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Lauren Willard, DO
Clinical Lead, Telemedicine
UPMC Endocrine Division
Archana Bandi, MD
Clinical Director, Telehealth Services
VA Pittsburgh Healthcare System
COVID-19, a disease caused by a novel coronavirus, SARS-CoV-2, has now become a worldwide pandemic. By October 2020, this disease has claimed more than 1 million lives worldwide, and more than 210,000 lives in the USA, with over 35.8 million cases worldwide.1 Originating as zoonotic transmission in wet markets in Wuhan, China, this disease quickly became highly transmittable in humans through aerosol droplets. The challenges of social distancing, containment, isolation, and surge capacity across hospitals, clinics, and emergency departments have led to an increase in demands for technologically-assisted care delivery strategies, such as telemedicine and web-based triage.2 Recognizing the dire need for telemedicine, the U.S. Department of Health and Human Services modified federal privacy and billing regulations under the CARES Act Provider Relief Fund, fueling nationwide escalated adoption of telemedicine modalities.3
The Endocrinology Telemedicine Unit, under the leadership of Lauren Willard, DO, (Clinical Lead, Telemedicine, UPMC Endocrine Division) and Archana Bandi, MD, (Clinical Director, Telehealth Services, VA Pittsburgh Healthcare System Endocrine Division) has experienced a rapid growth of telehealth services over the last two quarters. While the global COVID-19 pandemic encouraged this growth, our division had already recognized the importance of telehealth services and were on a trajectory to more broadly and rapidly incorporate virtual visits. These services were pivotal to the Endocrine Division, assuring continued quality care and connection with our patients, particularly our most vulnerable patients living in remote communities.
A diabetes team-based telemedicine glycemic management model, known as Telemedicine for Reach, Education, Access, and Treatment (TREAT) was introduced in 2010. Patients identified by their local primary care provider (PCP) are referred to TREAT, a model that includes the specialty services of an endocrinologist and diabetes educator, whose services are often unavailable to people in these outlying communities. The local diabetes educator attends the visit with the patient at the remote site and is able to help with implementation and provide ongoing follow-up and support for the treatment plan prescribed by the endocrinologist. Although TREAT was shown to improve glycemic, behavioral, and psychosocial outcomes4-6, the program was limited by requiring the patient to travel to the local teleconsult center. Patients with impaired mobility or access to transportation still experienced unaddressed barriers to care despite local teleconsult centers.
In 2019, to address these limitations as telehealth opportunities evolved and expanded, a video model was introduced that provided direct to patient video conferencing for access to specialist care. Patients are connected to the endocrinologist via their personal cell phone or computer, which eliminated the need to travel to a teleconsult center. With positive provider and patient feedback this program was expanded pre-COVID-19 to offer direct to patient video conferencing services care to patients with diabetes.
In addition to outpatient telehealth, our inpatient services, at all sites, are using HIPAA compliant video platforms to communicate with patients and provide effective inpatient consultations. As of 2019, under the leadership of Endocrine Medical Director Esra Karslioglu-French, MD, provider-to-provider e-consults were launched to address clinical questions and provide expedited care for PCPs with endocrine concerns for their patients. Provider-to-provider e-consults also help to improve patient access for when face-to-face or video encounters are required.
Since diabetes visits for glycemic management are data driven encounters, the ability to download data from insulin pumps, meters, and continuous glucose monitors became apparent and imperative to assure quality care. The Endocrine Division implemented the Tidepool system, a nonprofit organization committed to providing free software for the diabetes community.7 Tidepool software provides support to more than 50 diabetes personal devices and applications so that patients can use a single platform for data sharing with their providers. The UPMC Thrive Grants for Change allowed for the installation of Tidepool at our clinical sites, as well as hiring a liaison to help support staff and patients with creating accounts.
Although the Division was already engaging in telemedicine visits, the COVID-19 pandemic led to an increase from approximately eight outpatient video visits a week to more than 500. We were pleased to learn that the Division of Endocrinology had the most rapid expansion of all medicine subspecialties at UPMC. Due to our existing platform for synchronous video visits and engaging our providers pre-pandemic, we were prepared to widely implement synchronous video visits and phone consults for our outpatients promptly with the onset of social distancing restrictions.
To enhance service during the pandemic, clinical staff working remotely served as liaisons to patients, connecting them to the necessary technology. This additional support allowed for approximately 75% of our visits to be completed via video. Our division was able to successfully complete 5,075 video visits from March through early June. In review of this data, the average age of patients utilizing telemedicine did not differ from those requiring face-to-face visits. Our reach was extensive, with 86% of our patient telemedicine visit volume coming from seven adjacent counties. The data to date suggests that this platform is not just for younger, more tech savvy patients, but can be widely utilized by many of our patients despite their age and/or technological ability.
