From Surviving to Thriving: A Qualitative Study of Adapting Telehealth Systems for Specialty Diabetes Care Across Four California Medical Centers

We conducted and reported our study in adherence to the COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines (9). For this qualitative study, we conducted interviews with providers and staff involved in specialty diabetes care across four University of California (UC) health systems: UC Davis, UC San Francisco, UC Los Angeles, and UC San Diego. We identified participants through purposeful sampling, starting with existing contacts within the health systems, to identify information-rich cases. Participants were recruited through direct e-mail, and subsequent participants were identified through snowball sampling. Most participants were not already known to the study team. We continued to recruit participants until we had achieved thematic saturation and had spoken with at least one pediatric endocrinologist, adult endocrinologist, diabetes educator, and administrative staff member at each institution. Interviews were completed via videoconference between January and August 2022. This study was approved by the UC Davis Institutional Review Board.

The authors created a semistructured interview guide based on previous literature on telehealth for specialty diabetes care (10–12) and the authors’ collective experience with telehealth diabetes care. The guide included open-ended questions asking participants to describe how telehealth is offered in their clinic, their experience with telehealth, their perceptions of the appropriateness of telehealth for different types of individuals and situations, challenges they have faced, helpful practices, and plans for using telehealth in the future. The guide also included structured questions about telehealth policies, telehealth use in the clinics before the pandemic, attendance and no-show rates during telehealth visits, and use of specific platforms or technologies. The interview guide was pilot-tested with a pediatric endocrinologist (S.S.C.), who was also involved in the development of the guide.

One faculty researcher (S.C.H.) and one medical student trained in qualitative methods (M.S.) conducted the interviews. Interviews lasted ∼60 minutes each and were transcribed verbatim by a professional transcription service. Data were analyzed using qualitative content analysis with the qualitative software Dedoose (13). The researchers (S.C.H and M.S.) then used line-by-line coding to code each transcript using the constant comparative method, through which each line is compared with previous lines to identify themes (14). The researchers met after independently coding the first three transcripts to discuss and refine the codebook and subsequently met three additional times to discuss additional codes and preliminary themes. Excerpts were categorized by code and reviewed by the larger research team. Recommendations were generated and refined through group discussion of themes.

All clinicians approached agreed to participate in an interview except three, who did not respond to the recruitment e-mail. We completed interviews with 26 participants, including 5 pediatric endocrinologists, 7 adult endocrinologists, 4 diabetes educators, 2 diabetes pharmacists, and 8 administrative staff members involved in diabetes care (including patient navigators, medical assistants, and clinic managers/supervisors). Participants reported a mix of telehealth use in their practice, with some offering primarily telehealth visits and others offering telehealth only on certain days or when requested by a patient. The six main themes derived from the interviews and corresponding recommendations were grouped into two major categories: 1) optimizing telehealth operations for specialty diabetes care and 2) improving quality of telehealth diabetes visits. Table 1 summarizes the identified themes and recommendations.

Specialty diabetes care involves reviewing patients’ diabetes data to assess how they are managing their diabetes on a daily basis. These data are typically obtained from continuous glucose monitoring (CGM) devices, insulin pumps, and/or blood glucose meters. During visits, clinicians review these data with patients and adjust treatment as needed. For in-person visits, individuals commonly bring their devices to the clinic, where office staff upload their data to a secure, Web-based platform for their clinician to view. However, telehealth visits require that individuals upload their own data to these platforms before visits. Although many newer diabetes devices allow for passive uploading from a mobile device, configuring and maintaining this capability can be challenging for individuals without a high level of digital literacy.

Our study participants reported that most of their patients (an estimated 75–95%) are currently able to upload their data successfully before telehealth visits. Some clinics had developed more effective strategies to maximize patients’ success at uploading data before telehealth visits. One strategy that was viewed as highly effective was designating “diabetes navigator,” an administrative staff person who could be responsible for reaching out to patients before visits to ensure that their device data were uploaded and to assist with this process as needed. Effective diabetes navigators also work proactively with patients during in-person visits to ensure that they are prepared to upload data remotely for future telehealth visits.

For clinics that do not have the assistance of a diabetes navigator or other designated staff person, a significant amount of physician time (including during visits) is often spent helping patients upload data or read data verbally.

Providers reported unreliable and inconsistent methods of scheduling follow-up visits after telehealth visits. Many reported that a lack of an efficient workflow led to delays in care for some patients.

