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Nutrition411: The Podcast Ep. 34

The Benefits, Challenges of Telemedicine in Diabetes Care

Lisa Jones, MA, RDN, LDN, FAND

In this podcast episode, Lisa Jones, MA, RDN, LDN, FAND, interviews Rachel Stahl Salzman, MS, RDN, CDN, CDCES, and Livleen Gill, MBA, RDN, LDN, FAND, on the benefits and challenges of telemedicine in diabetes care, ways to overcome challenges in technology, changes in practice since the beginning of the COVID-19 pandemic, and cloud-based software that makes it easier for remote patient monitoring.

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TRANSCRIPTION:

Host: Hello and welcome to Nutrition 411: The Podcast, a special podcast series led by registered dietitian and nutritionist, Lisa Jones. The views of the speakers are their own and do not reflect the views of their respective institutions or Consultant360.

Lisa Jones: Hello and welcome to Nutrition411: The Podcast where we communicate the information that you need to know now about the science, psychology, and strategies behind the practice of dietetics. Today's podcast is part of a series of episodes on diabetes technology featuring Q&A with Livleen Gill and Rachel Stahl Salzman. Welcome Livleen and Rachel, thanks so much for having us. I'm excited about this episode. I want to take a moment to introduce each of you first. So, I will start with Livleen Gill. Livleen is president and CEO of Apostle Group, LLC, a consulting company that provides innovative solutions to clients in healthcare, food, and nutrition. She's also the CEO of Wholesome Village Inc. in Rockville, Maryland. Previously, she was a private practice nutrition consultant for more than 20 years, and the Food and Nutrition Services Director and outpatient dietitian at healthcare centers in Maryland. She will serve as the Academy of Nutrition and Dietetics President in 2024-2025 year. Next, I want to introduce Rachel. Rachel is a registered dietitian and diabetes care and education specialist in the Division of Endocrinology, Diabetes, and Metabolism. At Weill Cornell Medicine in New York City. Rachel is passionate about empowering individuals to make sustainable lifestyle changes and leverage diabetes technology and digital health to improve their health and quality of life. So again, welcome Livleen and Rachel.

Livleen Gill: Thank you.

Lisa Jones: We're going to talk a little bit about telehealth and the question I want to explore is the impact of telehealth on diabetes care. I'm really curious to hear about the benefits and the challenges in your opinion. So, Rachel and Livleen, what are your thoughts on... let's start with the benefits first, let's start with the positive.

Livleen Gill: Sure. For us the benefit was when you see the individuals, the patients, in their home setting, one of the things it took away was the issue of "I don't know what I wrote down and what my numbers were." You had access to the meter, you had access to the reports. You could also see in real time whether they knew how to use the meter. You could see whether they had the medication and were able to look at whether they could pull the insulin or not. Those were some of the things that for our team were very beneficial. Our cancellation rate also dropped significantly for the visit with telehealth. So the continuity of care and that access to care really was improved for us. So those were my takeaways from the benefits of telehealth.

Lisa Jones: Rachel, what are your thoughts?

Rachel Stahl Salzman: Yes, I would add that we are living in a more digital world than ever before, and now with access to cloud-based software that can integrate the data from the patient's glucose meter from their CGM, from their pump, right onto the internet allows us to easily be able to observe their data, not only during telehealth visits but also between visits. And the term I'm going to use here is that term remote-patient monitoring. That has definitely expanded and ultimately helped improve care. I would definitely agree with Livleen. People show up more than ever on these telehealth visits. The no-show rate, I completely agree, is very low. And this has been for many reasons, it's convenient for the person. You know, I live in New York City where people can have long commutes by car or by subway. Just this past week, President Biden was in town, and that caused so many delays in the subway.

Patients were arriving so late for the ones that were showing up on an in-person day. So, it's just allowed more convenience and people are actually wanting it. You know, since Covid and since the doors have opened back up, we've really been able to balance telehealth and in-person visits really based on demand. And what we see across the board in our adult endocrinology practice is that many patients still very much want virtual visits. We've seen great success in helping to ensure that they're using the technology the right way. I could demonstrate how to use an insulin pen by holding it up on the screen. They could have their device and I show them where to place it on their body, let's say if they're inserting a CGM, so it's been a really great experience overall.

Lisa Jones: Yeah, that's fantastic to hear, especially the point about the no-show rate being low. because it begs the question, I was thinking as you both were speaking, is do you have ever had any patients that are like, "No, I want to come in because I can't figure out how to use this technology"? Or there's a barrier there?

Rachel Stahl Salzman: Yes, I do think there's still a need for in-person for certain people or for certain times. I think what we've seen, too, is if we have all these virtual visits, it's important to get them in person to do a physical exam... to look at them physically, right? Because we do get a lot of concerns of people self-reporting their body weight. Sometimes it's hard to trust or if their scale is inaccurate. So there is definitely still the need, from my perspective, for in-person visits.

