Telemedicine and Diabetes Care
Telemedicine is looking to radically change your doctor visits
At 300 pounds, Chris Burke knew he needed to lose weight. He’d been diagnosed with type 2 diabetes in 2005 and promptly did everything his doctors asked of him. Initially, that meant following a diet and exercise regimen, along with taking daily doses of metformin. Eventually—as his condition worsened and he became insulin deficient—that meant giving himself injections of insulin up to seven times a day. But his blood glucose levels remained dangerously high.
After two years of trying to manage his diabetes, he was up to 425 pounds and his blood glucose levels were three times the norm. In 2007, he was hospitalized with diabetic ketoacidosis (DKA), a life-threatening condition in which extreme high blood glucose, along with a severe lack of insulin, results in a toxic buildup of blood acids known as ketones.
“No one could figure out why I wasn’t responding to the medication even though I was doing everything I was supposed to,” says Burke, 35, who lives with his wife and four children in the tiny town of Portales, New Mexico. In 2014, he had all but given up when a nurse at the local clinic where he received medical care told him about a team of specialists in Albuquerque who focused their efforts on treating stubborn cases of diabetes like his. But Burke, who didn’t have a car, had no way of making the 3½-hour trip to Albuquerque. He didn’t need to, the nurse explained. He would receive care by way of telemedicine.
Once a week, Burke’s primary care doctor would consult a team of diabetes specialists at the University of New Mexico School of Medicine through videoconferencing and then apply their recommendations during Burke’s regular appointments in Portales. Figuring he had nothing to lose, Burke agreed to give it a try.
Not to be confused with telehealth, which tends to encompass health-promoting technology such as fitness bracelets and apps, telemedicine involves using technology in the name of improving a patient’s clinical health status, according to the American Telemedicine Association.
“Telemedicine runs the gamut from something that feels very much like an office visit, but you’re in your home, to something that feels like a monitoring program,” says Joseph Kvedar, MD, vice president of Connected Health Partners Healthcare Inc. in Boston, and the author of The Internet of Healthy Things. That can mean downloading software to your computer (think Skype, but with added security to protect your privacy) for a face-to-face virtual visit with your doctor, texting or e-mailing your blood glucose readings to a licensed health care provider using a digital health care service (such as Livongo or WellDoc) for review, or even something as simple as using your doctor’s patient portal to access lab test results or ask follow-up questions.
Telemedicine can also mean, as in Burke’s case, using videoconferencing to connect specialists at teaching hospitals with primary care doctors in rural areas such as Portales, New Mexico.
Endo ECHO, the program that has benefitted Burke, was launched in 2014 by the University of New Mexico School of Medicine as a way to help local doctors better treat people with complex diabetes and other endocrine disorders who have limited access to an endocrinologist and rely on Medicaid to pay for health care. Once a week at the university, a team of health care providers—including two endocrinologists, a nephrologist (who specializes in kidney disease), psychiatrist, pharmacist, and certified diabetes educator, among others—gathers around a U-shaped conference table in front of two giant flat-screen TVs. One by one, the faces of local doctors in rural New Mexico appear, and they share their most complex cases with the ECHO team.
“Instead of connecting the provider with a patient, which is the traditional telemedicine model, we’re working to build capacity for more patients to receive specialty care in the communities where they live,” says Matthew Bouchonville, MD, CDE, medical director of Endo ECHO and associate professor in the Division of Endocrinology, Diabetes, and Metabolism at the University of New Mexico School of Medicine. In other words: The Endo ECHO team equips a doctor with what he or she needs to know in order to treat not only an individual patient, but also others who need similar care.
Imagine a wheel: “Specialists are at the hub, and the spokes are all primary care clinicians and other health care workers,” Bouchonville says. “Knowledge is being shared, so that a large number of participants are able to then provide care that they previously wouldn’t have felt comfortable delivering.”
Endo ECHO is a good example of just how quickly technology is transforming medical care. Since launching four years ago—as an outgrowth of the Extension for Community Healthcare Outcomes (aka Project ECHO), which treats more than 55 complex conditions—the program has spread to five other medical centers across the country, including Robert Wood Johnson Partners, the University of Nevada–Reno School of Medicine, and the University of Kansas Medical Center.
The Diabetes Connection
“Diabetes is the perfect medical condition to manage virtually because [telemedicine] allows people to connect more frequently with their health care providers,” says endocrinologist Martin Abrahamson, MD, associate professor of medicine at Harvard Medical School and codirector of the Division of Continuing Education at Beth Israel Deaconess Medical Center in Boston. “In our current system, a patient sees a health care provider, if he or she is lucky, once every three months.”
Although research is limited, studies show that telemedicine has the potential to significantly affect blood glucose levels in people with type 2 diabetes. For instance, an analysis of six studies published in 2015 in the Online Journal of Nursing Informatics found that people with diabetes who used some form of telemedicine not only lowered their A1C levels but also saw decreases in blood pressure, LDL (“bad”) cholesterol, and weight.
Research published in 2017 in JAMA Internal Medicine found that using telemedicine in a primary care doctor’s office—in other words, using technology to connect one clinic with another—can improve screening rates for diabetic retinopathy. Here’s how: In primary care clinics throughout Los Angeles, retinal screening cameras were set up so that people with diabetes could be examined for diabetes-related eye damage after their primary care checkup, rather than wait months to see an eye care specialist. Specially trained medical assistants and nurses took photos, then sent the digital images to optometrists who analyzed them. If the photos revealed damage, the patients were sent to eye doctors. Waiting times dropped by almost 90 percent—that’s important since vision loss can be prevented with early screening and treatment—and screening rates increased by 16 percent.
