Getting the Most Out of Your Remote Healthcare Visits

This content originally appeared on Integrated Diabetes Services. Republished with permission.

By Gary Scheiner MS, CDCES

A long, long time ago, before the days of coronavirus, there was a little diabetes care practice called Integrated Diabetes Services (we’ll just call it IDS for short). IDS taught people with diabetes all the wonderful things they can do to manage their diabetes. Word got out, and people who lived far from IDS’s local hamlet (better known as Philadelphia) wanted to work with IDS. Even people IN the hamlet wanted to work with IDS but were often too busy to make the trip to the office. So IDS had an idea: “Let’s offer our services via phone and the internet so that everybody who wants to work with us can work with us!” The idea took off, and IDS grew and grew.

And virtual diabetes care was born.

Today, in response to the COVID-19 pandemic, virtual healthcare has become a virtual norm. Often referred to as “telehealth” or “telemedicine,” people with diabetes are connecting with their healthcare providers for everything from medical appointments to self-management education to coaching sessions. Some consults are conducted via phone calls, while others utilize web-based video programs (like Zoom) or simple email or text messages. Regardless of the form, virtual care can be highly effective. But it can also have its limitations. Whether you’ve been receiving virtual healthcare for months or have yet to give it a try, it pays to learn how to use it effectively. Because virtual care will certainly outlive the pandemic.

What Can… and Can’t… Be Accomplished Virtually

Most diabetes care services, including medical treatment and self-management education, can be provided effectively on a remote basis. We have managed to teach our clients everything from advanced carb counting techniques to strength training routines to self-analysis of glucose monitoring data, all while helping them fine-tune their insulin program, on a 100% virtual basis.

Some clinics and private healthcare providers have gone 100% virtual since the pandemic began, while others are using a “hybrid” approach – periodic in-person appointments with virtual care in-between. Depending on the reason you’re seeking care, a hybrid approach makes a lot of sense. While virtual visits are generally more efficient and economical (and in many cases safer) than in-person appointments, there are some things that are challenging to accomplish on a remote basis. From a diabetes standpoint, this includes:

  • Checking the skin for overused injection sites
  • Learning how to use medical devices (especially for the first time)
  • Examining the thyroid gland and lymph nodes
  • Evaluating glucose data (unless you can download and transmit data to your provider)
  • Performing a professional foot exam
  • Listening to the heart rhythm and feeling peripheral pulses
  • Checking for signs of neuropathy and retinopathy
  • Measuring vital signs (unless you have equipment for doing so at home)

The Logistics

Virtual care can be provided in a variety of ways, ranging from a phone call to an email, text message or video conference. Video can add a great deal to the quality of a consultation, as it allows you and your healthcare provider to pick up on body language and other visual cues. It also permits demonstrations (such as how to estimate a 1-cup portion of food), evaluation of your techniques (such as how to insert a pump infusion set), and use of a marker board for demonstrating complex subjects (such as injection site rotation or how certain medications work).

When using video, it is important to have access to high-speed internet. A computer is almost always better than a phone for video appointments, as the screen is larger and has better resolution. If you have the ability to download your diabetes data, do so and share access with your healthcare provider a day or two prior to the appointment. It may also be helpful to share some of your “vital” signs at the time of the appointment – a thermometer, scale, and blood pressure cuff are good to have at home.

In many cases, care provided on a remote/virtual basis is covered by health insurance at the same level as an in-person appointment. This applies to public as well as private health insurance. However, some plans require your provider to perform specific functions during the consultation (such as reviewing glucose data) in order for the appointment to qualify for coverage. Best to check with your healthcare provider when scheduling the appointment to make sure the virtual service will be covered. At our practice (which is 100% private-pay), virtual and in-person services are charged at the same rates.

If security is of the utmost importance to you, virtual care may not be your best option. Although there are web-based programs and apps that meet HIPPA guidelines, there really is no way to guarantee who has access to your information at the other end. My advice is to weigh the many benefits of virtual care against the (minuscule) security risk that virtual care poses.

Optimizing the Virtual Experience

Just like in-person appointments, virtual care can be HIGHLY productive if you do a little bit of preparation.

