Dr. David Ahn compares standard, in-person diabetes visits to remote patient monitoring.
David on is an endocrinologist who actually did his fellowship alongside me. So we were buddies he also trained under Dr Edelmann and he has really become quite an expert in the field of diabetes technology. Um So he specializes in diabetes metabolism. He's also the program director of the Marian Dick Allen diabetes center at Hoke. Um He's an expert in the field very very passionate about empowering people with diabetes to optimize their blood sugars while minimizing the emotional burden of living with chronic disease. And if you've ever seen an article online about any diabetes technology, he's always the one quoted as the expert speaker. So we're very happy to have you today with us. Go ahead David. Thank you Samantha. That's really kind of you you know all these devices generate all this data which is fantastic. But it also makes challenges for us as clinicians because we only have so much time. Um So my disclosures are right right here pause. Yeah. Um Nothing directly related to anything I'll be talking about though I don't think. Um So you know this is very much preaching to the choir but I thought it would be great to kind of do a recap just to make sure we're all on the same page about what the problem really is. Um And so you know imagine a standard diabetes visit. Right? So whether you're in primary care whether you're an endocrinologist or whether you're a D. C. S. A. C. D. C. S. I'm about to do a visit. Typically you know it might be anywhere from 20 to 60 minutes that you have scheduled for your patient you know 5 to 10 minutes of that is going to be um spent downloading their devices if possible. 5 10 minutes is going to be rooming them measuring vitals. All that process 5 to 10 minutes is going to be spent charting and documenting what happened. And now you might not be doing every single aspect of that right. Your M. A. Might be doing the downloading a rooming or something like that but it's still all part of the process and it does take up either your time or one of your staff's time and when it comes down to it the average time that a patient spends with their physician Is 15-20 minutes. And to be honest when I saw that number even I thought that that was fairly large. Um in reality especially if you think of how a lot of doctors now are doing. You know 1530 slots. 2040 slots. The real life number might be a little bit shorter than that. Um and one survey from Medscape in published in May of 2020 reported that the average time spent on paperwork and administration among physicians was about 16.5 hours a week. Um and that definitely rings true you know because it definitely seems like that's what we're spending all our time on these days and that's definitely not compensated. Right. It's not reimbursed which is kind of a pain point for all this. So there's so much data being generated for a diabetes visit. So I kind of created this panel. Um So imagine it's kind of like driving into a car wash right? You're driving into a car wash and you get to pick which car wash you want. And that's kind of always the standard one there's like the middle one and then add some features and then kind of the premium one that adds more features. And I think this is kind of how I see how we're currently accessing data in these visits. Right So the standard visit hopefully at the very least um you're getting a meter download same day vitals and blood work either from labs that they had done coming in or maybe you're often this has a point of care. A one C. Machine. Um You know if you're like an endocrinologist or you're able to have a little bit more of a diabetes focused practice. Hopefully you're looking at a C. G. M. Report and potentially an insulin pump download and maybe other lab work. Um And then kind of the premium plus or deluxe option would be you know if they're bringing in a food diary or if they're bringing in a history of symptoms like they felt low at a certain time um you know dose adjustments medication record or a history of multiple daily injections. Right? So it's generally requires them to either manually record all their NovoLOG or human log injections or to be using one of these fancy smart pens that both of the previous speakers have mentioned. Yeah. And you know, as apple watches become more advanced and fitbits get more advanced and more sensors everywhere. We're just generating more and more data, right? Which is exciting from a consumer perspective and I think from a holistic perspective, but it's very overwhelming for us as clinicians um and knowing what to do with all this data. And so I think it's a good time to pause and think about telemedicine. So like Dr walia. Unfortunately, covid 19 is going to be taking a little bit of a part of my talk. But I think, you know, as we all, you know, shifted dramatically towards video visits um in 2020 I think we learned a lot and it really force the shift to virtual care and sharing of diabetes data. And it did open up some opportunities and provide some teachings for us as people who manage diabetes. And one thing is that diabetes care is ideally suited for virtual care, right? It's centered on self management. So the bulk of what is required is really what the patient needs to do, whether it's eating the right things, um being more active taking their medications. Um and also, you know, they have these devices like insulin pumps and continuous glucose monitors and blood sugar monitors that generate this data. That is kind of the most important part of the health care provider visit also you know we're not cardiologists listening for murmurs on hearts. Um And so the physical exam is relatively of limited utility in diabetes. Of course we should be doing feed exams and things like that. But obviously not every visit do we need to necessarily go fully in depth with our physical exam. And so COVID-19 just really revealed the need for the for better tools to transfer data. And this is where smartphones I think we're really really helpful and I think proved to be extremely valuable because smartphones served as the data hubs for everything whether it's health data, whether it's personal life data. But