Caring for Pediatric Diabetes Patients at UPMC Children’s: Telemedicine in the COVID-19 Era

Since its emergence as a novel pathogen in late-2019, the coronavirus that causes COVID-19 has exacted an enormous toll by any metric or lens through which one chooses to analyze it. No person, community, country, or continent has been spared. Health care is no exception. COVID-19 has posed monumental challenges to the provision of health care in the United States and around the world. All health care systems, specialties, and providers in inpatient acute care, outpatient and ambulatory care settings, and long-term care and skilled nursing have been affected. Everyone has been forced to adjust the means and methods of patient care and interactions, ensuring safety for all while remaining connected to their providers. 

Individuals with chronic health care needs may be more affected by COVID-19 for many reasons, including being at higher risk for severe complications if they contract the virus, challenges in the management of their underlying condition presented by COVID-19, and difficulties related to not receiving required timely care and services. Deferred or interrupted care can and does impact one's health. 

With winter at hand in 2020, and at the time of this writing, a resurgence in COVID-19 case counts and hospitalizations in the United States, health care systems and providers likely will be tasked yet again to provide care to their patients amid a raging epidemic when safe, in-person visits to the clinic become untenable or unwanted.

The Division of Pediatric Endocrinology, Diabetes, and Metabolism at UPMC Children’s Hospital of Pittsburgh has been a world leader in caring for patients with type 1 and type 2 diabetes. In the 1960s, under the leadership of Allan Drash, MD, UPMC Children’s pioneered the concept of team as the diabetes care model, incorporating nurses to educate children and families with diabetes. This clinical care model has evolved further and is the standard of care for children with diabetes worldwide. This spirit of pioneering excellence, ingrained in the fabric of the Division for decades, can be seen in its response to the COVID-19 pandemic.  

Telemedicine Takes Center Stage in Health Care

The Division adapted, adjusted, and accelerated wholesale changes in operation to meet the new reality of patient care during an infectious disease pandemic. Their efforts in implementing a telemedicine platform for diabetes patients is highlighted in a new manuscript that is being published.¹

"Before COVID-19, telemedicine for our diabetes patients essentially did not exist. We had little to no infrastructure in place, and we did not have any experience in providing care to diabetes patients virtually through a telemedicine platform,” says Ingrid Libman, MD, PhD, Associate Professor of Pediatrics and Director of the Diabetes Program at UPMC Children’s.  “Like so many institutions, we had to rapidly develop, scale-up telemedicine capabilities, and train our providers, patients, and their families on how to use the technology for managing various aspects of care.”

The response by The Division of Pediatric Endocrinology at UPMC Children's to COVID-19 and the lessons learned during implementation are outlined in the forthcoming paper. 

“Perhaps most importantly, we realized immediately that a comprehensive team approach would be the only path toward success. Every area of the Division was represented in planning and implementation of our telemedicine services and portal for staff and patients.  We were also supported tremendously by our IT infrastructure and support partners,” says Dr. Libman. 

Not all telemedicine platforms are built and designed equally. There are tradeoffs and a lack of desired features in any system. The key to finding the right system for the Division was to analyze the available options and have back-up solutions for individuals who could not access or use the preferred system for various reasons.

"Telemedicine is likely here to stay because of the pandemic. Regulatory bodies, insurance payers, and providers will need to adapt and continue to evolve the rules, regulations, and technologies around the use of these platforms so they can be leveraged appropriately when needed for patient care. It is interesting to think about diabetes patients in general, where the standard of care has been four visits to the clinic each year for follow-up and testing. Perhaps telemedicine will make it easier for patients and families who need extra support to interact with their providers between these in-person visits or for that occasional visit when the patient cannot be seen in person. It will be interesting to monitor the use of telemedicine vis-à-vis glycemic control and well-being for individuals and entire populations of patients," says Dr. Libman.

As part of the telemedicine visit process, UPMC Children’s providers incorporated check-in questions and assessments to evaluate the stresses placed on families by the pandemic. This included stressors related to education, work, and finances, as well as supplies for diabetes management. Financial distress that could manifest itself as food insecurity were probed, and resources or support provided if needed. 

“We were very concerned about the effects of the pandemic on the trajectory of our patient’s diabetes and other life situations. To the extent that we could screen for these issues, we made sure to incorporate them into our telemedicine visit routine with patients and families,” says Dr. Libman.

While continuing patient care in an uninterrupted manner was the driving philosophy behind the Division's work to implement telemedicine services for its diabetes patients rapidly, every effort was made to maintain a robust teaching environment for trainees – fellows, residents, and students. 

"We were able to maintain our teaching, and we also were able to ensure that our other team members who are crucial to our diabetes patients – social workers, dieticians, and our team of certified diabetes care and education specialists – were integrated into the workflow and telemedicine appointments with families. We made provisions for follow-up communications through a number of channels depending upon the individual patient’s needs,” explains Dr. Libman.

"We are encouraged that we were able to maintain contact with our patients and families and provide support during the COVID times. In fact, our no-show rates to diabetes clinic visits significantly went down with our robust transition to telemedicine," says Radhika Muzumdar, MD, Professor of Pediatrics and Chief of the Division of Pediatric Endocrinology, Diabetes, and Metabolism.  

Drs. Muzumdar and Libman are fully aware of some of the limitations of a televisit compared to face-to-face encounters. 

“In telemedicine visits with diabetes patients, we lack the ability to conduct comprehensive exams and monitor growth, which are standard during in-person visits so we can assess other patient factors outside of glucose levels and insulin use. It likely will be a challenge to replicate those interactions in a virtual visit, but telemedicine still offers an incredibly valuable service, in particular in these challenging times,” says Dr. Libman.

Unfortunately for the world, it appears that the COVID-19 pandemic will not disappear in short order, as all would hope. It will take a concerted and coordinated effort, the likes of which have rarely been seen, to stem its tide and come to grips with its existence. While there is nothing positive to say about the coronavirus that causes COVID-19, it has forced the broader health care community to take more rapid and dramatic shifts in the provision of patient care than it has before. 

“We realize that telemedicine offers unique access and opportunities to both providers and patients and is here to stay even past this pandemic. Lessons from this experience will allow us to identify barriers, devise potential solutions, and optimize patient care through these platforms for the future,” says Dr. Muzumdar. 

With telemedicine or other electronic visit platforms being a safe means of keeping socially distanced and therefore hindering the spread of the disease, their evolution and integration into the fabric of the health care system will likely become more robust and open new avenues of patient care, disease-state monitoring, and research to ascertain their long-term benefits and costs.

Reference

1. March CA, Flint A, DeArment D, Gilliland A, Kelly K, Rizzitano E, Chrisman A, Muzumdar RH, Libman IM. Pediatric Diabetes Care During the COVID-19 Pandemic: Lessons Learned in Scaling Up Telemedicine Services. Endocrinol Diabetes Metab. In press.