Lisa Jones: Yes, so of course, and then the other thing I was thinking is what's the number one thing then when you go to a doctor's office and you're waiting for your appointments say at noon and it's like 12:15, you're like "Okay, well they didn't call me back yet." So that's another reason why your no-show rate is down so much. Because people probably love it. Like if they have an appointment at noon, somebody's going to be there right at noon, you're not waiting in an office.

Rachel Stahl Salzman: I would just add there was always this concern. Even before Covid, we were starting to think about incorporating telehealth and it was for only certain types of select patients, only in certain places, like in New York State and this and that. And people were concerned that visits were going to lose the human element, the human touch, that we do have in true face-to-face, in-person appointments. But what I found is that we actually get to know them so well during telehealth, and I'm sure Livleen could agree. We see their family running in the background, we could go into their kitchen, and they could show us exactly the food that they're eating, that's in their house. So, I feel like it's been a really great way to have a personal touch, being able to meet with them virtually.

Lisa Jones: Oh, I love that. Especially about, you can see what's going on. They can show you their fridge, they can walk there and show you what's in their refrigerator. So, that's another great point. Now, what about the barriers or the issues that potentially come about? Like what are some challenges that you both have experienced using telehealth?

Livleen Gill: For us, and as I had said previously, our practice is over 60%, we see the senior population, and technological connectivity challenges have been, I would say the most. It's still difficult for them to understand and get the technology; how this is going to work, will the doctor who I'm going to see be the only one there? So those have been our biggest barriers. And to the other point that Rachel had talked about, the telehealth, yes they're right there, but they also feel that there is, if it's at home and they don't want the children around. It is a loss of privacy for them. And some of them do not want to have those visits. They'd rather come in person. So those have been the biggest challenges with our population that we see.

Lisa Jones: I definitely get that. That makes sense. The privacy aspect, it goes beyond trying to lock your door in an office, right? How about you, Rachel?

Rachel Stahl Salzman: I would agree with Livleen that there still are people who have some technological barriers or simply like just aren't interested in downloading the information that they need to support the video visit. We've done a really big overhaul in our virtual platform to try to make it easier for patients. We started with a separate link out through Zoom where if the person didn't have a Zoom account they'd have to create an account or that would just add another element. And more recently, it's embedded right into our electronic health record. So, it does make it easier for the person and we do provide an IT team to help support them. And I think just knowing that we're fortunate to have medical assistant staff who call the patients before each visit to make sure they're set up and make sure they're ready. That way, we're not stuck waiting for them trying to connect so that they're ready to go at the time of their visit. So, that's been helpful, just having the human support and access for them.

Lisa Jones: Wow, that's such a great system that you have in place with the support team. I have a doctor's office that does virtual calls, but there has never been anybody calling me before the visit to ask if I'm okay with the technology. Right. I think that's fantastic.

Rachel Stahl Salzman: Yes, again, it comes down to staffing, which I know could vary across people's workplaces. So, we are very fortunate in that regard. And the other thing, I'm curious if Livleen has used this, we have a backup. It's called Doximity. So, if they're not able to connect for whatever reason through the normal way, we do use Doximity where we can actually text the person to their phone, which is available, their number in the medical record, and then they would click the link from their text message and it would immediately open up a HIPAA-compliant video platform. So, we've used that if they're having trouble accessing the traditional method.

Lisa Jones: Wow. So you even have a backup. I'm impressed Rachel.

Livleen Gill: Rachel what you just said... we don't use Doximity, but we have a similar thing. It's just a link that goes to their cell phone and they just need to click it. It's easier that way and they're used to it. It would be a HIPAA-compliant text that goes, and it says your doctor is waiting for you or your dietitian is waiting for you, please click here. So yes, there. I think in the last four years, technology has really improved to be able to provide support and improve this connectivity with the patient. I know in the beginning it was mostly cobbled together whatever you could to get this done, but I think things have improved since then.

Lisa Jones: Yes, and that leads me into–well you kind of already answered it, Livleen–but it leads me into the next question because I'm curious to hear the changes in each of your practices since COVID-19 and the increased use of telehealth and also how quickly, how rapidly it's changing. And how do you keep up with it? So we'd love to hear your thoughts on that.

Livleen Gill: Our practice delivery method has significantly changed. So prior to Covid, we had four locations where we used to see patients. Right now, we have a single office, and most of our providers either do telehealth or they see patients from that office, or do home visits. So, we've been able to blend telehealth and in-person visits. In a way, it has brought down our overhead, but we have not missed a beat in being able to provide the care. And it's become more personalized, I would say, and more on-demand in the sense that we are able to look out for our patients more quickly and get them into a visit than before Covid.

