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The era of diabetes telemedicine has arrived.

In the midst of the current COVID-19 pandemic, clinicians of all specialties who were already incorporating telehealth visits into their practices are now ramping it up, while those who were not using the technologies before are now scrambling to put them in place.

A free access article, "Top Ten Tips for Successfully Implementing a Diabetes Telehealth Program," was published March 19 in Diabetes Technology & Therapeutics by pediatric endocrinologist Stephanie Crossen, MD, of the University of California, Davis, and colleagues.

Written before the COVID-19 crisis hit, the article offers detailed practical advice in 10 key areas (for more details, see further down the article):

Hardware

Video software

Diabetes software

Scheduling telehealth visits

Standardizing telehealth visit processes

Reimbursement (for the US only)

Electronic health record (EHR) integration

Patient expectations

Patient-centered care

Culture change among providers and institutions

The document focuses primarily on implementing patient-to-clinic video encounters, although it also discusses asynchronous data review of patient-generated data and clinic-to-clinic video encounters.

In an interview, senior author Aaron B. Neinstein, MD, an endocrinologist at the University of California, San Francisco (UCSF), told Medscape Medical News: "What people are realizing is that this is a lot easier and there are fewer barriers than they thought. I keep hearing this. It seems big and scary but once people start doing it they think it's great and not that hard."

"I hope these are pragmatic tips that help people get over the hump."

Even under normal circumstances, routine diabetes care, whether in an endocrinology or primary care setting, is particularly well-suited to the use of telehealth: much of it involves electronic downloading of data from devices and speaking with patients about their own self-management.

Greg Dodell, MD, an endocrinologist with Mount Sinai Hospital in New York City who moderates a Twitter chat about telemedicine for endocrinologists using the hashtag #endotwitter, spoke with Medscape Medical News.

"I think this is an excellent paper and really a 'wow!' It comprehensively covers the landscape of telehealth including the proper setup, reimbursement, scheduling, and most importantly, how it can potentially facilitate the clinical relationship by enhancing self-care and eliminating potential barriers to follow-up."

Although nearly all of the information in the article can be applied now during the COVID-19 pandemic, it doesn't address two emergency federal actions that affect reimbursement in the United States, Neinstein noted.

Effective March 6, the Centers for Medicare & Medicaid Services lifted Medicare restrictions on the use of telehealth services during the COVID-19 crisis so that physicians will be paid for telehealth services at the same rate as in-patient visits for all diagnoses, not just services related to COVID-19.

Patients can receive telehealth services in their homes, anywhere in the country from a physician anywhere in the country. And physicians can reduce or waive cost-sharing for telehealth visits.

In addition, the Office of Civil Rights of the US Department of Health & Human Services (HHS) has waived penalties for violation of the Health Insurance Portability and Accountability Act (HIPAA) so that during the COVID-19 pandemic healthcare providers can communicate with patients through technologies such as FaceTime or Skype.

Dodell said that in the current COVID-19 crisis, endocrinologists and other clinicians who see a large number of patients with diabetes are at a bit of an advantage because of how well suited the condition is to virtual care.

"As a small business owner, I'm stressed but would be a lot more stressed if I couldn't do what I do...I have a good friend who's a gynecologist and had to close," he told Medscape Medical News.

Right now Dodell is not having patients get routine lab work done, but normally that would happen prior to a telehealth visit.

And in usual practice, patients still need to come in once a year for a physical exam. Of course, those appointments are also on hold for now.

"There are tools like digital stethoscopes and the Apple watch, and home blood pressure reading is easy. I don't think any of that stuff should replace physical contact, but in a situation like we're going through with this pandemic they're great options," he notes.

Neinstein, who is director of clinical informatics at the UCSF Center for Digital Health Innovation, added that, as the situation evolves, different care models will need to be adopted.

"It will become clear that as the healthcare workforce is strained and there's less capacity [for] care for chronic disease, we need to be looking at...a lot more nonphysician visits coaches, mental health professionals, peer groups, group visits for education and a lot more...texting or chatting."

And in the non-COVID setting, Dodell points out that implementing telehealth could streamline office flow and even save money: "I can do a telemed visit in half the time [of a conventional office visit]."

There are actually far more than 10 tips in the article, but they are grouped under 10 headings.

Hardware: Basic requirements for video visits are a mobile device (smartphone or tablet), laptop, or desktop with audio and video capabilities, an internet connection, and software download capability. This section covers equipment including cameras, headphones, monitors, and room lighting.

Video software: Many options for video conferencing software are HIPAA-compliant (assuming the same rules return after the COVID-19 crisis). Patients need to download the software application or run a temporary application for the visit. Most platforms offer multiparty conferencing for calls with children, adolescents, or the elderly.

Diabetes software: Nearly all diabetes devices incorporate data-sharing platforms, although unfortunately at this time many aren't compatible with each other or with EHRs. This section lists several desirable features, including compatibility with the broadest array of devices including insulin pumps, continuous glucose monitors (CGMs), glucose meters, and smart pens, easy upload for patients, and "seamless and flexible" account administration.

Scheduling telehealth visits: The authors recommend setting aside a block of time for telehealth visits separate from in-person visits to avoid overlap.

Standardizing telehealth visit processes: Patients need to be trained in advance on how to upload their data prior to the visit, and instructed when and where to have lab work done. This section discusses the role of office support staff in these processes.

Reimbursement (United States only): In general, video visits should be coded using typical current procedural terminology (CPT) codes based on time, such as 99214 for an established patient visit lasting 25-39 minutes, with the modifier 95 and the point-of-service code 02 for telehealth. As with in-person visits, additional codes can also be added such as CPT 95251 for CGM review and interpretation. For the most recent regional and state policies on this, check the Center for Connected Health Policy's website.

EHR integration: Minimum requirements include having the correct billing codes built-in, the ability to designate a separate visit type in providers' schedules, and standardized documentation for video visits. "We're still a long way from integration," Neinstein noted. "There are still several device companies that will not let the patient move their data off the device into software that they want to use. When you're trying to run a virtual clinic that makes life really, really hard." But he also said that new HHS regulations aimed at lowering EHR burden on physicians and other clinicians should help, assuming that device manufacturers comply.

Patient expectations: Patients need to know when these visits are available, what they will cost (typically the copay is the same as an in-person visit, but not always), and when they will be expected to return in person.

Patient-centered care: Whereas traditional diabetes care is based on the provider's availability, "with telehealth, diabetes care can take place in the home at a frequency customized to the individual." This section discusses several other potential patient-centered benefits.

Culture change among providers and institutions: "Acknowledging concerns and building supportive practices will increase your likelihood of success. We have found it critical to engage all institutional stakeholders early in the process to allow for successful integration of telehealth practices into routine care," the authors write.

"Recent improvements in both diabetes technology and telehealth policy make this an ideal time for diabetes providers to begin integrating telehealth into their practices," they conclude.

Crossen has reported receiving research support from the National Center for Advancing Translational Sciences, National Institutes of Health. Neinstein has reported receiving research support from Cisco Systems; consulting fees from Nokia Growth Partners and Grand Rounds; serving as an advisor to Steady Health; receiving speaker honoraria from the Academy Health and Symposia Medicus; writing for WebMD; and being a medical advisor and cofounder of Tidepool.

Diabetes Technol Ther. Published online March 19, 2020. Full text

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More:
Top 10 Tips for Diabetes Telehealth Prophetic in Face of COVID-19 - Medscape

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