According to statistics compiled by the Health Promotion Administration at the Ministry of Health and Welfare (衛福部國民健康署), the number of people suffering from diabetes in Taiwan is increasing every year. As of right now, over two million Taiwanese are diabetic. But the National Health Insurance (NHI) only covers the cost of a single checkup plus a session of patient education every three months. The rest of the time, patients need to monitor and control blood sugar levels on their own.

“After speaking with a doctor, patients are usually directed to consult a nutritionist or a case manager for thirty minutes of patient education. But as soon as the patient walks out the door, you know they’ve probably forgotten half of what they were told. When they get home, they look at their health education pamphlet and discover the instructions are incompatible with their established routine. Receiving health education is one thing, but it's very difficult to put what you've learned into practice.

Dr. Kuo Jeng-Fu (郭仁富) is the head physician of the Department of Internal Medicine, as well as the Director of Diabetes Case Management Center and Diabetes Tele-care Center in Changhua Christian Hospital (CCH; 彰化基督教醫院). He accurately describes the hurdle many diabetes educators are facing across the country. 

Telehealth Technology Monitors Patients Remotely

In order to prevent complications such as stroke, cardiovascular disease, diabetic retinopathy, and diabetic neuropathy, patients diagnosed with diabetes need to come in for regular checkups once every three months. But a visit to a big hospital takes a lot of time and energy. Patients bitterly describe their experience as “three longs and one short”: long wait to see the doctor, long wait to get your prescription filled, long wait to undergo examination—but a very short amount of time is spent actually speaking to the doctor. 

Kuo says in the age of rapidly developing information technology, artificial intelligence, and wearable devices, patients don’t in fact need to go through the hassle of visiting a hospital. Telehealth, also known as telemedicine or tele-care, allows caregivers to remotely monitor the patient’s condition. 

CCH is famous for its track record of taking excellent care of diabetics, as well as its professional team of case managers. In 2005, CCH joined the government-run remote medical care program for diabetics (糖尿病遠距照護計畫). They worked closely with information technology providers to build a cloud platform that’s integrated with the internal hospital information system. They named it the Diabetes e-Institute (糖尿病健康e院). In recent years, apps that help diabetics manage their health, such as “Health2Sync” (智抗醣) and “iDiabCare” (愛糖寶), were also introduced into the e-Institute to help patients take better care of themselves.

To use iDiabCare as an example, this app was jointly developed by CCH and technology giant Compal Electronics in 2018. Patients who are registered with the Diabetes e-Institute can download this app on their smart phones or tablets. They type in their blood sugar level before a meal, upload a photo of their meal, then type in their blood sugar level again two hours after the meal. 

If the difference between blood sugar levels before and after the meal is greater than fifty to sixty percent, that means there’s too many carbohydrates in the meal, or its glycemic index is too high. The telehealth app will red-flag the aberration as something to watch out for—a drastic change in blood sugar levels. 

Far away, the CCH case manager assigned to the patient will get a notification on their computer screen. They can easily access the list of patients who’ve been red-flagged and who are awaiting consultation. They can study the patient’s blood sugar levels and the photo of their meal to determine if it contained food with too many carbohydrates or a high glycemic index. Through the app’s inbuilt chatroom, caregivers are able to quickly advise the patient on what to eat during their next meal to bring their blood sugar level back under control.

If you’re unsure about the amount of carbohydrates or calories contained in your food, simply upload a photo to iDiabCare. The AI will immediately give you an answer. 

Subscription System Ensures Quality Healthcare

Currently, CCH’s Diabetes e-Institute operates on a subscription business model. The monthly fee per patient is five hundred Taiwan dollars. About a hundred subscribers with different types of symptoms—such as patients with blood sugar control problems, pregnant women afflicted with gestational diabetes, subhealth patients, people suffering from metabolic syndromes or obesity, people suffering from the “three highs” (high blood pressure, high blood sugar, high cholesterol)—rely on this telehealth service to lead normal, productive lives. 

“In most cases, if the patient has strong motivation to control their blood sugar levels, and if they also have familial support, we can begin to see the benefits of tele-care fairly soon. For example, pregnant women with gestational diabetes usually benefit from this service quite quickly,” Kuo says emphatically. 

