April 07, 2020 Virtual Visits for Diabetes During a Pandemic - Practical Tips and Pearls

Dr. Ilana Halperin [00:00:03] Thanks, everyone, for joining us this afternoon for the Diabetes Candida Virtual Care update. I'm Illana Halperin, an endocrinologist from Toronto. And I'm joined by Dr. Rose Yeung, an endocrinologist from Edmonton.

Dr. Rose Yeung [00:00:15] Hi everyone.

Dr. Ilana Halperin [00:00:15] So over the next hour or so, we're going to be talking about a few things. I'm going to focus a bit on the value of virtual care for diabetes prior to the COVID-19 pandemic. And then we'll talk together about some strategies for converting multi-disciplinary clinics to virtual care during the pandemic. Appreciate some of the virtual tools available for sharing diabetes self-monitoring. And then we're very lucky to be joined by one of my patients who will share her perspective on virtual care for diabetes. So I like to start with this, cause sometimes it's funny how a little tweet on a warm summer's afternoon turns you into an accidental expert in virtual care, but I've been lucky to be involved in a pilot project with virtual care with the Ontario Telemedicine Network for over two years now. And I tweeted about doing a virtual clinic from my cottage and it kind of reverberated around the world. And since then, I've been asked to do a number of webinars on how to do virtual care. So here we are.

Dr. Ilana Halperin [00:01:12] So I think what that tweet showed us is that digital health can really advance the quadruple aim. So when I started my quality improvement training back in 2013, we talked a lot about the triple aim, which was better outcomes with improved patient experience at a lower cost. But that meant that we were asking a lot of health care professionals to do more with less. And that led to a lot of talk about burnout and poor provider experience. And so the fourth aim came to be, which is improve clinician experience. And I think the fact that I'm doing this webinar from my bedroom, in part because we're all self isolating, but that's really what this is showing us, is that digital health can improve the clinician experience as well as the patient experience and hopefully improve costs and access for the system as well. So when I think about digital health, it's not just about virtual care. I really do think that having a robust electronic medical record is at the crux of that, because without an electronical medical record, it would be hard for me to provide care from home, that's for sure. And obviously that's an important way for patients to access their own information using patient portals. They can access their electronic medical health data. But also they can share data with us through wearables and apps. And we'll talk more about what that looks like in the diabetes space. And then they might be able to do secure messaging through patient portal or an EMR and ask questions about their health between appointments and that might trigger us to start thinking, oh, maybe we need to have a virtual visit with this patient in between visits. Schedule visits don't always happen along when patients are having trouble with their diabetes management. And then finally, we might discover through talking with our patients that they have an issue that may not be diabetes related. And maybe instead of sending them to another specialist, I can just do a provider to provider e-consult to get an answer for them to improve access and decrease wait times. And I think everyone prior to the pandemic was talking about how can we leverage digital health? And there's two main drivers here for the digital health piece. One is that it should help us with timely access to care and the second is that there's a consumer demand for it. Patients say, if I can access my bank account information online and digital shop and all of that stuff, I should be able to access health care in a similar fashion. So as I mentioned, I was part of the Ontario Home Video Visits pilot, which has now been renamed the direct to patient videos. And so this was done through the Ontario Telemedicine Network, which was initially created to have patients who are in rural or remote locations have access to providers and tertiary care centers but it was done in center, so I couldn't do it for my personal computer and the patient had to go to a hospital. But in the last two years, we've moved towards physicians being able to do it from their own personal computers and patients being able to do it from any remote device (Ipad cell phone, personal computer). And you can see there's been a growing uptake and over the last three years and this is just a quick distribution of who, what kind of specialists in Ontario are doing it. And so you can see that mental health takes up a huge piece of the pie, which makes sense since they don't need a physical exam so essentially all their care could be virtual, but endocrinology has had a good uptake relative to what a small proportion we are because I think that speaks to how much care for diabetes can be done virtually.

[00:04:28] So these are my virtual care tips prior to the pandemic. I think it's really important to have a tech savvy admin assistant. That's part of the process is getting patients signed up to do the virtual care. They need to be able to access the software and troubleshoot in real time and so my admin assistants been fantastic for that. Obviously, prior to the pandemic, I was selecting the right patients. People who are technologically savvy and good at sharing their blood glucose reports with me easily electronically were an obvious, easy choice for the first patients to experiment with virtual care. I tried to schedule my virtual clinic separately. I actually book the first half an hour to an hour and the last hour and a half of the day for virtuals because it's a bit awkward to move back and forth between virtual and in-person when, at least in my waiting room is right outside my office door, and so my patients would assume I'm just kind of, you know, talking on the phone with a friend or something and not actually attending to them. And the workflow works better that way. I always just like a real person, we have to set expectations on appointment times. It's not exactly when it scheduled to be. And so often my admin assistant would say she'll likely log on around 4:00 but I'll email you a few minutes before she's ready so you can log on then because just like in person I run behind. Email consent was important because that's how we're transmitting information and getting people on boarded onto the video visits. And we'll talk more about consent in the next section. Getting patients to download and test their connections ahead of time and pre-pandemic, well it was always really important for me to have all the labs, imaging, and uploaded self-monitoring data ahead of time so that we can make the most out of the visit. But about two weeks ago now, we got hit with the concept that social distancing had to extend into outpatient and ambulatory care. So I quickly converted my office to a virtual first approach. I have automated reminders that go out to my patients. And so the reminders were changed to explain to everybody in our voice, outgoing voice mail and my secretary's email response basically all say this: due to the COVID-19 pandemic and the need for physical distancing, all encounters are occurring virtually first. The physician will then make an individual determination if there's a need to see a patient in person after they connect virtually. And we extended this to routine labs as well. So a lot of patients were calling and saying, "should I cancel my appointment? I haven't done my labs." And my secretary was encouraging people to keep their appointments and that's continuing to be our message so that I can talk to them and make an individualized decision about the urgency with which their labs need to be done and whether it's worth venturing out to the lab or not in the context of physical distancing. So I'm going to pass it over to Rose now to talk about virtual diabetes visits.

