Wide Reach, Personal Touch: How Neal Kaufman Helped Modernize Diabetes Telehealth

Neal Kaufman, MD, posed the question while describing the 2 paths he had taken in his medical career: academia and public health. The paths were similar in their intent: to improve the quality of healthcare, groups of patients at a time. But they could not be more different in practice.

For 27 years, Kaufman served in various capacities with the University of California Los Angeles (UCLA), the Los Angeles County Department of Health Services, and the Cedars-Sinai Medical Group. He worked as a primary care physician, a collegiate public health and pediatrics professor, and as a planner and facilitator of Los Angeles-based public health projects.

In 2004, all this diversified work afforded him the opportunity to take a breath and consider his future, so he thought of the future of healthcare itself. He thought about the internet—an avenue that has always been characterized by its ostensibly limitless potential. Having seen firsthand the difficulties of scheduling face-to-face interventions with at-need populations since the 1970s, Kaufman knew the internet could help reach them screen-to-screen.

Getting Help Online

“I decided it could change the delivery channel of direct intervention, so that it’s delivered through the internet and apps, in a way that makes identical—if not better—results with more spread,” Kaufman told MD Magazine®. He was imagining the modern telehealth system, and he pursued that model through his company Canary Health.Canary Health aims to provide a 3-pronged Swiss army knife that physicians can use in the fight against chronic disease, and most notably, diabetes prevention: long-held lifestyle management guidelines designed for improved health outcomes, a program designed to improve caregiver education and resources, and a care provider-led telehealth program tailored to individual patient needs.

Part of their work is inspired by and derived from Kate Lorig, PhD, who created the Chronic Disease Self Management Program (CDSMP) about 30 years ago. The Stanford University-based professor had tailor-made the program with consideration to patients potentially suffering from chronic comborbidities; CDSMP was intended to help address diabetes, arthritis, heart disease, pain, and depression. Lorig then expanded her program services to patients with type 2 diabetes (T2D), retaining the CDSMP’s primary feature of interactive, small classes among fellow community members.

Kaufman—along with his son Adam Kaufman, PhD, president, chief executive officer and co-founder of Canary Health—decided to bring this local health education approach onto the web, at a time when patients were still figuring the whole “Internet” thing out. In attempting to provide online courses to middle-aged adults with diabetes, Kaufman was hedging his bets that this patient demographic would be searching for diabetes education online.

“Early on, there was a concern that people didn’t know how to use the internet well enough, that older patients would never use a digital program,” Kaufman said. “We had a lot of challenges proving that was wrong.”

There were also doubts about whether such a program could reach lower-income patients—a population, Kaufman noted, that was in greater need of educational resources and new points avenues of care. Historically, lower-income areas in the US have had more limited internet access. Though the disparity has incrementally closed over time, payers remain reluctant to provide the Canary Health program to these populations. Kaufman believes this is driven by both logic and bias.

“Their logic is that lower-income individuals might prefer an in-person service that is culturally sensitive and pertinent to their background. But I think the bias for some people is that the lower-income community population is not internet-savvy,” he said, rebutting that claim. “They have become increasingly savvy, and even by a few years ago, were internet-skilled, but some people didn’t think that would happen.” There is also issue with lower-income individuals having a lower rate of email addresses per capita than average, Kaufman said—an issue that affects almost all similar programs trying to reach them now.

These struggles, along with a new business model that prioritized offering outreach services for organizations seeking work with the company, led to the molding of Canary Health as a comprehensive online resource for diabetic patients in need of management and preventive care. It wasn’t anything that patients hadn’t seen before; it was just a different approach of delivery.

Proven Methods

“What we were providing may overlap with what organizations were already doing,” Kaufman said. “We chose not to go direct to consumer. There’s no reason we couldn’t do that, but we thought sending it out in the context of a therapeutic relationship would be more effective, because individuals could be escalated to a higher level of service if something came out.”Kaufman’s gamble paid off. In June, a study published in the Journal of Medical Internet Research (JMIR) reported that Canary Health’s Better Choices, Better Health — Diabetes (BCBH-D) self-management program was associated with an annual mean savings of $815 in healthcare costs and improved measures of self-management.

It was one of the largest peer-reviewed assessments of a digital, community-based diabetes self-management program ever conducted, and it compared participating patients’ healthcare utilization 1 year following completion of the program versus patients with diabetes who did not participate. After controlling for variables, the findings were substantial: emergency department visits decreased by 110 per 1000 program member years, outpatient visits decreased by 2350 visits per 1000 member years, and patient return on investment was $3 for every $1 they spent on the online workshop.

The new data complemented the findings of a clinical efficacy trial for the program, published in JMIR in 2016. At the time, investigators found that patients who underwent the workshop had decreased their blood sugar (A1C) levels by a mean of 1.27% at 12 months, for those with an A1C≥9. Patients had also reported mean decreases in hypoglycemia and depression symptoms and, inherently, improvements in treatment adherence.

That last metric is one that Kaufman emphasized. Save for injectables, most diabetic therapies are relatively inexpensive. But when patients don’t see early results, they’re referred to combination doses and their expenses grow, without a significantly greater expectation for improvements set by physicians.

Public Health for the Individual

What Kaufman’s program provides is assurance for both patients and physicians. “Individuals need to follow the doctor’s orders,” he noted, “assuming that the doctor made the right diagnosis, and prescribed the right therapy.” Physicians similarly need to listen to their patients, as well as their network of providers—from nurses and dietitians, to social workers and psychologists.

“To be able to listen to that individual and identify the barriers they need help to overcome is critical,” Kaufman said. “It’s acknowledging that social and behavioral aspects are determinants of health.”

This is where Kaufman’s public health background shines. He knows better than most that, as difficult as good Wi-Fi reception is for low-income communities in flyover states, healthy food options are even more sparse. He also knows that tackling pediatric obesity rates takes the same approach as the lifestyle management program does to adults with diabetes; whereas adults rely on the authority of healthcare providers to improve their condition, children rely on the authority of their parents and schools to set the right example. Simple measures—a mother eating healthy during breastfeeding, a school not selling candy during lunch—can alter their future, Kaufman said.

The messages and lessons conveyed to patients in the program are simple enough—“Don’t bury the lead,” is how Kaufman pitches the healthcare provider’s job in BCBH-D—but the networks are complex, ill-defined, in need of far-reaching measures.

When Canary Health does reach patients, though, the results are real. $815 in saved healthcare costs and improved measures of self-management are not to be overlooked.

“I really think social and behavioral determinants of health are the issue,” Kaufman said. “They’re in your ecosystem, they’re in your environment. The presence of violence, the lack of good food, the inability to exercise, the use of drugs and tobacco. But they’re also key, the behaviors you pick for yourself.”

That’s how Kaufman improves the health of a population: one at a time.