The COVID-19 crisis necessitated an abrupt adjustment to the delivery of outpatient care in order to protect vulnerable populations from avoidable exposure to the virus while providing continuity of care to patients with chronic health issues. One result of the crisis was that telemedicine use exploded worldwide, especially in patients with diabetes [1-6]. In response to COVID-19, UPMC (University of Pittsburgh Medical Center) Central Pennsylvania made an immediate pivot to deliver most ambulatory care via telehealth, resulting in a 1000% surge in telehealth use across all medical and surgical specialties in the early months of the pandemic. In September 2020, we launched a virtual diabetes boot camp program to complement our existing services.

UPMC Central Pennsylvania is a large, integrated, not-for-profit health care system with over 2900 physicians across 7 acute care hospitals and 200 ambulatory care sites, serving over 10 counties in central Pennsylvania. UPMC Central Pennsylvania established their telehealth program in 2013, when a telestroke initiative was launched. The telehealth department has since grown and is led by the chief medical information officer and supported by a director, analysts, clinical implementation consultants, and trainers. It is also supported by a dedicated patient phone and email hotline for telehealth and portal issues. UPMC Central Pennsylvania uses the Epic (Epic Systems Corporation) electronic health record (EHR), the accompanying MyChart patient portal, and the EHR-integrated telehealth platform Vidyo (Vidyo Inc). The platform offers audio and video calls, messaging, file sharing, and automatic vital sign reporting. The diabetes boot camp also uses the website Tidepool (Tidepool Project) [7]. Tidepool is a 501(c)(3) nonprofit organization that provides a web-based platform to coview diabetes-related data entered by the patient.

The all-virtual, holistic diabetes program was conceived and developed in less than 3 months and includes diabetes education, nutrition counseling, coping mechanisms, planned exercise, and medication adjustment via a team of physicians, registered dieticians, and diabetes educators. Patients meet virtually with a team member once a week, alternating between a diabetes educator and a dietician, and regularly interact with the Tidepool application. Follow-up HbA1c (glycated hemoglobin) values are obtained after the completion of the 3-month program.

We started the program at selected pilot clinical sites, refining the program with input from all members of the team before adopting the program at the organizational level. Success was assessed by monitoring HbA1c improvement, weight and blood pressure control, and the number of patients completing the program. By using integrated workflows in the EHR and simplifying the process for both patients and providers, we were able to keep the changes minimal for most of those involved. Educating clinic staff to guide patients through enrollment and the use of the software was critical to the success of the program. Few studies have looked to described generalizable strategies to quickly design, launch, and implement a scalable virtual diabetes program across a large multispecialty ambulatory clinic group.

UPMC Central Pennsylvania is comprised of multiple primary care offices consisting of 300 primary care physicians across 50 clinics and 3 endocrinology clinics across a 10-county region. We have a dedicated telehealth department that guides strategy, implements, and supports all virtual programs across the organization. In July 2020, due to the growing need from patients with diabetes to be seen virtually, a diverse group of clinical, operational, and telehealth leaders were engaged to support the launch of a new way of taking care of patients with diabetes who required frequent appointments. The virtual program was developed to alleviate the need for frequent in-person visits during the pandemic using previous and new lessons learned through the pandemic and serve a large geography of patients traveling as far as 1 hour to see their endocrinologist. A quick timeline was decided for the program, and bimonthly meetings were held to optimize the project due to the pandemic emergency and to improve the virtual access of patients with diabetes to doctors.

We were able to embed the new virtual workflows into the Epic ambulatory EHR, facilitating ease of adoption and operational efficiency. A documentation template was created to guide diabetes educators through medication change-related decisions. We also created a unique electronic referral in the EHR for the virtual boot camp to identify it as a new clinical service and for tracking purposes. Both the dieticians and the nutritionist team could receive this referral from physicians. The Tidepool software was installed on provider, educator, and dietician computers. Tidepool provides a diabetes web-based data platform to view data from multiple patient devices and display it together on one timeline. Physicians and staff were trained on using the Tidepool software to download glucose monitoring home data. Our endocrinologists introduced primary care physicians to the program via virtual educational seminars.

Using the endocrinology office as a pilot, a patient registry of patients with diabetes who had laboratory values of HbA1c>8% was generated from the EHR. The endocrinologists discussed the virtual boot camp program with these patients and initiated the referral process for interested patients. Administrative support personnel scheduled the virtual sessions and guided patients through the enrollment process. Patient education, including online instructions for downloading and uploading glucose data (using the Tidepool software), was delivered via the patient portal. If the patients had difficulty following the online instructions, the patient help desk or clinic staff engaged them via phone to guide them through the process.

Each week, the patients met virtually for a 30-minute session, alternating weekly between a diabetes educator and a dietician, to review glucose monitoring data from their mobile app, diet, exercise plans, and lifestyle changes. The virtual meetings were also held to address other education and medication or therapy changes. Progress was followed closely, using real time blood glucose data. Weekly feedback showing improvements helped to keep the patients engaged and adherent to the program. We found that gamification of the process (by tracking the numbers closely and meeting target results) kept the patients motivated throughout the program. At the end of the 12-week program, HbA1c values were rechecked, and each patient had a follow-up telehealth visit with an endocrinologist. Our program’s success was assessed via changes in HbA1c levels, and by patient engagement as measured by the completion of the program. A survey assessed patient satisfaction with the virtual program. Following the launch at the pilot clinic site, the program was opened to patients with diabetes at primary care clinics. Education was provided by a lead endocrinologist champion to primary care clinics about the new virtual boot camp program, the patient criteria, its aim, and the referral process. This study was submitted for Institutional Review Board approval and was found to be exempt since it did not contain any patient-specific data.

Figure 1 describes the workflow for virtual boot camp program with a remote enrollment process using video technology.

After the program’s launch and successful implementation at the pilot clinic site, it was extended to all 50 primary care clinics in the UPMC Central Pennsylvania network. Within 3 months of the September 2020 launch, we referred and quickly enrolled over 100 patients. Our strategies in 5 broad domains reflect an effort to expedite the launch while creating a sustainable program that can grow beyond the pandemic. Various approaches can be deployed to overcome barriers to implement a virtual program. Using the experience gained through our decades of implementing telehealth programs, we propose recommendations that can be deployed at the system-level for health care organizations to overcome barriers in a rapid time frame (Table 1).

Of the 37 patients who completed the program, the mean age was 53 years, with the age range of 22-78 years, 62% (n=23) were female, and 38% (n=14) were male. Moreover, 81% (n=30) were White and 19% (n=7) were African American; 81% (n=30) of the patients had commercial health insurance, and 19% (n=7) were on government health insurance such as Medicaid (Table 2). Of the 30 patients who completed the full program, HbA1c levels decreased from an average of 10.2% to an average of 8.8% (P<.001), with a range percentage decrease of 0.7-3%. A survey after completion of the program showed that a majority (n=26, 88%) were very satisfied or satisfied with the virtual boot camp, while 76% (n=23) reported that they felt the virtual boot camp saved them time. A wide majority, 94% (n=28), would recommend the program to their family or friends.