Dr. Rose Yeung [00:07:08] Thanks Ilana. So unlike Ilana, in our practice here in Edmonton, we have not had a formal virtual care program. However, in endocrinology, we do use a lot of phone visits as part of routine care. But now with the pandemic planning, we wanted to go through some of the pros and cons specifically with regard to pandemic concerns. So under the pros side, we obviously know that this will reduce infection spread to support social distancing and social isolation. Furthermore, we know that vulnerable patients who cannot travel or no show are able to be seen. And this also alleviates pressure on patients for paying for parking or transiting. Now, the other interesting thing about doing video visits is that it's a bit like a home visit. So providers can get insight into the patient environment in the home that may help to influence care. We know that the convenience for patients apart from transit, is that it is less time off work and that some people really, really find it very convenient and it allows for what we can call high frequency, low touch care, so where visits or touch points, maybe quite short and unobtrusive, but very helpful. Now the issues with virtual care, as we've seen pivoting to support this is that it requires significant change management. So this is really contextual to your individual setup. But in, for example, in our facilities at Alberta Health Services, there are a lot of moving parts. And so it is quite a challenge to get everybody on board. Other challenges with regard to system is the remuneration in the health system acceptability, which seems to be in flux in all the provinces at the moment. So of a number of provinces have introduced virtual care billing codes for fee-for-service physicians that have helped to on-board virtual care. And this is an evolving area. I think a big thing that we need to consider is that virtual care visits may not take less time and in fact may take more time because of some of the workflow changes that need to happen, particularly relating to the next point, which is talking about obtaining glucose data. And so we know that there's a lot of tech to help us with this. But for many patients, we are using old fashioned techniques, right? Is it the paper or going through there their meters or doing the work for them to obtain that data when they're in clinic. So this is really us having to figure out how we can empower and educate people to help us with these processes. And of course, the last point there is talking about how we can facilitate a cohesive, integrated, multi-disciplinary communication. And so as Ilana had mentioned, you know, EMR is critical to this and virtual care is going to be very difficult without a common EMR. And so these are some of the challenges we've seen emerge. So the aims of virtual care during a pandemic. So we wanted to frame a few of the broad principles to ground us. And so of course, we want to provide the best care to patients given the limitations of the social distancing and isolation. And, you know, in diabetes care, arguably, you know, non pandemic or pandemic, we are preventing unnecessary visits to acute care and in this setting, we really want to avoid any unnecessary hospitalizations. We obviously are reducing the spread between patients and staff in all settings by doing that. And one of the things that I really want to bring up is we want to protect our workforce. We want to protect all the people working in diabetes clinics because we maybe get called to the front lines to deal with the more acute issues in a few weeks and so it's really important that we prioritize virtual care now to protect all our workforce members for potential future deployment. And while we are doing the pivot to virtual care, we want to make sure that everybody on the team is working at their full scope, that we're not doing redundant tasks and unnecessary documentation, and that people are continuing to feel valued throughout this time.

[00:12:37] So the bodies that govern our behaviors as physicians, so this is the Canadian Medical Legal Organization, and they have stated that virtual care can be an effective alternative means to interact with patients during the COVID-19 crisis and that the duty of confidentiality and privacy obligations continue despite the outbreak, and that we as physicians must obtain consent from patients to use virtual care. So that being said, this is being addressed by each of the colleges in the provinces as far as medical practice goes. So there are scripts that are available in your jurisdiction for use of teleconference and electronic communications. And of course, patients must be made aware that these communication systems are not as secure as an in-person visit. And so for the sake of completeness in these slides, we have included a couple of the examples from Ontario and from Alberta that you can take a closer look at at your own time. Now, in addition to scripts, they have also provided additional information that offices can post, physically or electronically, to further provide information on the implications of confidentiality and privacy with regard to virtual visits. And one note is that, at least in Alberta and this may be jurisdictional, because phone visits have been around for so long, it is assumed that when you have a visit on the phone with a patient that there is automatic consent. So no particular explicit consent needs to be done for phone.

