Exam
Telemedicine Diabetes Mellitus Evaluation
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Telemedicine Diabetes Mellitus Evaluation
, Telediabetes Care
See Also
Telemedicine
Type 1 Diabetes Mellitus
Type 2 Diabetes Mellitus
Type 2 Diabetes Mellitus in Children
Maturity Onset Diabetes of Youth (
MODY
)
Diabetes Complication Prevention
Diabetes Mellitus Education
Diabetes Mellitus Glucose Management
Nutrition in Diabetes Mellitus
Type 2 Diabetes Preparations
Continuous Glucose Monitoring
Home Blood Pressure Monitoring
Indications
Optimize diabetes care to improve patient access and decrease patient travel requirements
Address home social situation (e.g. food, housing, economic security)
Remote monitoring of
Glucose
See
Continuous Glucose Monitoring
High yield in high risk patients, underserved populations and the elderly
Efficacy
Provider and nurse
Telemedicine
visits improve outcomes and glycemic control
More effective in Type 2 Diabetes (including lifestyle modification) than in Type 1 Diabetes
Greatest results with younger patients, increased visit frequency and when video used (in addition to audio)
McDonnell (2018) Curr Diab Rep 18(7): 42 [PubMed]
Su (2016) Diabetes Res Clin Pract 116:136-48 [PubMed]
Remote Monitoring of
Glucose
has been among most effective strategies in lowering
Hemoglobin A1C
Particularly effective with
Continuous Glucose Monitoring
Text messaging and website portals have been used to modify medications based on
Glucose
readings
Faruque (2017) CMAJ 189(9): E341-4 [PubMed]
Cost effective for both patient and provider
Reimbursment by medicare and some private insurers is the same for
Telemedicine
as in-person visits
Reimbursement by medicaid and private insurers is varies by state and insurer
Retina
l Surveillance Exams by Ophthalmology
Telemedicine
More effective at reducing
Vision Loss
and less costly
Retina
l camera ($15,000) limited to larger medical systems
Whited (2005) Telemed J E Health 11(6): 641-51 [PubMed]
Garg (2012) Arch Intern Med 172(21): 1677-8 [PubMed]
Precautions
Assess patient's appropriateness for
Telemedicine
Digital literacy
Internet connection and compatible device (e.g. smartphone or computer)
No significant language barriers (not a contraindication if
Interpreter
s are available for visit)
Adequate
Vision
and
Hearing
Patient or family willingness to send clinical data before visit (e.g.
Glucose
logs, diet log,
Blood Pressure
s)
Additional contact may be needed in between
Telemedicine
provider visits
Phone calls
Electronic messaging
In person visits (new concerns, concerning findings on
Telemedicine
)
Patients may lack the electronic and internet resources to allow for
Telemedicine
Telemedicine
locations are being established in rural communities (e.g. VA partnerships with Walmart, American Legion)
Protocol
Clinic Staff
Ensure patient has necessary devices (facilitate DME prescriptions as needed)
Device and connectivity
Glucose
monitoring (e.g.
Continuous Glucose Monitoring
)
Blood Pressure
Cuff
Weight scale
TeleHealth
setup and troubleshooting with office staff
Obtain back-up phone numbers in case of technical difficulty
Obtain consent for visit, billing and privacy discussion
Gather previsit history and
Review of Systems
Inquire about new concerns
Update medical record including medications, habits, recent hospitalizations and surgeries
Remote
Glucose
monitoring (esp.
Continuous Glucose Monitoring
) is ideally performed between visits
Review
Glucose
trends, time in range, average
Glucose
and low
Blood Glucose
Medication adjustments may be made between visits
Cloud services include manufacturers (Dexcom, Clarity, Libreview) and platforms (Glooko, Tidepool)
Obtain clinical data before the start of the visit
Vital Sign
s (
Blood Pressure
,
Heart Rate
, weight)
Blood Glucose
readings
Lab test results ordered at last visit
Protocol
Clinical Encounter by Medical Provider
Confirm that patient has appropriate environment for visit (privacy, safety) and reschedule as needed
Patient not driving a vehicle or operating machinery
Patient can devote full attention to visit (not speaking to others, no significant background noise)
History
Review together any previsit history, positive
Review of Systems
and new concerns
Review
Vital Sign
s
Review
Blood Sugar
log
Review lifestyle (diet and
Exercise
)
Consider having patient demonstrate the food they eat, items in their refrigerator
Patient might demonstrate their process for medication use (e.g. pill boxes, use of
Insulin Pen
s)
Telemedicine
Focus Areas
Avoid sensitive exams via
Telemedicine
(e.g. genitalia)
Leg and
Foot
Exam (wearing shorts, and with socks and shoes off)
Hair Loss
or discoloration
May suggest
Arterial Insufficiency
Skin Wound
s, deformities and ulcers
See
Diabetic Foot Wound
Injection Sites
Patient should show their injection sites on video
Patient should palpate injection regions for firmness (lipodistrophy)
Suggests patient is overusing certain sites (encourage injection site rotation)
Plan
Adjust
Glucose
management (monitoring and medications) as needed
Review other medication changes
Review lifestyle modifications
Send patient an after visit summary
Follow-up Visits
Plan future labs before next visit
Alternate in-person (every 6 months) and
Telemedicine
visits (every 6 months)
Arrange in-person visit for additional concerns, complications or inadequate
Glucose
control
References
Mullur (2022) Am Fam Physician 105(3): 281-8 [PubMed]
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