UPMC dieticians and diabetes educators have also been engaging patients via telemedicine and have found this resource invaluable with gaining insight into home conditions, resources for cooking and preparing meals, and some understanding of how complex living situations could be affecting glycemic control. As patients are becoming more acclimated to this platform of online access and app-driven care, we expect that it will create broader opportunities for education and ongoing self-management support.
The expansion of the Division’s telemedicine services is due to consistent support from UPMC leadership with telehealth initiatives. UPMC is one of the nation’s leading integrated health systems, aiming to provide high quality and efficient health care to residents across the tri-state area. We have resumed in-office care when needed or preferred by the patient, i.e. for procedures such as thyroid imaging or biopsy. For patient safety, UPMC has expanded SARS-CoV2 testing, provided facemasks to all patients and visitors, mandated mask use in all clinical areas, provided entrance screening, and implemented visitor restrictions.
The pandemic required an immediate response and accelerated the ability of our providers, staff, and patients to adapt to telehealth approaches to care. We anticipate more than half of visits moving forward will remain virtual. Patients feel this platform has provided a beneficial alternative to in-office visits with use of supporting data-sharing applications such as Tidepool. These telehealth strategies will remain a vital means of delivering high-value ongoing care to our patients.
The VA Pittsburgh Healthcare System (VAPHS), an academic affiliate of the University of Pittsburgh, serves the western market of the Veterans Integrated Service Network 4 (VISN 4). Operating in a hub and spoke manner, with its two medical centers and five community-based outpatient clinics (CBOCs), VAPHS serves as the specialty care hub for remotely located spoke hospitals and CBOCs from Altoona, Erie, Butler, and Clarksburg. A majority of veterans seeking care at VAPHS reside in the mostly rural areas of Pennsylvania, New York, Ohio, and parts of West Virginia, and carry a higher burden of chronic medical conditions such as diabetes (~25%), obesity (~37%), COPD, and congestive heart failure, which instantly puts veterans at a higher risk of poorer outcomes should they contract COVID-19.
Starting in 2010, Dr. Archana Bandi led a system wide endocrine care delivery transformation at VAPHS, initially with electronic consult services, and shortly thereafter with Clinical Video Telehealth services for veterans across geographic distanced areas served by VAPHS. In a large study comprising of more than 400 veterans in each cohort, her team showed that e-consults provide expedient care for veterans with type 2 diabetes mellitus (T2DM) located in remote locations. This care was shown to be comparable to traditional face-to-face care in achieving glycemic control and allowed for better long-term control without burdening resources8. Furthering this approach of the telehealth model and creating collaborative pathways through Diabetes Care Network9, her team further elucidated the importance of breaking the silo model care using the telehealth technologies to expand the access to care for patients located in remote locations.
Prior to the pandemic, VAPHS had one of the most expansive telehealth programs in the nation, namely:
While the VAPHS was prepared to rapidly expand the majority of endocrine services to telemedicine, there were some challenges to overcome. In March 2020, based on CDC guidance and the state mandated lockdown, VAPHS initiated care delivery transition strategies to implement virtual modes to prevent the spread of COVID-19 amongst veterans and health care providers. Under the leadership of Executive in Charge Richard Stone, MD, VA central leadership created a COVID-19 response plan10.
Encompassing four phases, this plan laid out contingencies and planning strategies in phase-1 to sustainment operations and recovery in phase-4. For each of the four phases, telehealth is set to play a pivotal role in the provision of continuity of care for scheduled and incidental outpatient care for non-infected veterans, as well as limit the spread of COVID-19 infection to veterans and staff.
Thus, the day-to-day operations at the endocrine division at VAPHS transferred all new patients and continuity of care to virtual modalities. Due to clinic closures, heavily utilized CVT programs that offered well-designed mechanisms for veterans to rely on PC to coordinate their care with endocrinologists temporarily closed. Poor bandwidth of cell signal in rural areas, tech-related illiteracy in elderly veterans, and lack of equipment needed at home posed a new set of challenges for an overnight transition to video-to-home care.
Additionally, providers who were mostly accustomed to in-person care, or telehealth modalities such as e-consults or CVT, needed training in the transition to video-to-home care (VA Video Connect). While early adaptors of VVC quickly modified their work processes, the remaining infrastructure, including educators and ancillary support staff, needed to change their prior practices. Thus, during the early weeks of COVID-19, telephonic care and electronic consultations became the mainstay. Prior to COVID-19, approximately 50% of new endocrine consultations and up to 75% of diabetes consultations were scheduled as e-consults. Starting March 17, and up to June 5, 2020, the e-consults and phone visits became the major modalities of care delivery leading to more than 1,300 telephonic encounters, 275 diabetes e-consults, and 600 endocrine e-consults.