for us obviously we care most about health data and I think sometimes we forget how valuable it is when it comes to our patients being able to generate their diabetes data and the real secret sauce behind it. There's several components but one component of why the smartphone is so crucial is that it has always on internet right? I mean of course that you might be not have a cell phone data plan on your phone. But I would say the majority of patients do have a data plan on their cell phone. So their phones are always connected to the internet. And that it means that whenever their decks com is streaming data to their phone that data is instantly available to anybody that has permission to view it on the internet, whether it's their loved ones, you know like a parent monitoring their child with type one diabetes, you know when their kid is across the house or when their kid goes off to college or for when you see your provider when they're in a different city and that's very different than you know the decks com user who is using the physical receiver. I have one ready right here as a demo. But yeah, you know if you're using one of these then it's really hard to transmit that data to other people because there's no internet connection on this. The other thing is that smartphones also offer a really high tech computer right there super powerful now with all the iterations of iphones and things like that. They're high tech quality, high tech, high quality computers and they can do a lot that you know something that's super cheap like this can't do. Right? So for example on a dex calm. So pictured here on the right is a dex calm clarity report. And um this is something that there's a couple of reasons why I have this screenshot here, but this dex calm clarity report is viewable on an iphone user. Right? So if you have a smartphone and you have the decks. Com you have an app called the decks com G six app And that G6 app is gonna pretty much mimic this. Exactly it does all the same functionality of this. But there's also another app called the decks calm clarity app that you can download and the user can actually see reports like this pictured on the screen where they can look at their time and range. They can look at their average blood sugar and they can scroll and look at different days on their history. They can compare different time periods and this is all something that you can't do on something like this. So the smartphone just adds so much more value to what the patient can do And keep in mind the smartphone. Now these things are like $1,000 and they're super high quality. The resolution is getting better every year. Whereas this thing you know it barely registers your touch you like if you press it too hard the screen colors start to change and you know it's just a very different quality device so that's where smartphones can be very helpful. Yeah. Um Now during this whole telehealth the covid 19 pandemic C. G. M. S really Schunk shined because they go through the smartphone everything is pretty seamless. But meters were was a pain point where people were really struggling right and unfortunately many people still use meters and like dr Edelman I am very hopeful that this will change as fast as possible. Um but at least according to data published in 2018 um it showed that about 70% of type people with type one diabetes we're still using meters. Um now granted the past three years a lot has changed. So I hope that number is much lower. But still many people with type two diabetes are still using meters. And many people with type one diabetes are still using meters. And let's face it, I would say 99% of patients using meters at home are not downloading their meter, right? They're not connecting their meter to their computer to help generate a report for you furthermore, there are connected meters and they're actually pretty common these days. So even products like the one touch Vario and the accu chek guide, they actually have bluetooth capability. So if your patient is motivated and able to, they can actually install an app on their phone and synchronize the data from their meter to their smartphone. But the problem is there's really no incentive for them to do that, right? That's why they probably just use the meter. Like they used any of the old meters in the past because there's no real reason for them to think to do that. Also, even if they go to that extent and they have paired the app with their meter, I think the data synchronization synchronization process isn't automatic, like it would be on the decks. Com what you have to do is you often have to open up the app and push the data from the meter to the smartphone. So it's just not seamless and that's why many of you probably have been doing things like this pictured in the screenshot where my patients holding up their logbook to their screen and I'm kind of trying to write down what I see. Um And another highlight of this is my early quarantine haircut. This is when you know many of us were trying to hold out until the barbers opened up again. Um This is when you know very early stage so what this highlighted was it really changed the patient amount of patient responsibility leading up to the visit right? So before it was basically okay if I just bring my meter to my visit, I'm golden right and even then you know half our patients would leave their meter at home and that's where I created this meme where you know you can't leave your meter at home if you're already at home so at least the patients would have their meter and I can say go grab your meter and hold it up to the screen. But to really make the quality of data exchange important is the patient does have to you know the morning of the visit or the night before the visit. Really sit down and think okay what data does my doctor need? How can I get that data to them as as as efficiently as possible. So you know with insulin pumps just like I went into the house the smartphone change C. G. M. Sharing of data. The same thing happened with insulin pumps. So now tandem and omni pod and medtronic, they all have apps that take data from your pump to your smartphone and then from your smartphone you can go to the world. So if you're patient