Hyperglycemia is defined as high plasma glucose concentration, which may lead to long-term complications such as diabetic retinopathy, nephropathy, and neuropathy Lastly, average glucose variability was defined as the standard deviation SD of all plasma glucose levels in the 2-week period.

Data on glycemic control were collected at baseline visits, 6 month follow-up visits ±1 month , and 12 month follow-up visits ±1 month. Cost savings for the VHA were calculated on the basis of the difference between patient travel reimbursement costs associated with in-person visits at VA medical centers in either Birmingham, Alabama, or Atlanta, Georgia, and costs associated with telemedicine visits at community-based outpatient clinics.

Time savings for patients were calculated using Google Maps Google Inc and were based on the difference in estimated time to travel to community-based outpatient clinics versus the nearest VA medical center in either Atlanta, Georgia, or Birmingham, Alabama.

To evaluate telemedicine appointment adherence, we recorded the number of CVT appointments missed patient did not show up , cancelled, and scheduled. Telemedicine appointment adherence was reported as the ratio of the number of CVT appointments in which the patient showed up to the number of CVT appointments scheduled, excluding the number of appointments cancelled by the patient in advance.

To assess patient satisfaction with telemedicine, we administered via telephone a satisfaction survey published by the VA Telehealth Services Program. Data analysis was performed using Microsoft Office Excel Microsoft Corporation , SPSS version To analyze changes in diabetes outcomes, we conducted paired t tests from baseline data, 6-month follow-up data, and month follow-up data.

To analyze patient satisfaction survey results, we calculated the median, mean, and SDs of patient responses to each survey question. Among 54 patients enrolled in the Atlanta VAMC Endocrinology Telehealth Clinic, 32 patients had type 1 diabetes Figure.

Of the 32 patients with type 1 diabetes, 17 had follow-up visits at 6 months, and 9 had follow-up visits at 12 months.

Mean age was Abbreviation: VAMC, Veterans Affairs Medical Center. Telehealth patients generally received the standard processes of diabetes care Table 2 When seen at baseline visits and at 6-month and month follow-up visits, all patients had received the recommended blood pressure measurements and lipid panels.

Mean hemoglobin A1c levels decreased overall from baseline 8. The average frequency of hyperglycemia every 2 weeks increased from baseline to 6-month follow-up but was stable after 12 months. Lastly, there was a nonsignificant trend toward a decrease in mean 2-week blood glucose levels at 6-month and month follow-up.

Mean daily blood glucose level was Telehealth patients had a median of 5 scheduled appointments range, 1—10 scheduled appointments.

Furthermore, Two patients who preferred in-person care over telehealth stated that seeing their physician face-to-face was important to them.

Our findings suggest that telemedicine is a safe method of delivering type 1 diabetes care to rural patients. Telehealth patients in our study experienced improvements overall in diabetes outcomes, although our findings were not significant. Patients also had an increased mean frequency of hypoglycemia.

Our observation of increased hypoglycemic episodes is consistent with literature that suggests improved glycemic control, indicated by lower hemoglobin A1c levels, is correlated with an increased frequency of hypoglycemia Our findings are in line with those of other studies that suggest that diabetes care via telemedicine is comparable to in-person diabetes care.

Our findings, which demonstrated a 0. Similarly, Wagnild et al described the use of telecommunications for diabetes patients in Montana and found that patients showed improvements in hemoglobin A1c levels, blood pressure, and diabetes knowledge Our findings are consistent with literature that suggests that telemedicine may effectively deliver diabetes care to rural patients.

Our study has limitations. First, the referring diabetes specialty provider at CAVHCS also independently manages the diabetes treatment of many of the patients enrolled in the telehealth clinic, in some cases just before referral to the telehealth clinic but mostly with select patients between telehealth visits as needed.

However, use of midlevel providers such as pharmacists and nurses is common across the VA health system, is an integral part of the VA-established Patient Aligned Care Team model, and may represent the patient-centered care model in use Another limitation was significant loss of follow-up.