Lisa Jones: That's amazing. So it sounds like you're not only reducing the overhead but experiencing growth too.

Livleen Gill: Yes. So in a very different way. Yes. Technology in that sense has really helped us. Yes.

Lisa Jones: Yeah, pretty soon you'll be holograming into their houses so you don't need to do the home visits. How about on your end, Rachel?

Rachel Stahl Salzman: Very similar. As I mentioned earlier, we were starting to try telehealth a little bit before Covid, and then it was boom, we're moving 100% virtual. There was no doubt there were some challenges in the beginning, right? Being able to have them connect through the patient portal, many of them didn't have accounts and didn't have any interest in setting them up. Getting them on board with that was a big part of it. But we've had tremendous success. Once you kind of get through those initial growing pains, the telehealth platform does for the overall majority of people move and work very smoothly. We've also changed offices since Covid and downsized spaces, as well. Since we're doing a lot of virtual care, we're able to have more shared office space, rather than owning individual desk space. So, that's also been good and it actually has allowed us to be closer to the main hospital campus, which has been a positive move overall.

Lisa Jones: How about thinking about the data and how diabetes data can be downloaded from cloud-based software, how can that then make it easier for remote-patient monitoring? I know Rachel, you touched on it earlier, but if there's anything else that you wanna share about that, that would be helpful.

Rachel Stahl Salzman: Definitely. What I think has been very helpful is making sure that the people that we care for are connected with their digital devices. Many of the devices now have a corresponding app that could have some sort of code or a patient identifier that can be shared between the patient and the practice to allow their data to be shared automatically. And once that process is done, it's automatically in real-time. An example would be a continuous glucose monitoring platform. So, with that, we're able to have our medical assistants, a day or two before a virtual visit, go onto the cloud-based software to recognize if the patient's already connected. They would simply look up the patient, they would download the most recent report, and we usually do a two-week report. It's very, very common. And then they would download it and save it as a PDF.

This is where I do think virtual care and integration into Epic, into our medical record, still has yet to be faced, but the idea is they download it onto their computer and then upload it into the medical record. In the future, and I think in the near future, we're going to be able to see that step be eliminated and the data will just flow right into the medical record. So, right now it is requiring that extra step of our medical staff to download it in advance of the visit. Before that process, which again was a big workflow upgrade, in Covid, the providers would be spending time trying to look up the report on the platform, making sure the patients are connected and that would take away valuable time doing what we do best, right?–being with the patient and having that time to support them with their personal health goals. So, being able to have a team has been incredibly helpful with that. And similar for the insulin pumps, as well. Once they're connected, the data is continuous flow, and we just have the staff go in to download it in advance of the appointments.

Lisa Jones: That's excellent. Does the download take a really long time?

Rachel Stahl Salzman: It's typically very fast. But there are some patients... for some systems, maybe they got rid of, they closed out the app, or they got a new phone, or they changed their password. Sometimes that could throw off the ability to get that data quickly and in real-time, so there are, of course, some situations where we might need to contact the patient to find out why the data's not being connected with some technological issue. But for the overarching majority, for most people is it, it does work very well and fast.

Lisa Jones: Oh, that's good news. How about you, Livleen? Any additional comments on that? Is it the same or different?

Livleen Gill: It's similar on our side, our team is a little bit different. It's between the RD and the NP and only the most complex where they're not really able to be managed that the data is shared with the MD the RD typically will review the data and do a warm handoff with the NP. Yes, I'm a registered dietitian, but I believe that the dietitians are really trained and better able to look at the data and give the information that is needed to make those visits helpful and get the information across. They are the ones who usually will be the ones sitting with the patients to help them with their technology and with their reports. So that's kind of in our practice, that's how we've done it.

Lisa Jones: Oh, that's great. And it's almost like you're reading my mind, Livleen, because my next question is about the role of RDNs in diabetes tech, and you already kind of alluded to that. How can they become diabetes-tech champions in the work setting? And it sounds like in your setting they already are.

Livleen Gill: Yes. It helps that, as the CEO of the practice was an RDN, I do believe that that is the role of the RDN to be able to then integrate with the team and to bring the team on board. When we started, in the beginning, to bring on the technology, and Rachel is in a little bit of a different setting, our providers were not really trained in that, so they were a little bit hesitant in how they were going to manage. So, we had to put processes in place, workflows in place, yet the dietitians had to do one-on-one and would, so that's kind of how we ended up building the team and that's how the dietitian became the tech champion to lead the team forward with it.

Lisa Jones: And I love hearing that. That is so great. And Rachel, I can't wait to hear what you are going to say about the champions because I know there are a lot of listeners who are interested in this space, so how can they become one?

