, education related to their specific and personalized experience, and connection to their care community, which could include family, population managers, or physicians.   

The patient always has control and has the ability, at the touch of a button, to share either discrete readings within predefined ranges or a 30-day snapshot of their data with the care team they define. As noted, this can include their clinical team, their family, or their friends.

The relationship between Livongo Health and Cerner includes sharing the information automatically with Cerner’s information platform so it can be incorporated into existing workflows in HealtheIntent, taking into account the fact that most people have more than one chronic disease or condition and HealtheIntent can process all of the information, after which it will be made available in Millennium.

HDM: Who makes the decision to implement the system?

Tullman: The provider organization makes the decision to offer the program and the patient has to enroll to become a member of the program. Livongo is designed to have the patient do less, not more, which includes no entering of information, no ordering of strips, and no need to send information, as it happens automatically. Patients also receive unlimited strips for testing. 

HDM: Is the cloud analytic platform completely automated or is there some element of curation involved prior to the alert to a patient's PC provider?

Tullman: The cloud-based analytic platform is automated. However, there is an ability for patients to define the rules for which alerts are sent to their clinical care providers and other members of their care team.

HDM: How much does the service cost, and is that borne by the patient or plan?

Tullman: The suggested retail cost is approximately $70 per participant per month and that includes the cellular-enabled, interactive blood glucose meter, unlimited supplies, and value-added services. The cost is typically borne by the plan although, given the consumer acceptance and interest, we expect to be offering the service direct in the near future.

HDM: How does this device portend next-generation mobile/app-enabled data reporting and care coordination? Do you see a mix of automated analytics informing providers of patient status, or do you also see potential for curated data and remote providers who can serve as adjuncts to a primary care physician?

Tullman: The near future will focus on automated analytics informing clinical care providers about the status of various patients. While this is a big leap forward, the ultimate goal is to provide the information providers need to focus on the patients who are at higher risk and are having more difficulty managing their conditions. Those who are at lower risk and aren’t having difficulty managing their conditions will be treated in either remote or virtual ways to increase convenience and lower cost. For example, imagine a scenario where two patients have an A1c of 8. One of them has very stable readings on a daily basis. The other is experiencing frequent cases of hypo- and hyperglycemia but it all averages out. We want the care provider to be able to focus his or her time on the patient with challenges.

Burke: Our vision for population health is to cut the cost of care and reduce clinical visits by putting real-time information in the hands of a patient’s providers. We do that by making our population health platform, HealtheIntent, as open and interoperable as possible. The Livongo device is one of many technologies that we’re working to integrate with HealtheIntent and our EHR platform to make sure the right information is available to the right people at the right time.

HDM: How do you align everybody's incentives correctly? Will the patient have to be able to share in cost savings to get them to use it?

Tullman: In many ways the incentives are naturally aligned. The program is typically offered to the patient at no cost – or at a cost that is similar to what they pay today for a bottle of strips – and often there are incentives provided for participation. Given that we offer a cellular-enabled device, we are simplifying the process of managing diabetes. And with unlimited strips as a part of the per-participant per month fee, we have removed the disincentive to checking blood sugar more frequently.

The incentive for the patient to participate, beyond the financials, is that better information leads to a more effective ability to self-manage, which leads to better health.

The incentive for providers is to give them the information they need to identify those who need help the most; this way they can improve the health of their patients and get higher reimbursements at the same time. It also saves nursing time from downloading data from meters at the office.

The incentive for payers is to improve the care of people with diabetes and give them more control over their experience, which allows them to live life and not focus on their disease, while at the same time reduce the cost of care for their plan members who have diabetes. Livongo for Diabetes is able to do that by providing support when it’s needed—in the moment—and avoiding expensive ER visits.

HDM: How do you each plan to expand your respective parts of the ecosystem beyond Cerner/Livongo, respectively?

Tullman: Livongo plans to expand its ecosystem in diabetes by aggregating data from more devices including other blood glucose meters, continuous glucose monitors, activity trackers, medication data, etc. so we have a more holistic view of the people in our program. We plan to work with devices made by any manufacturer. Our system will be open and device-agnostic. The only requirement will be the ability to transmit in real time. In addition, we have plans to expand the platform to other chronic conditions such as COPD, asthma and the like.

Burke: This is one example of how Cerner is fostering greater consumer and clinical device connectivity inside and out of care facilities. Diabetes affects a big part of our population and the Livongo team has a device that’s ready to communicate today with our system, so it was important for us to move quickly to make that connection. In the very near future, we’re interested in integrating any devices that make information more accessible to the patient’s care team and that can create positive health outcomes.

HDM: Will the Livongo platform software be able to reside on any device at some point, thereby giving patients freedom of choice?

Tullman: We believe in an open platform. Our goal is to capture data from a variety of devices including blood glucose meters, continuous glucose monitors, fitness trackers, and the like. Our only condition is that the devices must include features like two-way interactivity so you can receive information and ask questions in the moment, which then allows you to create the teachable moment and help when it’s needed most. 

HDM: Does this solution need to satisfy Meaningful Use, HIPAA, and FDA requirements, and if so, can you elaborate on what will enable that?

Tullman: The Livongo for Diabetes solution meets both HIPAA and FDA requirements. The FDA cleared the In Touch blood glucose monitoring system on September 8, 2014. There is no Meaningful Use requirement to meet but a more empowered patient will always be a healthier patient. 

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