What Do You Need to Know About Diabetes and Telemedicine?
Kim A. Carmichael, MD—Series Editor
John T. Milliken Department of Medicine, Division of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St Louis, Missouri
Carmichael KA. What do you need to know about diabetes and telemedicine? Consultant. 2020;60(8):17-18. doi:10.25270/con.2020.08.00002
The author reports no relevant financial relationships.
Kim A. Carmichael, MD, Professor of Medicine, John T. Milliken Department of Medicine, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110-1010 (email@example.com)
The Centers for Medicare and Medicaid Services (CMS) have expanded access to telehealth medicine as of March 6, 2020, during the COVID-19 pandemic,1 and many institutions have developed systems for commercial and Medicaid/Medicaid reimbursement.2
Q. What are legal rules and regulations regarding telemedicine?
A. Most states have temporarily relaxed interstate billing requirements for clinicians to be licensed in the state in which the patient is residing at the time of the visit.3 Many states also require that there be at least one in-person visit before telemedicine visits or before prescribing certain medications.3 The Department of Health and Human Services’ Office for Civil Rights has provisionally adapted enforcement discretion in waiving penalties for violations of the Health Insurance Portability and Accountability Act (HIPAA) for clinicians who, in good faith, use caution with communication technologies such as FaceTime or Skype during this public health emergency,1 but less-secure applications such as Facebook Live, Twitch, and TikTok should be avoided.3 Some applications, such as Zoom, allow for HIPAA-secure platforms, including a “waiting room” to minimize the risk of “Zoombombing”—when uninvited attendees break into and disrupt a videoconference. One should also keep in mind that even when a state medical board allows for interstate visits, medical liability loss will be subject to the state in which the patient is located.3
Q. How do you determine which patients are appropriate for telemedicine visits?
A. Although there are no formal guidelines, good judgment would be to consider telemedicine for patients at greater risk with fact-to-face visits: those aged 65 years or older; those with uncontrolled diabetes, cardiovascular disease, class 3 obesity, chronic kidney or liver disease, or pulmonary, cardiovascular, or cerebrovascular illness; those on glucocorticoid or immunosuppressant medications; and those with an immunocompromised state. Clinicians also need to consider travel distance and accessibility to the office or clinic.
Q. What are the essential preparations for a virtual visit for patients with diabetes?
A. Before visits, it is important for the patient to understand the nature of a telemedicine visit, that one may not be able to experience the full level of service that could be provided with an in-person appointment, and that it will be a billable encounter.4 It is also advisable to have a signed informed consent form.1,4,5 The American Association of Family Physicians has developed a tool kit to help setting up telemedicine programs.1 Confidentiality and security are not as robust as in the face-to-face visits, so privacy measures should be optimized.5
Office scheduling templates may need to be revised, and both clinicians and patients alike will need appropriate communication hardware as well as video software.4 When video capacity is unavailable for patients, telephone virtual visits may need to be employed. Clinicians may want to develop standardized visit templates as well as processes for pre-visit and post-visit tasks so that the clinical encounters will be more productive and efficient.4 It can also be useful for the office to designate one or two staff members to specialize in navigating the visits.4
Many persons with diabetes have software for glucose meters, pumps, and continuous glucose monitors that often can be securely connected to the office and from which the data often can be uploaded from home.4 It is advisable to provide patients information on how to use these platforms in advance of each visit in order to have that information available during the encounter. The Federation of State Medical Boards has developed model policies for the appropriate use of medical technologies.5 The Food and Drug Administration has provided emergency guidance for use of noninvasive remote monitoring devices,6 and CMS also has allowed additional billing codes for continuous glucose monitoring.4,7
Q. What are the necessary components of a virtual visit for a patient with diabetes?
A. Patients and clinicians need to be aware that there will be cultural changes in the provider–patient relationship, but that patient-driven and patient-centered diabetes care will still be the primary goal.4 Telemedicine visits do not place the individual in a “junior” status compared with in-person visits.3
Good care for any patient includes a careful history, medication reconciliation, and general risk assessment. As with any visit, one should ask about diet, lifestyle, diabetes symptoms, hypoglycemia, comorbid conditions, and overall glycemic control. The clinician should use sound judgment regarding the timing and relative urgency of routine laboratory tests.
Documentation in the medical record should include all elements of the history, problem assessment, and treatment plans, and in the case of video visits, there are often elements of the examination that can be described.
One should be familiar with multiple CPT billing codes for telephone and video visits, including interpretation of continuous glucose monitoring devices.4
Q. Where do we go from here?
A. The COVID -19 pandemic has placed an urgency on developing telemedicine in general, with particular applications for persons with diabetes. The workflow of many offices may change forever, with a blend of in-person and telemedicine encounters. Therefore, each office will need to customize patient workflow, scheduling, billing, electronic medical record integration, and strategies for continuity of care.4
- American Academy of Family Physicians. General Provider Telehealth and Telemedicine Tool Kit. 2020. Accessed July 6, 2020. https://www.aafp.org/dam/AAFP/documents/advocacy/prevention/crisis/CMSGeneralTelemedicineToolkit.pdf
- Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. N Engl J Med. 2020;382(18):1679-1681. doi:10.1056/NEJMp2003539
- Yasgur BS. Seven things to consider when transitioning to telemedicine during COVID-19. Endocrinology Advisor. Published May 20, 2020. Accessed July 6, 2020. https://www.endocrinologyadvisor.com/home/topics/practice-management/seven-things-to-consider-when-transitioning-to-telemedicine-during-covid-19/
- Crossen S, Raymond J, Neinstein A. Top 10 tips for successfully implementing a diabetes telehealth program. Diabetes Technol Ther. Published online April 21, 2020. doi:10.1089/dia.2020.0042
- Federation of State Medical Boards. Model policy for the appropriate use of telemedicine technologies in the practice of medicine: report of the State Medical Boards’ Appropriate Regulation of Telemedicine (SMART) Workgroup. 2014. Accessed July 6, 2020. https://www.fsmb.org/siteassets/advocacy/policies/fsmb_telemedicine_policy.pdf
- Food and Drug Administration. Enforcement policy for non-invasive remote monitoring devices used to support patient monitoring during the coronavirus disease 2019 (COVID-19) public health emergency (revised): guidance for industry and Food and Drug Administration staff. June 2020. Accessed July 6, 2020. https://www.fda.gov/media/136290/download
- Center for Connected Health Policy. Finalized CY 2019 physician fee schedule. November 2018. Accessed July 6, 2020. https://www.cchpca.org/sites/default/files/2018-11/FINAL%20PFS%20CY%202019%20COMBINED_0.pdf