Voice of the Diabetic

Voice of the Diabetic

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TALKING BLOOD GLUCOSE MONITORING SYSTEMS

by Ed Bryant

Photo: Portrait. Caption: 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 five

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 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

MONITORS. 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 EO609, FOR

METERS AND/OR ADD-ON VOICE SYNTHESIZERS, AVAILABLE FOR DIABETICS AT

LEAST LEGALLY BLIND. For information, telephone: 1-800-633-4227, and

ask for “Durable Medical Equipment.”

Highlights

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 new 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 completely new 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 an insulin vial identifier. If you use

Eli Lilly insulins, and they are new enough to be barcoded (January 2001

expiration date or later), 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 barcoded, or 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 makes 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, 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 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 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-$525, 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 8:00am to 5:00pm, EST,

weekdays. The NFB offers this meter for $475.

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 have advised Roche of this problem, but they have not yet rectified it.

2.) The Voice-Touch speech synthesizers, for the LifeScan

One Touch II or LifeScan Profile:

Myna Corporation, 239 Western Avenue, Bldg. A21, Essex,

MA 01929; telephone: (978) 768-3999.

Myna makes a pair of light, compact, convenient, and reliable

glucose meter speech modules. The two models are not interchangeable. The

Voice-Touch modules attach firmly to the meter, adding little bulk, and

forming a single reliable unit. There are no separate switches to remember;

the modules operate off the controls of the LifeScan monitor. The box is

capable of male or female voice enunciation. A Spanish-speaking Voice-Touch

is also available.

The Myna Corporation offers the Voice-Touch speech synthesizers for $225

for One Touch II or Profile, the LifeScan meters alone for $115 (One Touch

II or Profile). An optional AC adapter is offered, as is a carrying case,

$15 each. Myna's instructional cassettes and large-print instructions clearly

explain the speech modules, but do not describe operation of the LifeScan

glucose monitors.

The LifeScan One Touch meters and Voice-Touch speech synthesizers

are 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 8:00am to 5:00pm, EST, weekdays. The

NFB offers the combination (One Touch II meter plus voice module) for $309

(the lowest price for a talking glucose monitor in the U.S.), the voice

module alone for $189 (specify whether for One Touch II or Profile), or

the glucose meter alone for $120 (One Touch II) or $135 (Profile). An optional

AC adapter costs $12.

3.) The Digi-Voice modules, for the LifeScan Basic, One-Touch

II, 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. Voice boxes designed for the One Touch II will

not operate with the 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, and the Mini Digi-Voice

modules alone for $199 (9-volt battery) or $219 (with AC adapter). Remember

to specify which meter you own. They offer the LifeScan Profile glucose

monitor for $120. The One Touch II meter is no longer available; and though

they still can supply you a talk box for it, they report there has been

little demand for some time.

4.) 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: $169.95, or $299.95 with a new Profile

meter.

5.) The Diascan Partner talking glucose monitor: Formerly

offered by Home Diagnostics, Inc., of Ft. Lauderdale, Florida, is out of

production and unavailable, as are test strips for existing Partners.

Medicare

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 (EO609), 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. “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 II

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.

LifeScan Modifications

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. (Editor's Note: Thanks to Ann S. Williams, RN,

MSN, CDE, 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, and the other

attaches directly to the test strip holder. Both devices aid in proper finger

placement, and serve 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.

A Sure Drop made for the One Touch II will not fit the Profile, and vice

versa. The unit for the Profile appears well-made and easy to use. Both

units are priced at $24.95 each.

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. The Diabetes Action Network of the National

Federation of the Blind, a support and information network, welcomes your

input on blood glucose testing.

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