The Power of Telemedicine in Diabetes Care: Remote Patient Monitoring

According to the American Hospital Association, the prominence of telehealth has been steadily increasing over the past decade, with 76% of hospitals having fully or partially implemented computerized telehealth systems.

Telehealth boomed even more during the COVID-19 pandemic. Data shows that telemedicine encounters increased by 766% during the first 3 months of the global outbreak!

Since then, telehealth—also referred to as telemedicine and connected care—has garnered the attention of clinicians and patients, as indicated by several statistics.

This begs the question of how telemedicine and remote patient monitoring have impacted diabetes management. What benefits has it offered? And what are some of the challenges it’s currently facing?

Read on to learn all about the role of telemedicine in diabetes care.

In concept, telehealth seems particularly well-suited for diabetes care. After all, the treatment of chronic disease relies mainly on patient-generated health data and health coaching, which can be done remotely.

To understand how telehealth has revolutionized diabetes care in practice, we should talk about its prevalence before and during the COVID-19 pandemic.

Although telehealth was gaining traction way before COVID-19, growth was gradual and limited in scope compared to the meteoric rise resulting from the pandemic.

As early as the 1990s, research indicated that more frequent interactions between diabetes patients and healthcare professionals helped improve clinical outcomes.

However, even with care coordinators, committing to frequent in-person clinic visits could have been more feasible, which led medical professionals to supplement clinical encounters with phone calls.

In recent decades, notable technological developments have allowed for more comprehensive telehealth utilization. A few examples include:

• Videoconferencing platforms compliant with privacy regulations
• Bluetooth-connected glucose meters
• HIPAA-compliant online data management platforms
• Reimbursement codes for telehealth services

With these tools and developments, pre-pandemic telemedicine interventions provided improved access and satisfaction for patients in rural areas.

Other benefits included increased frequency of diabetes care encounters, more primary care provider knowledge in managing diabetes, and better glycemic control across different populations.

The results of pre-pandemic telehealth interventions were heterogeneous, which is no surprise considering the variability of telehealth modalities and populations.

That being said, several published reviews and meta-analyses of telehealth interventions concluded that the effects of telehealth are larger with type 2 diabetes patients compared to type 1, and with adults compared to the youth.

The COVID-19 pandemic led to an abrupt and dramatic increase in telehealth utilization across the board, not just in the diabetes control sector, due to stay-at-home orders.

Diabetics and healthcare providers were especially hesitant to meet in person, as observational data showed higher COVID-19 risks for those living with diabetes.

During the outbreak, new pandemic health policies removed many of the barriers that stood in the way of telehealth. For instance, privacy regulations were relaxed to allow for wider videoconferencing use.

Further, reimbursement requirements were waived by the U.S. Centers for Medicare & Medicaid Services (CMS) so that telehealth services are provided to new and established patients, and reimbursed similarly to in-person visits.

As a result of these changes in healthcare, along with changes in economic conditions, the use of telehealth surged, comprising the majority of care services provided by many diabetes centers by mid-2020.

Surveys conducted in the spring of 2020 indicate that most endocrinologists switched to virtual care and that 28% of all diabetics engaged in remote diabetes care as a result of the COVID-19 outbreak.

Also interesting is a 2021 study revealing that telehealth made up only 1% of diabetes visits to clinics participating in the T1D Exchange Quality Improvement Collaborative (T1DX-QI) before the outbreak and that it jumped to make up most visits post-pandemic.

Among T1D Exchange patients and community members, 65% reported using telehealth during the outbreak. These statistics show a night-and-day difference between telehealth use before and after the pandemic.

Continuous glucose monitoring (CGM) has become increasingly popular and integrated into diabetes management, with some of the most common systems including Medtronic Guardian, Dexcom, and Freestyle Libre.

These tried-and-tested systems feature a sensor you insert under the skin to measure interstitial glucose levels. They also feature a transmitter that wirelessly sends data to a reader or smartphone app.

In some systems, the data can also be sent to integrated pumps for automatic insulin suspension or delivery. These pumps are known as sensor-augmented insulin pumps (SAP).

Note: Each CGM system has a free online platform to download printable data reports.

Patients and health care providers can review CGM data remotely or in person and make treatment changes based on emerging glucose patterns that aren’t easily detected by periodic fingerstick testing.

Some CGM systems can alert impending high and low glucose levels, facilitating real-time intervention to keep the patient’s glucose levels within the target range.

Further, most CGMs nowadays have dedicated smartphone apps and can connect to third-party data management platforms like Tidepool and Glooko—a subscription fee may be required, though.

Fingerstick meter brands like OneTouch and Accu-Chek now have internet-enabled models that feature memory to log and integrate key factors such as blood glucose readings, medications, and physical activity.

Moreover, some connected meters, like Livongo and Dario, offer diabetes coaching and education. These services are offered for a fee, which may be covered by some health insurance plans and employers.

