by Ed Bryant
Includes photo of Ed Bryant.
As editor of Voice of the Diabetic, I am often asked about the relative strengths and weaknesses of the various voice-enunciation equipped home blood glucose monitors available today. As regular blood-glucose metering is tremendously important, and as new developments regularly occur, I periodically update and reprint this article.
There is no "best" talking glucose meter; no one monitoring system is ideal for everyone. Features, prices, convenience, and clarity of instructions vary. Although many companies make blood glucose monitors, and some of these display their results in large print, only four currently available meters allow voice enunciation, in which the device's voice synthesizer "speaks" the meter's instructions and test results.
I advise all new blood glucose monitor users, blind or sighted, and all those uncertain of their meter's operation, to obtain further instruction from their health care team, and I advise them to self-test in the presence of their doctor or diabetes educator.
MEDICARE PROVIDES COVERAGE FOR THESE MONITORS, AND FOR ADD-ON VOICE SYNTHESIZERS FOR THESE BLOOD GLUCOSE METERS. THEY ARE CLASSED AS "DURABLE MEDICAL EQUIPMENT," AND COVERED UNDER MEDICARE PART B. BE SURE YOU AND YOUR SUPPLIER FOLLOW ALL GUIDELINES FOR REIMBURSEMENT. THERE ARE TWO "SPECIFICATIONS" TO NOTE: EO607, FOR "NON-ADAPTIVE" METERS, AND (this is new) E2100, FOR METERS AND/OR ADD-ON VOICE SYNTHESIZERS, AVAILABLE FOR DIABETICS AT LEAST LEGALLY BLIND. For Medicare information (in English or Spanish), telephone: 1-800-633-4227, and ask for "Durable Medical Equipment."
My personal favorite is the Accu-Chek VoiceMate. This talking meter, which incorporates the proven Accu-Chek Advantage into a system designed and built by Roche Diagnostics, is the most advanced on the market today, and the easiest for a blind person to use. Its Comfort Curve test strip allows quick and reliable nonsighted placement of the blood sample. No more hanging drop of blood--just smear or dab it on; the strip sticks well out of the meter, and you just find the tactile cutout on the side. Even if you have fairly severe neuropathy in your hands, this feature should make it easy to find the blood placement spot. And blood never drips onto the meter--so there is far less need to clean it. Its voice is clear and understandable. The VoiceMate includes two unique features: A "code key" system for calibrating the meter to a new set of strips (no more numbers to punch in!), making this the only talking meter a blind person can calibrate without any sighted aid at all; and a talking insulin vial identifier. If you use Eli Lilly insulins, you can insert them into the special opening, follow the spoken directions, and the machine will tell you what type of Humulin insulin you have there. (If your insulins are not from Eli Lilly, the VoiceMate's other features will still be completely operational.)
The VoiceMate can be ordered through any pharmacist. Have your pharmacist contact Roche Diagnostics; telephone: 1-800-428-5076, and ask for catalog #2030802.
NOTE: For customer service department and meter user advice, in English or Spanish, you should call: 1-800-858-8072.
The LifeScan One Touch meters: The Profile, and the now-discontinued One Touch II, are often adapted to voice synthesis. Recently, the LifeScan Basic and SureStep meters became speech-capable as well. The three One Touch meters: Basic, II, and Profile use the same procedures, the same test strips, and feature the same detachable test strip holder. All require a "hanging drop of blood." All are accurate, but their operating drill may make them difficult for blind users. All three accept "talk boxes," but voice synthesizers designed for the One Touch II will not operate with the Profile or Basic, and vice versa. Note: The LifeScan SureStep, a very different type of meter, features a "touchable" test strip, and does not require a hanging drop of blood.
The "voice boxes," speech synthesizer modules that plug into the meter's data port and provide its voice, are not made by LifeScan, but by several competing firms, described below. These manufacturers have been producing voice units for the old One Touch II, and updated versions for use with the Profile, and now for the SureStep. If you already have a LifeScan One Touch II, Profile, Basic, or SureStep, no modifications are needed to allow use of the appropriate speech synthesizer. If you do not yet own a LifeScan monitor, shop around, as some pharmacies and major discount stores sell these glucose monitors substantially below list price.