Dr. Ilana Halperin [00:14:53] OK, so I'm going to take the mic back over for a minute and talk about how we converted our interprofessional clinic, which for me was the gestational diabetes clinic at Sunnybrook Hospital, very rapidly into a virtual clinic. And so within 48 hours, essentially we changed our approach and started doing our new gestational diabetes patient class, which is a class that runs every week for about eight to ten women with a nurse and a dietitian into a Zoom class. So the patients were called first by the nurse or dietician and obtained email consent and the consent for using Zoom. And then usually they would fill out a history form and then be given a diet record and a blood glucose record to fill out for the next 20, for like for the next week and then bring it back into clinic. But instead we emailed them out and we asked everybody to send things back to what we would call a blind e-mail account, which we created the diabetesandpregnancy@sunnybrook.ca email account, which can be handled by three or four different health care professionals can access that account. And then, as Rose alluded to, the need for an interoperable electronic medical record is huge. Because I do internal medicine and I still have to be in contact with some patients at the front lines, I really didn't think it was safe or appropriate for me to be going in person to the diabetes and pregnancy clinic anymore. And in fact, that first week I was symptomatic and was waiting for a return of a COVID swab, of which thankfully was negative. But so the first week was a little bit of a oh, I woke up in the morning and said, I'm not coming to work today, we're going to have to do this by the phone. And so the nurse and the dietician would connect with the patient first by phone. Gather the appropriate information, enter it into the EMR and then message me to call the patient back. And then I would complete the encounter and book the patient for their next virtual visit. And we tried to not overwhelm the front desk staff. We just sort of said, OK, if your appointments at 9:00, your appointment will be at 9:00 again two weeks from now and recognizing that we're calling you on the phone so that could really be anywhere from 8:30 to 9:30. And with each week, we've never done it for three weeks, it's getting better. And we're getting into a more well-oiled machine, but we're still innovating. And I'm looking at ways to work and creating patient portal right into our EMR. So instead of the patients emailing a blood glucose record, that then is going to get manually double document entered into the EMR, we're hoping we're going to start collecting that data and bringing it right back in using some cool software that's available in Ontario, maybe available in other parts of the country as well now, the Ocean software that integrates with our Accuro EMR. And when it comes to insulin starts, I think that's a big part of what we do in interprofessional care and diabetes. We're really taking that case by case. So we kind of have the nurse connect with the patient and get a sense about the patient's health literacy and technology literacy. Can they learn to take insulin over Zoom? Can we fax in a prescription and have them pick it up and then learn that over over a video call with the nurse? But if we feel that, you know, there's too many barriers there, then that would be considered an essential care that has to happen in person and we bring that person in. But really, we usually would see 40 women a day in the gestational diabetes clinic. And now the only patients that are coming in person are those who have to also see the maternal fetal medicine specialist and have their ultrasound. Everyone else is being managed by phone.

[00:18:09] So one question that, you know, is often asked is how do we get diabetes self-management data virtually? And so, you know, some of that some of our patients are just taking a picture of their log book and emailing it to that blind e-mail account. Some people are sending us stuff right out of their meter app. And then, of course, we've got some great sharing platforms for pumps and CGMs. So I just wanted to share the results of a study that I did with the fantastic medical students at Western University, Michelle Newing where we did a systematic review of all available diabetes apps available as of August 2019. We presented this in Winnipeg this year and the manuscript's under review with CJD right now. But as you can see, when you search diabetes, there's quite a few apps, but we included seventy five finally. And we looked at what the different app features are that might be useful to a diabetes health professional and a person living with diabetes. And as you can see, there's quite a bit of variability across the apps in terms of whether or not they provide support for carbohydrate counting, whether they have Bluetooth connectivity with meters. And then we look specifically at the types of reports that the blood glucose, that these apps can generate for health care providers. And again, as you can see, it's a small percentage of the of the reports kind of meet all the features that we as health care professionals would consider to be the, you know, a report that helps us make useful clinical recommendations. But based on some functionality scores, the top five that we came up with and recognizing that the digital health space is moving so quickly, so there may be new apps that have come out since the summer of 2019. But these are the ones that we're recommending to people and certainly recommend that other health care professionals have a look at these different apps to see if that would help their diabetes community. And then, of course, most of you who do care for patients with type one will know that we have a lot of different sharing platforms now for CGMs and pumps. And I ask you to stay tuned, because I'm going to be doing another one to two webinars on the approach to interpreting data from these various platforms. All right. This is you, Rose.

