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 other 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)
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.
Virtual care can be
HIGHLY productive if
you do a little bit of
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 counts. 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 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 https://integrateddiabetes.com, email firstname.lastname@example.org, or call (877) 735-3648; outside North America, call + 1-610-642-6055.
An award-winning Certified Diabetes Educator, Masters-level Exercise Physiologist and person with type-1 diabetes since 1985, Gary Scheiner has dedicated his professional life to improving the lives of people with insulin-dependent diabetes. He was named 2014 Diabetes Educator of the year by the American Association of Diabetes Educators. Gary has authored six books: You Can Control Diabetes (1997), Think Like A Pancreas (2004, 2012, 2020), The Ultimate Guide to Accurate Carb Counting (2007), Get Control of Your Blood Sugar (2009), Until There’s A Cure (2012), Practical CGM (2015) and Diabetes-How To Help (2018), as well as dozens of published articles related to diabetes education for consumer and trade magazines and diabetes websites. He speaks at local, national and international conferences on a multitude of topics in diabetes care. Gary is certified to train on all models of insulin pumps, continuous glucose monitors and hybrid closed loop systems, and has personally used every system that is currently on the market.