  • Do yourself and your healthcare provider a favor and download your devices, including meters, pumps, CGMs, and any logging apps you may be using, prior to the appointment. If you don’t know how to download, ask your healthcare provider for instructions, or contact our office… we can set up a virtual consultation and show you how. If you have not downloaded your information before, don’t be intimidated. It is easier than you think. People in their 80s and 90s can do it. Oh, and look over the data yourself before the appointment so that you can have a productive discussion with your healthcare provider.
  • Be prepared with a list of your current medications, including doses and when you take them. Check before the appointment to see if you need refills on any of your medications or supplies. If you take insulin, have all the details available: basal doses (and timing), bolus/mealtime doses (and dosing formulas if you use insulin:carb ratios), correction formulas (for fixing highs/lows), and adjustments for physical activity.
  • Try to get your labwork done prior to virtual appointments. This will give your healthcare provider important information about how your current program is working.
  • To enhance the quality of the virtual meeting, do your best to cut down the background noise (TV off, pets in another room, etc…) and distractions (get someone to watch the kids). Use of a headset may be preferable to using the speakers/microphone on your phone or computer, especially if there is background noise or you have limited hearing.
  • Use a large screen/monitor so that it will be easy to see details and do screen-sharing. And use front lighting rather than rear lighting. When the lights or window are behind you, you may look more like a black shadow than your beautiful self. “Ring” lights are popular for providing front-lighting.
  • Provide some of your own vitals if possible – weight, temperature, blood pressure, current blood sugar. This is important information that your healthcare provider can use to enhance your care.
  • Prepare a list of topics/questions that you want to discuss. Ideally, write them on paper so that you can take notes during the appointment. If there is a great deal of detail covered, ask your healthcare provider to send you an appointment summary by mail or email.
  • Be in a private place that allows you to speak openly and show any body parts that might need to be examined – including your feet and injection/infusion sites.
  • Be a patient patient! Technical issues can sometimes happen. It is perfectly fine to switch to a basic phone call or reschedule for another time.
  • Courtesy. Be on-time for your virtual appointment. If you are delayed, call your healthcare provider’s office to let them know. And if you are not sure how to login or use the video conferencing system, call your provider beforehand for detailed instructions. This will help to avoid delays. Have your calendar handy so that a follow-up can be scheduled right away. Oh, one other thing: Try not to be eating during the appointment… it is distracting and a bit rude. However, treating a low blood sugar is always permissible!

If there is one thing we’ve learned during the pandemic, it’s that virtual care is a win-win for just about everybody. Expect it to grow in use long after the pandemic. In-person care will never go away completely, but for treating/managing a condition like diabetes, virtual care has a lot to offer… especially if you use it wisely.

Note: Gary Scheiner is Owner and Clinical Director of Integrated Diabetes Services, a private practice specializing in advanced education and intensive glucose management for insulin users. Consultations are available in-person and worldwide via phone and internet. For more information, visit Integrated Diabetes.com, email sales@integrateddiabetes.com, or call (877) 735-3648; outside North America, call + 1-610-642-6055.

Source: diabetesdaily.com

A Diabetes Educator Walks Us Through a TeleHealth Endo Appointment

With our country slowly heading back to our “new normal,” we will likely have to go back to our regularly scheduled lives, which includes being diligent about keeping up with all our routine doctor visits. It is even more important when living with diabetes to have annual eye appointments, physicals, dental appointments, and of course, our endo and diabetes educator appointments.

Since many are apprehensive about this new set up and wondering how exactly it will work, I thought it would be great to talk to Dawn, a nurse practitioner and certified diabetes educator who works in an endocrinologist office and have her walk us through the process and what we can expect.

Thank you, Dawn, for taking the time to talk to me today! How long have you been living with type 1 diabetes? 

24 years at the end of this month. 

Did living with diabetes play into your decision to become a CDE?

I had a great CDE in 1995 in a rural town which was unheard of. Then in college, I had a great nurse practitioner (NP) that I still look up to as a mentor for my practice. She talked to me like a person. She talked to me without pressure, shame, guilt, accusations and disappointment. She helped me come to terms with my diabetes and I will forever be in debt to her. I want to pass on that experience to other people living with diabetes.

How has your endocrinologist office responded to COVID-19? Have you closed down? How did you prepare for seeing your patients virtually?

We stopped seeing patients in the office at the end of March. We do still need labs so our lab is open but that significantly reduces foot traffic. We are only ordering labs that are necessary and will dictate current decisions. If they are not needed right now, then they can wait. We have two practice locations and staff are staying at one location. This way, if one office is quarantined we still have the other office to ensure patients have medical support.

We transitioned to virtual visits using the telehealth visit option within our EMR (electronic medical record) and we are using doxy.me as well. We are calling patients ahead of time to let them know about the change in the appointment and encouraging them to try to log in and make sure it works prior to their appointment. This would give you the chance to troubleshoot technical issues prior to your appointment.  We have had a few patients who still needed to be seen in person but almost all of our visits can be completed via telehealth.

I know many patients are curious about how an appointment like this will work. Is there anything the patient needs to do prior to the appointment? I know my son has an upcoming telehealth appointment and we had to download a certain app.

