This Index of ten European countries shows, positively, a broad engagement with the fundamental digital health policies necessary to support digital diabetes care, including the presence of underlying eGovernment and eHealth plans, the utilisation of electronic health records, and the presence of national diabetes policy. However, to enable digital diabetes care at scale, changes may be needed to key enablers of access to digital diabetes tools: reimbursement pathways; guidance and diabetes plans; assessment and evaluation processes and training in digital diabetes tools.

Ensuring that people with diabetes can access digital diabetes tools that could improve their lives is the ultimate goal
Reimbursement decisions act as de facto guidelines and can influence which digital tools are used in practice. Established digital tools such as real-time glucose monitors, flash glucose monitors and insulin pumps are widely reimbursed. However, newer digital tools such as closed-loop insulin delivery systems, smart phone applications and smart insulin pens are reimbursed in less than half of the included countries. The role of reimbursement decisions in enabling the use of digital diabetes tools and therefore determining what digital tools are used, underscores the need for a rigorous, but evolving approach to evaluating new technologies arriving on the market. Such policy also needs to recognise the specific value that digital tools provide beyond simply digitising once analogue tasks. Reimbursement is the only incentive to encourage the use of digital diabetes tools in half of the included countries, therefore it is also important that reimbursement is set at a level that incentivises this change in practice and does not have a negative financial impact for healthcare providers.

Thinking beyond reimbursement could provide a new way to fund innovative technologies. The Index found no evidence of alternative ways of funding access to digital tools, beyond traditional reimbursement. Payment methods that reward and encourage innovation, such as risk-sharing models (or value-based contracts) have been adopted by payors and pharmaceutical manufacturers to fund innovative pharmaceuticals. There may be scope to adapt these approaches to digital diabetes tools, to improve access by enabling a new way of recognising their value.

National diabetes plans and guidelines should provide specific recommendations about digital diabetes tools. Clinical guidelines can harmonise best practices, quicken the diffusion of new evidence and tools into clinical settings, and reduce variations in care quality. The Index has found that only four countries explicitly include recommendations or guidance on implementing digital diabetes tools in practice. As the number of available digital tools increases, a lack of integration into guidelines may limit the uptake of effective innovations. Clinical guidance will also be critical if trends continue towards the integration of digital diabetes tools into broader health information systems. This lack of guidance may impact on access to digital tools for people with diabetes, as healthcare professionals may not be aware of them, feel confident in using them or understand the advantages of using digital diabetes tools.

Digital tools have been integrated into existing health technology assessment processes used for medical devices and general reimbursement pathways, but are these fit-for purpose? There is a need to reflect on whether HTA is the best way to evaluate digital diabetes tools, or whether different approaches could better evaluate the value of digital diabetes tools to all stakeholders. Many of the advantages of digital diabetes tools are not as easily measurable as clinically-defined outcomes, for example how do you measure the value to a person with diabetes of feeling better able to manage their own condition?

Digital diabetes training for health professionals is not yet comprehensive, which may be a lost opportunity to raise awareness and uptake. Healthcare professionals are key stakeholders in the digital diabetes landscape as trusted advisors to people with diabetes. Digital health is covered in initial health sciences training, but diabetes-specific training is lacking in specialist training for GPs, endocrinologists and diabetes nurses. There is widespread coverage of digital diabetes training in on-going, post-qualification training; however, this topic will be competing with others for healthcare professionals’ continuing professional development time and budget. Training plays a key role in ensuring that relevant healthcare professionals are aware of digital diabetes tools, understand their value and feel confident in using and recommending them to their patients.

What else is needed?
Diabetes is a major challenge for the European region, with an estimated 59 million people affected. Diabetes is a promising domain for the application of digital technology which can improve communication between healthcare specialists and people with diabetes, support self-management and monitoring, and ease communications between different specialisms involved in treatment. Stakeholders can, by working together, leverage the power of currently existing and future digital technologies by ensuring the right regulatory frameworks, incentives and support mechanisms, and education levels. In so doing they can greatly support people with diabetes, healthcare providers and health systems in responding to diabetes.

Insights from experts have highlighted the role of financial structures and policy in the form of clinical guidelines and diabetes plans in guiding clinical practice, which in turn impacts on access to these tools for people with diabetes. This emphasises the importance of ensuring that a solid policy foundation is in place to facilitate access to digital diabetes tools. Future work could evaluate the gap between policy and implementation in further detail to explore the impact on access to digital diabetes tools.

Covid-19 has brought a welcome engagement with digital technology but this has been uneven and new tools and platforms need to integrate the views and needs of users. Experts warn that use of digital health technology during Covid-19 has not been equal, with some users and healthcare professionals more engaged than others. Platforms have also been rolled out quickly. Going forward, any new technologies that become routine need to integrate the views of people with diabetes in terms of user-friendliness, access, benefit and data privacy/protection.