Many patients had follow-up visits that did not meet our study criteria of 6- and month follow-up points. This apparent loss of follow-up may have been because the Atlanta VA Telehealth Endocrinology Clinic is available only once per week.

As more patients enrolled in the clinic over time, the intervals between follow-up appointments necessarily increased. Remote monitoring is any health data continuously collected from the patient e.

The use of telemedicine increased during the COVID pandemic. The Veterans Health Administration was an early adopter to improve access to care and outcomes for a primarily rural population of veterans with multimorbidity, including diabetes mellitus. Telemedicine used for the comprehensive management of diabetes i.

The American Diabetes Association recommends improving care delivery at the systems level, offering self-management support, and using shared decision-making in the care of patients with diabetes.

It also improves outcomes by adding video visits and virtual nurse check-ins between physician visits, which improves diabetic glycemic outcomes. Telemedicine provides an opportunity to improve patient-centered approaches in diabetes care.

Medicare now pays for most telemedicine visits at the same rate as in-person visits for all types of telemedicine and patient locations. The future success of telediabetes care will depend on continued financial reimbursement and requires systemic solutions to overcome gaps in digital literacy.

Telemedicine poses challenges that require unique solutions in the care of patients with diabetes. Adaptations are required by the physician, ancillary staff, and health care organizations to ensure equitable and cost-effective care.

Office staff must be able to teach and troubleshoot telehealth technology. Relevant previsit information and home data about blood glucose levels and vital signs should be collected before the visit, which can offset the time saved from rooming patients and measuring their vital signs.

Plans for follow-up from the physician should be detailed and include the laboratory tests and measurements required before the next visit. Between visits, electronic messaging or telephone calls to the patient may be needed from nursing staff, diabetes educators, and office staff.

Patients may require an in-person visit to address needs identified in a prior telemedicine visit. The rapid increase in telemedicine use has revealed barriers to implementation. Telemedicine implementation could further isolate patients at high risk and exacerbate health care disparities.

Physicians may struggle to use telemedicine if they lack resources for implementation and support Table 1 7 — Efforts to address these challenges are ongoing. The U. Department of Veterans Affairs ATLAS Accessing Telehealth Through Local Area Stations program partnered with organizations such as Walmart and the American Legion to establish telemedicine locations for patients without stable internet in their homes.

There are 12 stations in the United States with plans to expand. Telemedicine has been implemented successfully in diverse subsets of populations with diabetes. Most of these studies demonstrate modest but clinically relevant improvements in glycemic control.

One meta-analysis found a greater impact of telemedicine on type 2 diabetes than on type 1, which may be attributed to greater responsiveness to lifestyle modifications among patients with type 2 diabetes. In a large systematic review of diabetes types and a heterogeneous mix of telemedicine modalities and interventions, telemedicine interventions led to a 0.

Remote monitoring uses text messaging or website portals to adjust medication doses based on glucose readings. Telephone calls were less effective, and telediabetes care did not affect quality of life, number of hypoglycemic episodes, or mortality.

A recent umbrella review of telemedicine in type 2 diabetes also showed clinically relevant reductions in A1C levels. A limited study of video vs. telephone modalities of telemedicine outside of diabetes care suggests that video improves diagnostic accuracy with equivalent outcomes overall.

The benefit of telemedicine for diabetes care during pregnancy is uncertain. In a Cochrane review of pregnancies complicated by preexisting diabetes, telemedicine monitoring of blood glucose did not improve outcomes. However, telemedicine monitoring did improve outcomes for gestational diabetes in another recent large systematic review.

Remote monitoring uses telemedicine and additional human and technological support to gather and intervene on health data. Initial studies of remote monitoring involved a patient reporting self-monitored blood glucose to their physician to facilitate medication adjustment.

Remote monitoring can include routine check-ins by a nurse, automated and interactive messaging, and direct telephone calls with physicians. In a meta-analysis of patients with type 2 diabetes, remote monitoring reduced A1C levels by 0.

Interventions varied, with some requiring frequent contact with staff. In the past decade, continuous glucose monitoring has become increasingly utilized for the remote monitoring of patients who are prescribed insulin.