Rachel Stahl Salzman: Yeah, well I think the field of diabetes technology, I can't emphasize enough, is so exciting. And the role of the dietitian plays such a crucial role in unlocking the data in a way that's understandable for the person to help them support positive behavior change. I think one of the biggest ways, a few ways to become a diabetes tech champion, is if you're able to get your hands on these technologies, one of the best ways to really understand it is if you do have the ability to try it out, to understand how to use a blood glucose meter practice with some insulin pens. Maybe there's an opportunity for you to wear a CGM and that helps you to really understand from the patient's perspective, what it feels like to place the device. Does it hurt? How does it feel?

Being able to provide some personal feedback around that could be really, really helpful. And then I think, as the RDN, this is our time to shine stepping up to the plate to really show the value that you can provide in your practice setting once you're more comfortable with the technology. For example, maybe it could be sharing updates on diabetes technology at your staff meetings. I think we can all agree there are new FDA approvals each month. It's hard to keep track of it but do your best to stay up to date. I would also add, that having that CDCES credential has been extraordinarily helpful and to build the confidence of being comfortable with diabetes technology and really great resources from the Association of Diabetes Care and Education Specialists and the American Diabetes Association. And of course, I have to shout out the Diabetes Practice Group. There's a wonderful team there. There's actually a mentorship program, so again, if you are interested but not really sure, we now have a mentorship program where you have the opportunity to potentially connect with a mentor who can help support you.

Lisa Jones: Yes. Mentor. I think that's always so great to grab a mentor, especially if it's a space that you want to get into. It's helpful to have a mentor to help you.

Rachel Stahl Salzman: It's helped me so much, but being able to shadow. Asking to shadow providers who are seeing a lot more of diabetes technology and having discussions with them. I think a lot of it just comes out to being proactive as much as you can to be exposed to it.

Lisa Jones: Yes. Great tips. Thank you. Now how about some examples of initiatives that you led in your practice settings to be a diabetes champion? I know you just talked about the mentorship. Is there anything else? Any other initiatives that you'd like to share?

Rachel Stahl Salzman: Sure, yeah. One initiative that I've been co-chairing for a few years now with my colleague, Dr Jean Sealey, is the Diabetes Champion Committee. This is a group across our NYP Cornell Hospital system, with a goal to provide knowledge and skills training for healthcare professionals in diabetes care. So we have a dedicated group of nurses, dietitians, pharmacists, and other staff both in inpatient and outpatient. And we feature every month different diabetes topics. And naturally, diabetes technology is a common one that we talk about. So, it's an opportunity to share with others and get people engaged on diabetes topics.

Lisa Jones: I love that. The name, is so simple, right? How about you, Livleen? Any other initiatives you want to share with us?

Livleen Gill: The providers... we meet with a rep. They'll call in to go over any new technology or any new paper that has been released to look at it. We're much smaller than Rachel's team, but that's kind of how there is more initiative led by the RD and not necessarily the docs, but they all come together in terms of the education piece of it.

Lisa Jones: What I want to know next is we had this discussion about telehealth and at the end of it there were so many takeaways, but if you could just identify one key takeaway for our audience, what would that takeaway be? Let's go to Rachel first.

Rachel Stahl Salzman: You know, something that really excites me is that we are just in the beginning of what telehealth can offer for us. I think about how it's really moved to face-to-face from in-person to the computer screen. But I think what we're going to be seeing and hearing more of is how we can incorporate other aspects of virtual care into it. Maybe virtual reality, being able to simulate real-world scenarios with the person. I think about bringing them to their restaurant, their favorite restaurant, and helping them decipher the menu. Or how to connect with their favorite Aunt Betty who insists on having them try apple pie when they know they want to try to eat less. How we can take the knowledge that we share during our face-to-face visits and maybe simulate more engagement? Kind of this idea of more virtual reality into our meetings.

Lisa Jones: Virtual reality. I love that. That's great. I keep seeing more and more, and I'm sure, Rachel, you probably keep up with the research on that as well, but I keep seeing more and more talk about that and it's advancing. So, thank you for that. How about you, Livleen?

Livleen Gill: I think telehealth is here to stay for the long term, and it's going to shift and change a little bit, but it's just going to be one of the delivery modes of care. It's not going to replace completely the in-person visit. But it's definitely a needed modality to provide access to care for those individuals living in rural-urban areas. And to be able to bring, as Rachel said, the aunts and the family members into the picture when you're providing the care so that everything is right there. You don't have to wait for the next month to bring them in.

Lisa Jones: Yes, that is great. It's just another delivery mode in the future. Like, there's probably going to be other ways too. I'll be talking about it in another couple years. Thank you both for sharing your wisdom on this episode.

Livleen Gill: Thank you.

Rachel Stahl Salzman: Thank you.

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