Telehealth—Team care without walls
Telehealth (or telemedicine) is the use of secure high-speed Internet connections for real-time video conferencing for medical, diagnostic, monitoring, and therapeutic purposes when distance and/or time separates the participants. Telehealth can expand access to health care and education for patients and health care professionals in remote rural and medically underserved locations, as well as increase the delivery of evidenced-based medicine and improve the consistency of care.
Telehealth applications that expand the reach of the diabetes team include
- primary care digital retinal imaging for diabetes eye screening to augment or enhance regular comprehensive vision and eye health exams
- video conferencing for provider education (such as “Brown Bag” conferences)
- video conferencing for group diabetes education and individual counseling
- individualized telehealth for medical nutrition counseling (covered by Medicare)
- remote monitoring of self tests for blood glucose and blood pressure
- pediatric care for youth with type 1 diabetes in remote areas
- shared web-based clinical information connecting the patient, endocrinologist, primary care provider, pediatric care experts, other specialists, and other team members
- secure email and remote management
- web-based patient surveys and information libraries
- customized patient portals or personal health records
- hospital “grand rounds” education sessions
(See Case Studies 1 and 2 that address telehealth.)
Ocular telehealth programs
These programs can deliver eye care in the form of retinal screenings to those with limited care access and may in some cases improve care for those with regularly available vision and eye health care. Validated telemedicine programs using remote digital imaging systems are able to detect diabetic retinopathy but may not adequately detect other ocular co-morbidities associated with diabetes, including refractive errors, glaucoma, cataracts, dry eye, nerve palsies, and iris neovascularization. Retinal images are examined remotely by trained professionals.
The Indian Health Service (IHS)-Joslin Vision Network Teleophthalmology Program uses telemedicine technology to provide annual eye exams to American Indians and Alaska Natives with diabetes who live far from health care centers. A digital camera transmits photographs of a patient’s eye to a central reading center, where IHS eye doctors interpret the images and send a report to the patient and primary care physician. The report includes the level of diabetic retinopathy, the presence of any non-diabetic retinal disease, and a recommended course of treatment. A four-year study showed that the program resulted in
- 50 percent increase in annual eye exams
- 51 percent increase in laser treatments to prevent blindness
- lower cost with quality equal to or better than a traditional dilated eye exam (See IHS resources.)
Designing, building, and implementing an ocular telehealth program for diabetic retinopathy requires a clearly defined mission, goals (e.g., to preserve vision, reduce vision loss, and provide better access to limited forms of eye care), and guiding principles. When possible, these goals should be consistent with using telehealth to augment or enhance existing comprehensive eye care services. (See Resources under American Optometric Association and the Ocular Telehealth for two key documents that help an organization develop an effective and sustainable program.)
Early detection through annual screening and treatment of diabetic retinopathy can reduce vision loss by 90 percent. Remote assessment of diabetic retinopathy using telemedicine is an accurate and potentially low-cost way to identify retinal lesions and facilitate appropriate and timely use of specialty care. Future studies will hopefully provide cost-effectiveness data for this service.
Other telehealth programs
These programs provide a sample of possible uses of telehealth to expand the team care concept.
The Arizona Diabetes Virtual Center of Excellence (ADVICE) is a comprehensive program for diabetes prevention, assessment, and management, carried out via Arizona Telemedicine Program Network. The ADVICE program primarily provides diabetes education and individual telenutrition consultations in Spanish and English for Hispanics and American Indians who have inadequate access to health care.
The Indian Health Service is expanding its use of telemedicine to bring primary care and specialty medicine to remote locations to reduce geographic barriers between remote, smaller communities and health care professionals (see IHS resources).
Veterans Rural Health Resource Centers, opened by the Department of Veterans Health Administration in Vermont, Iowa, and Utah, are finding out how best to extend telehealth services to veterans living in rural areas (see Veterans Affairs Resources).
Florida has a state-funded telehealth program that provides diabetes care to pediatric patients who live in Daytona Beach and the surrounding areas and are insured through state and federal programs. At the time of a clinic visit, an on-site registered nurse obtains a standardized patient history, downloads the patient’s blood glucose meter data, and faxes the information to the University of Florida, Gainesville, pediatric team. The nurse also arranges appointments with other providers such as a dietitian, a psychologist, or an ophthalmologist (see Case Study 2).
Shared medical appointments and group education
A method to increase practice efficiency is shared medical appointments, where a multi-disciplinary team sees a group of patients. This model of care is a response to factors that include the increasing prevalence of chronic diseases such as obesity and diabetes, an aging population with a greater number of complex needs, the need to include family members in disease management and education, and limitations of the short traditional office visit.
Structure and setting
Usually eight to ten patients participate every three months in a one- to two-hour appointment, although 20 or more patients can be seen in longer sessions. Successful shared medical appointments for people with diabetes have been reported in various settings:
- health maintenance organizations[47, 49]
- a Veterans Health Administration (VHA) primary care clinic at a tertiary care academic medical center
- a hospital-based secondary care diabetes unit
- an adult primary care center serving uninsured or inadequately insured patients
Interventions usually focus on diabetes self-management support. Time is included for patients to meet individually with the primary care provider for evaluation of new medical problems, medication adjustments, and yearly checks for complications. Evaluation teams usually include two or more health care professionals, as needed, such as a family physician, clinical nurse specialist, nurse educator NP, pharmacist, clinical health psychologist, dietitian, and podiatrist. Some of the health care professionals were certified diabetes educators (CDEs). Other care providers, such as eye specialists and dental professionals, could also be included. (See Appendix 2 for information on the role of CDEs.)
Success of the group visit model depended on
- skilled use of social and facilitation techniques by the health care team
- identification and scheduling of appropriate patients using a patient registry
- interpersonal sharing between patients
- training support staff
- active participation by all stakeholders
A meta-analysis of randomized controlled and controlled clinical studies of group education programs for adults with type 2 diabetes was compared with routine care, wait list control, or no intervention. Studies were included if the intervention was at least one session with a minimum of six participants and if the length of follow-up was at least six months. Fourteen publications describing 11 studies that involved 1,532 participants were included. The analysis found significant improvements in
- fasting blood glucose levels and A1C
- self-care knowledge
- systolic blood pressure levels
- body weight
Diabetes medication dosage was reduced in one out of five participants.
Other studies of group visits report
- fewer hospitalizations and emergency room visits[47, 49]
- improved quality of life
- increased patient satisfaction
- lowered cardiovascular risk
- weight loss, smoking cessation, increased physical activity, and improved depression scores (See Case Study 3 on group visits.)