FEATURE ARTICLE

Use of Diabetes-Related Applications and Digital

Health Tools by People With Diabetes and Their
Health Care Providers
Kacie Doyle-Delgado and James J. Chamberlain

The proliferation of smartphones over the past decade a statement in 2011 to better define mHealth technol-
has led to the development of a seemingly endless ogies. The WHO adopted the mHealth definition used by
number of digital applications (apps) designed to im- the Global Observatory for eHealth in its worldwide
prove users’ health and fitness. This article addresses survey on electronic health: “medical and public health
the regulation of these apps and provides details about practice supported by mobile devices, such as mobile
the apps most commonly used by patients in the primary phones, patient monitoring devices, personal digital as-
care and diabetes settings. Those described in detail sistants . . . and other wireless devices” (8).
include the American Diabetes Association’s Standards
of Care app, apps for blood glucose monitoring and This year, the European Association for the Study of
tracking and continuous glucose monitoring, lifestyle Diabetes and the American Diabetes Association (ADA)
apps, a glucagon use app, prescription cost-saving apps, jointly published a consensus report on diabetes digital
and apps for do-it-yourself automated insulin delivery. app technology (9). Their report focuses on the role of
regulation in diabetes digital health apps, the accuracy of
The first Apple iPhone was released in June 2007, and the and clinical validation of diabetes apps, data on the safety
Apple App Store became available 1 year later, offering and efficacy of diabetes apps, and recommendations to
500 applications (apps). Worldwide, .3 billion people help resolve some of the deficiencies in the diabetes health
now have smartphones (1), and ~500 million people are app space.
using mobile apps for diet, exercise, and chronic disease
Diabetes apps focus on one or more diabetes self-
management (2). In 2019, there were 2.2 million apps
management tasks such as blood glucose monitoring,
available for Apple’s iOS operating system and 2.6 million
medication or insulin dosing, obtaining diabetes or
for Android smartphones (3), with .2 billion app down-
general health education, and tracking nutrition or
loads (4). Consumers worldwide spent $120 billion on apps
physical activity. The Association of Diabetes Care &
in 2019, including $1.5 billion on health and fitness apps,
Education Specialists provides an app review library
which was up 130% from 2017. One health app (Fitbit) was
(DANAapps.org) as part of its technology initiative. This
the sixth most downloaded app in the United States in
resource offers reviews from an independent organiza-
2019. There are now .40,000 health care apps available
tion, DHX Laboratories, which assesses apps on their
online from both the App Store and Google Play (5,6).
security and privacy, operability, usability, functionality,
The term mobile health (mHealth) seems to have first performance, data management capabilities, and the
been used by Robert Istepanian in 2005, who described quality of the behavior science behind the app. Quanti-
“emerging mobile communications and network tech- tative trust scores with direct links for app download are
nologies for health care” (7). With the explosion of health available through this platform. The data-sharing capa-
and fitness apps and their rapid increase in use worldwide, bilities of apps focused on glucose data may provide
the World Health Organization (WHO) decided to publish further insight in diabetes management, providing health

St. Mark’s Hospital and St. Mark’s Diabetes Center, Salt Lake City, UT
Corresponding author: James J. Chamberlain, [email protected]
The publication of this special-topic issue of Clinical Diabetes was supported by unrestricted educational grants to the American Diabetes Association
from Abbott Diabetes Care and Dexcom.
https://doi.org/10.2337/cd20-0046
©2020 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not
for profit, and the work is not altered. More information is available at https://www.diabetesjournals.org/content/license.