Dr. Rose Yeung [00:20:21] Yeah, so now we're going to shift a little bit to talk about the process change management in this pandemic planning time. And so really this is contextualized to your individual clinic or hospital and to look at who is around you to help you make change and who do you need to engage to make sure that things can run smoothly as you pivot to virtual care. So this may require management if there is a medical director. All the clinical staff involved with providing frontline care. And of course, the people organizing the logistics medical office assistants or the unit clerks that that are contacting patients and are are critical to making sure that the bookings and communication with patients is happening smoothly. And of course, to speak with patients, to make sure that the processes that are put in place are acceptable. And the things that we've been talking about within our clinic groups are, you know, what is considered urgent? So here in Alberta, we have been given the directive from Alberta Health Services that ambulatory care should be shutting down non urgent visits. And so this is really quite challenging in the space of chronic disease management because arguably we are trying to prevent hospitalizations preventing that acute care need. And so this can be quite contentious and this, I think, has to be discussed within your local clinic group to make sure people have a good idea of what we should be seeing in-person still, if there is still a need vs. who can be seen virtually. And so this brings up who can be canceled, who can be rescheduled. I think another concern has been for specific vulnerable populations such as those who have English as a second language or require interpretive resources. And so within Alberta, we are lucky we do have phone intraoperative resources available, but I know not everybody is is in that same position and so this may have to also require making sure that family members or other people can be available to help with the interpretation as necessary. And another thing that we're having to consider is, as mentioned before, the potential redeployment of staff. And so to think about who is capable of being redeployed and what that might look like in your local setting. And so continuing on the focus on the local context. You know, big, big issues of how are decisions and policies being made at your side. Who is driving the decision making shift? How can you be of support or if you are it, how are you engaging others around you to make sure that those changes are feasible and acceptable? For example, within our setting, you know, we have been talking about who needs training in the various technologies that are available and who can access remotely things like the EMR. We also have to consider phone versus video. And we know that video is such a powerful tool as we're currently using this webinar. But for things like insulin administration teaching, this can be quite a huge help. And there are a number of web resources that exist, but even things like being able to demonstrate it on Zoom or whatever video technologies available may go a long ways to preventing people from having to come to clinic.

[00:24:50] The other big thing we talk about a diet (excuse me) and diabetes is how to access medication and who can help with the administration instructions. So, for example, at least in Alberta, we do have a lot of community based diabetes educators at the pharmacies who do a lot of the insulin teaching. And so if we know that those services are available and that that person has to go to the pharmacy to pick up their medication anyway, then perhaps bundling these kinds of things together makes more sense than making them go to two different places to obtain information or support. Another thing to consider is the workflow around digitizing your processes. As mentioned regarding glucose and if you're using paper, are we still giving out books? Are we getting patients to print out recording sheets at home or just go digita using the apps that Ilana plans on presenting later. But all of these things have to be thought through and this will likely depend on your own individual patient population and what is feasible given the access in your area. One thing we've been discussing, we offer at our center, we offer a number of group classes around diabetes education, from gestational diabetes through to the various type 1 and type 2 classes. And so a big thing that we are currently talking about right now is how we can convert these to online formats. But this takes a lot of support from our health authority to make sure that all the educators are supported to do this, and once again liaising with the the unit clerks to make sure people are getting the right information to log in.

Dr. Ilana Halperin [00:27:10] Rose, do you want to do this or you want me to take this?

Dr. Rose Yeung [00:27:13] So I think maybe Ilana, I'll let you get back on this since we. Yeah, OK.

Dr. Ilana Halperin [00:27:20] So what we thought we'd kind of finish off with is the checklist. And we recognize that, as Rose has said so many times, so much of this changes is context specific. It's not just provincial or jurisdictional, but, you know, even within one two clinics within the same hospital, you know, I basically have a non-pregnant diabetes clinic and a pregnant diabetes clinic with different managers and different staff and different workflows. So, but we thought that these checklists might be a starting point for some people to find helpful as they kind of face the overwhelming task of converting their whole clinic virtual. And so a checklist for administrative staff would be the very basic, starting with contacting patients to change appointments to virtual and provide a window of time, recognizing that even just like in person, on the phone, we can't call people at exactly the prescribed hour that we were that's been designated for them. They should be collecting email addresses and collecting pharmacy information. So often we just hand patients a prescription at the end of their visit. But now that we're not seeing them in person, we need another way to get the prescriptions to the pharmacies. We might want to assign a single staff in more of a group clinic to monitor the emails that the patients might be sending their glucose data back to you and adding incoming details to the chart. Then, of course, every group is going to have to make their decisions about whether administrative staff can do their work from home. And there's lots of technological challenges that need to be managed. And then the last thing we would ask our administrative staff to do is provide patients with a virtual care checklist, which includes some information about consent. So as Rose hass mentioned before, there's a lot of good resources that have been put out by the CMPA, which is a national organization, as well as the various provincial colleges around virtual care consent information. So as part of the checklist that you might provide to a patient, you may include a link to more information about consent. But the bottom line is that patients need to understand that email, video and phone calls are not as secure as in-person communications and have their limitations in terms of not being able to do a physical exam. And then we ideally want our patients to be ready to share their self-monitoring of their blood glucose data with the clinic ahead of time so that we don't have to spend time once we're already on the phone either going through blood glucose levels in a meter one by one, or even just getting all the technology connecting. It's also really important for patients to prepare an up-to-date medication lists and ideally share it ahead of time because that can be a time saving feature instead of reading it out over the phone. If possible, patients should be checking their weight and their blood pressure at home ahead of time and then also be prepared to share their pharmacy information. And then finally, the checklist for providers is that we want the providers again need to review consent at the start of the encounter. Hopefully the patients have already read over the consent, but what's been considered adequate at this time, given physical distancing, is signatures are not required. Providers just need to document consent at the start of the encounter that they've gotten informed verbal consent from the patient. Ideally, they want to have that self-monitoring blood glucose data ready and available. I have to say, since I've been working from home, I really miss my two screens where I could have one screen with a Clarity app and the other screen with the patients with my EMR. And sometimes I wish I had a third screen because I also need the pump settings, which is a whole other conversation. But otherwise once you've got those things going, your clinical encounters, otherwise the same. I work through my same diabetes forum and ask similar questions, but when it comes to the physical exam, I ask the patients about their home BP, their weight, and if I'm doing a video, I comment on how they look. And then at the end of the encounter, if we need to do any prescriptions, that's the time to fax or e-prescribe depending on the type of EMR that you use and then thinking about follow up labs. So generally we would also print off a lab requisition and hand it to the patient but in these cases, it might be reasonable to either email the lab Rx, patient can print it off for their next visit or depending on your jurisdiction, some places have the ability to fax a lab Rx to a central location and the patient, when they show up with their health card number, it's there. But really, I think now is the time to choose wisely and think about do patients really need those routine lab tests. You know, patients have an A1C every three months the whole year. Missing one is probably not going to be the end of the world and may not be worth it. But obviously, if we're, you know, rapidly titrating thyroid medication and we really need to know the response to that medication, you may feel that that is an essential lab work to be done.