Talking Glucose Monitors and Voice Boxes
1.) The Accu-Chek VoiceMate talking glucose monitor: Roche Diagnostics Corporation, 9115 Hague Road, Indianapolis, IN 46250-0100; telephone: 1-800-858-8072.
The Accu-Chek VoiceMate, developed in cooperation with Eli Lilly and Company, incorporates the Accu-Chek Advantage glucose monitor. The VoiceMate is small, portable, and weighs only 12.5 ounces. It contains a "bar code reader" to describe insulin type (Lilly insulins only). First offered for sale in 1998, the VoiceMate is supplied with a new type test strip, the Comfort Curve, which vastly simplifies the problem of blood sample placement. Very good audiocassette and large-print instructions are supplied (in English). Suggested retail $495.00-$525.00, available through your pharmacist. Spanish-language customer service is available. Purchase price includes a carrying bag with adjustable strap. The VoiceMate is also offered by the National Federation of the Blind (NFB), Materials Center, 1800 Johnson Street, Baltimore, MD 21230; telephone: (410) 659-9314.
Note: The Materials Center is open 8:00 am to 5:00 pm, EST, weekdays. The NFB offers this meter for $475.00.
The only weakness I have detected in this otherwise excellent meter concerns the lack of a "Not Enough Blood" warning. The VoiceMate cannot distinguish between not enough blood on the strip and a low blood glucose reading. This occurrence seems to be uncommon, and Roche advises "double-dosing" the test strip (applying a second drop of blood to the same strip within 15 seconds of the first) in such cases. You might find it beneficial to test in front of your doctor or diabetes educator, who can advise you if you are not getting adequate blood onto the strip. I advised Roche of this problem, some time ago, but they have not yet rectified it.
2.) The Digi-Voice modules, for the LifeScan Basic, Profile, and SureStep: Science Products, Box 888, Southeastern, PA 19399; telephone: 1-800-888-7400.
Science Products makes several versions of their robust and reliable Digi-Voice speech module: The big Digi-Voice Deluxe, and the smaller Mini Digi-Voice. Old voice boxes designed for the One Touch II will not operate with the Basic or Profile, and vice versa--and the SureStep requires its own! The Basic uses the same talk-box as the Profile. Be SURE to tell them WHICH meter you have--they will supply the correct synthesizer for it! The Digi-Voice modules connect to the meter by a 22-inch patch cord, providing audio output for its readings. Controls are simple; on the Deluxe a volume control knob and a toggle switch run the voice synthesizer, separate from the monitor's controls. The Mini's single button both turns on the voice box and adjusts the volume control, again, separate from the meter's controls. Readings are announced in a clear, somewhat military, male voice. Thorough cassette instructions explain the voice box and briefly cover the Profile meter, no large-print instructions are supplied. Science Products sells the Digi-Voice Deluxe module alone for $275.00, and the Mini Digi-Voice modules alone for $199.00 (9-volt battery) or $219.00 (with AC adapter). Remember to specify which meter you own. They offer the LifeScan Profile glucose monitor for $120.00.
3.) The LHS7 Module, a voice box for the LifeScan Profile: LS&S Group, P.O. Box 673, Northbrook, IL 60065; telephone: 1-800-468-4789.
The small and light LHS7 attaches to the bottom of the Profile glucose meter by means of a Velcro patch, and operates through the meter's controls. Two-position volume control (loud and soft); AC adapter included in purchase price. English-language voice only; no audiocassette or large-print instructions are provided. Cost: $185.95, or $299.95 with a new Profile meter.
As mentioned above, Medicare recognizes home blood glucose monitors as "Durable Medical Equipment," and coverage is provided for diabetics, under Medicare Part B. Glucose meters without audio output have one specification on the "Fee Schedule" (EO607), and glucose meters with voice synthesis, or add-on voice boxes for home blood glucose monitors, have another (E2100), available to diabetics who are at least legally blind. Be sure to use the correct specification, and to follow all guidelines for reimbursement. For further information, call Medicare's main telephone: 1-800-633-4227, and ask for "Durable Medical Equipment."