VOLUME 38, NUMBER 5, SPECIAL ISSUE 2020 44 9

DIABETES TECHNOLOGY FEATURE ARTICLE Diabetes Apps and Digital Health Tools

care providers (HCPs) with an easy way to visualize trials, cohort studies, or case-control studies on app-based
patterns to inform medication adjustments. Information interventions and their effects on health behaviors and
on the most widely used diabetes apps is provided outcomes. Apps are constantly being updated, and this
below (10). evolution limits the ability to carry out long-term, well-
conducted studies. There are also obstacles for clinicians
with respect to adequate education and training, as well as
Regulation issues with app accuracy, clinical validity, and quality of
The European Medicines Agency (EMA) and the U.S. Food information. Technological challenges such as interop-
and Drug Administration (FDA) are responsible for erability on Apple iOS or Android platforms, frequent app
pharmaceutical regulations for traditional health prod- updates and revisions, lack of standardization of infor-
ucts and software. In the European Union, the European mation, and variable shareability of data are additional
Commission regulates medical devices under the stan- barriers. Other concerns for HCPs include the endorse-
dards set by the E.U. Medical Devices Directive, and each ment or recommendation of specific apps by professional
member country maintains its national pharmaceutical organizations and the quality of data and privacy security
regulatory authority. The EMA classifies mobile apps as with app use.
medical devices if they are used “specifically for diagnostic However, there are also benefits of using apps in diabetes
and/or therapeutic purposes.” These apps include those care. Health apps allow PCPs to communicate about
used for diagnosing, preventing, monitoring, and alle- glycemic data and improve health outcomes and quality of
viating or treating disease (11). Devices that meet the care for their patients with diabetes in ways that were not
standards set by the Medical Device Regulation policy previously possible.
standards (more recent guidelines that expand those in
the Medical Device Directive) are given the CE (Con-
formité Européene) mark. This process has generally had Reimbursement
fewer obstacles compared with the device approval
There are financial incentives for spending time inter-
process of the FDA (12).
preting mobile app data. Interpretation of .72 hours of
In the United States, the FDA regulates medical devices continuous glucose monitoring (CGM) data collected via
and pharmaceuticals, including some medical mobile mobile app or receiver can be billed monthly using Current
apps. Higher-risk apps such as those that calculate insulin Procedural Terminology (CPT) code 95251 (16). Since 1
dosing are regulated by the FDA, whereas low-risk January 2018, the Centers for Medicare & Medicaid
medical apps that offer only diabetes support and health Services has allowed eligible practitioners to bill for re-
tracking are not regulated (13). Digital therapeutics, or imbursement for time spent interpreting and collecting
digiceuticals, are clinically validated health technologies health data generated by patients remotely. These data
intended to treat a medical or psychological condition, must be recorded and transmitted to the provider, with a
with a focus on improving clinical outcomes. These apps minimum of 30 minutes of time spent outside of the
require regulatory approval from the FDA similar to patient visit, and billed using CPT 99091 (17). Table 1,
prescription drugs (14). The FDA published a Digital which summarizes details of some of the most commonly
Health Innovation Action Plan with the goals of providing used apps for diabetes, includes information, where
clarity on medical software, launching a precertification appropriate, on specific costs and billing codes.
program for digital health technology oversight (referred
to as the “FDA Pre-Cert for Software”), and building
agency expertise. This action plan program offers a ADA Standards of Care App
pathway for the development and potential approval of The ADA first published its Clinical Practice Recom-
safe and effective, high-quality digital health tools (15). mendations in 1988. Now known as the Standards of
Medical Care in Diabetes, these guidelines are published
each January in the journal Diabetes Care and made
Apps in the Primary Care Setting available for free online (18). The Standards of Care is a
With the rapid expansion of digital health apps have come comprehensive guide to diabetes treatment, therapeutic
both potential benefits and challenges for primary care goals, and tools to evaluate quality of care. An abridged
providers (PCPs), who must be familiar with commonly version of the Standards of Care for PCPs is also published
used apps to advise patients with diabetes on their use of annually in the journal Clinical Diabetes and made
these products. There are limited randomized controlled available for free online (19).

4 50 CLINICAL.DIABETESJOURNALS.ORG
 DOYLE-DELGADO AND CHAMBERLAIN

TABLE 1 Summary of Diabetes Apps

App Platform* Type Cost Patient Benefits HCP Benefits
ADA SOC Apple/Android Medical care Free — • Full access to ADA
recommendations Standards of Care
• Online Web app
available
• Interactive tools for
evidence-based
decisions
• Quick access to the
summary of new
revisions to the
Standards of Care
• Classifications for
diabetes type and
special populations
OneTouch Apple/Android Glucose tracking Free • Wireless data pairing • Data sharing
Reveal • Glucose alerts • HCP reports
• Food, medication, and
activity tracking
My Sugr Apple/Android Glucose tracking Basic: free; premium: My • Wireless data pairing • HCP reports
Sugr PRO $27.99/year • Medication and • A1C prediction
subscription; coaching carbohydrate tracking
plans: $19.99–$399.99
iHealth Gluco- Apple/Android Glucose tracking Free; requires iHealth • Wireless data pairing • Data sharing
Smart Gluco-Monitoring System • Diet and activity tracking • Secure Cloud data
storage
One Drop Apple/Android Glucose tracking Basic: free; premium: • Wireless data pairing • HCP reports
$17.99/month digital- • Diet, medication, and
only membership; activity tracking
$30.99–$89.99 • Real-time decision support
membership with via personalized coach
digital plus glucose
meter and strips
Health2Sync Apple Glucose tracking Basic: free; advanced: • Manual glucose tracking/ • HCP reports
$2.99/month download with smart cable
subscription • Biometric tracking
• Food, medication, and
activity tracking
BeatO Smart/ Apple/Android Glucose tracking Free • Glucose meter connection • HCP reports
BeatO Curv via 3.5-mm audio jack/
charging port for data
pairing
• Option to connect with • Glucose trend
diabetes specialists analysis
• Activity tracker
• Link to diabetes-friendly
foods and products