With the continued resurgence of COVID cases, more veterans became amenable to coordinate care via assistive technology such as the use of VVC or equivalent virtual platforms. Often, these decisions are driven by the complexity of the veteran’s medical condition, comfort with technology, family or caregiver’s support, and availability of training staff at the medical center. Thus, between the period of June-July, VVC modality in the Endocrine division grew exponentially from less than 1% prior to March 2020 to almost 50% of care delivery by July 2020. The VA also provided funding and technical support for issuance of tablets to conduct VVC for veterans who had no access to such devices. VAPHS strategically opened the in-person clinic capacity (~25%) to continue maintaining an environment to support social distancing and limit the potential exposure to veterans and staff. VAPHS resumed CVT clinics for smaller CBOCs and spoke hospitals, thus offering virtual care to veterans who were unable to conduct VVC visits. Telephonic visits and home telehealth services have continued as additional modalities.
Thus, the COVID-19 pandemic has been a watershed moment in health care delivery bringing telehealth technologies to the forefront. Laggards in this field were led to quick adoption of the virtual modalities and sweeping changes in CMS payment rules and waivers of federal requirements hastened that adoption. We share two very different experiences of uniquely different organizations in terms of adoption on the part of patients and providers to show that there are challenges that are common to both and challenges that are unique to each.
Well-designed processes and organization specific infrastructure, including tech support for veterans, will be an important key for continued use of virtual care in a post-COVID environment in value-driven systems such as the VA. ACCESS the Internet Act11 – a bipartisan bill recently proposed in the Senate – aims to provide funding of up to two billion dollars across the government for distance learning and telehealth initiatives. Continued restructuring of the billing and regulatory mechanisms in support of telehealth technologies will be key for private sectors. Well-designed studies to understand outcomes for chronic conditions are needed to better delineate the appropriateness of telehealth technology use for long-term care. One thing is certain, telehealth strategies are here to stay and likely to play an even greater role in our future, long after the pandemic ends.
1. Coronavirus.jhu.edu/map.html. CSSE accessed on 10/7/2020.
2. Stawicki SP, Jeanmonod R, Miller AC, et al. The 2019-2020 Novel Coronavirus (Severe Acute Respiratory Syndrome Coronavirus 2) Pandemic: A Joint American College of Academic International Medicine-World Academic Council of Emergency Medicine Multidisciplinary COVID-19 Working Group Consensus Paper. J Glob Infect Dis. 2020;12(2):47-93. Published 2020 May 22. doi:10.4103/jgid.jgid_86_20
3. U.S. Health and Human Services. https://www.hhs.gov/coronavirus/cares-act-provider-relief-fund/index.html
4. Toledo F, Ruppert K, Huber K, & Siminerio L. Efficacy of the Telemedicine for Reach, Education, Access and Treatment (TREAT) Model for diabetes care. Diabetes Care. 2014, 37:179–180.
5. Siminerio L, Ruppert K, Huber K, Toledo F. Telemedicine for Reach, Education, Access and Treatment (TREAT): Linking telemedicine with diabetes self-management education to improve care in rural communities. The Diabetes Educator. 2014, 40: 797-805.
6. Griffith M, Siminerio L, Payne T, Krall J. A shared decision-making approach to telemedicine: Engaging rural patients in glycemic management. Journal of Clinical Medicine. 5. 2016; 1-7. 5103; doi:10.3390/jcm5110103.
7. Tidepool. https://www.tidepool.org
8. The Impact of Electronic Consultations compared to Face-to-Face Encounters on Glycemic Control among the Veterans with Type 2 Diabetes. Presented at Endocrine Society 2018 annual Meeting/ Chicago,IL.
9. Archana Bandi, MD, Meg Larson, DNP, Janice Beattie, CDE, Ashley Summerville, PharmD, Brandi Lumley, PharmD, Stacey Lutz-McCain, DNP, and Monique B-Kelly, PhD Diabetes Care Network: A Telehealth-based Collaborative Approach to Scale the Endocrine Expertise J Endocr Soc. 2019 Apr 15; 3(Suppl 1): MON-LB002. Published online 2019 Apr 30. doi: 10.1210/js.2019-MON-LB002
10. Veterans Health Administration - Office of Emergency Management https://www.va.gov/opa/docs/VHA_COVID_19_03232020_vF_1.pdf
11. U.S. Senator Joe Manchin of West Virginia. https://www.manchin.senate.gov/imo/media/doc/2020_0806%20ACCESS%20the%20Internet%20Act%20One%20Pager%20CLEAN.pdf?cb