Continuous glucose monitoring measures interstitial fluid glucose and stores data trends in a cloud-based system. The analysis of glucose trends helps facilitate diet and insulin modifications without the need for frequent fingerstick measurements.

Flash continuous glucose monitoring systems provide on-demand readings, whereas real-time continuous glucose monitoring systems measure glucose trends and alert the patient to impending hypoglycemia.

Two new measures have been proposed to track glucose control and variability with continuous glucose monitoring. Time in range indicates the percentage of time in which the blood glucose level is at goal, and the glucose management indicator reflects average blood glucose measurements, analogous to an A1C level.

Current guidelines and reimbursement rules recommend continuous glucose monitoring for patients with diabetes who require multiple daily injections of insulin; continuous glucose monitoring in these patients is cost-effective.

Continuous glucose monitoring can be implemented by primary care physicians and sustainably reimbursed. Further studies combining continuous glucose monitoring with other telemedicine interventions are needed to clarify the use of this technology in primary care.

Telemedicine interventions have some evidence of improving nonglycemic measures such as body weight and blood pressure by using the distribution of standardized scales and automated blood pressure monitors.

These interventions have also been shown to improve health literacy and medication adherence. Telemedicine body weight outcomes are based primarily on people with prediabetes.

The Diabetes Prevention Program, a clinically validated nutrition, weight loss, and physical activity program, has been adapted for use with telemedicine. Remote monitoring of blood pressure may be most valuable for patients at high risk, the underserved, and older populations.

In one small trial, daily monitoring of blood pressure resulted in improvement if patients with type 2 diabetes were also supplied with targeted lifestyle advice via a cellular telephone app.

Retinal surveillance examinations can be completed using telemedicine. Asynchronous teleretinal imaging allows patients to be screened during routine appointments using a retinal camera that does not require pupillary dilation. Images are then sent to off-site eye-care specialists who can review and recommend follow-up for abnormal findings.

Simulations conducted for U. government health systems suggest that teleretinal screening is more effective at reducing vision loss with a cost savings compared with in-person ophthalmology evaluations. Patients with known retinopathy should have a follow-up with in-person examinations performed by an ophthalmologist.

Before initiating telediabetes care, consider scheduling an in-person visit to establish baseline digital literacy and determine patient needs and appropriateness for virtual care follow-up Figure 1. Patient preparation for virtual visits involves transmitting blood glucose logs, diet logs, and blood pressure and weight measurements for physician review.

Digital health tools such as home scales, blood pressure cuffs, and continuous glucose monitors can help streamline the collection of these data. Continuous glucose monitoring can be tracked through manufacturer-supported cloud-based websites e.

Preparation requires administrative and patient time, which is partially offset by eliminating the office check-in process. Physicians may choose to optimize their clinic workflow by designating a specified number of clinic slots for telediabetes care. A significant amount of relevant physical examination information can be gathered by video, and standardized patient-assisted virtual physical examination frameworks have been proposed.

Although complete foot examinations cannot be performed virtually, telemedicine evaluations were recommended by podiatrists during the COVID pandemic. Confirm self-monitored blood glucose data or diet log upload if not using continuous glucose monitoring. If the setting looks unsafe or inappropriate to the physician or patient i.

Guide the patient to perform a diabetes mellitus—focused examination by video for real-time assessment. Of particular interest are the lower extremities: hair loss, ulcers, bony deformities, and discoloration should prompt an in-person visit for peripheral vascular disease and neuropathy.

If there is concern for medication administration issues, ask the patient to bring their medications into view or demonstrate their use. Visually inspect insulin injection sites, ask patient to self-palpate for firmness repeated injection of insulin in the same area can cause lipohypertrophy ; abnormal findings should prompt in-person teaching on the rotation of injection sites.

Discuss the follow-up interval and if the next visit will be in-person or via telemedicine based on glycemic control and the need for examination. Review any adjustments to the blood glucose monitoring regimen, changes in medication dosing, and treatment of hypoglycemia.