I would recommend as listed above making sure your means of communication works. Do a trial run at the location you plan to be at. If you will be at work during the call, make sure it works at work. If you are at home, then make sure it works at home. Will you use a computer or a smartphone? Do you know how to troubleshoot the speakers, video and microphone? Do you have a pump, continuous glucose monitor, or meter to download ahead of time? If you do, then get these downloaded at home prior to your appointment. Do a practice run a week ahead of time so if you need to call for help you have time to do so.

Having blood sugar readings and pump downloads ahead of time has streamlined my practice. I can view them prior to the appointment and focus on key items to make the appointment more productive. We are encouraging all patients to download at home, but we have made the exception for a few (elderly) to come and download at the office.

Can you walk us through what to expect during the appointment?

My wonderful medical assistants (Ariel, Tonya, and Whitney) have been calling patients to go over medications, any new changes to medical history just before the appointment and checking to make sure the telehealth app or doxy.me is working. Hopefully, I have already reviewed blood glucose logs and pump downloads ahead of time. If not, I will encourage the patient to get that for me.

What are some of the drawbacks of a telehealth appointment? I know my endocrinologist usually examines my thyroid, heart, etc. How will the doctor be able to check vitals as well as other routine measures? 

Yes, not being able to physically assess a patient sometimes is tough. However, if I am concerned enough that we need an in-person assessment ASAP, then they likely should have an urgent appointment with their primary care provider. If someone is complaining of an enlarged thyroid, with a keen eye, we can visualize that in most people via video. However, nothing replaces a hands-on assessment. We will see a patient in the office urgently if needed.

Do you find that overall providers have more or less time to spend with their patients this way?

When we have data (CGM/BG/Pump/labs) there is more time for providers to spend having meaningful conversations with patients. This streamlines appointments.

As a medical professional, how are you finding the telehealth appointments? What do you find most challenging?

  • When I have the data prior to an appointment, I love telehealth. I also love that I can go over reports with the patient and educate them on what I am seeing.
  • The most challenging part is obtaining data prior to the appointment. My medical assistant makes 2-3 calls prior to an appointment trying to prepare each patient. If I don’t have data, then essentially we are making an educated guess about what medications need to change.
  • For example, a patient can complain of afternoon hypoglycemia. However, it could be a reduction in basal insulin needs, overcorrection of pre-lunch blood glucose, or a too aggressive carb ratio. If we do not have data (CGM/BG/Pump) information, there is no way to tell for sure. So we ask questions around and around to try to figure out the most likely scenario but if we are wrong, you may have less hypoglycemia but BG will run higher. I know I do not want my provider to essentially guess at what needs to change.
  • Another example is a high A1c and the provider increasing the long-lasting insulin (basal) or basal rates unnecessarily causing low blood sugar in the middle of the night. I see this often when providers are grasping at straws trying to improve blood sugar control. When the real reason may be significant after-meal blood sugar spikes.

For someone who is unfamiliar with Zoom and other related apps, it may present a novel challenge. Have you found patients are having trouble with the new set up? Do you provide explicit directions on how to get set up for the appointment?

Most patients who have reliable internet access and have a smartphone or computer with a camera the platforms we use work beautifully. Doxy.me just requires the patient to click on the link we provide in an email. Click and then wait for me to start the appointment.

What do you think the patients will find the most pleasant about the virtual appointment? And what about the worst aspect?

The best part is that you can sign on from anywhere with cellular service or Wi-Fi. So your time away from work or other commitments is minimal. The worst part is that you are still at work or home and there are often other distractions. For example, if children or a dog are disrupting the appointment, this can be distracting and cause the appointment to take longer. It is also not a good idea to have an appointment while driving.

What can you tell us about privacy compliance? How can patients be sure their information is safe?

When using the Healow app or Doxy.me, the voice and video access is encrypted, keeping the visit private. The actual video does not access the patient chart in any way.

Looking forward, what do you think our medical system will look like after COVID-19? What about in 10 years?

I have no idea. I have learned to never assume anything in medicine because just when we think something will happen, the opposite occurs. I am hoping this opens doors allowing more rural telemedicine. This will provide medical care, especially those with chronic diseases, living in rural areas that travel 1, 2, or sometimes 3 hours for appointments. Historically, telehealth is not covered by insurance and the cost falls onto the patient. This hopefully will allow for proper insurance billing of these appointments to be more cost-effective and convenient.

Thank you so much, Dawn, for taking the time to walk us through what a telehealth appointment will look like. I have had two so far and they both went successfully! Best of luck and thank you for what you do!

Source: diabetesdaily.com

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