And similar to CGM systems, some connected meters can integrate with third-party data management platforms for optimized self-care and clinical decision-making.

Smart insulin pens and pen caps are nifty devices that offer digital tracking and analysis of insulin dosing data. They have built-in technology to record and transmit information about insulin doses.

Both devices provide bolus calculators that consider the patient’s programmed insulin-to-carbohydrate ratio and correction factor, in addition to the current insulin on board. They also offer reminders to prevent missed doses.

Smart pens and caps are excellent options for diabetics who want more engagement in dosing decisions without using an insulin pump.

Coupled with a continuous glucose monitoring system, the datasets of an intelligent pen or cap can be reviewed remotely to evaluate dosing patterns, timing, and medication adherence.

Smart insulin pens and caps can also be integrated with platforms like Glooko and Tidepool.

Insulin pumps are sophisticated devices that provide customized insulin therapy for diabetes care. They’re used to provide programmed continuous basal insulin infusion.

These high-tech devices also come in handy for calculating mealtime bolus doses and correcting high blood sugar (hyperglycemia) based on customizable carb ratios and insulin correction factors.

Traditional insulin pumps are worn on the body with a subcutaneous catheter. The wear time varies from patient to patient, but the infusion site needs to be changed every 2-3 days. Patch pumps are also a viable option.

All of the data from insulin pump devices, paired CGM systems, and their respective settings can be uploaded and shared using proprietary or third-party platforms.

Millions of people use health apps for lifestyle tracking and disease management. Even apps are designed specifically for chronic conditions like diabetes mellitus.

Fitness, wellness-tracking, nutrition, and medical monitoring apps usable on smartphones and smartwatches have been particularly popular since the pandemic. That’s not to mention standalone wearable devices like Fitbits.

What’s important to note about health apps is that they’re not FDA-reviewed. Only high-risk ones, like insulin dose calculators, are regulated by the FDA.

Separately, digital therapeutics (DTx), which are evidence-based therapeutic interventions driven by software, must undergo full FDA approval, similar to prescription drugs.

When it comes to selecting appropriate diabetes management apps and devices, guidance is offered by entities like the European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA).

It’s worth pointing out that the ADA has a comprehensive consumer guide to diabetes devices and medications that gets updated every year.

Telehealth provides access to diabetes care regardless of distance, enabling endocrinologists to serve people living in rural locations with provider shortages.

Thanks to telemedicine, patients no longer need to travel to healthcare facilities to receive proper care. This, in turn, saves a lot of time and expenses associated with commuting.

Patients appreciate the convenience of attending care appointments from the comfort of their homes. Diabetics with busy schedules also appreciate the flexibility of telehealth appointments compared to in-person visits.

A survey of 1,452 diabetics backs this up, with 62% of the patients reporting that telehealth was as effective or more effective than in-person care and 82% reporting that they would use telehealth for some or all future appointments.

Telehealth enables the participation of additional caregivers who might have struggled to attend in-person visits due to rigid work schedules or other restrictions.

In addition, telehealth provides healthcare professionals with a view of the patient’s home environment and diabetes supply storage, which gives insight into challenges the patient might fail to raise during in-office visits.

Telemedicine allows for tailored care plans based on individual patient needs. It enables patients who are struggling with their conditions to receive more frequent contact with their primary care providers.

It also enables patients with high self-efficacy and glycemic control to replace most, if not all, of their in-person visits with telehealth appointments.

Telemedicine isn’t without its challenges and limitations. One key challenge with telehealth in diabetes care is lower utilization among certain groups of patients.

Research shows that those with public insurance, racial/ethnic minority status, older age, and limited proficiency in English have lower rates of using telehealth services.

Contributing factors are likely to include disparities in access to smartphones and internet connectivity and low digital literacy skills.

Another notable challenge is limitations in privacy and the ability to discuss sensitive health topics during telehealth visits. This is especially common among patients living in small homes or multigenerational households.

Obtaining and integrating patient glucose data such as A1C values and BGM results has also proven challenging in many telehealth diabetes care programs.

To elaborate, accessing patient-generated data from glucose meters, insulin pumps, and CGMs can be challenging, especially for those needing reliable home internet access. Equally difficult is trying to seamlessly integrate this data into electronic health records.

Lastly, telehealth in diabetes care seems to be limited by uneven access and care receipt, as evident by the wide variability in how much telehealth is offered by different diabetes clinics and care providers.

Telehealth has the potential to completely revolutionize diabetes care by making it more accessible, convenient, and patient-centric, regardless of geographical constraints.

By facilitating remote monitoring and management of diabetes, telemedicine can help people with diabetes manage their condition with high efficacy and live healthier lives.

Telehealth isn’t without its challenges, though. From lower utilization among certain groups of patients to limitations in privacy, improvements are needed to increase the impact of telehealth in diabetes care.