Telemedicine provides clinicians with a unique opportunity to evaluate the home environment and any concerns with medication use. In-person evaluations of people with diabetes should occur at least annually for a complete foot examination with monofilament testing and retinal screening.

Vaccinations and laboratory monitoring can be updated at these visits. Patients with poor blood glucose control or complications will need more frequent in-person care. Data Sources: PubMed was searched using the key terms telediabetes alone and with telehealth, teleretinal, remote monitoring, outcomes, pregnancy, diabetes, and continuous glucose monitoring.

The search included meta-analyses, randomized controlled trials, reviews, and editorials. Reference lists from the included meta-analyses were reviewed for potential sources. Smartphones are one of the basic modalities for telemedicine application.

Mobile phone messaging applications, including text messaging and multimedia message service, could offer a convenient and cost-effective way to support desirable health behaviors. There are diabetes-related mobile apps mainly focusing on self-management of diabetes, lifestyle modification, and medication adherence motivation.

With the widespread availability of high-speed Internet, remote monitoring has also become popular. There are hundreds of tech platforms for diabetes management, of which only a few with proven efficacy and safety are recommended by physicians. The Diabetes and Nutrition Study Group DNSG of the European Association for the Study of Diabetes EASD.

Jessica L. Harding, Meda E. Pavkov, … Edward W. Scott C. Mackenzie, Chris A. Diabetes mellitus and its costly complications have attained epidemic proportions across the globe and are currently considered one of the most challenging public health concerns 1. In India, we have around 80 million people affected with diabetes 2.

The disease is associated with several health-related complications and high morbidity and mortality rates and thus imposes substantial social and economic burdens worldwide 3. The effect of an increasing diabetes population has resulted in increased costs and overburdened physicians 4.

Existing diabetes treatment strategies have not completely been able to prevent disease-related complications. The average glucose remains high in those people with diabetes, raising concerns of these complications affecting the working age population, since the age of onset of diabetes is now relatively early.

To help resolve this puzzle, digital technologies to improve diabetes self-management are being established. The review shed insights into the currently available digital technologies for diabetes care, such as mobile apps, smartphone-based retinal screening, significance virtual COVID IP, and significance of Electronic Medical Records EMR.

which would aid health-care professionals and patients to become aware of the potential benefits and cost-effectiveness of these technologies 5. But there is a standard perception among the common men that technologies increase the cost of diabetes care and this has been the experience in the past.

For example, when mobile phones were launched, it was too expensive for the common man during the initial few years, and when more and more people started using mobile phones, the cost came down.

The story was similar with other devices and technologies which are now being used in our daily lives. Even automobiles were once unaffordable to the common man. New therapies, monitoring, and technologies applied to health care represent a historic opportunity to improve the lives of people with diabetes.

Connected care will supplement more expensive, less convenient face-to-face clinic visits by enabling new models of care that increase the velocity to control with more aggressive and frequent interventions that speed up the achievement of glycemic goals.

Telemedicine Telemedicine includes timely transmission and remote interpretation of patient data for follow-up and preventive interventions. The main purpose of this approach is to facilitate a productive interaction between the patient and the health-care provider to achieve improved treatment results and lower treatment costs.

Reducing outpatient clinic visits and doctor office visits through the use of telemedicine allows patients to save time, money, and other resources. The five essential components of a sound telemedicine system include Fig.

The widespread utilization of telemedicine during COVID pandemic not only legalized, but also proved its overall superiority and cost-effectiveness in many specialities 8. For instance, a study conducted by Anjana et al. Telemedicine has proven benefits in diabetes treatment by improving the short-term and long-term outcomes even though it is not a replacement for face-to-face consultations Mohan et al.

The study shows that among the 27, adult population living in 42 villages, A total of diabetes subjects were screened for complications. Diabetic retinopathy was detected in The mean hemoglobin A1c levels among the diabetes subjects in the whole community decreased from 9. The study outcomes emphasize the significance of adopting telemedicine for effective diabetes care in India The Chunampet model is found to be successful and can be applied in people residing in remote areas, where specialized diabetes care facilities may not be available Remote care reduces the use of resources in health centers and improves access to care, while minimizing the risk of direct transmission of the infectious agent from person to person.

