MON-674 - Implementation and Early Evaluation of A Longitudinal Digital Care Framework Integrating Clinical Intake, Continuous Monitoring, and Multidisciplinary Lifestyle Intervention for Type 2 Diabetes

Background: Care for people with type 2 diabetes (T2D) is often limited by fragmented outpatient workflows, poor monitoring between clinic visits, and limited time for clinicians to provide lifestyle counselling and motivation. Digital care frameworks that combine structured intake, continuous monitoring, and team-based lifestyle support may improve continuity of endocrine care.


Objective: To describe the study design and early system validation of a longitudinal digital care framework intended to support coordinated T2D management before, during, and after clinic visits.


Methods: A prospective controlled study has been designed to enroll adults aged 18 years or older with established type 2 diabetes (T2D). The digital care framework includes three main components: (1) a pre-visit digital intake that collects symptoms, wearable data, and medical history to automatically assign risk levels; (2) AI-supported clinical documentation and patient triage with clinician review; and (3) post-visit lifestyle support that provides personalized nutrition guidance based on glucose and wearable data, real-time diet tracking, medication reminders, and structured physical activity programs delivered by a multidisciplinary care team including a nutritionist, fitness consultant, and nurse practitioner.

Continuous glucose monitoring data are used to identify glucose elevations in real time and trigger food-based self-management guidance. The primary clinical endpoint will be change in HbA1c at 6 months. Secondary endpoints include changes in body weight, cardiometabolic indicators, patient engagement, and safety outcomes including hypoglycemia events, inappropriate AI-generated recommendations, and clinician override rates.


Results: During system validation and workflow testing, the risk classification module achieved an overall accuracy of 96.4% and correctly identified 97% of high-urgency cases. For emergency-level cases, the system achieved 97% precision and recall, ensuring critical cases were not missed. For urgent cases, recall was 80%, with most errors reflecting conservative over-triage, which aligns with clinical safety principles.

The framework supports real-time tracking of symptoms, glucose trends, physical activity, and adherence data within the care workflow. Clinicians reported improved visit preparation and easier access to longitudinal patient information. No safety issues were identified during system validation.


Conclusion: This study design and early validation support the feasibility of deploying a longitudinal digital care framework integrating clinical intake, continuous monitoring, real-time nutrition guidance, and multidisciplinary lifestyle support for outpatient T2D management. Ongoing prospective evaluation will assess its impact on glycemic and metabolic outcomes.

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