The advantage of the telehealth system is clear: fewer visits to the hospital, spontaneous medical advice and consultation. Technology has broken the barriers of time and space for most patients. However, as with all else in life, not everything is picture perfect.

Kuo Jeng-Fu, head physician of the Department of Internal Medicine at CCH, says the hospital can help patients control their blood sugar levels at home by using telemedicine technology to provide remote medical care. Patients can also receive professional dietary advice about how to control their blood sugar by accessing online or telephone consultation; they never have to set foot inside a hospital.

For instance, many elderly diabetics in Taiwan are in fact cared for by foreign caregivers during the day. If they cannot read the app’s Chinese interface, then telemedicine has failed. On the flip side, if family members help patients record health data and the ingredients of their meals in the system, and if they maintain close communication with the case manager, it becomes another level of protection for the diabetic, and so the end result is almost always positive.  

What’s more, since app developers are used to quickly launching a product in the healthcare market, and then updating the software online at a later date, some key features may be unavailable at launch. Take for example iDiabCare, which began working with CCH last year. Sections of the app’s interface are still under construction. CCH actively collects their users’ valuable feedback and communicates with the app developer about how to fine-tune the software. 

“If our patients are not accustomed to using an app, our case managers will call them on the phone to get a clearer understanding of things.” Kuo says in addition to using the telehealth platform to help diabetic patients take care of themselves in their daily lives, CCH also goes the extra mile. They’re working with the Facebook fan page set up by the Changhua Christian Hospital Health Exam Center (CCHHEC; 彰化基督教醫院健康管理中心) to provide patient education instructions and videos, and to promote educational events. Their end goal is to disseminate easily accessible information about diabetes to the general public. They interact with the public online and answer health-related questions. As of July 2019, over seven million users have browsed their fan page. 

Taiwan has become an aged society. Elderly citizens who are afflicted with chronic diseases such as diabetes or high blood pressure may live outside of cities, and they may not be able to visit hospitals due to travelling difficulties or personal health issues. They need telehealth services that provide the mutually complementary benefits of “offline diagnosis and online supervision”. Medical teams can remotely monitor the blood sugar levels and blood pressure of elderly patients who are under their care. By offering full coverage no matter where you live, Taiwanese hospitals may finally be able to fulfill the dreams of many senior citizens: “to retire to the country and live happily ever after.” 

 彰基「糖尿病健康e院」團隊由醫師、個案管理師、護理師、營養師及管理師組成，提供醫療、衛教諮詢、健康狀況追蹤與監測，以及衛教宣導、健康資訊推播等服務。（左起為醫療行銷管理師張桐瑋、醫師郭仁富、個案管理師蔡幸君）

The CCH Diabetes e-Institute is run by a team composed of physicians, case managers, nurses, nutritionists, and administrators. Working together, they provide various services such as healthcare, consultation, health status tracking and monitoring, and patient education. (Pictured from left to right: Medical Marketing Administrator Chang Tung-Wei, Dr. Kuo Jeng-Fu, Case Manager Tsai Hsing-Chun.)

Modus Operandi

The combination of healthcare and artificial intelligence is an inevitable trend. More and more hospitals will invest in this field in the future, so the government wants to use AI to increase the penetration and improve the quality of healthcare. 

Large medical centers have the human resources and hardware they need to develop telehealth services. But local hospitals, clinics, and small or midsized hospitals may not have all the resources they require to implement a telemedicine system. They run the risk of being marginalized in the long run. Therefore, they need the government to coordinate their efforts. One possible solution is to pool regional telehealth resources and form a healthcare alliance to ensure telehealth services are fairly distributed among local hospitals. 

Hospital Profile

• Changhua Christian Hospital’s Diabetes e-Institute
• Founded: 2005
• Technological applications: Utilizes cloud computing, artificial intelligence, and big data technology to build a weight maintenance and diabetes health management platform. Continues to adopt new technology such as diabetes remote medical care apps such as “Health2Sync” and “iDiabCare”.
• Results: From March 2018 to February 2019, among the patients who registered with the remote medical care program and used the app “iDiabCare”, seventy percent of them reduced the duration of their hospital visits by ten percent.

Translated by Jack C.
Edited by Sharon Tseng
Content sponsored by The National Development Commission