BARBARA DAVIS CENTER
TELEMEDICINE AT THE BDC IN 2020 AND BEYOND BY DR. PAUL WADWA
THE HISTORY OF TELEMEDICINE While most people were not using videoconferencing for
healthcare before 2020, telemedicine has been used at the Barbara Davis Center (BDC) and other clinical settings long before the COVID-19 pandemic. Telemedicine falls under the umbrella of telehealth, which is the delivery of health-related services and information via electronic and telecommunications technologies to improve a patient’s health status. Categories of telemedicine include store and forward, remote monitoring, and real-time interactive services. Store and forward, the process of capturing an image or data, storing it to then be forwarded for review by medical specialists has long been used in radiology, cardiology, pathology, and dermatology. In diabetes, remote monitoring can be done with continuous glucose monitoring (CGM) or artificial pancreas (AP) systems. Though the COVID-19 pandemic has led to a rapid expansion in the use of real-time interactive services like direct patient care through videoconferencing, healthcare providers were already implementing the use of telemedicine prior to the pandemic. By 2015, 90% of health care providers reported that their organization had already begun developing or implementing telemedicine programs. The Veterans Health Administration, another early adopter, saw a 20.4% decrease in days of hospital stays for diabetes patients.2 Though telehealth showed promising outcomes, barriers to implementation hampered widespread utilization. These included limited insurance coverage and reimbursement, licensure to use telemedicine across state borders, privacy and security concerns (HIPAA compliant software), and the challenge of convincing stakeholders of the value of telemedicine visits.
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TELEMEDICINE FOR DIABETES CARE Telemedicine works well in diabetes care in part because of the way diabetes care differs from other fields of medicine. A provider gives recommendations for a management plan and patients and families implement the plan in their daily life. Once a plan is implemented, insulin doses are adjusted based on information from the family as well as data from glucose meters, insulin pumps, and CGMs. The BDC provides clinical care for patients from a sixstate region and serves over 80% of pediatric patients with type 1 diabetes in Colorado and Wyoming. The pediatric clinic conducts 11,000 to 12,000 outpatient visits in any given year. For those who are not in or near the Denver metro area, however, in-person visits can be a challenge. Barriers to care for patients in rural Colorado and Wyoming include travel time and expense, weather barriers, and now a global pandemic. Telemedicine can bridge the gap in caring for these patients by improving their access to care, supporting local providers in rural communities, reducing travel expenses for families, and reducing travel burnout. In May 2012 the BDC began its telemedicine program for youth with type 1 diabetes in rural Colorado and Wyoming. Patients and their families visit local diabetes centers or pediatric offices to meet with their BDC providers via videoconferencing. Upon arrival to their local center, patients have data from their meter, pump, or CGM uploaded. Their provider at the BDC is then sent reports via fax or secure email. The local medical staff measures height, weight, blood pressure, HbA1C, and blood glucose. From there the patient and family are taken into a room with video conferencing equipment where the BDC provider conducts a routine visit, just as they would in a BDC patient room. The BDC provider adjusts insulin doses and identifies topics of review with the local diabetes educator, such as sick-day management, hypoglycemia, and injection techniques. The family then receives a packet of their after-visit summary (AVS) with recommendations from the visit. If needed, prescriptions are e-prescribed
