The Clinicians' Guide to Diabetes Telemedicine

Chapter 4: Troubleshooting Telehealth

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

Problem: Loss of Connection

It happens. You are in the middle of a video visit and one of you loses connection.

Solution: Prep and Make Contingency Plans

  • Before your visit, test your equipment (speakers and camera) and your connection. Remind your patient to do so as well.
  • Turn off any notifications from other programs on the device you are using for the duration of your visit.
  • Check permissions for the video platform to use your camera and microphone.
  • If you are using Zoom, use only Zoom for Healthcare.
  • Be as close to your router as you can.
  • If you or your patient gets disconnected from a video visit, finish the visit via phone. You may want to communicate that plan at the beginning of the video visit so your patient knows what to expect.

Problem: Patient Resistance

Not surprisingly, most adults do not relish the opportunity to be on camera. Patients also worry that video visits will not deliver as much value as face-to-face visits.

Solution: Meet Your Patients Halfway

For camera-shy patients, suggest starting with video just long enough for you to do a quick physical exam and then they can feel free to turn off the camera.

The key to keeping up with virtual appointments is for patients to see the value in them, and the harsh reality is that the less engaged patients are in managing their diabetes, the less value they see in visits. You may have patients who have been doing visits less often than recommended because they are not getting their blood labs done, which means you do not have the data you need to get the most out of that visit. Helping them find convenient ways to get their labs done can give them incentive.

Problem: The Technology Gap

Beyond the occasional connectivity issue, there is a larger challenge for telehealth: the gap between what technology makes possible and what is possible for the majority of people with type 2 diabetes. Monitoring devices, apps, data sharing, and even video visits are of little use to people who are uncomfortable using technology and for those with severely limited resources and unreliable internet access.

For example, endocrinologist Elena Christofides MD, chief executive officer of Endocrinology Associates, Inc. and of Endocrinology Research Associates in Columbus, Ohio says she is well aware of the abundant new technologies enabling patient data collection. “But I have not been participating in any of that because it requires people to be desirous of telehealth, desirous of electronic monitoring, and type twos in particular are not willing to do so,” she says. This is because her patients in Columbus, Ohio, tend to be older, less technologically savvy, and more concerned about data privacy issues.

Solution: Recruit Family Members

Find out if the patient has family members or even caregivers who can attend video visits with them and assist in navigating the technology.

An added bonus of having a family member accompany your patient is that they can often fill in details about the patient’s situation and can better help manage the diabetes care.

Problem: CGM is Still Out of Reach Financially

CGM has long been seen as a tool mainly for people with type 1 diabetes. It can be very effective in influencing behavioral change for type 2 patients as well because the readings help patients see the effects of food and exercise on their blood sugar in real time, which helps patients prepare for their telehealth visits. Remote monitoring also helps physicians provide well-targeted care and can reduce in-office medical visits. Endocrinologist Disha Narang MD of Northwestern Medicine Lake Forest Hospital in Lake Forest, Illinois says this is why it is every bit as valuable for type 2 patients as for type 1. Her patients have told her, “‘Wow, this has been game changing because now I know how to eat to keep my blood sugar stable.’”

Unfortunately, it is hard to get insurers to cover CGM for type 2 patients, especially if they are not on insulin. Given all the other costs of diabetes care, paying out of pocket for CGM simply is not possible for many people.

This is changing, but oh-so slowly. The FDA has permitted expanded use of connective, non-invasive remote vital sign monitors through the pandemic emergency. Devices with FDA Breakthrough Device designation, like the FreeStyle Libre 2, have automatic Medicare coverage for four years once authorized.

But state Medicaid coverage for type 2 patients is still quite limited; it is either restricted (to minimum blood glucose daily testing requirements and / or insulin use) or not at all covered. According to a 2020 report, “Current Eligibility Requirements for CGM Coverage Are Harmful, Costly, and Unjustified,” 14 states do not even specify online whether or not CGM for type 2 is eligible for Medicaid.

Where Medicaid goes, so go insurance companies. Most of the largest private insurers either restrict CGM eligibility along similar lines or are not at all transparent about eligibility criteria. The authors lament that “it is certain that valuable clinician time and staff resources are wasted when clinicians take the time to prescribe CGM only to find that their patients are ineligible.”

Solution: Advocacy and Data

It is going to take data and advocacy (with legislators and insurers) to turn it around. The authors of the eligibility report mentioned above recommend comparing study subjects who achieve significant clinical benefit through CGM with those without. You can also underscore the potential savings from reducing incidence and severity of complications from diabetes. Collect stories from the research and from your own practice.

When Not to Use Telehealth

Virtual visits are an appropriate option for many kinds of routine care, but providers still need to use discretion in deciding if a patient would be better off coming in person, depending on how well they are controlling their diabetes, what medicines they are taking, and what complaints they are having.

The Future of Telehealth

“I think the cat is out of the bag, and there’s no way that we are going to not have telehealth moving into the future,” Dr. Christofides. Even after the pandemic, there will always be people who prefer telehealth, or at least want the option available for when they are unwell or other obstacles arise. Her patients who lack mobility post-surgery, for example, have been more willing to keep their appointments because video visits are an option.

Dr. Christofides envisions a hybrid practice, combining in-person and telehealth, “Because it allows me to accommodate many more patients that need more urgent visits in real time.” Telehealth is here to stay, she continues, but it will evolve. "Providers are reevaluating their priorities about what data they need for visits," she says. “I think patients are also going to be reevaluating their priorities for visits and what they expect from their providers.”

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