II. Indications

  1. Optimize diabetes care to improve patient access and decrease patient travel requirements
  2. Address home social situation (e.g. food, housing, economic security)
  3. Remote monitoring of Glucose
    1. See Continuous Glucose Monitoring
    2. High yield in high risk patients, underserved populations and the elderly

III. Efficacy

  1. Provider and nurse Telemedicine visits improve outcomes and glycemic control
    1. More effective in Type 2 Diabetes (including lifestyle modification) than in Type 1 Diabetes
    2. Greatest results with younger patients, increased visit frequency and when video used (in addition to audio)
    3. McDonnell (2018) Curr Diab Rep 18(7): 42 [PubMed]
    4. Su (2016) Diabetes Res Clin Pract 116:136-48 [PubMed]
  2. Remote Monitoring of Glucose has been among most effective strategies in lowering Hemoglobin A1C
    1. Particularly effective with Continuous Glucose Monitoring
    2. Text messaging and website portals have been used to modify medications based on Glucose readings
    3. Faruque (2017) CMAJ 189(9): E341-4 [PubMed]
  3. Cost effective for both patient and provider
    1. Reimbursment by medicare and some private insurers is the same for Telemedicine as in-person visits
    2. Reimbursement by medicaid and private insurers is varies by state and insurer
  4. Retinal Surveillance Exams by Ophthalmology Telemedicine
    1. More effective at reducing Vision Loss and less costly
    2. Retinal camera ($15,000) limited to larger medical systems
    3. Whited (2005) Telemed J E Health 11(6): 641-51 [PubMed]
    4. Garg (2012) Arch Intern Med 172(21): 1677-8 [PubMed]

IV. Precautions

  1. Assess patient's appropriateness for Telemedicine
    1. Digital literacy
    2. Internet connection and compatible device (e.g. smartphone or computer)
    3. No significant language barriers (not a contraindication if Interpreters are available for visit)
    4. Adequate Vision and Hearing
    5. Patient or family willingness to send clinical data before visit (e.g. Glucose logs, diet log, Blood Pressures)
  2. Additional contact may be needed in between Telemedicine provider visits
    1. Phone calls
    2. Electronic messaging
    3. In person visits (new concerns, concerning findings on Telemedicine)
  3. Patients may lack the electronic and internet resources to allow for Telemedicine
    1. Telemedicine locations are being established in rural communities (e.g. VA partnerships with Walmart, American Legion)

V. Protocol: Clinic Staff

  1. Ensure patient has necessary devices (facilitate DME prescriptions as needed)
    1. Device and connectivity
    2. Glucose monitoring (e.g. Continuous Glucose Monitoring)
    3. Blood Pressure Cuff
    4. Weight scale
  2. TeleHealth setup and troubleshooting with office staff
    1. Obtain back-up phone numbers in case of technical difficulty
  3. Obtain consent for visit, billing and privacy discussion
  4. Gather previsit history and Review of Systems
  5. Inquire about new concerns
  6. Update medical record including medications, habits, recent hospitalizations and surgeries
  7. Remote Glucose monitoring (esp. Continuous Glucose Monitoring) is ideally performed between visits
    1. Review Glucose trends, time in range, average Glucose and low Blood Glucose
    2. Medication adjustments may be made between visits
    3. Cloud services include manufacturers (Dexcom, Clarity, Libreview) and platforms (Glooko, Tidepool)
  8. Obtain clinical data before the start of the visit
    1. Vital Signs (Blood Pressure, Heart Rate, weight)
    2. Blood Glucose readings
    3. Lab test results ordered at last visit

VI. Protocol: Clinical Encounter by Medical Provider

  1. Confirm that patient has appropriate environment for visit (privacy, safety) and reschedule as needed
    1. Patient not driving a vehicle or operating machinery
    2. Patient can devote full attention to visit (not speaking to others, no significant background noise)
  2. History
    1. Review together any previsit history, positive Review of Systems and new concerns
    2. Review Vital Signs
    3. Review Blood Sugar log
    4. Review lifestyle (diet and Exercise)
    5. Consider having patient demonstrate the food they eat, items in their refrigerator
    6. Patient might demonstrate their process for medication use (e.g. pill boxes, use of Insulin Pens)
  3. Telemedicine Focus Areas
    1. Avoid sensitive exams via Telemedicine (e.g. genitalia)
    2. Leg and Foot Exam (wearing shorts, and with socks and shoes off)
      1. Hair Loss or discoloration
        1. May suggest Arterial Insufficiency
      2. Skin Wounds, deformities and ulcers
        1. See Diabetic Foot Wound
    3. Injection Sites
      1. Patient should show their injection sites on video
      2. Patient should palpate injection regions for firmness (lipodistrophy)
        1. Suggests patient is overusing certain sites (encourage injection site rotation)
  4. Plan
    1. Adjust Glucose management (monitoring and medications) as needed
    2. Review other medication changes
    3. Review lifestyle modifications
    4. Send patient an after visit summary
  5. Follow-up Visits
    1. Plan future labs before next visit
    2. Alternate in-person (every 6 months) and Telemedicine visits (every 6 months)
    3. Arrange in-person visit for additional concerns, complications or inadequate Glucose control

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