Continued on p. 452 »

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DIABETES TECHNOLOGY FEATURE ARTICLE Diabetes Apps and Digital Health Tools

« Continued from p. 451

TABLE 1 Summary of Diabetes Apps (continued)

App Platform* Type Cost Patient Benefits HCP Benefits
Dario Health Apple/Android Glucose tracking $25–$70/month • Glucose meter connection • HCP reports
Diabetes subscription; covered by via 3.5-mm audio jack/
Management insurance for some charging port for data
pairing
• Tracks carbohydrates,
insulin, and activity
• Database of 500,000 food
items
• Emergency GPS location
services
• Proven glycemic
improvement for
hyperglycemia and normal
glucose (80–120 mg/dL)
for patients with type 2
diabetes
Glooko Apple/Android Data management and Free to individuals; • Multidevice compatibility • Remote patient
monitoring custom pricing for and integration (.100 monitoring
clinicians devices)
• Database of 500,000 food • HCP reports
items
• Diet and activity logging • Insulin pump,
insulin pen, CGM,
glucose meter, and
smart app integration
Dexcom G5/G6 Apple/Android CGM Free • Real-time alerts —
CGM • Severe hypoglycemia
prediction alert (G6 only)
• Rate-of-change alerts
• Data sharing
Dexcom Follow Apple/Android CGM Free • Real-time alerts for high, —
low, and urgent low (,54
mg/dL) glucose
Dexcom Clarity Apple/Android CGM Free • Time-in-range glucometric • Remote patient
data monitoring
• Comprehensive reports • HCP reports
with retrospective glucose
patterns and trends
• Data sharing with clinic • CPT code 95251 for
• Daily or weekly notifications reimbursement
via e-mail
• Connects with HCPs and
caregivers to seamlessly share
glucose information
• Food, insulin, and activity logging

Continued on p. 453 »

4 52 CLINICAL.DIABETESJOURNALS.ORG
 DOYLE-DELGADO AND CHAMBERLAIN

« Continued from p. 452

TABLE 1 Summary of Diabetes Apps (continued)

App Platform* Type Cost Patient Benefits HCP Benefits
FreeStyle Apple/Android CGM Free • Real-time glucose values • Remote patient
LibreLink updated every minute monitoring via
• Painless, 1-second scan to LibreView
see glucose value and trends • Standardlized AGP
• In-app reports with report with CGM
retrospective glucose trends metrics included in
and patterns, including Time HCP reports
in Target and Daily Patterns • CPT code 95251 for
(AGP) reimbursement
• Connects with HCPs and
caregivers to seamlessly
share glucose information
• Food, insulin, and activity
logging
LibreLinkUp Apple/Android CGM Free • Shareable with up to 20 —
followers
• Notifications include current
glucose and trend arrow
• Logbook of previous glucose
values
Medtronic Apple/ CGM Free; Guardian CGM • Real-time glucose data and • Data shared to HCP
Guardian Android-under prescription required alerts clinic
Connect development for use • Predictive alerts (60
minutes)
• Data auto-uploaded to
Medtronic CareLink
SugarIQ Apple CGM Free; Guardian CGM • IBM Watson analytics for —
prescription required pattern detection
for use • Personal insights based on
retrospective data provided
via text messages
Eversense Apple/Android CGM Free • Real-time glucose data and —
alerts
• Predictive alerts
• Temporary glucose profiles
and do not disturb mode
• Sharable with up to five
followers via Eversense
Now app
CGM in Apple/Android CGM Free • Real-time access to various • Remote patient
the Cloud/ CGM device data via monitoring
Nightscout personal website, smart
watch, or app for CGM
users and their followers
• All CGMs are compatible • HCP reports
with Nightscout • CPT code 95251 for
reimbursement
Tidepool Mobile Apple/Android CGM/multidevice data Free • Compatible with pumps, • HCP reports
management CGM systems, glucose
meters
• Insulin, CGM, carbohydrate • Secure and
data tracking with notes anonymous data
donation for future
research

Continued on p. 454 »