Dr. Ilana Halperin [00:31:50] So now I'm going to welcome Taryn to our conversation. And so Taryn was one of my first patients after I became a staff physician. We actually met in the diabetes in pregnancy clinic. I followed her through two pregnancies and she's one of my first patients that I started doing virtual care with. And so she's going to share her perspectives with us now. So the first question I ask Tara to prepare for is, from your perspective as a patient, what makes virtual visits successful?

Taryn O'Donohue [00:32:19] So in my opinion, and I'm sure every other type one diabetic's opinion, managing diabetes is so time consuming from counting carbs and remembering to bolus 15 minutes before eating. Adjusting your basal rates if you're using a pump, dealing with your highs and lows, all of these things can take upwards of 15 to 20 minutes every single time you're eating or dealing with an issue. So having virtual care visit is just one less thing that I have to worry about. Most patients that I know of have to go in four times a year. Now, I only have to go in to see Dr. Halperin twice a year because my other two appointments are all done virtually. I'm saving on gas, parking, a lot of time, not worrying about having to schedule my appointments around picking up my kids from school. And the easiest thing is that when I'm expecting an appointment, let's say it's 4 o'clock, I get an email about five minutes before she's logging on from Dr. Halperin's assistant. And then I hop on. It's easy. If it's late, then I'm not worried or waiting around.

Dr. Ilana Halperin [00:33:29] So, Taryn, can you help us understand why patients might be hesitant to connect virtually with health care providers?

Taryn O'Donohue [00:33:36] Yes, I can definitely understand why there might be some hesitation because you might feel like you're losing a bit of that personal touch, but that's never really been a problem for me. I've been doing virtual visits with you for about a year now. And in my opinion, if I don't need to have my feet checked or something looked at in person, what's the point of going through the whole process of driving to the hospital, parking and waiting? Everything about diabetes is numbers. So I don't need to be sitting in your office for you to tell me what my bloodwork results are or to give me suggestions on my basal rates. It's all done so easily over the computer.

Dr. Ilana Halperin [00:34:22] And Taryn, share with us what benefits you've experienced that you think other patients could learn from or that might help alleviate their hesitations or concerns?

Taryn O'Donohue [00:34:31] Well, the easiest things which I've mentioned already, which are saving in a lot of time, but also the ease I'm a pump where and CGM user. So being able to upload and send these reports over to you is really simple and that's just the basis of it. Furthermore, I love being able to talk to you virtually because as you remember, I was on vacation out of the country at the beginning of the year and my pump actually died. And of course I didn't plan ahead and get an extra pump vacation loaner sent to me. So I was totally lost. I only had a syringe and insulin and I have been using a pump for more than twelve years. So it's been a long time that I've had to do, I say the old school way of delivering insulin. So I emailed you right away and you responded right away. And because I had sent you all my reports from my previous office visits or sorry, from our virtual visits, you had all the data that I needed. All the numbers, you gave me, my basal rates, how to convert them to adding them into my bolus. And I wasn't, I wouldn't have been able to do that if you hadn't had access to all that material right then and there. And you responded right away and thank goodness for that. I was able to to be calm and cool and collected for the rest of my vacation. And when I got back, it was easy to just switch everything over to the new pump that I got. So I was very lucky. I think that that was a huge bonus. And why I love virtual visits, so much.