has that app installed on their phone, whether it's an omni pod, medtronic or tandem app sharing data is a breeze, but if they don't then they would need to plug and plug it into their computer the morning of or the night before. Similarly, with meters as I talked about and see GMS as I talked about, another thing is, you know, what happens now is when a patient walks into my office, if they haven't had their labs and I'm I can just say, hey tight, I'm going to do an A one C to at least get some ballpark view of how your blood sugars are doing. But on video, you know, if you're patient hasn't had their labs done and they don't, they're not testing their blood sugar. You're kind of just looking at each other on the screen telling me, oh, how do you think things are going and you know, that's not going to be particularly useful unfortunately. So this is an article that was written, believe it or not, it was actually written prior and published prior to the COVID-19 pandemic, Very fortuitous tiny. Um but some of my friends here wrote this article um top 10 tips for successfully implementing a diabetes telehealth program and out of necessity I think many of you now have probably learned all these tips yourselves unfortunately. But you know it involves things as complicated as you know changing the way you schedule your patients. Right? So some people I know do they block off certain half days or things like that for telemedicine visits? Other people please them into their schedule per usual. You know some people will kind of designate designate an M. A. It's like a telehealth navigator to call the patient beforehand, remind them to do all the uploading of data and getting their blood work done ahead of time. We're just helping them troubleshoot how to connect to zoom and as I'm sure you all remember you know early on in the pandemic like no one could figure out how to get the audio working in the beginning of every call. So with all this data and all the importance of telemedicine, how do we integrate this data, what do we do with all this data and you know one really useful tool and if you if your office hasn't taken advantage of either of these options, I would highly recommend it um Is that there are third party companies that have basically created software that will work with many of the various devices on the market to consolidate and take all of those various streams of data. I'm like holding this receivers. Sorry. Um that will take all these various streams of data and put them into one single report. So the left half of the screen is one company called type pool and this is their visualization software. So as you can see um it's pulling into their C. G. M. Data, it's pulling in random meter checks as calibrations and those are represented by the dots. Um the patient can write in little notes, little memos, you know, like say they felt low, they can put a little memo there and then down here it even has the pump data. So this is the basil rate data on the pump, this is the bullets data on the pump. And then here you have, you know, different visualizations of the C. G. M. Time and range average glucose insulin reporting from the pump. And it's just nice to be able to see it on one page. And on the right half of the screen is a similar screenshot from a competitor called Glue Co. And that can be helpful as well. And this is basically is a replacement for what we used to do and you might still be doing this to where you're kind of printing out all these pages and you're kind of trying to line up the right C. G. M day with the pump day and you're spreading it out on your cable and you're starting to look at one of the, one of these conspiracy theorists and it's just not a very good solution. So these third party consolidated reports can be very helpful. Now there's also first party Consolidated Reports and first party meaning it's actually the device manufacturer themselves consolidating data into one stream. So this is a report taken from the in pen similar to what Dr Edelmann highlighted earlier. And so they're pulling in CGM data right here in the purple and then patient reported carved data with tiny in the green bars, patient reported long acting insulin dozing in the slight blue circle and then automatically sync from the smart pen Bullis data here um in the blue whale shaped looking things. Um and that's kind of a really cool visualization as dr Edelmann highlighted earlier. So the other really important thing is we have to figure out a way to start integrating this data with E M R. S better. Right. So this screenshot is probably something you're all familiar with no matter what am are you use? But we get all this data in this example, it's a lab report, but it gets stored in our EMR like a picture. Right? And that's not very helpful because it's, you know, we need discrete variables. We want to be able to graph these things over time to be able to do searches to find exactly where we're going through when we're looking at five years of data and these PDFs and images are just not helpful to they're not functional. And the annoying thing is they're always, you know meant to be viewed vertically whereas your screen is horizontal. So you have these weird zooming in and zooming out things that's never fun. And so better integration will help us have continuity of care over time. It's easier to visualize data if there's a handoff from one doctor to another or one provider to another, they can find data more easily. And for reimbursement a lot of times we want to be able to show hey we did download that C. G. M. And that's why we should get reimbursed for this. So one exciting demo was done earlier this summer at A. D. A. And this was done in collaboration between the liberate people. Um and at the international diabetes center. And this is an epic screenshot. Epic as in the company, not the adjective, although I do think it's pretty exciting. Um So this is a screenshot from epic where they're showing that they're pulling in the data from lee bray as discrete variables in their EMR. So you can see here this is a time and range data. There is average number of days of the sensor was born, average blood sugar. And this is really exciting because you