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DIABETES TECHNOLOGY FEATURE ARTICLE Diabetes Apps and Digital Health Tools

« Continued from p. 453

TABLE 1 Summary of Diabetes Apps (continued)

App Platform* Type Cost Patient Benefits HCP Benefits
Livongo Apple/Android Lifestyle support $73–$99/month • Real-time support from • HCP reports
subscription; typically diabetes response
provided by insurance specialists
plan • Health nudges: recipes,
tips, and articles
• Unlimited test strip and
lancet ordering via app
Apple Health Apple Lifestyle support Free • Glucose and medication/ • Streamlined health
insulin tracking data sharing
• Laboratory value storage • Patient portal linking
• Apple HealthKit-linked CGM with affiliated health
and glucose meter data care organizations
• Personal health data
storage
MyFitnessPal Apple/Android Lifestyle support Free • Database of 11 million food —
items
• Barcode scanner for
packaged foods
• Custom goals for weight loss
and exercise, with
community support
Calorie King Apple Lifestyle support Free • Database of 100,000 food —
items from 260 restaurants
and fast-food chains
Figwee Apple Lifestyle support Basic: free; advanced: • 8,000-item visual food —
$7.99/month diary
• Portion adjusting tool for
carbohydrates
Glucose Buddy Apple Lifestyle support Basic: free; advanced: • A1C and blood glucose —
$59.99 tracking
• Medication, weight, blood
pressure, and dietary
tracking
Meal IQ Android Lifestyle support Basic: free; premium: • Customized meal planning —
subscription TBA† based on diet, cost,
ingredients, and
macronutrients
• Linked to online grocery stores
Diabetes Apple/Android Lifestyle support Basic: free; premium: • Synchronized data from —
Connect $1.99/month; lifetime: multiple glucose meters
$26.99 • Insulin, exercise, vital sign,
and mood tracking
Diabetes M Apple/Android Lifestyle support Basic: free; premium: • Bolus and basal insulin • HCP reports
$4.99 calculators
• Glucose and food tracking
Beat Diabetes Android Lifestyle support Free • Basic education for users —
new to diabetes
• Information about
complications and
treatments
• Modern medicine and
Ayurvedic practices

Continued on p. 455 »

4 54 CLINICAL.DIABETESJOURNALS.ORG
 DOYLE-DELGADO AND CHAMBERLAIN

« Continued from p. 454

TABLE 1 Summary of Diabetes Apps (continued)

App Platform* Type Cost Patient Benefits HCP Benefits
Diabetic Diet Android Lifestyle support Free • Healthy eating guides —
• Audio lessons for healthy
eating and weight loss
Sugar Sense Apple Lifestyle support Free • Glucose, insulin, —
carbohydrate, weight, and
exercise tracker
• Step counter
• Estimated A1C
BlueStar Apple/Android Combination blood Free; requires access • Artificial intelligence– • Connected to HCP
glucose data code from employer or derived feedback team
management and health plan • Custom reports and • Access to diabetes
lifestyle support education care and education
specialists
• Wireless data pairing • Electronic medical
• Medication, food, sleep, record integration
exercise, and blood
pressure tracking
Glucagon Apple/Android Medication Free • Simulation for use —
management • Audible and visual
instructions
• Glucagon kit tracker
• Reminder notification
GoodRX Apple/Android Prescription cost- Free • Comparison of drug prices —
saving • Coupons for print or in-app
use
• Price tracking and alerts for
drugs and medical supplies
RxSaver Apple/Android Prescription cost- Free • Comparison of drug prices —
saving • Coupons for print or in-app
use
• “My Meds” list for coupons and
personal prescription list

*For specific compatibility details, check listing on app websites such as the App Store or Google Play. †Subscription plan still under development. AGP,
ambulatory glucose profile.

The ADA now also offers a Standards of Care app, based on a patient’s characteristics and preferences,
available from the App Store and Google Play. A Web app guidelines for diabetes screening in asymptomatic
is also available for online use (20). The app provides adults, and a tool for entering patients’ blood test
access to all 16 sections of the Standards of Care. results to help clinicians diagnose diabetes and
identify prediabetes.
In addition, it includes interactive tools that provide easy,
evidence-based decision support for HCPs. These inter- There is also a general information section providing quick
active tools provide recommendations for hypertension access to the summary of the latest revisions to the
treatment in patients with diabetes, drug class-specific Standards of Care. A comprehensive section on improving
information (i.e., efficacy; hypoglycemia risk; weight care and promoting health in certain populations also
change effects, cardiovascular and renal effects, cost, adds a tremendous amount of practical information for
route of administration, and other important clinical HCPs, including strategies for caring for patients with food
insecurity, homelessness, migrant or seasonal employ-
considerations), recommendations for glucose-lowering
ment, and language barriers.
medication selection based on a patient’s individual
clinical characteristics, practical advice for intensifying Finally, the app provides a thorough review of the clas-
from oral to injectable therapies, help setting A1C targets sification of diabetes, including type 1 diabetes, type 2