Dr. Ilana Halperin [00:36:14] Thanks Taryn. And I like that you give that example because I think it actually widens the concept from virtual visits to digital health. So it's not always about what we would call a synchronous virtual visit where you and I are connecting over the phone or over the computer, but an asynchronous way of communicating, using email and secure messaging. And again, a good EMR, I was able to respond to Taryn with what her rates were because I can log into my EMR from home on the weekend and I'm so privileged to be able to provide that kind of care to my patients that I know is really making the difference and really keeping people out of hospital.

Dr. Ilana Halperin [00:36:50] So that's the end of a formal part of our presentation. We are going to answer some questions now for those who are joining us live today. But we've left our contact information here. This is such an evolving field. Sometimes these crisis's force us to embrace change in a much rapid or pace than we're comfortable with. But hopefully the end result will be that virtual care continues to be a big part of diabetes care long after the COVID-19 pandemic is over. So thanks so much.

Dr. Ilana Halperin [00:37:26] Hi there. So now I'm live. I hope this is working. Is it working?

Dr. Rose Yeung [00:37:34] Yes, we can hear you, Ilana.

Dr. Ilana Halperin [00:37:35] OK. So somebody asked me to. The only question we've gotten so far is to share the video again of the screenshot again of the apps from the review that I did with the medical student who I realized when I was watching myself live. I was actually, I misnamed her and her name is Mary Newin at Western University. She's fantastic. And she's helping me out with getting forms for my diabetes in pregnancy clinic so that we can further iterate in our virtual care life. So I'm going to... Hopefully I'm sharing my screen now and have got that slide that people ask for back up. Can people see the top five apps by MARS score? Rose, do you see that?

Dr. Rose Yeung [00:38:28] Yep.

Dr. Ilana Halperin [00:38:29] OK, perfect. OK. Anyways, hopefully now somebody from CJD is watching and they will get the review process on this article done so everyone can get the whole article because it's under review right now. But I think when it comes to talking about these apps, the MARS score was is sort of validated medical app rating scale. And so it looks at a whole bunch of functionality and usability things. So we looked at those five that had the top five MARS scores and then included some other details. I think from a health care perspective, we also want things that give us useful blood glucose reports. And so these these five apps also give pretty good blood glucose reports that are, we know if a patient can generate a report out of the app. And those can be helpful. Have we got any other questions? I'm trying to open.

Dr. Rose Yeung [00:39:20] A number, yes. So I believe that for those of you asking for the webinar and the slides, a PDF will be posted in time. Right. Is that right? Lindsay?

Lindsay Clark [00:39:36] Yep, as well as the video.

Dr. Rose Yeung [00:39:37] OK, great. So you can share and access all this information later. So there's a question on foot assessment and sensation assessment. I can try to answer that one. So basically, I think that this comes down to urgency. So if somebody is having an acute foot problem, they need to be seen in person. I don't think that that is going to be something that is going to necessarily be able to be handled virtually depending, I suppose, on the degree of the the issue. So if there is concern for infection, that just needs to be seen in person somehow. Now, for routine sensation assessments, I think at our center we have deemed that non urgent for now. So I think that this is probably context specific. If you're dealing with a specific foot clinic where you're dealing with a lot of high risk patients who need to have evaluations, then I think that that becomes a bit trickier. But I think there a video modality would would definitely be helpful because then you can at least get a sense of what things look like and ask the patient to do provocative maneuvers to get some sense of of how to triage that patient. Ilana, would you have anything else to add to that?

Dr. Ilana Halperin [00:41:12] Yeah, I think actually I completely agree with Rose. I mean, I think routine foot care, even blood pressure and weight monitoring, the things that we would consider to be part of our every visit can't be done in person. Patients can be encouraged to look at their own feet since it's an extra visit that we're not doing. I'm certainly asking everybody if they have any ulcers or infections that they're concerned about. I do have a good example, again, of asynchronous medical care. So a patient actually sent me an e-mail to say she was quite worried because an ulcer had opened up and her chiropodist office had shut down because of the pandemic. And I wrote back and asked for her permission to send me a photo. And if I could forward it to my vascular surgery colleague who when I showed it to her, said, I want to see her in person this afternoon. And you know why he could see her in person this afternoon? Because all his routine stuff is canceled. So she was very quickly looked after. And I think it's a great example of essential care during the pandemic. He saw her, he debrided it, he got wound care to come into the home. And so all of that is still happening. And because of the use of email and telecommunications sending a photo, all of those things made sure she got the care she needed. Somebody asked this to share the CPSA script. So I've placed that on the main screen now. So hopefully you guys can see that. And again, to reiterate the checklists and the entire slide deck has been made into a PDF and we'll be available on TimedRight.

Dr. Rose Yeung [00:42:51] There was a question on the Ocean. Yes. All right. That's for you, I guess.

