In Brief

Caring for people with diabetes is frought with challenges, including a rapidly growing population, shrinking reimbursements for care, multiple treatment variables, an onslaught of numeric data, and the need for effective lifestyle intervention. Use of video chat technology for conducting appointments allows for provision of a wide range of clinical services while improving efficiency, accessibility, and communication between patients and providers.

It is no mystery that diabetes is very different from other disease states. From the patients' perspective, diabetes management requires a serious commitment to appropriate lifestyle behaviors and frequent decision-making. From the standpoint of health care providers (HCPs), diabetes management requires ongoing coaching and expert guidance.

For the majority of patients with type 1 diabetes, numbers play a prominent role. Balance the myriad factors that influence blood glucose levels and match the insulin dose to the body's needs, and glucose control should improve. And, for most patients with type 2 diabetes, disease progression and comorbidities necessitate aggressive medical management, as well as an ongoing effort to manage weight. What do both have in common? The need for frequent contact with qualified health care experts.

Given the time and resources needed to properly care for the rapidly growing diabetes population, the situation might appear hopeless. Or maybe not. Diabetes care lends itself to quick snippets of contact between patients and their HCPs. Review log books and data downloads; make a medication change here, an insulin dose adjustment there; and throw in some timely teaching moments and regular pep talks, and you have the makings for quality outcomes.

Furthermore, the vast majority of diabetes patient-provider interactions do not require physical contact. Most of what needs to be done can be accomplished remotely via electronic forms of communication. In fact, remote consultations can be more efficient and just as effective as face-to-face encounters. In 2005, a group at Harvard Medical School showed that professionally moderated Internet discussion groups can be useful for engaging patients with diabetes and improving coping skills.1  And those groups did not involve individualized care. Imagine what can be accomplished through one-on-one telehealth.

The U.S. Department of Health and Human Services defines telehealth as, “the use of telecommunications and information technologies to provide or support clinical care at a distance.” The scope of telehealth is ever expanding and now includes health care delivered via phone, e-mail, text message, and video chat.2  Essentially, any form of indirect two-way communication between patients and providers can be considered telehealth.

Our practice provides diabetes education and management services primarily for insulin users. We have been using telehealth as a means of working with clients worldwide since 2008. Appointments are usually conducted through Skype (a web-based video chat program) for both new and existing clients. Each appointment includes a review of self-monitoring of blood glucose data to fine-tune the therapeutic regimen and pertinent diabetes self-management education. Most appointments originate from our office, but on occasion consultations have been provided from our clinicians' homes (e.g., when a clinician was caring for a sick family member or waiting for a repairman to arrive).

I must admit that, at first, I was a bit nervous about conducting appointments remotely. How would our clinicians be perceived? Would we be paid for appointments that are not held in person? What kind of technical glitches would occur?

However, our experience with diabetes telehealth has been overwhelmingly positive, with virtually no concerns or complaints on the part of our patients or our staff of providers. There are occasional technical snafus with the video portion because of Internet limitations (mostly at the patients' end), but we can always switch to a phone call when such problems occur. And, when everything is working properly, which is now 95% of the time, I feel like George Jetson calling his wife, Jane, at lunchtime on the video monitor—real space-age stuff.

Traditional telehealth was exactly what it sounds like: health care services provided over the telephone—physicians, nurses, and subspecialists offering their guidance and expertise through a phone call. Patients could share symptoms and other relevant information, and HCPs could provide diagnoses and treatment recommendations.

With the advent of high-speed Internet in the 2000s, two-way audio/video communication (also known as video chat) became functional and widely accessible. Patients in remote locations such as rural areas could communicate with their HCPs by visiting a local clinic that housed video conferencing equipment. Under the supervision of a nurse or allied health professional, an appointment could be conducted between a patient and a provider who were hundreds or thousands of miles apart.

Today, through the use of mobile applications, video chat can be enhanced to include real-time electrocardiography, electronic digital stethoscopes, and ultrasound reports. Furthermore, patient-provider video chats need not involve an intermediary; consumer electronics now permit direct video-enhanced communications via desktop or laptop computers, tablets, or even web-enabled phones.

Health care in the 21st century is frought with economic and logistical challenges. Reimbursement for clinical care is often restricted or capitated. Overhead costs are spiraling upward. Patients need and desire frequent contact with their providers, yet the number of patients is outpacing providers' ability to care for them. And the costs of travel (e.g., time, fuel, tolls, parking, or public transportation fare) for appointments are reaching new heights.