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DIABETES TECHNOLOGY FEATURE ARTICLE Diabetes Apps and Digital Health Tools

diabetes, cystic fibrosis–related diabetes, post-transplant blood pressure readings, daily activities (i.e., food, ex-
diabetes, monogenic diabetes syndromes (e.g., categories ercise, and medications), and weight (26). The app then
of maturity-onset diabetes in the young), diabetes from provides comprehensive statistical glucose information
pancreatic disease, and gestational diabetes. and blood pressure and weight trends. The app is available
from the App Store and Google Play.
Blood Glucose Meters and Glucose Tracking The BeatO SMART (for iPhone and Android) and BeatO
Several blood glucose meters with Bluetooth capability Curv (for Android only) meters connect to smartphones
are available that can connect and transmit data to a via the 3.5 mm audio jack or charging port. The data are
smartphone app. The OneTouch Verio Flex meter syn- then synchronized to the BeatO app available from the
chronizes data automatically to the OneTouch Reveal App Store and Google Play. The app provides glucose
mobile app, which is available from the App Store and trends and statistics, connects users with in-house spe-
Google Play. The app allows patients to track blood cialists, tracks fitness levels, and provides a digital store for
glucose averages; enter food, medication dosing, and diabetes-friendly food products (27). Patients’ data can
activity data; set personalized lifestyle goals; share their also be shared with family, friends, and HCPs.
data with others, including HCPs; get alerts for repeated Dario Health provides a meter that connects to smart-
high or low blood glucose readings; and integrate data phones via charging ports and synchronizes with the Dario
into the Apple Health app (21). Smart Diabetes Management app that is available on the
The Accu-Chek Guide, Guide Me, and Aviva Connect App Store and Google Play. This diabetes management
meters can all be paired wirelessly with the mySugr app, system requires a subscription, some portion of which may
also available from the App Store and Google Play. This be covered by insurance. (See Table 1 for specific cost
app allows users to enter diet and medication information, information.) The app records and tracks blood glucose
provides glucose analysis and motivational feedback, levels, carbohydrate intake, insulin and medication dosing,
shows predicted A1C, and can integrate information into and physical activity. It also provides a 500,000-item food
the Apple Health and Google Fit apps (22). library and provides global positioning system (GPS) lo-
cation identification in the event of a diabetic emergency
The iHealth Smart meter can be paired with the iHealth (28). Data can be shared with HCPs and others. The Dario
Gluco-Smart app, available from the App Store and system showed a reduction in high blood glucose events
Google Play. Similar to the other apps, this one provides (180–400 mg/dL) by 19.3% (from 28.4 to 22.9%) and an
statistical glucose data, allows users to enter diet and increase in normal glucose readings (80–120 mg/dL) by
activity information, and can export data to HCPs and 11.3% (from 25.6 to 28.5%) with use of the app during
family members (23). 2017 in 17,156 people with type 2 diabetes (29).
One Drop provides a Bluetooth-enabled glucose meter Glooko is a diabetes data management software platform
that synchronizes with the One Drop mobile app, available that is compatible with roughly 100 different diabetes
from the App Store and Google Play. The app tracks and devices, including glucose meters, insulin pumps, CGM
analyzes blood glucose data, medications, food, and systems, fitness apps, and smart insulin pens. Patients can
activity levels. Real-time decision support is provided download the Glooko Mobile app to a smartphone from
based on blood glucose readings, and personalized the App Store or Google Play. They can then synchronize
coaching is available to users. Data can be synchronized or upload devices to the mobile app to see data from
with many other health apps, including Apple Health, multiple diabetes devices in one place. They can log food
GoogleFit, FitBit, and Dexcom, among others (24). (See and activity data, and a 500,000-item food database is
Table 1 for specific cost information.) Use of the One Drop included. Patients can export reports to their HCP (30). In
system resulted in a 0.96% improvement in A1C levels HCP offices, compatible devices can be uploaded to a
among active users of both the app and a coaching computer (PC or Mac platform) using a synchronizing
program during 3 months in 93 patients with type 2 infrared or USB cable and Glooko Uploader software.
diabetes (25).
Many of these glucose-reporting apps and Web-based
Other apps allow patients to enter diabetes health in- reporting systems allow patients to export glucose reports
formation manually or connect to glucose meters via to their HCP or download reports from websites as PDF
audio jacks and charging ports but do not connect files that can then be incorporated into most commonly
wirelessly to meters. Health2Sync is an app that allows used electronic medical record (EMR) systems. This
patients to input information such as blood glucose and feature enables HCPs to look back with patients at

