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Dr Matthew Crowley Discusses Key Advantages and Challenges of Telehealth Among Underserved Populations


Matthew Crowley, MD, MHS, associate professor of medicine, Duke University School of Medicine, discusses telehealth initiatives at Duke Health, as well as overcoming virtual challenges and barriers that underserved and underinsured patient populations who need diabetes care face.

While there are many challenges in accesing virtual care among rural, underserved, or underinsured patients, there are also ways to overcome these barriers, says Matthew Crowley, MD, MHS, associate professor of medicine at Duke University School of Medicine.


Can you discuss some key advantages of incorporating telehealth solutions into diabetes care in terms of improving patient access, affordability, and outcomes?

I would say there are many advantages to implementing telehealth at Duke and within other systems as well. The first thing I would mention is that telehealth tends to be a more effective approach to diabetes care in terms of hemoglobin A1C reduction and achieving diabetes control. And that's particularly the case for patients who have not responded well to standard clinical approaches such as clinic-based care.

We [Duke Health] and others have done a lot of research showing that among these treatment-resistant patients, you can really achieve pretty substantial hemoglobin A1C improvements with telehealth as compared to standard approaches.

Beyond the clinical effectiveness of telehealth, in general, patients really like telehealth-based approaches and remote care. And that's due to the ease of access, the savings in terms of travel time, travel costs for patients, things like parking, and many other benefits.

Are there any key data or metrics that health care providers should focus on to assess the value and effectiveness of their virtual health initiatives in diabetes care?

Sure! It’s really important for providers and systems to think about tracking metrics of value when it comes to assessing their telehealth efforts. First off, clinical outcomes I think are really important to consider; that includes hemoglobin A1C, as I mentioned. Hemoglobin A1C tends to improve even for treatment-resistant patients with telehealth. But there are a number of other clinical outcomes that are important to consider and that studies have shown tend to improve with telehealth, too, and that includes things like diabetes self-care, diabetes distress, self-efficacy, and many other important patient-centered outcomes.

Another important metric for systems to consider are the costs of telehealth implementation, especially in comparison to reimbursement opportunities that are available. I think that it's necessary to think about telehealth and design telehealth in ways that are going to be sustainable over time. For that reason, thinking about cost and reimbursement is really critical.

And then when we think outside the box, there are a lot of other cool outcomes that can be impacted by telehealth that I think really need to be considered. One of those would be the climate impact of telehealth. Recently, we've started looking at the climate impacts of health care, which are quite substantial, and how telehealth might help mitigate some of those, including fossil fuel consumption, greenhouse gas emissions, and others. So, there's a wide variety of outcomes and metrics that providers and implementing sites should be thinking about.

What are some top challenges that need to be addressed when implementing virtual strategies in diabetes care in rural or underinsured populations?

There are certainly challenges when we think about implementing telehealth, and some of those are unique for certain populations. When it comes to rural populations, broadband access can be a real challenge for certain types of telehealth in particular. For example, video-based modalities may not be as feasible in areas where patients don't have good internet access. However, there are ways to work around these limitations and that includes use of telephone or other simpler modalities where appropriate, use of store and forward technologies, and things like that.

When we think about underresourced patients, such as underinsured or uninsured patients, there are certainly some limitations there as well related to technology access, access to good data plans, and that's not even to mention the many other relevant challenges that are ubiquitous in diabetes care that these folks tend to disproportionately face. That includes things like affording supplies and medications, housing insecurity; it's tough to do telehealth if you don't have a reliable place of residence. And then lack of reliable electricity or utilities. Those can be issues, in particular, for telehealth, too.

So, in these cases, you really need to tailor your telehealth approaches toward available resources, such as leveraging patient assistance programs as we do for all our diabetes patients. Fortunately, there have been a number of studies that have shown that even our underinsured or uninsured patients do tend to generally have pretty reliable data plan access. So, there's no reason telehealth can't be used in a tailored manner in those populations.

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