Given that brief but frequent interactions are usually necessary for providing optimal diabetes care, the low cost and high convenience of video chat makes it an ideal way to interact with patients.

For providers, conducting appointments through video chat offers several benefits. Compared to telephone-only interaction, video chat permits relationship-building and greater understanding of the patient's mindset. Posture conveys important information regarding attitude and persuasion. Facial expressions convey emotion and likelihood of applying given recommendations.3 

With video chat appointments, the rate of no-shows and late arrivals is reduced considerably because weather and traffic conditions are no longer an issue. This allows for greater productivity and more efficient scheduling. Exposure to patients with contagious illnesses is greatly reduced. Providers also have the opportunity to see patients in their natural domain, gaining insight into their living conditions and other environmental factors. Overhead costs are reduced because there is no need for a waiting area, exam room, or ancillary staff to prepare patients for their clinician encounter. For those running private clinics, there is a reduced need for parking space.

For patients, video chat appointments provide cost and time savings, as well as convenience. The time and costs of travel are eliminated, not to mention the stress involved in getting to an in-person appointment on time. Waiting times are minimized because patients can do other things at their home or office until their provider logs in for the appointment.

With video appointments, patients who are ill need not go outdoors, and those with anxiety disorders are spared the trials and tribulations of visiting a health care facility. For many patients, particularly those who are young and technologically savvy, communicating through electronic means encourages a more natural and comfortable dialogue than face-to-face interactions.

For these reasons, we have found that the majority of our clients, even those who live or work reasonably close to our office, prefer to conduct their appointments via video chat. We are more than pleased to comply.

Almost any thing that can be accomplished during a face-to-face appointment can be achieved via two-way video. This includes, but is not limited to:

  • Reviewing glucose logs (faxed, e-mailed, or downloaded) for purposes of adjusting medical regimens

  • Teaching basic diabetes physiology, including complications and preventive strategies

  • Training on the use of blood glucose monitoring equipment, with demonstration and return demonstration

  • Training on continuous glucose monitoring (CGM) and evaluation of CGM data

  • Educating patients about medication options (including oral and injectable agents)

  • Teaching self-injection techniques, including timing of injections, pen use, and proper site rotation

  • Training patients on self-adjustment of insulin doses

  • Programming insulin pumps, both basic and advanced

  • Training about hypoglycemia treatment, including glucagon administration (by sending a practice kit in the mail before a scheduled appointment)

  • Providing nutrition education, including portion estimation using food models, carbohydrate counting using books and food labels, and specialized meal planning

  • Counseling patients about exercise, including guidance regarding glucose control during exercise, exercise planning, and strength training instruction via demonstration and return demonstration

  • Outlining sick-day management guidelines

  • Downloading devices and teaching self-analysis of diabetes data

  • Counseling patients about weight loss

  • Evaluating mental health issues via screening instruments and providing appropriate counseling when necessary

  • Offering psychotherapy and stress management exercises

  • Developing strategies for reduction of high-risk behaviors (e.g., smoking and alcohol and drug use)

  • Counseling patients about pregnancy, including prenatal, perinatal, delivery, and postpartum issues

  • Making effective use of health care and community resources

During appointments, a downward-facing camera (mounted to a stand), also known as a “document camera,” can come in quite handy. This can be used to capture and transmit printed charts or diagrams, demonstrate detailed procedures (e.g., programming an insulin pump or filling a syringe), and show patients simple diagrams drawn on a dry-erase board. When using a document camera, it is best to use a picture-in-picture feature on your computer screen so you can see exactly what you are showing your patient while simultaneously capturing the patient's reactions to the video they receive.

To make productive use of the time spent during each appointment, we make a habit of sending educational materials ahead of time. Most educational materials can be sent via e-mail. Printed materials can be scanned and saved as pdf (portable document format) files for easy attachment to an e-mail. Non-printed materials such as glucose meters, glucagon kits, demonstration pens, and logbooks can be sent through traditional mail.

For those who prefer working with groups, some video chat programs offer the opportunity to conduct interactive educational sessions with multiple people simultaneously. This can be used whenever patients' learning needs and pace are fairly homogenous. Group sessions allow for cross-training among participants, as well as between patients and instructors.