4 56 CLINICAL.DIABETESJOURNALS.ORG
 DOYLE-DELGADO AND CHAMBERLAIN

previous glucose statistics to assess progress and set current glucose and trend arrow and creates a logbook of
ongoing glycemic targets and other therapeutic goals. previous glucose levels (32).
Medtronic’s Guardian Connect app displays current
CGM Apps glucose with a trend arrow along with event markers and
glucose history. There are real-time alerts for high or low
Dexcom CGM mobile apps record interstitial glucose data
glucose with predictive alerts up to 60 minutes in advance.
every 5 minutes and allow users to set customizable alerts
Data are automatically uploaded to Medtronic CareLink
and share their data by inviting others to use Dexcom
Connect to be shared with HCPs. This app offers automatic
Follow to remotely track their glucose. HCPs can engage
text message alerts that allows patients to share their CGM
patients’ family members and caregivers by teaching CGM
alerts with up to five care partners. SugarIQ is a separate
users about these Follow features. Both the Dexcom CGM
associated app that uses IBM Watson analytics for
app and Dexcom Follow are also available for compatible
detecting patterns and provides real-time personalized
smartwatches. Dexcom offers separate apps for its G6, G5,
insights (33). This app allows Guardian Connect CGM
and G4 Platinum CGM systems, and are all available from
users to add meal choices. These features cannot be used
the App Store and Google Play.
for patients using the Medtronic 670G system; they are
Dexcom Clarity is an app for Dexcom CGM users that only available to patients using Medtronic CGM only.
allows them to review their glucose trends and patterns in
The Eversense app displays glucose sensor data from the
interactive reports that are available to share with their
Senseonics Eversense implanted CGM (implanted for up
health care team either by using a “share code” or by
to 90 days) every 5 minutes, along with rate of change
downloading and sending reports via e-mail. Data from
arrows and real-time and predictive alerts. Temporary
each user are continuously and automatically uploaded to
glucose profiles and a do-not-disturb mode are available
Dexcom Clarity from the Dexcom CGM app, and the
within the app. Up to five friends or family members may
Clarity app is compatible with all Dexcom CGM systems.
receive these data remotely with Eversense NOW (34).
The reports provide clinically relevant statistics with
suggestions for possible changes for both patients and CGM in the Cloud, also known as Nightscout, is a do-it-
HCPs. Reports can be viewed, saved, and printed for clinic yourself (DIY) open-source app that allows for real-time
use and CGM interpretation is billable (using CPT code access to CGM data via a personal website using Dexcom,
95251) under private insurers and Medicare. The Clarity Medtronic, or FreeStyle Libre CGM systems. These CGM
app sends users a weekly summary with glucometric data, systems are paired to Nightscout and allow any Web-
including average glucose, time in range, glycemic pat- connected device to display and view sensor glucose
terns, and trends. Patients can also quickly access their data (35).
data to view their average, time above range, time below
Tidepool Mobile is an open-source mobile app supported
range, hypoglycemia risk, and estimated A1C (called the
by public foundations, including the Juvenile Diabetes
“glucose management indicator”). They can add addi-
Research Foundation, the Goldsmith Foundation, and the
tional personal data such as information on exercise,
Leona M. and Harry B. Helmsley Charitable Trust. It
carbohydrates consumed, illness, alcohol intake, stress, or
allows users to upload data from their insulin pump, CGM
menstrual cycle (31).
system, and glucose meter in Tidepool Uploader at home
The FreeStyle Libre 14-day system offers a mobile app on Mac or PC platforms or in the clinic. Users may add
called LibreLink. This app allows users to scan their sensor context to track daily events such as meals and exercise, as
using near-field communication (NFC) to wirelessly well as personal notes from their phone, in a digital diary.
transmit data to NFC-capable smartphones for blood Tidepool Mobile may be connected to Apple Health for
glucose readings up to the past 8 hours as well as trend continuous data synchronization of CGM with other
arrows. LibreLink also allows users to track their food, health data. This platform prompts users to voluntarily
insulin, exercise, and other events. Users access their data donate their anonymized data and demographics securely
on the ambulatory glucose profile report to view their to help device makers and researchers develop new di-
average glucose, time in range, time above range, time abetes devices (36).
below range, glucose management indicator, and active
CGM time to self-adjust insulin therapy. FreeStyle Libre
LinkUp is an app for up to 20 family members or friends of Lifestyle Apps
FreeStyle Libre users to share sensor-recorded readings The Livongo mobile app monitors blood glucose by linking
from the CGM user. It remotely sends notifications with to its associated meter to provide personalized insight into