Meet and Greet
With telemedicine, you can meet virtually with your own health care provider if he or she is equipped with the technology to do so. You can also meet with a doctor who’s on call by going online and logging onto a health system that’s tied to your employer or a digital health care service such as Teladoc, MDLive, or American Well. Something to keep in mind: Physicians and other health care providers delivering telemedicine must be licensed in your state.
Phoning It In
Worried that in-person doctor visits will go the way of dial-up Internet? Know this: Telemedicine is meant to complement in-person care, not replace it, say experts. In fact, a study in PLOS One found that a combination of telemedicine and usual in-office care resulted in improved blood glucose management and reduced weight in people with diabetes. “Doctors’ offices will never disappear, because certain things require human touch and a physical examination,” says David Klonoff, MD, FACP, clinical professor of medicine at the University of California–San Francisco and medical director of the Diabetes Research Institute at Mills-Peninsula Medical Center in San Mateo, California.
The reality is that virtual doctor visits still aren’t widely available. Part of the reason for that has to do with insurance reimbursement, says Abrahamson. Although more than half the states in the country have passed laws requiring coverage of telemedicine, “many doctors aren’t willing to invest in the technology until reimbursement is more common,” he says. Right now, people who live in rural areas have the greatest number of telemedicine options. That’s because insurance coverage tends to favor beneficiaries who live in rural and other medically underserved areas, as defined by Medicare (see “Telemedicine: Is It Right for You?” below).
“Although there aren’t many people receiving it, the number using telemedicine is increasing by a high percentage every year,” says Klonoff. “It’s changing faster than anything we’ve ever seen before.” How fast? According to 2017 research conducted by Healthcare Information and Management Systems Society, more than 70 percent of health care providers are using telehealth or telemedicine tools to connect with patients, up from 54 percent in 2014.
Chris Burke can understand why. When his primary care doctor shared the details of his case with the ECHO team in Albuquerque, they reached a consensus: Burke, who initially used a pen before switching to a syringe to give himself insulin injections, wasn’t getting the insulin he needed; they suggested his primary care doctor have him switch to a longer needle. “That immediately started bringing my numbers down, which got me feeling better, so I was able to step up my exercise and start losing weight,” he says.
With the improvements to his health, he was in a position to consider metabolic surgery. Now, two years after surgery, Burke is down to 236 pounds and his diabetes is in remission. “Portales is remote and it’s small—you don’t have options, you just have what’s there,” he says. “You have to travel at least 100 miles to really get options.” With the help of telemedicine, he had options—minus the commute.
Telemedicine: Is It Right For You?
Research suggests that more than 70 percent of health care providers are connecting to their patients with the help of both telehealth and telemedicine tools. Before you ask your doctor about options available to you, consider the pros and cons.
1. Access to Quality Care
If you have diabetes and live in a rural area, telemedicine is the great equalizer, bridging the geographic gap between you and health care access and making it possible to get the same standard of care as those who live near specialists in urban areas. Plus, “you’re connecting to [your provider] more frequently,” says Martin Abrahamson, MD, associate professor of medicine at Harvard Medical School and codirector of the Division of Continuing Education at Beth Israel Deaconess Medical Center in Boston.
The commute to a laptop or webcam in the next room is a lot faster than the one to your doctor’s office across town. It also eliminates the need to take time off from work. “It’s more convenient for you to connect when and where you need to versus having to travel somewhere, sit in a waiting room, then get five minutes with your health care provider,” says Joseph Kvedar, MD, vice president of Connected Health Partners Healthcare Inc. in Boston. “Whether it’s having a phone conversation about monitoring data, an exchange by e-mail, or a video chat—they’re all designed to make life more convenient for the patient.”
3. Cost Reduction
Research in a 2013 issue of Diabetes Spectrum found that people with diabetes who live in remote areas can dramatically reduce their need for urgent care and hospitalization by using telemedicine. Why? Better communication with a health care provider can make it easier to successfully manage diabetes. Translation: less money spent on hospital stays.
1. Spotty Insurance Coverage
Connecting with your health care provider in real time is usually a requirement for reimbursement. For Medicaid beneficiaries, all but two states offer some form of reimbursement for telemedicine services. Medicare currently covers beneficiaries in rural areas where there is a shortage of health professionals (go to hpsafind.hrsa.gov to see if your area qualifies), and only if care is received in a qualified hospital, doctor’s office, or clinic. In most states, private health insurance policies are required to provide coverage, but the approaches to doing so vary widely.
2. Less-Personal Care
You’re sacrificing so-called “high-touch” (in-person) medical care for “high-tech” (at-a-distance) care. “With telemedicine, the doctor and patient get right to the point,” says David Klonoff, MD, FACP, clinical professor of medicine at the University of California–San Francisco and medical director of the Diabetes Research Institute at Mills-Peninsula Medical Center in San Mateo, California. “There are certain visual clues that a health care provider can’t get over a TV screen.”
3. (Potential) Loss of Privacy
Anyone who’s had their e-mail hacked can tell you that technology isn’t foolproof. However, notes Kvedar, “the upside is great, and the potential for data loss is far less in a medical environment because doctors are required by law to keep your information private.”