The COVID-19 pandemic has led to a dramatic increase in the use of telehealth to provide diabetes care. Stephanie Crossen, MD, MPH, associate professor with the University of California Davis Department of Pediatrics and Center for Health and Technology, discusses what health care professionals have learned about the benefits and challenges of delivering diabetes care remotely.

Q: What is telehealth or telemedicine? Can telehealth be used to provide care for people with different types of diabetes?

A: Telehealth or telemedicine refers to any health care that’s provided remotely via telecommunications technology. This can include care provided by electronic messages, encounters through video-capable devices like smartphones, or telephone encounters. I’ll be focusing on telehealth encounters mainly using video, but also using the telephone, in the context of the COVID-19 pandemic.

Diabetes is one of the best-suited conditions for telehealth, and telehealth can be used to provide care for any type of diabetes. Diabetes management depends on patient-generated data and the health-coaching relationships between patients and their health care professionals, and both of those things can be easily incorporated into a telehealth visit. In the last decade or so, with improved cloud connectivity and data sharing for so many diabetes devices, accessing patient-generated data remotely is easier than ever. That lets us meet people where they are and deliver care in a way that’s more convenient for them.

Q: What kinds of diabetes care can be delivered via telehealth?

A: Telehealth can be used to deliver many kinds of diabetes care, beyond interpreting data and adjusting medicines. For example, health care professionals can use telehealth to provide

• more frequent care for patients who are struggling or need extra support during challenging times
• mental health support and behavioral therapy for patients with diabetes and their families
• school-based care for children with diabetes
• peer support through virtual peer groups and shared medical appointments
• provider-to-provider education and remote consultations between diabetes subspecialists and primary care providers

Q: How has the use of telehealth to deliver diabetes care shifted during the COVID-19 pandemic?

A: A study that examined data from multiple U.S. clinics found that less than 1% of diabetes care visits were conducted via telehealth in January and February 2020. By April 2020, after the pandemic began, most diabetes visits were being conducted via telehealth. 

A survey of U.S. endocrinologists found that the majority were using telehealth for most or all patient visits by spring 2020. However, only 11% of those endocrinologists had any experience or training in telehealth prior to the pandemic. A fall 2020 survey of people with diabetes that I conducted found that 65% of respondents had received some diabetes care via telehealth, but only about 5% of those using telehealth had any experience with it before the pandemic. So, it was a sudden shift for everyone.

Telehealth use skyrocketed for many reasons, including

• the need for social distancing and the higher risk of COVID-related morbidity and mortality for people with diabetes
• patient difficulties seeking in-person care due to economic hardships
• temporary federal and state policy changes that removed barriers to telehealth by allowing health care professionals to use any video conferencing platform, receive equal reimbursement for telehealth and in-person visits, and provide telehealth care across state lines

Q: During the pandemic, have some groups of patients been more likely than others to use telehealth? What factors influenced telehealth use?

A: Many studies involving people with diabetes or other conditions showed that older adults, people with public insurance, and people from racial and ethnic minority groups were using telehealth less. They were more likely to use in-person care than remote care, and more likely to use telephone care than video care. These differences may be related to internet access, access to video-capable devices, or digital health literacy—comfort with using the technology.

Early in the pandemic, we saw large disparities in telehealth use for non-native English speakers. These disparities have improved as health care centers have incorporated interpretation services into telehealth. However, centers have been slower to switch to telehealth applications that are available in multiple languages.

Q: What have health care professionals learned about the benefits of using telehealth to deliver diabetes care?

A: For patients who are willing to let you see and learn about their home environment, telehealth visits can help you understand their challenges. I've had patients show me difficulties—such as not having a refrigerator to store insulin or not having access to healthy foods—that they didn’t discuss during clinic visits.

As a pediatric health professional, telehealth has been an amazing way to engage a child’s caregivers. Often, one person brings a child to all clinic visits. Through telehealth, I’ve been able to connect with other family members who provide diabetes care. Telehealth also allows pediatric health professionals to continue diabetes care when patients move away for college. I’m sure that continuity of care is a benefit for adult patients as well.