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DIABETES TECHNOLOGY FEATURE ARTICLE Diabetes Apps and Digital Health Tools

glucose patterns and offers real-time support and expert specific cost information.) The Diabetes Connect app
coaching from diabetes response specialists via phone call syncs glucose data from multiple devices into standard
or text message. Its reports are shareable with HCPs and glucose statistics. Users can input data on insulin doses,
caregivers. The app includes “health nudges” such as blood glucose, medications, exercise, moods, vital signs,
recipes, articles, and tips for improving glucose control. It and notes into the app (43). The Diabetes M app has a
can also store blood pressure readings and steps walked bolus dose calculator that can be used with an insulin
and allows users to order unlimited test strips and lancets pump or multiple daily injection insulin regimen. Its
directly from the app at no additional cost to patients. This logbook, food database, and basal insulin tracker can be
service is provided primarily by employers and contracted used to create detailed charts with reports that can be
through insurance plans, but it also sells monthly sub- shared with HCPs (44).
scriptions to individuals (37). (See Table 1 for specific
Beat Diabetes is an Android-only app geared toward
cost information.)
people with newly diagnosed diabetes. It provides in-
The Apple Health app comes pre-downloaded on formation about managing blood glucose, facts about
iPhones and other Apple devices and integrates data diabetes complications, and treatment strategies in-
from the user’s iPhone, Apple Watch, iPad, and third- volving modern medicine and Ayurvedic practices. It also
party apps. Apple device users can grant it permission to contains lists of best and worst foods for diabetes and
read and write data types to HealthKit, which allows for recommends a diet based on the American Heart Asso-
tracking carbohydrate intake, insulin use, blood glucose ciation diet (45).
levels, and previous laboratory test results such as
Information on healthy eating and weight loss for people
A1C. HealthKit has the capability of linking with many
with diabetes can also be found on the Diabetic Diet
glucose meters and CGM systems to store and track
mobile app. It may be useful for family members of people
glucose information over time, along with other per-
with diabetes, offering a straightforward and instructive
sonal health data. The app streamlines data-sharing
crash course via audio lessons and healthy eating guides
between patients and HCPs. Users can link Apple Health
(46). The Sugar Sense mobile app records blood glucose,
to securely access their patient portal at affiliated health
insulin, carbohydrates, weight, and exercise and also
care organizations (38).
estimates A1C based on these data. It uses a step counter
MyFitnessPal gives users access to its database of 11 and a nutrition log to provide more comprehensive health
million foods, allowing them to track nutrients by entering data (47).
their own recipes, reviewing restaurant menu logs, or
using a barcode scanner for packaged foods. They can
customize goals for weight and water intake, track ex- Combined Blood Glucose and Lifestyle App
ercise from other mobile apps, and connect to a social The BlueStar app by Welldoc, available from the App Store
network of users for community support (39). and Google Play, combines data and information on blood
The producers of the popular nutrition book Calorie King glucose, blood pressure, medication dosing, food, exer-
also offer a food database app by the same name that cise, and sleep. The app tracks and analyzes users’ in-
contains .100,000 foods from .260 restaurants and fast- formation using artificial intelligence–driven algorithms.
food chains (40). Figwee is a food visualization app that Messages from the app health team become more indi-
helps users determine macronutrient content in their vidualized for each user over time and are designed to
meals using the Figwee food library. Users match their prompt real-time action. On-demand diabetes education is
food to the visual portion tracker for information about also available to users. The app is integrated with .300
calories, fat, carbohydrates, protein, and micro- other apps, devices, and EMR systems (48). Users can only
nutrients (41). get the app by obtaining a code from their participating
employer or health plan and entering the code into the app.
The Glucose Buddy diabetes management app has fea-
tures to record and track A1C, blood glucose, medications,
exercise, blood pressure, and weight, as well as a car- Glucagon App
bohydrate food database. Meal IQ helps people with Eli Lilly released its glucagon mobile app for use on Apple
diabetes understand how certain foods affect blood devices in September 2012 and on Android devices in July
glucose. A premium version is available with advanced 2015. This app was designed for use by insulin users and
options and access to other health, nutrition, and exercise their caregivers, as well as HCPs. It is a tool that teaches
apps made by developer Azumio (42). (See Table 1 for glucagon injection technique, with a step-by-step,

