I have wanted to develop "Just-in-time" care for patients with diabetes via the idea of a virtual clinic. What this means to me is that the right patient is connected with the right diabetes team at the right time.
Our current paradigm is to have pre-scheduled clinic visits - a nice, tidy, orderly progression of patients coming to see the team for advice. There are several problems with this model - it's not really the best use of limited resources. Patient selection is random in that patients who come happen to be the ones who were referred, but this does not necessarily equate to those who need to be seen the most. Conceivably, if each member of the team (RN, RD, MD) spends time with the patient, up to 3 or more hours are dedicated to serving one patient. It's just not efficient and it's not really patient centred care when the patient has to take time away from work and the costs also include transportation, parking, childcare etc. For many patients the time away from work also means without pay.
Now, in this time of a pandemic, we can do some really creative things. Many visits for diabetes care amount to reviewing blood glucose records with the patient, as well as recent lab tests, checking blood pressure and doing a focussed physical examination. Most of the time, the value in the visit comes from troubleshooting glucose management, and ensuring that the patient's lab tests and blood pressure meet current recommendations (to the best of our ability) to minimise their risk of complications.
Most of this can be done virtually.
Imagine a virtual visit that goes something like this:
The diabetes team meets, after independently reviewing uploaded records that the patient has shared, as well as laboratory tests done ahead of the visit. Priorities are discussed and a basic plan is ready. The patient is then contacted via a secure audiovisual communication platform. The patient also has access to the same information that the team has via the electronic health record - so they can see their lab test results. On the patient side - having access to their electronic health records means that they can update medications and ask questions as well as access educational resources relevant to their particular health concerns, as well as send and receive messages from their care providers, make and cancel appointments.
The visit would address both the concerns of the patient as well as those of the team, and during this, it would be easy to determine if an in-person visit was needed. Patients who have regular physical examinations with their primary care provider may not need to see the specialist who typically focuses on a small aspect of care. Patients who check their blood pressure at home or with the pharmacy, don't necessarily need the team to do it as well. The beauty of this approach is that patients would come to clinic because it was value-added for them. It would save patients enormous amounts of time, and it would preserve limited clinic space for the right patients. The entire system would work more efficiently and have greater capacity.
So why doesn't this happen already? The fee-for-service model does not support this kind of patient-centred care because the remuneration is a fraction of what an in-person visit provides. Virtual visits take about the same amount of time for the health care team, but save the patient enormous amounts of time (saving the time spent commuting and waiting in the waiting room), and money. The infrastructure required to deliver virtual care is a bit different (freeing up the clinic rooms for patients that need to come to clinic), however the system still needs administrative support for scheduling, technological support to manage the platforms and provide the infrastructure to conduct the visit, and the teams need space to work. The teams, could however conceivably work from anywhere - I have been working from home as much as possible during this pandemic and with a platform that allows multiple people to log in and provides both audio and visual feeds - it's great. It's almost the same as being in the same room.
The other huge benefit to this is the social justice that this could bring to society. Suddenly individuals in small towns, or the far North could potentially have better access to health care reducing the disparities that currently exist (of course this model depends on having some kind of internet access and a smart phone as a minimum).
In Saskatchewan, several doctors have been conducting virtual visits - both clinic and hospital - for a couple of years. Imagine living in the far North and having emergency care in your own home and sleeping in your own bed that night? Wow.
What other changes are needed to move this forward? Well we need to move to a model that allows patients to access their teams on shorter notice - away from a model that has long wait lists and lines of patients. Just think of how many emergency room visits we could eliminate? How many patients who could get help when they need it and appropriately go to the emergency room instead of using it like a walk in clinic. I think this can be done by offering just-in-time care to those who need care now and want it. I've conducted so many clinic visits with patients who were there because we asked but not because they really wanted to be there. The reality is that it's unlikely that the unmotivated patient is getting much out of that time. Perhaps there are some benefits - reminders of better habits etc, that can help, but I doubt the value of these is significant.
Imagine a world where your diabetes team was just a click away?
In case you want more - read the article below about some of the latest diabetes technology. We are living in exciting times.
The Walrus Article "Hacking Diabetes"
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