Given that lapses in care are associated with short- and long-term morbidity for people with diabetes (15–19), effort is needed to develop and implement mechanisms to ensure that individuals are appropriately scheduled for follow-up in a timely manner. One strategy adopted by some clinics was to automatically schedule follow-up appointments for patients and send this information to them via e-mail, Web portal, and/or telephone. Other clinics attempted to have check-out staff join at the end of video visits or call patients by phone directly after telehealth visits, although this required additional coordination between providers and staff members who were not colocated. One participant mentioned using a dot phrase (a shortcut phrase that can be quickly inserted into a patient note) to mimic the in-person process of scheduling through the front desk. However, others mentioned that front desk staff were sometimes unable to reach patients by phone reliably.

Specialty diabetes care is designed and recommended to include many team members in addition to an endocrinologist, including diabetes educators, registered dietitians, diabetes pharmacists, and other staff (1). In-person visits benefit from the physical presence of these team members in one place, but lack of colocated teams can present a barrier to effective telehealth diabetes care or require additional intrateam coordination.

Some providers reported that they relied heavily on text messages to invite other members of the care team to join a telehealth visit. Other clinics adopted separate appointments such that individuals were scheduled for visits with a physician and a diabetes educator on different days. Some providers minimized the negative impact of virtual visits on this system by conducting telehealth visits in the clinic.

One advantage of telehealth cited by study participants is that it allows care team members to view and better understand patients’ home environment, which can be particularly relevant and helpful in diabetes care. Clinicians and educators reported that they were able to perform more effective medication reconciliation by asking patients to show them medications and devices, which also prompted discussions about management strategies the patients use at home (e.g., carbohydrate counting).

Study participants reported that the quality of telehealth diabetes care is highly dependent on where patients (and caregivers, for pediatric visits) are located at the time of the visits. Many clinicians cited disruptive environments in which patients are not giving their full attention as a major impediment to conducting successful visits (e.g., if patients are driving or shopping during visits). Some clinicians perceived this to mean that patients were not treating telemedicine visits as “real” visits.

Some clinicians developed strategies for reviewing diabetes data with patients over telehealth visits. Clinicians who successfully adopted a screen-sharing function on the telehealth platform had positive perceptions of this experience. Those who viewed data on a paper printout or on a separate device such as a tablet experienced more difficulty reviewing data with patients. Screen sharing during telehealth diabetes care visits was perceived as a beneficial opportunity for patients to be more involved in their care and to share insights about glucose patterns in a more efficient manner.

The widespread adoption of telehealth diabetes care took place urgently and haphazardly during the COVID-19 pandemic to meet patient, provider, and population needs under rapidly changing circumstances. More than 3 years later, telehealth continues to play a central role in how specialty diabetes care is delivered. However, minimal evidence is available to inform official recommendations for telehealth use in this patient population. A recent policy statement about telehealth use by the Endocrine Society (8) acknowledges the available evidence for telehealth effectiveness within diabetes care, but notes that the use and frequency of in-person and telehealth visits for a given patient must be individualized based on a variety of factors. It also indicates the need for additional research on what practices can improve telehealth efficiency and satisfaction for clinicians and optimize the delivery of team-based care.

Our study begins to address this need by synthesizing expert opinion on current best practices in telehealth for specialty diabetes care, which can be used to direct ongoing adaptations of telehealth diabetes care delivery while awaiting a broader evidence base. In addition to highlighting specific gaps that should be addressed to improve quality of telehealth diabetes care visits, our findings support the overarching theme that telehealth should not seek to replicate in-person care in a virtual setting, but rather should be thoughtfully designed as a complementary and unique component of diabetes care.

Our study suggests several important strategies to improve telehealth operations for specialty diabetes care. First, dedicated staff support is essential to obtain patients’ device data ahead of telehealth visits. This assistance can improve access to care for individuals with limited digital literacy, save valuable clinician time during visits, and prevent unnecessary rescheduling of appointments. Study participants cited reliable access to patients’ diabetes data as a key factor in whether individuals were offered telehealth visits, a finding that is supported by previous research on telehealth endocrinology care (20,21). Because individuals who have difficulty uploading device data may also face barriers to attending in-person visits, helping these people upload data successfully is crucial to enabling person- centered and equitable specialty diabetes care delivery. Improving this process will also likely improve clinicians’ experience with telehealth visits (22). Second, efficient workflows around scheduling follow-up visits are needed to ensure that individuals do not experience lapses in care, which are associated with poor diabetes outcomes. Third, clinics should identify the best ways to facilitate team-based diabetes care during telehealth visits and create workflows to support this effort, which may vary at the clinic level based on team structure and locations. These findings agree with recommendations recently published by the Endocrine Society and challenges observed during the pandemic at adult and pediatric diabetes centers across the United States (7,8).