Although two-way video chat allows for a multitude of patient care options, there are some services that cannot be performed at a distance—mainly those that require physical contact or examination of minute details. For example, examining infusion/injection sites for lipodystrophy usually requires hand-to-skin contact. The same can be said for palpation of the thyroid gland, checking feet for protective nerve sensation, and examining fingertips for calluses and scarring.

Although many patients have scales and blood pressure monitors at home, taking vital measurements from a distance can be an inexact science. These, along with girth measurements and skinfolds (body fat percentage), are best taken in person.

In addition to the constraints of nonphysical contact, video chat also poses challenges to the documentation process. Unlike a simple e-mail or text message, which can usually be “cut and pasted” into a progress note, audio/video programs such as Skype do not have recording capability. For those needing to record and save video appointments in patients' official charts, more sophisticated equipment will be required. In our practice, we usually document video appointments using traditional SOAP (subjective, objective, assessment, and plan) notes similar to the documentation that follows a face-to-face appointment.

There are also certain technical limitations when conducting video chats. When using a high-speed Internet connection, audio is slightly delayed compared to video. This can be a distraction to novice users. Fluid conversation can also be difficult. Unlike during a phone call, only one person can speak and be heard at any given moment. This is sometimes compared to a garden hose; water can only flow in one direction at a time. One must wait for the other party to finish speaking before responding. On the bright side, this ensures that you can finish your sentences before the other party interrupts!

As is the case with any form of remote care, patients will not be showing up with laboratory results, logsheets, and reports in hand. It is necessary to have this information transmitted electronically before scheduled appointments. This means patients need to be taught (and to have the capability) to download their various data-containing devices, including glucose meters, insulin pumps, CGM devices, and smartphone apps. Patients who rely on their HCP for supplies and samples may also be hard-pressed to obtain what they need unless their provider is willing to mail samples to their home.

Table 1.

Summary of Video Chat Advantages and Disadvantages

Summary of Video Chat Advantages and Disadvantages
Summary of Video Chat Advantages and Disadvantages

Finally, billing to third-party payers is not always accepted unless patients are seen face to face. Many, but not all, health insurers now recognize the value and efficiency afforded by telehealth. Since 2001, Medicare has had provisions for covering telehealth visits that originate from a hospital, physician's office, or rural clinic and are provided by physicians or certain mid-level providers and mental health professionals. According to the American Telemedicine Association, providers must be licensed in the state where they are physically located, as well as in the state where their patients are located.

If the major health insurance plans in your area have not come around to reimbursing for telehealth, consider setting up contracts with recipients themselves: corporations, schools, correctional institutions, local governments, and even health care provider systems. It is more than reasonable to charge patients directly for telehealth services given the time and cost savings they experience.

Table 1 offers a summary of the advantages and disadvantages of conducting medical appointments via video chat.

Video chat appointments can be conducted with minimal equipment. Most laptop computers, tablets, and smartphones come equipped with built-in video cameras and microphones.

Desktop computers may or may not have a webcam included. However, webcams are inexpensive and easy to obtain and use; they simply plug into a USB port on the computer and are ready to use right away. If you need to purchase a webcam or want to upgrade the one built into your device, look for a video camera that offers at least 640 × 480 pixels or DVD-quality frames. Cameras with glass lenses produce the sharpest video. These typically cost $75–150.

For audio, the speakers on the computer must be turned on. Alternatively, a headset can be plugged into the computer, tablet, or phone's audio port. Of course, video chat is a two-way form of communication, so your patients will need to have a webcam, microphone, and speakers as well.

A high-speed Internet connection is also necessary to conduct a video chat. Bandwidth is a major consideration; the quality of both audio and video depend on it. DSL and other “high-speed” broadband connections are available in most areas. Video chat rarely works on anything less.

The final piece to the puzzle is software. Popular options include Skype, Google Video Chat, TokBox, iChat, and Vsee. In most cases, the free version of these programs will perform the job well enough. Premium versions with enhanced features are available for a modest monthly fee. Table 2 summarizes the available software options.

Nobody is suggesting that you switch your entire practice over to exclusively video chat. Try it on a pilot basis with a few patients, and see if it is something you might want to use on a more regular basis. If you plan to make video appointments an ongoing part of your practice, take the time to do it right. Experts in the field of video conferencing recommend the following:

  • Background. Set up a backdrop for your video appointments. It should be solid and dark to minimize data transmission (bandwidth) use and maximize the clarity of faces and handheld objects. Ask patients to do the same, if possible. Speaking in front of a bright background such as a window makes things more difficult for the person on the other end.