Telemedicine thus provides numerous possibilities for diabetes care such as to create awareness among urban and rural population about the risk factors and prevention of diabetes, to facilitate patient monitoring, remote diabetic retinopathy screening, and in diabetes prevention at the primary, secondary, and tertiary level Thus, telemedicine is an attractive, effectual, and affordable adoption of technology.

Treatment of diabetes fails in the majority of patients due to non-adherence to the advice on medications, diet, and exercise. Self-monitoring of vital parameters along with self-management techniques cannot be taught only during face-to-face visits to hospital. Successfully overcoming these barriers requires motivation, acceptance, encouragement of the use of health-care providers, political and structural adjustments, collaborations with companies working in diabetes technology, and most notably patient awareness of the need to adopt diabetes care in an outpatient setting.

The professional judgment of a Registered Medical Practitioner RMP should be the guiding principle for all telemedicine consultations. An RMP is well positioned to decide whether a technology-based consultation is sufficient or an in-person visit is needed. Seven elements need to be considered before beginning any telemedicine consultation Fig.

should be the guiding principle for all telemedicine consultations. In patients with diabetes, patient—physician interactions are essential for improving health outcomes and preventing long-term complications.

Frequent traveling to clinic appointments is inconvenient for patients with busy schedules and particularly burdensome for patients living in rural areas, those with low financial background, the elderly, and people with disabilities Virtual telemedicine appointments are becoming increasingly common to enable patients to interact with physicians and educators without the barriers of distance and commute time.

In diabetes, telemedicine has been proven to have phenomenal benefits in preventing long-term complications by ensuring adherence to medications and lifestyle advice.

The use of telemedicine visits has been well studied in populations with limited access to specialized clinicians, registered dietitians, and diabetes educators. Telemedicine programs with visits that match usual care models for diabetes treatment have already demonstrated success in helping patients maintain or improve their health DTMS ® consists of a multidisciplinary team of physicians, nurses, dieticians, diabetes educators, pharmacists, and psychologists, who with the help of a customized software and user-friendly interface titrates the dosages of medications and provides advice on diet, lifestyle, etc.

to all enrolled and willing patients irrespective of the distance from the hospital. The successful treatment of diabetes requires normalization of fasting blood glucose, postprandial blood glucose, glycosylated hemoglobin HbA1c , blood pressure, low-density lipoprotein LDL cholesterol, body weight, and waist circumference.

To attain multiple goals of therapy in a single patient, continuing education, motivation, empowerment, and advice on healthy food habits, physical activity, and accurate use of monitoring and injection devices are required Current diabetes guidelines recommend diabetologist or general practitioner consultations at least every 3 months to evaluate HbA1c and, if applicable, adjust the diabetes therapy and optimize the treatment of cardiovascular risk factors It should be noted that regular patient visits and examinations in the outpatient setting are necessary not only to optimize diabetes control, but also to effectively treat associated comorbidities diabetic foot syndrome, diabetic retinopathy, hypertension, CKD, CAD, etc.

A study conducted by Rajalakshmi et al. Another study by the group on the effectiveness of tele-ophthalmology over face-to-face DR screening in 30 diabetic care centers shows that it is feasible and effective for STDR detection in India and hence urges for a wider adoption The role of artificial intelligence AI -based automated software for detection of diabetic retinopathy DR and sight-threatening DR STDR by fundus photography taken using a smartphone-based device was assessed by Rajalakshmi et al.

The benefits and challenges of telemedicine in the management of diabetes are discussed below Table 1. Smartphones are one of the modalities for telemedicine application.

Smartphones can be used to communicate with patients via text messages, Facebook Messenger, WhatsApp messages, and video platforms for telemedicine consultations with the doctor, nurse, and patient care provider participating in a conference call and sharing the screen from electronic medical records.