4 58 CLINICAL.DIABETESJOURNALS.ORG
 DOYLE-DELGADO AND CHAMBERLAIN

interactive audiovisual tutorial featuring a simulation to (54,55). Detailed information for the required compo-
practice glucagon administration. The app allows for nents and instructions for building and using these apps
reminders to users to repeat the practice and preparation are available on their respective websites.
for glucagon use. Users can enter their glucagon kit
Although these automated systems do not currently have
expiration date and location of kit and get reminders for
reordering. The app also contains drug safety information FDA approval, there are ongoing efforts in progress to get
them, and their apps, approved. The FDA has safety
and indications for glucagon use, as well as a link to full
concerns about these apps being used by hackers to in-
prescribing information for HCPs. The app was last
terfere with insulin delivery, although there is little in-
updated in July 2018 (49).
formation to substantiate this claim.

Prescription Cost-Saving Apps Consumer demands for mobile phone control of insulin
delivery devices continue to increase (56). In 2018, the
The price of insulin for patients and health plans doubled
Diabetes Technology Society developed a consensus for
between 2012 and 2016, from $2,864 to $5,705,
cybersecurity and new industry standards known as
according to a report from the nonprofit Health Care Cost
DTMoST (Diabetes Technology Society Mobile Platform
Institute (50). Many patients with diabetes have looked
Controlling a Diabetes Device Security and Safety
for ways to reduce costs not only of insulin, but also of
Standard) to promote the safe control of diabetes devices
noninsulin diabetes drugs, glucagon, and glucose test
via mobile apps. The DTMoST addresses concerns
strips. Several commonly used prescription cost-saving
about malicious hacking and interruptions in device
apps have helped patients save significantly on their
connectivity (57).
medications and related costs. GoodRx and RxSaver are
two popular ones.

The GoodRx app is the number-1 free medical app Conclusion

available from the App Store and Google Play (51). It Mobile apps increase the accessibility of data for HCPs
allows users to search for drugs and supplies and compare because patients may access data from their smartphone
prices at .70,000 U.S. pharmacies. The app constantly even if they do not have their blood glucose meter with
gathers current prices and available discounts and provides them during clinic visits. New connected diabetes tools
users with anticipated costs from local pharmacies. GoodRx such as app-enabled insulin pumps, app-enabled CGM
coupons can save users up to 80% on prescription costs and systems, and smart insulin pens continue to become
can be printed from the GoodRx website or displayed to the available. The diabetes app space will thus continue to
pharmacy via the mobile app. The average GoodRx cus- change and develop with frequent updates and new
tomer saves $355/year on prescription costs (52). Patients products. Apps will become more customizable with
can also track prices and get automatic alerts on potential incorporation of machine-based algorithms to provide
savings for their specific drugs and supplies. customized treatment recommendations and remote
The RxSaver app by RetailMeNot is another popular pre- health coaching.
scription cost-saving app. It functions similarly to GoodRx in
that it allows users to search by drug name and compare FUNDING
prices at various pharmacies near them. The app then The articles in this special-topic issue of Clinical Diabetes were
provides a coupon for prescriptions offering up to 80% supported by unrestricted educational grants to the American
savings. Users can print coupons or show them to the Diabetes Association from Abbott Diabetes Care and Dexcom.
pharmacy via the mobile app. Patients can save their pre-
scription details in the “My Meds” section, making it easier to DUALITY OF INTEREST
access coupons and keep an accurate personal drug list (53). J.J.C. is on speaker’s bureaus for Dexcom and Eli Lilly. No other
potential conflicts of interest relevant to this article were
reported.
DIY Automated Insulin Delivery Apps
AUTHOR CONTRIBUTIONS
Some patients have built their own DIY apps for sensor-
Both authors researched the data and wrote and edited the
augmented pump therapy. These apps, such as Loop,
manuscript. K.D.-D. is the guarantor of this work and, as such,
OpenAPS/Nightscout, and AndroidAPS, work with an accepts responsibility for the integrity of the manuscript and
insulin pump or pod and real-time CGM system using a ensures that all statements in the manuscript are true to her
controller and an algorithm to automate insulin delivery knowledge.

VOLUME 38, NUMBER 5, SPECIAL ISSUE 2020 45 9

DIABETES TECHNOLOGY FEATURE ARTICLE Diabetes Apps and Digital Health Tools

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