  • Position. Cameras should be at face level for both patient and provider to best simulate natural conversation. Cameras that are too low cause unnecessary shadows and create an air of dominance; those that are too high make it difficult to take notes or perform demonstrations during the discussion.

  • Screen shot. The camera should capture your upper torso and head within the screen. That way, hand gestures can be seen. Look at the camera when you speak. When using picture-in-picture, there may be a natural tendency to look at yourself in the small window. When speaking, try to look into the camera the same way you would look into a person's eyes. Position the camera just above the video monitor so you can also see the person you are speaking with.

  • Audio. Whenever possible, use a headset with a microphone for the audiocomponent. Using a headset helps to cut down on background noise so you can hear patients more clearly. It also gives patients a sense of intimacy and privacy. Having a microphone right near your mouth provides better clarity for patients and minimizes the risk of echoes and reverberation.

Table 2.

Available Video Chat Software Programs

Available Video Chat Software Programs
Available Video Chat Software Programs

Remember, patients will not be showing up with log books and devices in hand when doing a video appointment. You will need to be somewhat adept at using various forms of software for obtaining patient data. You may also need to instruct your patients about how to transmit their information. Developing written procedures to give (or send) to patients is helpful so they know how to get their information to you in time for their appointments.

Meters. Downloading software is usually free and can be done from the meter company's website or by obtaining the software on a disc. Download cables, which plug into the computer's USB port, are either free or modestly priced. Some of the newer meters connect directly to mobile devices that have applications for displaying the data. Table 3 offers information about obtaining meter downloading software.

The iBG Star meter from Sanofi syncs directly with the iBGstar app on iPhones. Data from this app can be e-mailed directly to providers.

Insulin pumps. Pumps contain extensive information that can be used for pinpointing problem areas and revealing sources of problematic blood glucose patterns. The historical information stored in pumps includes insulin delivery (both basal and bolus), daily insulin totals, blood glucose entries, carbohydrate entries, alarms/alerts, and priming of tubing and infusion sets.

Medtronic insulin pumps download wirelessly to a web-based program called Carelink (https://carelink.minimed.com). Once patients download their data to Carelink, it can be viewed by their HCP or imported into a professional version of the software. The downloading process requires a radio transmitter/receiver that plugs directly into a USB port on any computer. It is included with most pumps when they are shipped; they can also be purchased directly from Medtronic. In addition to reading Medtronic pump data, Carelink also reads data from a number of blood glucose meters and CGM data from Medtronic's Guardian CGM systems.

Animas insulin pumps download to a web-based program called Diasend (http://diasend.com). Like Carelink, Diasend can integrate data from multiple devices (blood glucose meters, Dexcom CGM devices, and Animas pumps) and is shareable with HCPs.

The OmniPod personal diabetes manager (PDM) and Deltec Cozmo insulin pumps download to the Copilot software program from Abbott Pharmaceuticals (http://www.abbottdiabetescare.com/copilot-health-management-system.html). However, to read data from the pumps, extension software must be added to Copilot. The extension software can be obtained from the pump manufacturer or through the pump company's website. Downloading the OmniPod PDM requires a cable that plugs into the port on the top of the device; downloading the Cozmo requires an infrared device.

The Accu-Chek Spirit and Combo insulin pumps download wirelessly (using an infrared reader) to Accu-Chek 360 software as well as SmartPix (http://www.accu-chekinsulinpumps.com). Although the pumps contain only insulin delivery information, the SmartPix program can integrate data from other Accu-Chek devices (meters and Combo programmer) to create more comprehensive reports.

The Tandem t:slim pump downloads to a web-based software program called T:Slim Connect. At the time this article was written, the software was newly approved by the U.S. Food and Drug Administration and was not yet available for trial.

CGM. CGM systems have limited capability to produce useful historical reports on their own display screens (only the past 24 hours is accessible), so downloading is necessary for detecting patterns, trends, and statistics. Medtronic CGM systems, as mentioned above, download wirelessly to the web-based Carelink program via a Carelink USB radio receiver. Dexcom CGMs download to a PC-based program called Studio. Older versions of Dexcom (before G4) also download to the web-based Diasend program described previously.