Dr. Ilana Halperin [00:42:56] So, I mean, I'm really just getting started. So Ocean is is a product by a company called Cognizant MD, started by a couple of physicians in Toronto. Initially only integrating with the Telus EMR, but now integrating with some other EMR is around the country, including my EMR, which is Accuro. And so what I've just started working on is building up the types of forms that patients would have filled out in the GDM clinic with in person. And so they would have filled out that form when they came to the class, perhaps. And then they would be bringing their books back on a weekly basis for us to review their blood glucose. And also, they all bring a three day diet record for their first visit to review with the dietician. So we're just turning those forms into electronic versions. But what's cool about Ocean is that we can send it directly out of the EMR and then the results can come back into our EMR in the form of like a text note. And they even have some formulas that we're working on. So it can do some of that little bit of assessment for us. So what was the lowest blood sugar? What was the highest blood sugar and how many of them were outside of target and sort of each of the columns that we look at when we're assessing GDM? So I think we haven't done it yet, but I think there's certainly that just ability to improve our efficiency. Because right now we are doing that virtually. But there's an email and then the nurse or the dietician has to transcribe what was in the email into our EMR. And so we're just still trying to find ways that we can increase efficiency. And I suspect if these forms worked the way I'm hoping them work that again, that's a tool that we might continue to use post pandemic because it just increases are our documentation efficiency and spends less time documenting, more time actually talking to patients and answering the questions that are important to them. There's a question here I can ask you first, Rose. I know that using email communication through Gmail or Hotmail accounts is not completely secure, but is it something to favor in the context of the pandemic? What do you think those.

Dr. Rose Yeung [00:45:02] Absolutely. The big caveat is to let the patient know that it is not as secure as different encrypted means of communication. So various members do have encrypted patient messaging portals, but the colleges have basically said this is acceptable to use as long as you obtain consent. So what I've been doing is that if I speak to the person on the phone, I inform them that, you know, I obtain consent and the scripts are there to talk about the levels of security and to say, you know, this is not exactly as safe as our phone conversation, but if you would like the information by email, I'll send you something. Or if they send me something, then it's implicit consent that they've agreed to that. But it is important to have that conversation up front because you don't want someone coming back later on and being upset that they weren't aware that e-mail is hackable and these sorts of things. So it is said that it's okay to use, but that consent piece is important to do. And note in the chart.

Dr. Ilana Halperin [00:46:28] Yeah. So I agree. And I have been somebody who e-mails with my patients for a long time. As Taryn alluded to on the call. But, you know, usually when people join my office, they, part of joining my practice is filling out that email consent and letting us know how they want to communicate with us. I think I'm not sure if I mentioned, but I also use an electronic reminder system with my EMR where patients get to choose: do they want the electronic reminder and email text message or like robo call format? So we've been doing that kind of work for a long time, so that helps make this transition from a pandemic perspective easier. Somebody asked a question about this apps for sensor based monitoring systems. So I mean, most of the sensors have their own platforms and I am preparing another webinar that I don't think the advertisments have gone out yet, but should be happening on Monday, the 13th at noon is part 1 where we'll be talking about how to access data from CGM devices and how to interpret the reports and help patients improve their time in range. And then part 2 is going to be more of a focus on accessing data for pump systems and with a focus on automated insulin delivery and and interpreting those reports. So I'm doing that with Danielle Goudge from St. Mike's, a nurse CDE. So hopefully guys will tune in for those as well and we can talk get more into the details about that.

Dr. Rose Yeung [00:47:55] There's the question in our town about pharmacy there. Sure. So in Alberta, I'm not aware of any virtual pharmacy care options. But in the past three weeks, I've had probably more conversations with pharmacists than ever because our EMR is not faxing prescriptions. So I actually have to call all my scripts in at the moment, but I know that a lot of EMR is will do auto faxing. Does yours Ilana?

Dr. Ilana Halperin [00:48:28] So that's I mean it's a mind blowing that yours can't do that.

Dr. Rose Yeung [00:48:32] Bonus. Ilana, do you have any experience doing virtual care with pharmacists?

Dr. Ilana Halperin [00:48:38] You know, I don't really. I think one thing that I think is interesting is kind of getting all on the same line about teaching insulin. And that kind of speaks to some of the other questions that we have them here about insulin initiation, training videos. And so I will put a shout out to some of my colleagues in Toronto. I'm not sure if any of you guys are familiar with the QUEST, Quality Education and Safety Group outside of the Banting and Best Diabetes Center. I'm a member of that group and they have a whole bunch of diabetes videos on their website. So I urge you to check it out. That's Q-U-E-S-T. And they do have some nice insulin initiation videos there, like YouTube videos but you can find them on that website and teach patients how to start insulin. And there's one on how to use a glucometer. So those are helpful videos. But, you know, I had one of my patients who was pregnant and I wanted her start insulin. So I told her about the video and sent her to the pharmacy. But then the community pharmacist got nervous that she was pregnant and suggested that she injected her leg. But in fact, we know that the fit technique for pregnancy still recommends the abdomen as the first choice for injections. So, you know, I think that's part of the challenge that we're experiencing, is that different people have different levels of comfort. And there is a bit of that kind of silo between the hospital based clinics and the community pharmacies. But I hope that this opportunity allows us to just break down those silos a bit more. And I can see, yes, I will type in the website and I can see that some people are talking about pharmacies doing virtual care, which I think is fantastic. And I don't have any any specific experience in Ontario, but it looks like Alberta is doing some. So that's, I think, really cool. One other challenge I'm having with pharmacies right now, it's not exactly virtual care related one, but I'm sure we're all going to encounter this is one month prescriptions. So because of fear of because of fear of running out of medications, a lot of our patients are being told they can only have one month prescriptions, which is making them anxious because it feel like it's excess exposure to pharmacies and the like. So I don't really have an answer to that right now and certainly worries me for my patients who are struggling with their income to be paying excess dispensing fees when I've always given out three month prescriptions. So I guess it's not really an answer as much as something that as Diabetes Canada we might need to look into to advocate for our patients. Rose, I don't know if you want to follow up on that at all.