can graph this out over time and you can see what's happening and drill drill into the data in a really elegant way. And so if you're wandering so that solution I believe is available but it's a cost of course which is which plays the importance for this piece. But yeah. So the lead that lead to a solution is available, but it's for pay. You basically have to pay for the privilege to be able to import that data into Epic. And that highlights the importance of open data. Right? So as all these different devices are generating more and more data. That's really exciting. But the problem is a lot of these companies try to hold on to the data for because it's worth something right? There's economic value. It's holding in their patients to be customers. But that's not what's right for patients and providers. Right? So it's really important for us as clinicians, um, to really push companies to open up their data and not just pool data. Right? So some companies will say, hey, we're all about open data. We'll import all the data from all the other companies and put it into our app. But then they're not as excited about sharing their own data with other companies. So the data exchange has to be bidirectional as to be going both to and from your device. And if we can do that, there's not going to be as many data silos. And that will really help the patient provider relationship because it will simplify data transfer right? You only need to connect to one device and then you can get all the data, it caters to user preference because I don't think any user is saying, oh I want to go to this device for this and this device for that it's just inconvenient and the consolidation I think really improved decision makers. So that's one of these things I really push for all of you whenever you're talking to these companies to really factor that in. Now. This is probably the most exciting but also the hardest to talk about because I feel like it's a little bit of the white whale. The reimbursement reimbursement for this time is really challenging. So I'll start by kind of the easiest and most guaranteed droughts and then kind of go to the more liberal are sorry the more innovative unproven ways to get revenue. So first is you know um as a physician or a nurse practitioner or a P. A. At the very minimum make sure your billing properly for your visits right? You don't want to leave money on the table both for your institution and for you. So it's important to note if you're not aware already that 2021 brought about a lot of changes in the way that we built for evaluation and management um and they simplify things a lot and for most people it actually is favorable believe it or not. Um And one big change now is that the documentation only requires a medically appropriate history and examination. So before if you remember it would be you know you needed nine elements here and you needed two things here and you needed the review of systems and and um it was just this really complicated list of things you needed in your notes. But now it's the level of service is primarily determined by medical decision making. So how complicated the visits are or time and even time is no longer limited to face to face interaction. So before it was, how much time are you spending actually talking your patient in the room? Whereas now it includes other things like ordering medicines, talking to other doctors reviewing results. Um Looking up information about their condition with the caveat that it does have to be that same day. Um that time has to be within that same day and you can't use other people's time. You can't say oh my M. A. was spending 10 minutes doing that. You can't include that time unfortunately. But yeah so this does make it much much much easier to get to level four visits at least and maybe even level five visits for your patients. So if you're not primarily doing that or aware of that, I'd highly recommend looking into it. And this is just a breakdown for timing purposes. I won't dive too deep. But these are the time cut off. So you can either build by these columns by time purely by time um or by medical decision making, purely by medical decision making. So that's really important to know now for some visits right? You have a patient who you're really just having to spend an hour and a half because they have they know nothing about diabetes but yet they're wanting to learn so much or a new diagnosis of type one or something where it's just ends up being you know an hour and a half. There are ways to code for extended services beyond the 99215 or 99205. And it's a little bit confusing because CMS. So Medicare and um non Medicare, so this is A. M. A. Of the american Medical Association but this is what a lot of commercial insurances used ended up using different codes. So CMS went with something called G. 2 to 12 And I am a went with something called 99417 and The only difference is literally about five minutes or sorry 15 minutes. So you can see here that the time cut offs are slightly different. So just be aware of that if you're doing a lot of long visits now this table this is kind of the second category of things and these things are very reimbursable that's happening all the time. You may or may not be aware of this. But if you aren't this is something that you very much could get jump in and get your institution doing now and this is basically billing for C. G. M. Training building for professional C. G. M. And interpreting C. G. M. So if your patients coming in with a C. G. M. You're printing out the report looking at it coming up with an analysis that's a 95251 right there every time you should definitely do it. And that would reimburse reimburse roughly anywhere from $36 200 dollars depending on which insurance company. So that's a huge value to you as a provider. If you're doing that now this can be only built no more than once a month. Um And it can it has to be a physician nurse practitioner or ph for this part. And this is purely the interpretation. Now if you're giving them a training on how to use a C. G. M. Then that's something called 95249. And and that can be provided by anybody that's qualified to do the training. So it can be your R. D. It can be a