Evidence suggests that telehealth can lead to higher engagement and self-efficacy for many people with diabetes. Patients may find it empowering to connect with health care professionals from their homes, where they’re in charge. Taking on pre-visit tasks—such as having lab work done and preparing to share data—can also help patients take ownership of their diabetes management. This sense of ownership may contribute to patients’ high satisfaction with telehealth visits.

Q: What are some challenges of using telehealth to deliver diabetes care?

A: Patients who don’t have much private space for telehealth visits may find it hard to address sensitive topics like mental health or personal relationships that affect diabetes management. Also, some patients aren’t comfortable with telehealth visits that allow health care professionals to see their home environment.

Establishing rapport and trust via telehealth can be more difficult, especially if you don't have a long provider-patient relationship or are working with very young patients. Lack of internet access and problems sharing data or connecting via video can also be challenges.

For health care professionals, the ability to physically examine patients via telehealth is quite limited. However, for many patients with diabetes, I don’t need to perform a detailed physical exam unless a specific concern arises. Another challenge is delivering team care via telehealth, especially if members of the diabetes care team—nurses, social workers, dietitians, psychologists—aren’t joining telehealth visits in real time.

Q: How has the role of telehealth in diabetes care changed since the early days of the pandemic? What role might telehealth play in the future?

A: For most medical centers across the United States, telehealth use peaked in the spring and summer of 2020 and then decreased. By early 2021, most centers returned to delivering most diabetes care in-person but continued to use telehealth at much higher rates than before the pandemic. Telehealth use varies and has changed over time due to local COVID infection rates and precautions.

We’ve seen the potential for telehealth to facilitate patient-centered, flexible, and individualized diabetes care. However, we don't have a lot of evidence yet about how telehealth should be used. Are certain telehealth modalities or frequencies most beneficial for specific populations of people with diabetes, depending on their diabetes type or their age or their device use? Many organizations are currently developing telehealth consensus statements to help guide health care professionals, which is great.

We also don’t know what the telehealth practice environment will look like in the future. Health care policies may limit telehealth use once the temporary pandemic policies expire. There have been efforts to implement permanent telehealth policies, but these policies vary. There’s also a national effort to increase broadband internet access, but it’s not clear how wide-reaching the effects of that will be. 

Thankfully, many health systems are working to improve access and equity in telehealth. For example, health systems are working to offer telehealth interpretation services, adapt software applications for more languages, and provide telehealth navigators for people with limited digital health literacy.

Q: What advice do you have for health care professionals or organizations considering starting or scaling up a telehealth program for diabetes care?

A: I coauthored an article, Top 10 Tips for Successfully Implementing a Diabetes Telehealth Program, which was published in March 2020, the same month the COVID-19 lockdown began. A lot of the advice in that article is still applicable.

I would urge health care professionals to

• invest in telehealth products and processes that promote equity, such as software that requires lower digital health literacy and uses multiple languages
• allow for both video and telephone encounters, as some patients may want to receive remote care but have trouble using video applications
• schedule blocks of telehealth visits and coordinate efforts to deliver diabetes team care via telehealth
• determine how your practice will standardize or individualize diabetes care plans to incorporate telehealth
• provide flexibility by converting in-person visits to telehealth visits when needed
• have staff members who serve as telehealth navigators
• provide orientation and training for any health care professionals involved in telehealth

Q: What research is being conducted on the use of telehealth in diabetes care?

A: Thankfully, there’s so much research in this space that I can’t summarize all of it. Exciting areas of research include

• using telehealth for shared medical appointments and virtual peer groups, which can improve the experience and outcomes of diabetes care for adolescents and young adults with type 1 diabetes
• analyzing remote data to figure out which patients need more support and when they need it
• comparing outcomes from remote monitoring and from more frequent telehealth visits
• delivering behavioral health and mental health support to patients with diabetes via telehealth
• connecting diabetes specialists with primary care providers through programs, such as Project ECHO (Extension for Community Healthcare Outcomes), that facilitate remote consultations and provider-to-provider education