By AACE members Gauri Behari, MD, Karyne Vinales, MD, and Ricardo Correa MD, Es.D, from the Endocrine Division of the Phoenix VAMC and the University of Arizona College of Medicine-Phoenix
The National Institutes of Health (NIH) developed a series of initiatives for tele-medicine research since the 2000s. Some projects were focused on the immediate needs of the country. This initiative includes programs that address health issues in remote regions, monitoring of newborns with high-risk conditions, and transmission of information from ambulances to hospitals. Many interested groups are cooperating in this ﬁeld. A very good example is the Telemedicine Information Exchange website. Through this website, viewers can read about recent advances in the medical community, review on-going projects, and ﬁnd bibliographic references. Even thought this was develop at the NIH, there were several problems on implementation of this technology.
Common Problems When Implementing Telemedicine Prior to the Pandemic
- Data transmission speed problems.
- Difﬁculty describing ﬁndings over video conferences. License limitations in other countries or regions.
- Lack of malpractice protection or insurance.
- Lack of complete technical support.
- Lack of technological culture by health care providers.
- Lack of implementation of daily use protocols.
- Patients are not willing to participate.
COVID-19 and Telemedicine
Due to the actual COVID-19 pandemic, the resources of telemedicine have been flourishing on an exponential rate. The American Medical Association and the American College of Physicians have provided resources to educate the community on telemedicine technology.
Endocrinology is an area of medicine that must embrace telemedicine immediately and for the future. Our patients are mainly in the outpatient setting, telemedicine decreases no show rates and missed opportunities, allows for follow up on chronic conditions like diabetes and obesity, increases adherence to treatment plans, and provides convenient and improved access to care for patients.
Tele-endocrinology has been established in rural areas in Georgia since 2015. In this program, patients had improvement in their endocrine conditions even though the community didn't have a local endocrinologist. Primary Care Physicians expressed provider satisfaction. With this information, national organizations developed and published best practices for telemedicine (please refer to the above links). In 2016, we developed the first international Tele-Education meeting in conjunction with the International Medical Society (IMS) where international speakers gave presentations remotely and trainees presented their scholarly activity using different platforms. Furthermore, the Tele diabetes program officially started at the Phoenix VA Medical Center in 2019. Within the first 6 months, this program demonstrated decrease in HbA1c, increased patient satisfaction, and increased provider satisfaction within its first 6 months, which has been presented in national meetings. Below you will be able to read some of the stories of patients and physicians about their use of telemedicine to help our community.
Personal Experience of Telemedicine Prior to COVID-19: Cases Presentation
57-year old male with uncontrolled diabetes who has missed his endocrinology appointments for the last two years. After he missed his appointment with endocrine and his PCP for the 4th time, the endocrine division decided to call him. The patient explained he had to retire early to take care of his elderly parents and is not able to make it to his appointments because he is only available after hours. We offer him a telemedicine appointment and he completed it the same day, we were able to examine his feet and insulin injection sites, sent him logs to record his blood glucose and blood pressure, ordered labs, and refilled his medications. He agreed to do another telemedicine visit in three months. One month later, he sent a message to the hospital leader mentioning that “telemedicine visit changed his life”. Since that visit, his blood sugars and blood pressure improve, he has more energy and understand his condition and how to take care of it.
62-year old female with uncontrolled diabetes and has a high no show rate. She missed two appointments with endocrine because her husband was in the ICU for acute decompensated heart failure. We completed a telehealth visit while she was in the ICU room so she would not have to leave her husband’s side. Since then, she has not missed a single appointment and has expressed new motivation to improve her health.
These two cases showed that being able to bring medicine to patients using telemedicine technology has allowed them to prioritize their health care while still being able to take care of their loved ones.
Personal Experience of Telemedicine During COVID-19: A Statement
Due to the COVID-19 outbreak, patients and physicians are more willing to utilize Telemedicine In Endocrinology, The use of cloud-based continuous glucose monitoring (CGMs), insulin pump and glucometer data allows us to exercise meaningful virtual visits with our patients. Most brands have healthcare professional options to link with patient accounts for data sharing. These linked accounts are user friendly and require the patient to provider their email and password or to share a patient-specific code generated by the device’s website. A phone call to our patient is enough to link these accounts and will typically expedite the appointment time. The current barrier to meaningful appointments appears to be glucometers, however options like Glooko allow for patients to utilize Bluetooth enabled glucometers (or a Bluetooth dongle which connects to most name brand glucometers).
For patients who are less comfortable with technology, a medical assistant or nurse can call the patient to collect blood glucose data over the phone prior to the appointment and upload it to them EHR. This practice has been very valuable and timesaving in our practice during this crisis time. Lastly, one cannot underestimate the importance to maintain blood glucose control to decrease diabetes as a risk factor for fatalities so tele-diabetes has come to help on solving that issue.
In conclusion, the COVID-19 crisis accelerates the use of telemedicine in endocrinology. More physicians recognize the importance of technology in their clinical practice; administrators have accepted the utilization of telemedicine; CMS opened the doors for the use of a new system for patient encounters; the licensing board expanded their recommendations. All of this reduces the burden and restriction of telemedicine, making it the present (and not the future) of medicine in the twenty first century.
There is a lot more info about this topic in endocrinology. We tried to make this first blog very simple with some experience and statement for our community. We will continue creating more specific papers regarding billing issues, how to establish telemedicine, best practices, how to be successful in telemedicine, other concern, etc.