An Invitation to Manufacturers
Currently available "talk boxes" (speech synthesizers) make use of the same "data port" installed in the meter to allow interfacing with and downloading to a computer. For many monitors, the hardware is already in place, and adding speech compatibility should be a simple process. The National Federation of the Blind urges manufacturers to go the rest of the distance, and make talking versions of their monitors available to those diabetics who need and want them. NFB Resolution 97-12 (adopted at the 1997 annual convention in New Orleans, Louisiana) calls on monitor manufacturers to make their meters speech-compatible.
Hints and Tips
If an insufficient amount of blood is placed on the test strip, the test will not take place, or the results will be inaccurate. Most meters will indicate "not enough blood." You may even have to prick your finger again! There are several possible explanations for this frustrating occurrence:
A. The initial drop of blood was too small: Some folks don't bleed enough.
They can get more blood by holding hands below waist level for about 15 seconds, shaking them, and/or washing/soaking hands in warm water for a few minutes before the test. Warm water stimulates the flow of blood to the fingers. A slightly longer lancet, with deeper penetration, may help some. (Are you using the shortest lancet? It may not be appropriate for you.) "Milking the finger" (squeezing it gently) can also help, as can wrapping a doubled rubber band between the first and second joint of the finger to be lanced. This will help cause the finger to become engorged with blood. Hold the rubber band down with the thumb while lancing. Remove the band as soon as you lance.
Doctors and diabetes educators who treat heart patients have noted that "prophylactic aspirin therapy," an enteric-coated aspirin a day to thin the blood and reduce risk of a heart attack, may make it easier for their diabetic patients to obtain a blood sample. If you are a "difficult bleeder," the same therapy with enteric-coated aspirin might help you, too. Be sure to talk to your primary-care doctor about aspirin, and to your eye doctor as well, because blood thinners like enteric aspirin can increase the risk of retinopathy.
B. There may have been enough blood, but it was placed onto the wrong part of the test strip (i.e."You Missed"): Some folks bleed fast, and may lose the blood off the finger before they're ready. By the time they get the finger to the test strip, the blood has fallen in the wrong place. A fast bleeder needs to work closer to the test strip, and perhaps to employ one of the blood placement aids discussed in this article. Users of the LifeScan SureStep should try bending up the tail of the test strip as an aid to location and placement. If you are new to your meter, I suggest you test in front of your diabetes educator, or someone familiar with your meter--perhaps there is some part of the drill you could do better.
C. Some enthusiastic people, placing the blood on the strip, press down too hard and push the blood out of its correct position, squishing it onto the wrong part of the strip: If you use the LifeScan One Touch meters, II, Basic, or Profile, it is best to very gently deposit a hanging drop of blood onto the test strip. Marla Bernbaum, MD, writing in The ADEVIP Monitor, offered the following suggestion, pertinent to diabetics with severe neuropathy (who wouldn't feel the otherwise painful fingertip "stick" she discusses here):
I have discovered another way to apply blood to the LifeScan test strip, which has been useful for several of our patients. This method allows them to stick the tip rather than the side of the finger. We use the same platform modification [described below], with a dot of Hi-Marks or T-shirt paint on each side of the strip guide near the depression where the blood is to be applied. For this approach the meter should be turned sideways. The patient can then place the pad of the finger on the raised dot perpendicular to the length of the strip and rock the finger forward so that the tip of the finger lines up with the depression on the strip and deposits the blood droplet in the appropriate place. This method increases the portion of the fingertip that can be used, and is preferable for some patients, particularly for those who bleed slowly and therefore must place the blood drop in precisely the right location.
If you use any of the LifeScan "One Touch" series glucose meters, some blood placement problems can be solved by modification of the Test Strip Holder (LifeScan Part #043-123, and note this same part fits all LifeScan "One Touch" meters). The idea is simply to provide tactile locating aids for finger location and placement of the blood sample on the test strip. A raised dot on either side of the test strip will work for some, but diabetics with limited sensation in the fingertips may find a U-shaped guide more useful. Most diabetics puncture the side of a fingertip, but those with severe neuropathy, who can't feel the lancet, and who prick the center of the fingertip, may be helped by the U-shaped guide. With practice, and the use of such tactile cues, blind diabetics can correctly place blood samples on the test strip. (Note: Thanks to Ann S. Williams, R.N., M.S.N., C.D.E., for providing the modified LifeScan Test Strip Holders mentioned here.)