C. D. C. Yes it could be your RN and depending on scope of practice rules where you are it may even be an Emma that can do this and this would be putting on the C. G. M. Showing them how it works, showing them how the phone works and that's time you can be compensated for perhaps as well and here's some RV you reference points and cash value reference points. And there's also a similar thing for professional C. G. M. So these talked to can be done by your staff um or C. D. C. E. S. S. Um And this can be done by physicians PSR mps. And these reimbursed quite frequently. So I I see these charges go through my center all the time successfully. Now this is where things get murky and this is kind of this is part where everybody's eyes glaze over and you've probably heard that there's all these building codes that you can potentially bill for. But you know it seems like nobody wants to take the time or take the risk of trying to figure out if it actually works how much you get paid whether it's worthwhile doing. And in my mind every time I thought about this this is literally what I think of. It's just like oh my God so many different words I don't even know if it's going to get paid what's going to happen. And so there's another visualization that a company provided that helps me understand it a lot better. And this is my last slide because I'm bleeding into my question time. So they categorize it here. So these two codes. So 99453 and 9454 are purely dedicated to setting things up. Right? So if you have a new remote patient monitoring plan that you want to do It's gonna you're gonna have to give them the device you're going to have to show them how it works and that's what this is for. So 9453 is for the setup And 99454 is for the supply. Right? So if they need a new supply every month then you can build for this. Um and I should zoom out again. So all these building codes are for remote patient monitoring which is kind of the white whale. We're all trying to figure out remote patient monitoring because we know there's money there and we know that there's a way to get reimbursed for our time. But nobody seems to have figured out. Or very few people have actually figured this out. So this is at least laying a framework for what you and your institution might work towards understanding and getting done. So this is a setup. Now the actual ongoing data review and process is the second two thirds of the slide and you have to pick basically one or the other. So this is one option. And this is where your staff can spend time collecting the data, doing some data analysis, bringing you in for some of the communication and interpretation and you can build based on time. So for 20 minutes every 30 days per patient you can build this and if it's more than 20 minutes you can build for this. And this is a combination of time spent from the physician nine P. P. A. And your EMA or support staff. Alternatively you can go buy this building code alone And this is purely physician time. So physician MPP a spent interpreting glucose and insulin delivery data and it reimburses slightly more but you do have to recruit 30 minutes over 30 days now. Just like my last slide shows, there's a lot of little stipulations but just to show you that there is a path forward for getting reimbursed. It's just brand new. So I think like a year from now if I gave this talk you'd all be familiar with it. But we're at this point where nobody is doing this yet and we just know it exists much like telemedicine January 2020 we all knew it existed but no one had really figured out how to get reimbursed for it. So practical tips really work with your institution, build the right team because members some services can be done by Emma's and um you know other parts of the team manage patient expectations right? You don't want them to be surprised by a charge. Um and also consider prepackaged solutions. So companies like Bigfoot which dr Eyer I'm sorry Dr Edelman talked about um they are promising to offer rpm services for a monthly fee and then they take a cut and you take a cut and maybe that's better, you know getting a pre packaged solution as you're learning the ropes and trying to understand how it works. But anyways um that's my final slide. I do have a facebook group of technology inclined diabetes clinicians if you want to join and here's my contact info and I'm sorry, I feel like I always go a little bit long. But thank you. That's OK, David, thank you. That was so interesting and I was overwhelmed looking at the billing codes to and I know that I'm sure it's a whole other can of worms when it comes to the different positions for dietitians versus diabetes, educators, nurses for all the building codes that are out there. So, great job a few questions. Um I'll keep it brief. But somebody asked a question about the downsides to close loops um such as athletes who do vigorous cardio activity. Yeah, for sure. So I think that's honestly the weakest point right now on these algorithms. So I agree with Dr Edelmann and that they're fantastic. Like, I can't tell you how many patients are telling me this is the best day one c I've ever had or but I do think that with athletes it is kind of a weak point because they don't tend to be responsive enough to prevent hypoglycemia. So I think it is a big downside. But there are some workarounds and hacks to kind of mitigate it. Right? So all of them have like activity mode or exercise mode, which even then I still have a lot of patients go low. Um and then there are some you know, kind of behavioral modifications, like you know if you know you're going to exercise later, try not to take as much bullets insulin, like maybe take half the amount of bullets insulin before you would, you know, like if you're eating lunch at noon and you're going to go on a run at three, maybe take half as much insulin at noon that you know, then you normally would have. So a lot of behavioral workarounds exist, but it is a probably the weakest point of these algorithms. Yeah, It seems like exercise can, Can be so difficult for so many reasons. People with diabetes especially type one. So thank you so much. Um, that was awesome. It was a pleasure having you and we'll see you again soon.
