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With telemedicine, now the technology is so great. So if a patient doesn't show up for a telemedicine visit, you're still able to do other work. You can call in your prescription calls, you can call patients back, so there’s not a lag of time.

[Telemedicine: the use of electronic information and communications technologies to provide and support health care when distance separates the participants.]

The most common venue for telemedicine is video conferencing. This is, I think, a great application for reaching people in far-reaching communities.

TREAT is our telemedicine model and it stands for Telemedicine for Reach, Education, Access, and Treatment.We have an academic hub with a cadre of endocrinologists. Our endocrinologist has a schedule and they have telemedicine mornings where they know that they're working remotely those days.

Right now, we have two rural communities. They’re at least three hours away from Pittsburgh and those rural communities have a number of primary care practitioners where those patients have been receiving their care. We also in those two communities – and our endocrinologist would not do this model unless there was a diabetes educator who was available in those communities who could serve as a liaison.

The other thing that we insisted on with our TREAT model is that we only did glycemic management. It's about controlling blood sugars when we're clearly aware that it's part of blood pressure management, lipid management, and checking feet, but we really want to be the specialist for glycemia and helping in that area and allowing the PCP to manage the blood – the ongoing, the life-long course of lipid management and blood pressure management.

So we schedule our patients based on referrals from the local PCP. And so, everybody's familiar with the patient – the patient comes in, the educator’s sitting with the patient. The endocrinologist reviews the patient’s current plan, their history, comes up with the glycemic management protocol, and communicates it with the patient. The educator repeats it – you know, teach, reteach, and makes sure the patient understands it, and then looks at the gaps. “Oh, this patient is starting on insulin.” So then the educator sits and teaches the patient. So then the endocrinologist hands that off, so the educator works with the patient. The information is sent to the PCP, and the patient has the opportunity to receive aggressive management.

The TREAT model, I think, has many benefits. For one, patients get improved outcomes. And so they feel better. And not only do they have improved clinical outcomes, but because they have now a virtual team – you know, we can't get teams in all these areas – they have a virtual team, so now they receive education about how to take care of their diabetes and they have somebody in their community now, that they never even realized was a part of a team that they can call.

The key components, at least from my experience, that were needed to make this work is a dedicated team that knew that they could work together and agree to work together. There has to be a community that wants it.

You need to understand what your system, insurance-wise, will cover. In some places, it's according to zip code for Medicaid payment.

I think you need to have a central person. And for us, it was a diabetes educator, but there could be other people like nurse practitioners or dietitians who could be trained to do this kind of thing. It needs to be a team.

And I think that when you go into this, you better be thinking about how you're going to sustain it, because otherwise it's just one of those things that drop in and then everybody's disappointed when it leaves.

I really thought that for the population we were working with, seniors in a rural community, many of them think it's – to go to the city is like a big thing – and we thought, "Oh are they going to like this technology? Are they going to engage in it?” 100 percent satisfaction. The benefit that they got from it was just overwhelming to me. And the other thing that I was surprised by was how the primary care providers also saw it as an added plus. They weren’t threatened by it, and again it was because of the way we did the model. We included them, we weren't trying to take away patients or anything. It was about building a model that could be sustained in a community.