The Test Strip Holder is detachable, and modifications as described will in no way interfere with the operation, accuracy, or cleaning of the LifeScan meter. LifeScan's Technical Services Department (phone: 1-800-227-8862) will provide a spare Test Strip Holder upon request, without charge. It is recommended that the modifications be to this spare.
The dots and U-shaped ridge were created with T-shirt paint, of the type that stands up sharply from a fabric surface. Upon application, the paint spreads a little, so apply sparingly. Best results come from "tack-painting," applying a small amount, then letting it dry (minimum 12 hours), with subsequent applications to build up the height. Practice first on some other material (posterboard or paper plate), as the paint can come out quickly. Be sure to have the Test Strip Holder OFF THE METER when applying the T-shirt paint. For best results, insert a test strip in the holder as an aid to placement of the dots or U-shaped ridge. T-shirt paint is inexpensive and is available at most craft and fabric stores. Although a full spectrum of colors is available, bright, contrasty colors like orange may aid in low vision situations. Brands and types vary; find one that gives you a nice hard tactile ridge. Some paints feel too rubbery. "Puffy paint" flakes off too easily. You may have to experiment.
Several vendors offer commercial alternatives to modifying the test strip holder. One slips over the LifeScan meter. This device aids in proper finger placement, and serves to guide the drop of blood more surely to the test strip. Science Products (address above, telephone: 1-800-888-7400), makes the Sure Drop, which slips over the body of the meter. The special Teflon-like coating on the surface of the device helps direct the blood, but can be damaged by bleach or a hard brushing--clean with mild soap and warm water. The unit appears well-made and easy to use. Price: $24.95.
I have discussed the strengths and weaknesses of the blood glucose monitoring systems with voice enunciation currently manufactured. This evaluation should help blind diabetics and those losing vision, who are just as capable as the sighted of independently testing their blood sugar levels, and performing all the other tasks of daily diabetes self-management. Both blind and sighted diabetics are encouraged to consult with their health care team, and with individuals experienced in use of glucose monitoring equipment.
Choosing the most appropriate home blood glucose monitor is an important step in diabetes self-management. As blind diabetics increase their participation in the mainstream, efficient glycemic control is needed to maintain good quality of life. As new companies and inventors grapple with the problem of talking blood glucose monitoring systems, we should see steady improvement in this equipment. The Diabetes Action Network of the National Federation of the Blind, a support and information network, welcomes your input on blood glucose testing.
Voice DISTRIBUTORS NEEDED
Since the Voice is now offered free, our Diabetes Action Network will provide extra copies to anyone wanting to help spread the word. We will gladly send from five to five hundred-plus copies each quarter to be used as free literature. Medical facilities can order as needed for patients. Individuals can usually place copies of the Voice in libraries, pharmacies, hospitals, doctors' offices, or other public locations.
Diabetes education is essential. Anyone who distributes the Voice will be helping people with diabetes, and their families, to learn about the disease and its ramifications; to learn that they have options; and that their world is far greater than whatever "limits" may be imposed by the disease. If you would like to help spread the word by distributing the publication, please contact: Voice of the Diabetic, 1412 I-70 Drive SW, Suite C, Columbia, MO 65203; telephone: (573) 875-8911; fax (573) 875-8902. NOTE: Please provide a phone number so we can reach you.
MEDICARE REFERENCE CODE CHANGE
Medicare has very specific "code specifications" for the various medical devices it will fund. For proper reimbursement, you need to use the correct number. There have always been two such "reference codes" for glucose monitors: EO607 for conventional glucose monitors, and EO609 for talking glucose meters, or talk boxes for existing meters. This second number has been changed. For purchase of a talking glucose monitor, or voice synthesizer for a glucose monitor, the correct specification is now E2100. Don't use EO609 anymore.