The Clinicians' Guide to Diabetes Telemedicine

Chapter 1: The Advantages in Using Telemedicine for Diabetes Treatment

Diabetes patients stand to benefit the most from telehealth because the built-in mechanisms for reminders and medication adjustments have the potential to enhance self-management

With Rachel Pessah-Pollock MD, Disha Narang MD, and Elena Christofides MD

Caduceus made of telemedicine iconography

Until very recently, telemedicine looked like the distant future, an emerging modality of care with great promise, but limited access. Then clinics and patients alike were lurched into that technological future whether they were ready or not. Now that so much infrastructure has been built in the past year, and so many of us have adapted, telehealth is here to stay.

As we step into this new phase of telemedicine, it is time to move from ad hoc solutions and use what we’ve learned so far (see our article, Telemedicine and COVID-19: One Year Later) to implement systems and best practices that will best serve patients and providers alike in the years to come.

One thing that has become abundantly clear is how essential telehealth has become for diabetes care. First, there is the vulnerability of the population. Between the comorbidities of the disease and other factors, diabetic patients are at greater risk for complications if they become ill. “For them, reducing that risk has been very important,” says Dr. Rachel Pessah-Pollack, an endocrinologist and clinical associate professor at NYU Langone Health in New York City. “But we also don't want to lose these patients to where they don’t get the care they need,” she adds. 

Telehealth integrates well into diabetes care because it relies heavily on diagnostics and patient management. Treatment can include a combination of:

  • Video or telephone visits
  • Text reminders
  • CGM systems
  • Bluetooth glucose meters
  • Patients uploading data to the cloud for doctors to review
  • Software that aggregates device data
  • Mobile apps that pair with diabetes health coaching services

Of course, that is under the best circumstances, with patients who have a certain level of comfort with technology. Still, endocrinologist Disha Narang MD of Northwestern Medicine Lake Forest Hospital in Lake Forest, Illinois says that telehealth use through the pandemic has revolutionized the way physicians treat patients in a virtual manner across all specialties. “I think it is been especially impactful for endocrinology because we are a lab specialty, and we're not doing procedures, so a physical exam is not always absolutely necessary,” she says. Dr. Narang has been able to accomplish most of her objectives through video or even phone visits, depending on the technology her patients have and are accustomed to using.

Once Dr. Narang has her image studies, lab work, blood sugar readings, insulin and medication dosing in front of her, she finds the process very efficient. “It is almost easier on both the patient and the physician, depending on the right situation,” she says. Now that continuous glucose monitoring is becoming a standard of care, her office can also download that data remotely. From there Dr. Narang is able to access the patient’s diet history through a phone or video call to determine if there is anything else going on or if she needs to adjust the patient's medication.

In a 2020 retrospective cohort study, telemedicine was found to be more effective in controlling glycemic index in diabetes patients than in-person medical appointments

For many years, researchers and doctors were looking to telehealth to better serve patients in hard-to-reach rural areas. The earliest studies date back to the 1990s, but a 2018 meta-analysis comparing clinical outcomes of telehealth and in-clinic care in the treatment of diabetes showed the potential benefits of remote care. In 19 randomized controlled trials (with 6294 participants) telehealth was more effective than in-person care in controlling glycemic index in diabetes patients. It was also found to be equally effective for improving total cholesterol and quality of life. Finally, it “showed promise” in lowering both systolic and diastolic blood pressure levels. 

Diabetes patients with higher HbA1c levels (≥9%) stand to benefit the most from telehealth because the built-in mechanisms for reminders and medication adjustments have the potential to enhance self-management among patients who are struggling with nutrition, exercise and medication adherence.

A 2020 retrospective cohort study showed that telehealth could benefit underserved populations as well. Medicaid patients referred to an endocrinologist before the implementation of eConsults were compared with those referred a year after the implementation. Only 138 out of 356 (37%) pre-eConsult referrals were completed, while 281 out of 469 (59.9%) referrals were completed once eConsults were implemented. The latter referrals were completed either by in-person visits or via eConsult; 194 (41.4%) did not require an in-person visit. Clinicians reported the eConsults sufficient as well. 32 out of 36 (89%) said they were satisfied with them, and 19 out of 36 (53%) did not feel like the process created extra work.

Once the infrastructure is put into place, telemedicine can make financial sense, too. A review of literature focused on cost effectiveness, also from 2018, found that using telemedicine for retinal screening was both beneficial and cost-effective for diabetes management. Telemonitoring and telephone reminders also proved to be cost-effective modalities of care.

For endocrinologist Elena Christofides MD, chief executive officer of Endocrinology Associates, Inc. and of Endocrinology Research Associates in Columbus, Ohio, the benefits to telehealth go beyond convenience. Patients will often have the support of family members during the visit. Plus, she is able to see her patients' living conditions. When she is concerned about a patient, seeing whether their home environment is a factor is “very, very useful,” says Dr. Christofides.

Dr. Narang appreciates the flexibility and efficiency that comes with telemedicine. With in-person visits, she says it takes 10 to 15 minutes to check in a returning patient and get their vitals, leaving only 15 minutes or so for her to talk with the patient. But with telehealth, Dr. Narang gets more time to work directly with her patients. It is also a convenient backup when inclement weather makes travel difficult or dangerous, she adds.

On the other hand, it can also be easy to do a very quick call if a patient has limited time or only needs a minimal amount of help. “On any given day I’ll get 20 to 30 messages, and if a patient is calling that their sugar level is high, they may live 45 minutes away and are not able to come in,” says Dr. Pessah-Pollack. But she can book that patient into her schedule for a telemedicine visit to adjust their medications that day rather than wait. “It is a more expeditious way that I’m able to connect with them,” she says.

Dr. Elena Christofides, chief executive officer of Endocrinology Associates, Inc. and of Endocrinology Research Associates in Columbus, Ohio says that while her office moved to all remote visits at the beginning of 2020, many of her patients were slow to warm to telehealth. “We had a lot of patients who refused to do it in the beginning,” she says. With time, Dr. Christofides noticed patients becoming more compliant with remote visits as they adjusted to them.  Now, many of them have grown to prefer remote care. “I now have many patients with diabetes that I've seen through telemedicine who are choosing to maintain contact with me in this way,” says Dr. Pessah-Pollack. “Because so much of diabetes care can be done through telemedicine, it is actually an ideal format for diabetes care.”

How do you set up a robust and resilient telehealth practice? 

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