We Love Our Patients – We Just Can't See Them in Person Right Now
By Mark Harmel MPH, CDCES
Mark Harmel, MPH, CDCES, discusses how his clinic is moving to telemedicine in the time of COVID-19 and how to share data from many diabetes devices
One attraction of taking care of patients with a chronic condition is that you get to see them as often as every three months, and we have patients in our practice whom we have seen for decades. We love the visits, catching up on their lives and helping with their diabetes care, but we want to model proper social distancing while continuing to provide care. Therefore, we are shifting our appointments to telemedicine.
We also have the added risk of a history of known cases of the novel coronavirus in our office, and our primary care colleagues are swabbing patients to identify new cases. We are nowhere at the level of risk of our emergency room or intensive care room providers, as they are taking care of the sickest patients without proper protective equipment. They are the heroes who need our greatest support by lobbying to get them equipment, and we should all be doing our part to flatten the curve. So, stay home as much as possible and wash your hands.
This is where telemedicine can come into play, as diabetes is the perfect chronic condition for video and phone visits. Many of you have long-term relationships with your provider already, and much of your visit revolves around reviewing your diabetes data. We started experimenting with telemedicine visits a couple of months ago; we offered this option mostly to patients with long commutes. Last week we ramped up the invitations so that half of our visits were in-person and the other half online and we are now moving to as many telemedicine visits as possible.
I've recently been busy contacting patients to switch them to telemedicine visits. I inquire how we can support the transition, and in the coming week almost all the visits will be by phone or video conferencing. The biggest challenge will be viewing their diabetes data, especially in our practice that is focused on helping people with type 1 diabetes.
Some patients have data streaming into cloud-based services already, and others are learning how to upload from home to share their data. Frankly, getting data from diabetes devices as patients walk into the clinic has long been the weak link in providing care to patients. It seems like every blood glucose meter, pump company, 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.
I'll provide some tips on sharing data below, but first I want to answer the most common question I get: "What about my A1C?"
Click to jump down to learn how to share your diabetes device data: Tidepool, Dexcom & Clarity, Companion Medical InPen, Abbott Freestyle Libre, Tandem T:Connect, Loop, Insulet OmniPod, Medtronic/MiniMed Carelink, Meters.
Fortunately, many of our patients are using continuous glucose monitors (CGM) that are now providing what is called the glucose management indicator, or GMI, which is the CGM equivalent to an A1C for the time period displayed. You most likely know that an A1C is a three-month average of your glucose range, and it is easy to generate a three-month report from Dexcom Clarity that is as good as an A1C equivalent (some people even prefer this report). But we are often only looking at the past two weeks of data, and we are now concentrating more on the time in range numbers and glucose variability. We can also view the GMI number for those two weeks as well, and while the A1C number will be around for a while, these other numbers are becoming more important.
Even with meter data, we may not know a precise A1C number, but we know if you are in the range of a 7, 8, or 9 percent A1C. What is more important is still connecting with our patients face to face, and talking about their life, diabetes management and general health.
I understand that telemedicine and the added burden of uploading devices from home and holding video conference meetings works better where I practice in the more affluent and better educated West Los Angeles. Our Director, Dr. Anne Peters also conducts research and a teaching clinic in East Los Angeles where patients are just starting to get diabetes technology and holding telemedicine visits there would be so much harder.
Unfortunately this evolving reality of sheltering in place is only increasing the digital divide in diabetes care, and attention needs to be devoted to providing outreach in the population that call for greater attention.
The Telemedicine Technology
For our video visits we are using a HIPAA compliant (heath data secure) version of the Zoom video chat software. Many office workers are familiar with this already or know how to use a similar software like Skype, Google Hangouts, Go To Meeting, and others. We started with a different University-based system that became overloaded in the past week, and we switched in mid-stream. Your providers may use a different system, and they may also be making things up as they go along. So please be patient.
Zoom requires a computer, preferably with a video camera, or an iPad or smartphone. Some of our older patients that we most want to keep out of the office – due to current health risks – are tech savvy, but for others a simple phone call works as well.
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 make sharing hard (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, which was started by Howard Look and is 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 to view 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 I 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.
The iPhone has the ability to use the Health app to serve as a bridge to automatically share Dexcom, some meters, and Loop data to the Tidepool app and upload to the website. Specific instruction for your device can be found on the Tidepool support page. The current major omissions are pumps running the new Tandem Control-IQ software (it works, but doesn't properly display when the activity settings are activated) and LibreLink data.
Dexcom plays well with others, and its CGM connects 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 need before the visit. The receiver can also be uploaded to the Clarity website and shared as a pdf.
Patients using the InPen can also integrate their 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 can be emailed as a pdf.
The Libre receiver can be uploaded to Tidepool, but if you want to use the LibreLink app 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 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.
Currently the only way to view data from the new Control-IQ system is through T:Connect, but Basal-IQ and earlier software versions work in Tidepool. 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.
Unfortunately, the early adopters of Control-IQ may also have the new Mac Catalina OS, and the uploader does work yet on Catalina, but it is possible to update the software of a Basal-IQ pump to Control-IQ.
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.
Medtronic pumpers can either use their Contour Next meter or an uploader to serve as the communication bridge with the pump. Pumps can be uploaded to Tidepool or to Carelink.
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.
Hopefully we will all get through this time of coronavirus, and once we are on the other side, you will decide how often you want an in-person visit or you are sold on the telemedicine experience.
This article is part of a series on time in range made possible bysupport
Mark Harmel, MPH, CDCES (CDE) is the Clinical Research Coordinator and Diabetes Care & Educational Specialist at the USC Westside Center for Diabetes.