Dr. Rose Yeung [00:51:20] Yeah, sorry, I was just, um, looking at the questions.

Dr. Ilana Halperin [00:51:26] So I just said pharmacies are being directed to do this by the government.

Dr. Rose Yeung [00:51:30] Yeah, that's right. With the one month.

Dr. Ilana Halperin [00:51:33] To ensure ensure adequate supply. But then they should probably be giving people a break on the dispensing fees.

Dr. Rose Yeung [00:51:40] Yeah. Our, I don't think our dispensing fee, I think our dispensing fees are in accordance to the time. So I don't think that there's a difference between.

Dr. Ilana Halperin [00:51:50] So yeah, it you would be less each time. Yeah, maybe.

[00:51:52] I think depending on the plan. But I welcome someone to put in the chat box if that that is true. Here we have Alberta Blue Cross reducing co-pay for delivery.

[00:52:04] Yeah, curbside pickup. Yes, that's what I told my patients and I mentioned to look into that.

Dr. Rose Yeung [00:52:11] Yeah, I think the biggest thing with doing virtual care and involving community colleagues is just to try to have an integrated approach and to make sure the communications are still open. Because, of course, if this is a time where there is a risk of fragmentation of care and to make sure that the whole team that is involved in that person's medication management is aware of what's happening. So I encourage if you are a community practicing clinician, to liaise back with a family doctor, liaise back with the specialists and make sure everybody is aware of what's going on so people can keep on the same page. And that's the challenge because the EMRs are not connected to the pharmacies in terms of sharing notes and things like that. So I think this is one of the risks of of everybody trying to help out. But, you know, ensuring that there is a coordinated and integrated approach. I also have posted a website that the Diabetes Educators Group in Calgary has created. They have a wonderful resource. It's www.diabeteseducatorscalgary.ca and I have just posted on a bunch of the answers, the links to their blood glucose and insulin resources, which include videos amongst many other things. So you can take a look there but I know that the team in Calgary has been really proactive in in curating really good resources.

Dr. Ilana Halperin [00:53:57] Yeah. So I just put in the diabetesquest.ca. And now I'm sharing my screen. And so let's see, under diabetes resources. They've got a section called diabetes videos. So you'll be able to find a bunch of videos that you could potentially share with your patients here. A guide to testing your blood sugar, a guide to using your insulin pen and some other things like that. Are there any other questions about delivering virtual diabetes care? Think we've... glucose testing apps discussed in today's call? Oh, yeah. OneTouch. Yeah. So the OneTouch app was something that people highlighted. I agree. I find it helpful. OK. Rose, any final comments?

Dr. Rose Yeung [00:54:54] No. Well, I wish you all well in this chaotic time and I hope you all stay healthy and please be in touch with Diabetes Canada about future webinar requests. We want to stay relevant to make sure that we're pushing out the right information to support the community. So thank you for attending and thank you for your questions and your participation today.

Dr. Ilana Halperin [00:55:23] I just want to echo that. Actually Diabetes Canada made a nice video. That's not in TimedRight, it's like right on YouTube and on the Diabetes Canada website. So it's directed at patients and answering the most frequently asked questions about diabetes and COVID-19. And Peter Senior, Jan Hux, Alice Cheng, Jen Hanson... a bunch of great folks with diabetes can are talking about, you know, mental health and finances and how to manage your blood sugars in spite of 15 or 20 minute video. Overall, it's a great watch. So we recommended you guys can share that with patients who are calling in with their frequently asked questions.

Dr. Rose Yeung [00:56:02] Yeah. One thing I forgot to mention, when you are pivoting to virtual visits and phone visits. Yes. The thing that we forgot to put on the checklist that we updated, the checklist is to let patients know to accept blocked calls, because a lot of us are using our our personal phones to call patients. And so to avoid the rejected call, people need to change their phone settings or accept the blocked IDs to ensure that the calls go through.

Dr. Ilana Halperin [00:56:37] Good. Yeah. Completely agree. And so with that, it's almost the end of the hour. So I think we'll close the webinar and I hope you guys will join us again next week when I talk, I delve more into CGM data management. And everybody stay safe and stay sane. Thank you very much for joining us today.

Dr. Rose Yeung [00:56:58] Take care.