Table 3.

Where to Obtain Downloading Programs for Glucose Meters

Where to Obtain Downloading Programs for Glucose Meters
Where to Obtain Downloading Programs for Glucose Meters

It is difficult to identify all of the privacy issues facing telehealth providers, but it is safe to say that they are similar to those facing providers who are not using telehealth. Providers should have written policy procedures regarding use of information collected electronically. Common-sense precautions include use of software passwords, digital signatures and encryption, backup systems to ensure integrity of data, and a disaster recovery plan.4 

Karen W.

Background. Karen is a school teacher in rural Pennsylvania. She has had type 2 diabetes for several years, for which she takes metformin. Her BMI is 35 kg/m2, and she is being treated for high blood pressure. With the nearest endocrinologist several hours away (and already overbooked), she sees only her primary care physician for diabetes care.

Intervention. After an initial intake assessment conducted over the phone, Karen began working with our registered dietitian on a weight management program. For 3 months, Karen and the dietitian met every other week through video chat on Skype. She was educated on carbohydrate counting and meal planning, and she began to exercise. Karen was also educated on the potential benefit of adding a glucagon-like peptide-1 medication to her treatment. She brought information to her physician, who prescribed liraglutide. Karen was instructed about proper injection technique by our staff nurse via Skype.

Outcome. In the past 6 months, Karen has lost > 20 lb, and she has kept her fasting glucose levels < 120 mg/dl for the past month. Her A1C is down to 6.4%, and she continues to have monthly video chats with the certified diabetes educators (CDEs) at our practice. Before each appointment, Karen faxes her blood glucose records and her workout chart, and the CDE e-mails her educational notes for the upcoming appointment. We plan to continue working with Karen to reduce her cardiac risk factors and continue motivating/challenging her with ongoing weight loss and exercise efforts.

Marcus A.

Background. Marcus is a high school student who lives in the city with his mother and four siblings. He developed type 1 diabetes last year and recently transitioned to insulin pump-therapy. Marcus' mother Betty has a full-time office job and has a very busy schedule tending to all the kids. She wants to see Marcus manage his diabetes better (most recent A1C 9.5% with occasional hypoglycemia) but struggles to keep appointments at the local children's hospital.

Intervention. Betty and Marcus began working with the nurse practitioner at our office last month. All appointments have been conducted via Skype, at lunchtime with Betty and after school with Marcus. Marcus also uses text messaging to send blood glucose results to the nurse and downloads his pump to a website each week. Given his recent pump start, his appointments have focused on effective troubleshooting, diabetic ketoacidosis prevention, use of advanced insulin pump features, and strategies for preventing hypoglycemia during sports activities. Between appointments, the nurse works with Marcus to fine-tune the basal and bolus settings on his pump.

Outcome. Marcus's average glucose is down to 180 mg/dl, with a standard deviation of 75 mg/dl and > 60% of the readings within his target range. His most recent A1C was 8.4%. Marcus and his mom are now considering CGM. Ongoing educational efforts will focus on self-analysis of glucose data, appropriate self-adjustments to pump settings, and strategies for transitioning Marcus toward greater independence with his diabetes care.

Looking Ahead

There is no doubt that telemedicine in general, and video chat in particular, can play a major role in the care of patients with diabetes. As technology becomes even more efficient and accessible, and as third-party payers expand coverage for telemedicine, the question may not be whether to use it, but how to strike a healthy balance between remote and in-person appointments.

George Jetson's health care team would be proud.

Cynthia Halfen of the Marshfield Clinic in Eau Claire, Wis., contributed background material and personal expertise to this article.

1.
Zrebiec
J
:
Internet communities: do they improve coping with diabetes?
Diabetes Educ
31
:
825
836
,
2005
2.
U.S. Department of Health and Human Services
Health Resources and Services Administration
:
2001 Telemedicine Report to Congress
.
Rockville, Md.
,
U.S. Department of Health and Human Services
,
2001
3.
McLaren
PM
,
Ball
CJ
:
Interpersonal communications and telemedicine
.
J Telemed Telecare
3
(
Suppl. 1
):
5
7
,
1997
4.
Armstrong
M
,
Frueh
S
:
Telecommunications for Nurses: Providing Successful Distance Education and Telehealth
.
New York
,
Springer Publishing Company
,
2002