A Pandemic Forces United States to Leap Forward

I have learned that what seemed just too difficult a month ago has proven to be essential in a COVID-19 world, and it is both workable and challenging. The ability to assess patients via video telemedicine is only as strong as the weakest link in a chain of connected apps and devices that the young and those in midlife have generally already mastered, but some seniors can find them either unavailable or possible but indecipherable. We successfully use the Health Insurance Portability and Accountability Act (HIPAA) compliant doxy.me system from Doximity. We have found it invaluable to have clinic staff contact the patient ahead of time and get them to test one the multiple ways we have to connect to the patient. ¹ That staff effort is worthwhile in order to streamline the visit and reduce time wasted on connectivity logistics.

We embrace diabetes technology that has been traveling for some time on the road toward a connected universe via an internet of medical things. Stand-alone continuous glucose monitoring (CGM) devices have led the way, having the advantage to preferentially function via smartphone platforms that can automatically upload to cloud-based software. The presence of a reimbursable interpretation code for CGM has also incentivized clinics to develop this remote capability. Once linked, the results can be easily accessed remotely by a clinic. It is the most important data set to access because it is the most complete and the most actionable. We prioritize obtaining CGM data above all else.

The worthy predecessors of CGM, blood glucose meters (BGMs), have not yet been able to provide similarly easy connectivity, though platforms like Tidepool and Glooko that connect and integrate multiple devices can, in some cases, provide a feasible conduit. LibreLink can be used for both CGM and BGM. In our clinic, which has embraced CGM fully, BGMs rather than CGM are still the mainstay for most with type 2 diabetes. However, many BGMs require another device or cord to allow transfer of information and may not supported by the above-mentioned multisystem platforms, or have been so dumbed down by the economics of tight margins that they have limited memory or resources to devote to downloading data. As a consequence, BGMs can be much more challenging to remotely access, often forcing us to fall back on written records or patient recall, with all the attendant limitations. In-office downloads of BGM by clinic staff provide valuable insights, but the coaching effort needed to remotely download BGM data is often not worth the effort.

Fortunately, the currently available insulin pumps have invested in developing both useful data management systems and remote connectivity, and are generally compatible with the multisystem platforms. Our experience has been that Tandem is the most reliable one to remotely access, because it has a USB port and a charging cable that can connect to a PC or laptop, though not most tablets or smartphones. Medtronic CareLink has a highly developed system, but has one key limitation in that the patient must have and be able to find a functional widget to download—usually the Bayer Contour Next meter that came with it but might have been lost, broken, or not be in use because the insurer does not cover the strips needed for that meter. Omnipod Classic or Dash can be accessed via Glooko or Tidepool. We consider pump downloads very useful, and usually possible, so we make this the second priority after standalone CGM, or the first priority with CGM integrated pumps. The InPen Smartpen reports fall into the same category in terms of high utility, and fortunately, are easily forwarded by the patient to the clinic via fax or email.

In the future, I predict that telemedicine encounters will become a much larger percent of routine follow-up visits, and in some cases, new patient evaluations. The many restrictions previously imposed by insurance and regulators have for the most part been temporarily waived. Let us hope that the value of this form of practice will be permanently recognized and fairly reimbursed, rather than again becoming unfairly marginalized and limited. Reimbursed meaningful remote assessment meets a great need in the modern world, even outside of the current existential risk posed to patients and clinicians in the COVID-19 pandemic. As a bonus, the encounter is unexpectedly intimate; you sometimes get to meet children, spouses, or pets, and get a deeper sense of who someone really is. It is a fundamental principle of treating those with diabetes, to strive to meet them where they are. Telemedicine allows diabetes clinicians to do just that.