Increasing patient contact, by including more frequent telephone calls, has been shown to improve patient motivation, therapy adherence, and metabolic control Due to the widespread availability and usage of mobile phones, such interventions to monitor treatment goals can be established easily and flexibly.

For instance, calls can be planned as an add-on after an outpatient clinic appointment. Clinical recommendations, such as the frequency of self-monitoring of blood glucose values SMBG , recommendations for insulin therapy, and physical activity or dietary advice, can be given to evaluate the effectiveness and adherence of these measures during later telephone visits.

A therapy management plan diary that includes dates of telephone visits can be distributed during the onsite visit. Web-based psycho educational interventions have helped adults with both type 1 and type 2 diabetes to cope up with depression and emotional distress Frequent video consultations, used as a supplement to routine care in the pediatric setting, have been found to reduce disease burden and increase treatment satisfaction in patients with scant evidence of improved glycemic control 23 , 24 , and they have shown encouraging levels of acceptance among diabetes professionals Video calls are essential for selected patients who need to see the face of the health-care professional to build up trust and confidence in those guiding their daily therapy Similarly, the health-care professional can better assess the mood and motivation of the patient during a video call.

A further advantage of video calls is the chance to properly inspect glucose data documented in a conventional paper diary. In clinical practice, virtual training sessions via telephone or video calls have been introduced, enabling remote training on specific diabetes-related aspects such as handling technical devices, dietary advice, or behavioral recommendations There are numerous diabetes-related smartphone apps, most of which emphasize incentive for medication adherence, lifestyle modification, and diabetes self-management To continuously engage patients in their diabetes care, mobile devices have become convenient and effective instruments The DM m-Health applications include Glucose Buddy, mySugr, Diabetes: M, Blood Glucose Tracker, and OneTouch Reveal mySugr is a diabetes management app that helps to record the blood glucose data, along with meals, exercise, and medicines.

It provides daily, weekly, and monthly reports that can be shared directly with the doctor. It also provides help calculating insulin doses, and the new coaching features turn it into a full-service learning and support program. It also provides an estimated A1C value. It helps in including the images of pretty much anything, be it a plate of food or a bag of snacks or a drink bottle and thereby helps to better visualize the records.

It can be used in both T1D and T2D. mySugr Coach helps to connect with a diabetes educator who can offer support, tips, and help through the app, via email or text message. This health-care professional can help analyze the diabetes data and offer insights based on the goals or specific questions.

By simply tapping into mySugr on the smartphone, it is guaranteed to get a notification and personalized answer within one business day This helps to manage diabetes much better than when compared to meeting the doctor once every 3 or 4 months.

Patients feel comfortable and it is convenient to interact with a user-friendly popular app. The mySugr Pump Control is designed to enable people with diabetes to control an insulin pump directly via a smartphone: import its data, view its status, and remotely deliver a standard bolus.

mySugr Pump Control is able to get support from the mySugr Bolus Calculator, which calculates the needed amount of insulin for meal and correction boluses.

It considers current blood glucose level, estimated carbohydrate amount, and previous insulin injections active insulin based on data from the mySugr Pump Control Home monitoring can be done by Glucose meters or continuous glucose meters for glucose.

Co-monitoring in diabetes patients also includes monitoring blood pressure, body weight, waist circumference, and if possible other parameters related to diabetes care.

This depends on the level of education and motivation of the person. It is preferable to use connected devices for home monitoring so that when measuring body weight, it will be automatically recorded via Bluetooth on the phone and cannot be altered, preventing errors and manipulations.

For example; when a patient is using a digital glucose diary, corrections cannot be made, whereas if the patient is using a diabetes diary or paper, which is a conventional method, readings are often incomplete and potentially incorrect.

Therefore, manipulations can be avoided while using technology-assisted devices in home monitoring The main advantage of this program was treating patients in their homes eliminating the mental stress of hospitalisation and at minimal costs thus decreasing the burden on local hospitals and making beds available for much sicker patients.

A hospitalization for 10—14 days is 20 times as expensive as VCIP management for the same period Figure 3 shows the workflow of VCIP.