We Love Our Patients — We Just Can't See You in Person Right Now
One attraction of taking care of people with a chronic condition is that we get to see you every three months and there are patients in our practice whom we have known for decades. We love the visits with you, catching up on your lives and helping with your diabetes care, however this can be done via telemedicine nearly as well as in person. Therefore, until the COVID-19 crisis has passed we will be doing essentially all visits via telemedicine, to reduce risk to you and to our staff.
Diabetes is the perfect condition for video and phone visits since many of you have long-term relationships with us already, and much of your visit revolves around reviewing your diabetes data. We started experimenting with telemedicine visits a year ago; we offered this option mostly to patients with long commutes. However, due to lack of consistent insurance coverage its utilization was limited. Now, with new reimbursement policies and the COVID-19 pandemic we ramped our telemedicine utilization so now nearly all of our visits are done this way.
Our office has recently been busy contacting patients to switch them to telemedicine. The biggest challenge is viewing your diabetes data. Some people already have data streaming into cloud-based services, and others are learning how to upload from home to share their data. Frankly, getting data from diabetes devices as people walk into the clinic has long been the weak link in providing care. It seems like every blood glucose meter, pump and CGM company has its own proprietary cable and software platform. Downloading to the software program or uploading the device to the cloud requires finding the cable, logging onto to the program and hoping that you are not blocked by the clinic's computer security team. With luck, it all works, but it is a high wire act that telemedicine could alleviate.
One common question we get when we contact a patient is, "What about my A1C?" There are two answers, the first option is doing a Home Access A1C test. test. It is a validated test that only requires a finger-stick and costs $40. The other option uses the data from a continuous glucose monitors (CGM) that provides what is called the glucose management indicator, or GMI, which is the CGM equivalent to an A1C for the time period displayed. More than numbers, however, we care about you, and helping you through this time of stress and uncertainty. We can help keep you healthy and we definitely want you to reach out to us!!!
The Telemedicine Technology
For our video visits we are using both the USC TeleCARE system and a HIPAA compliant (heath data secure) version of the Zoom video chat software. We are still experimenting with what system works best and we ask for your understanding as we make this shift to a new system.
USC TeleCARE visits can use either a computer or an iPhone, and Zoom requires a computer, with a video camera, an iPad or smartphone. Some of our older patients that we most want to keep out of the office due to the current health risks are tech savvy, but for others a simple voice or video phone call is also working.
Diabetes Device Data
This is where the fragmentation of the diabetes devices, including meters, pumps and CGM's, creates chaos. Some devices play well with others and are easy to share (Dexcom leads in this area), while others are locked into their own silos that complicate sharing (Abbott's LibreLink mobile system is a prime offender).
Whatever system you use, don't expect it to work the first time you try to share data. You are going to have to look for cables and try to remember passwords, and you will run into computer issues. Some of these steps are easy; others are much harder than they should be. Start early, do a test run and call tech support or your diabetes team for help at least a day before your visit. Our lives have enough added stress, so run the test and then add the last bit of data just before your visit. This also allows you to repeat the process to confirm that you know how the system works. Good luck!
Fortunately, the wonderful non-profit company Tidepool, started by Howard Look and supported by JDRF, was tailor-made for this crisis. This is the Swiss Army knife of diabetes data platforms, and it is our first choice for viewing data. It has the ability to accept data from multiple devices and display it together all on one timeline in a way that adds insight to your diabetes management. This data is available to both providers and patients, and we often encourage patients to review their data to improve their ability to make treatment decisions.
The main part of Tidepool is web based and runs on the Google Chrome browser. There is also a mobile app that can be used for creating notes and to transmit data collected in the Apple Health app.
The website has a separate uploader application, which can be downloaded for Mac or Windows computers. Once downloaded, you select your device, plug it in and upload it to the cloud. When you have more than one device, it is important that the times and dates all match, as this allows the data to be properly synched.
Dexcom & Clarity
Dexcom is great at connecting its CGM with smartphones, pumps and its own receiver. There is a direct connection with Tidepool to your Dexcom account (the best way) or through the Apple Health bridge.
The Clarity app can also generate a sharing code that is easy to enter into its Clarity website. Patients can either share the code or download and email a pdf before their telemedicine session. For most patients using insulin pens, this is all that is needed before the visit. The receiver can also be uploaded to the Clarity website and shared as a pdf.
Companion Medical InPen
Patients using the InPen can also integrate their insulin dosing and Dexcom data into the InPen app. This paired CGM and insulin dose data creates a robust report similar to what we get from insulin pumps, and the report is easily generated in the app and emailed as a pdf.
Abbott Freestyle Libre
The Libre receiver can be uploaded to Tidepool, but if you want to use the LibreLink app on your smartphone to scan the sensor, that data needs to go to the LibreView website, where a pdf report can be generated. Alternatively, you can create a direct direct connection with your provider by entering a clinic code or by accepting an email invitation. On the plus side, once the connection has been made, the data streams continuously, and we can look-up and view our patient's Libre data.
The best way to view data from the new Control-IQ system is through T:Connect, which is the only way that displays all of the new automated features. But Basal-IQ works in Tidepool as does most Control-IQ data. Create an account and download the uploading software that allows for uploading your paired pump/CGM data. Then create a pdf to email or make a connection with your health care team by sharing your username/email and password.
This could be the easiest solution because if you are tech savvy enough to build the DYI Loop hybrid closed-loop system, you should also know how to send your data to Apple Health and then stream into Tidepool. Once you make the connection, your data streams into Tidepool and your job is done.
OmniPod provides the Glooko software to use to upload your pump. You can generate a pdf and email a report or connect with your provider with a ProConnect Code. This software works with either the traditional PDM system or Dash system. It can also be uploaded to Tidepool.
Try Tidepool to upload the meter or use the software from your meter company and send a pdf.
Once you master the diabetes data upload process, there is a learning curve on using your provider's telemedicine platform. Take a deep breath. The first time will be a challenge, but once you learn the system you will appreciate being safer and having no commute.
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