Study participants also identified several strategies and opportunities to optimize the quality of virtual diabetes visits. First, they recommended using the home environment to identify and discuss potential barriers to and facilitators of diabetes management. This recommendation aligns with evidence that people learn better in authentic learning environments (23), thereby making telehealth diabetes visits valuable opportunities to enhance patient education, and with evidence that medication reconciliation can be accomplished effectively via telehealth (24). Providers also noted that telehealth offers an opportunity for shared data review and recommended screen sharing to enhance patients’ engagement in their care. This recommendation aligns with findings from a previous qualitative study with a national sample of endocrinologists, which found that screen sharing may facilitate patient education (20). Finally, many providers reported challenges with telehealth diabetes visits when patients joined from distracting environments and suggested the development and dissemination of patient guidelines for successful telehealth diabetes care. Such guidelines should set clear expectations with patients about the environment, attention, and technology needed for video visits; the importance of uploading data before visits; and expectations regarding what will happen during visits. These suggestions mirror those made by other practitioners before and since the start of the COVID-19 pandemic (8,12,21), but will likely require ongoing adaptations by providers and clinics to be implemented consistently.

Strengths of this study include representation from a large number of clinicians and staff at four different large, academic medical centers. We succeeded in recruiting information-rich participants for interviews to provide perspectives on the use of telehealth for specialty diabetes care at these institutions. One limitation of our study is that we only included providers in California, where attitudes toward telehealth, patient populations, and access to technology may be different from those in other states. Second, we did not speak with department chairs, hospital administrators, or other leaders who may be influential in determining policies and procedures around telehealth. Given that the landscape of telehealth reimbursement is evolving rapidly and indeed has changed dramatically since the start of this study in 2022, we suspect that administrator perspectives about telehealth also have been in a state of flux, whereas clinician perspectives on what makes telehealth visits effective are more durable. However, it is important to note that further exploration of the contextual factors influencing telehealth implementation could improve adaptation of telehealth programs in the future. Despite these limitations, our study offers important insights into ways in which telehealth can be optimized for individuals receiving specialty diabetes care, if and when clinical administrators and leaders support its implementation.

Finally, our study focused only on clinician perspectives, rather than including patient perspectives on using telehealth for diabetes care. Understanding patients’ experiences and preferences is also essential for delivering person-centered care. Data collected during the COVID-19 pandemic indicated that a majority of people with type 1 diabetes in the United States and worldwide who used telehealth felt it was effective and hoped to continue receiving virtual diabetes care post-pandemic (25,26). However, additional research in this area should be prioritized, particularly now that pandemic-associated restrictions on in-person care and corresponding exceptions for telehealth payer coverage have abated. We chose to focus on clinician perspectives and clinic operational factors, and our findings can serve as a complement to ongoing research on patient perspectives so that clinician- informed and person-centered best practices for diabetes telehealth can be developed.

Optimizing telehealth diabetes care practices is essential for improving health equity as well as overall health among people with diabetes. Use of telehealth for specialty diabetes care during the COVID-19 pandemic was lower among marginalized groups (27), and higher telehealth use at the clinic level was associated with higher loss to follow-up for patients with diabetes (28), despite evidence that telehealth diabetes care has the potential to improve many of the access barriers faced by marginalized populations (29). Clinic- and provider-level adaptations suggested by our findings have the potential to improve equity by helping under-resourced individuals upload their diabetes data, receive individualized team-based care, and schedule follow-up visits reliably from their home environments. Our findings serve as a basis for the development of thoughtful and deliberate policies that will benefit all individuals seeking specialty diabetes care as we move into a new era of telehealth.

The authors thank Dr. Tejaswi Kompala (UC San Francisco Department of Medicine, Teladoc Health) for her assistance in recruiting participants and conceptualizing the study.

This study was supported by a research award from the Children’s Miracle Network in association with UC Davis Children’s Hospital. S.S.C. also receives support from the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health (NIH), through grant number K23DK125671. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

A.B.N. is a full-time employee at Notable (including holding stock options); has received research support from Cisco Systems and Philips; has received consulting fees from Eli Lilly, Intuity Medical, Medtronic, and Roche; has received speaking honoraria from Academy Health and Symposia Medicus; and has received compensation for writing for WebMD. A.B.N. and J.C.W. are medical advisors and cofounders of Tidepool, for which they have received no compensation. J.C.W. has received research support from Abbott Diabetes Care, Dexcom, and Tandem Diabetes Care for work unrelated to this article. No other potential conflicts of interest relevant to this article were reported.

S.C.H. conceptualized and designed the study, conducted interviews and data analysis, and wrote and revised the manuscript. M.S. conducted interviews and data analysis and reviewed and revised the manuscript. A.B.N., J.C.W., P.F.T., J.P.M., and S.S.C. conceptualized and designed the study, assisted with interpretation, and reviewed and revised the manuscript. S.C.H. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.