Telemedicine is more than one thing, which most people don't really recognize. Telemedicine is both synchronous, which means you're talking to the patient in real time; it's asynchronous, which is the work that you do behind the scenes before you actually communicate with the patient and then afterward; and then it's also remote monitoring. And all of those three pieces are incredibly important in the management of people with diabetes when it comes to telemedicine.

I work in two parts of town: one part of town is in Beverly Hills, where patients have access to all the health care that they need. But in East Los Angeles, it's an underserved population.

There are real barriers to trying to deal with underserved individuals with telemedicine where they don't have access to health care, they have lower incomes, they have often lower educational levels, they're often challenged by lower health literacy, lower numeracy skills. They have a hard time even getting to clinic visits; they often have to take two and three buses. They generally don't have smartphones. They don't have computers at home. Most of them have some form of a telephone, but their access to those can be erratic.

I have, literally, 20 and 30-year-olds who have amputations, who go blind, who are on dialysis, who have all of the complications of diabetes young, all because of access issues.

But I became really convinced that the best way to reach our patients was through telemedicine, or at least for some portion of their visits, because if you do telemedicine at the right time, which would probably be the evenings or maybe early morning or the weekends, then we could reach a whole lot of patients. But the whole system would have to change in terms of staffing when we do what we do, so that we can reach people more effectively.

In terms of remote monitoring and the acquisition of data, having devices that talk to the cloud and give you data is the answer. If we can't get data, we can't manage our patients. So, a lot of them in the beginning were trying to tell us the data from their meter memories, and a lot of them couldn't really figure that out and it was hard for them to do. There are continuous glucose monitors that do that seamlessly, and there are glucose meters that also do that. Our county patients, by and large, don't have those devices.

But one of the things that we did really early on was we were able to get grant funding and we started being able to give devices—continuous monitors—to our patients who are on insulin. And then we set up a system whereby we could get data into the clinic.

What happened after that was that because we now had data, we became able to get the patient's health insurance—which primarily was Medi-Cal or Medicaid in other places—to allow us to actually get the devices for patients through their health plans. And so, increasingly we began to be able to do remote monitoring and get data.

If, in the old days, a patient had their blood sugars go up and they needed help, they could call and then someone might get back to them and it was a pain. And then maybe they come in for a clinic, but it was two weeks later. Now they can call, we can have our assistant get all the data that day, and then send it to us. And I can get data on a patient that I can then look at and then I can give information back to the patient about what to do to help manage their diabetes.

So, it allows for a quicker turnaround, that allows for patients to do better, and it's much easier than a patient going to the walk-in clinic or to the ER because we can manage a lot remotely that we couldn't manage before because we've developed systems. Now again, these are baby systems, this is the beginning of systems development, but I can see what's possible and I couldn't before.

Telemedicine can help me keep patients out of the hospital for ketoacidosis because I'm able to, in a very immediate way, talk to patients several times a day if necessary, have them give insulin, drink fluids, ingest carbohydrates, do whatever I need to do to keep them safe at home. But that requires something that I call my Diabetes ICU. And what I do is I take patients who I think are sick—so they're either new onset patients, or patients whose diabetes has gone wildly out of control, or patients who’ve developed COVID, whatever it is—they’re patients I'm worried about. I have my patients in my ICU on a specific frequency. And so, some of my ICU patients may need me to monitor them a couple of times a day, some patients need daily monitoring, and some patients need weekly monitoring. And I have my diabetes educator, whatever the frequency is, to send me the data. So, they look in the cloud, they get me the CGM tracing or whatever they have or need, they send it to me, and then I make treatment decisions. And so, it's in real time, just like if I had a patient with me in a bed in my house and I take care of them, and I then prevent them from going into the hospital, but I also help them control their diabetes better. But it's very high maintenance, it requires that I'm available 24/7, and I can't scale it if it's just me and a diabetes educator because I can't do this to thousands of people.

I think we need to do a lot of research to develop these systems of remote monitoring and feedback to patients, because if we can do it in near real time and adjust, intensify, use it to pick up patients who are falling out of the system, we can really help bring them back. And I think it might make people feel safer. It might make them have less diabetes distress. If you knew somebody was always looking out for you, wouldn't you feel better? And if you knew you could just reach out and call somebody and talk to somebody who could discuss things with you and help you? Diabetes isn't just about blood sugar, it's about all the factors that go into raising that blood sugar and making people feel safe, and making people feel not judged, and making people feel that success is possible.

My advice to practitioners is that telemedicine is a great tool, as long as you have the resources to prepare for diabetes management, which means getting the data in advance, then having it available to access to help patients, and then having some follow-up so patients can follow your advice.

But the second thing is, is telemedicine alone is not enough. Because I've started going back into the office on the west side where I was strictly doing telemedicine and I've seen people come in who had foot ulcers that they didn't really complain to me about on the phone because they couldn't really see their feet. And I've seen patients where their medications were mixed up where they couldn't figure out how to download their meters, so I couldn't get the data. And so, I think that there's got to be a hybrid model.

The key to all of this is having a team. Diabetes management has always been about educators and dietitians and social workers and psychologists and ophthalmologists and everybody else; it does take a team.

There's no one size-fits-all, and every community has its own solutions. But I think we as physicians and researchers need to figure out what would work for a community and help them achieve that. And I think we can do a wonderful job. I think we can really change people's lives. But in some ways, it's one situation at a time, and I think people should always be optimistic that we can help, and I've certainly seen ups and downs and funding come and go, but we really need to believe in the process.