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COVID-19 disrupted health care, causing a decline in the health of patients with chronic diseases and a need to reimagine diabetes care. With the advances in telehealth programs, there is a need to effectively implement programs that meet the needs of patients quickly.
The aim of this paper was to create a virtual boot camp program for patients with diabetes, in 3 months, from project conception to the enrollment of our first patients. Our goal is to provide practical strategies for rapidly launching an effective virtual program to improve diabetes care.
A multidisciplinary team of physicians, dieticians, and educators, with support from the telehealth team, created a virtual program for patients with diabetes. The program combined online diabetes data tracking with weekly telehealth visits over a 12-week period.
Over 100 patients have been enrolled in the virtual diabetes boot camp. Preliminary data show an improvement of diabetes in 75% (n=75) of the patients who completed the program. Four principles were identified and developed to reflect the quick design and launch.
The rapid launch of a virtual diabetes program is feasible. A coordinated, team-based, systematic approach will facilitate implementation and sustained adoption across a large multispecialty ambulatory health care organization.
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 [
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) [
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.
Workflow for virtual boot camp program with a remote enrollment process using video technology. HbA1c: glycated hemoglobin.
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 (
Implementation strategy and recommendations.
Implementation strategy | Challenges | Recommendations |
Project coalition |
Need a wide array of representation of stakeholders Agreement on the concept of redesign care Creating a vision to improve care in new models during a pandemic Creating a vision to improve care in new models during a pandemic |
Include representation from clinical, operational, and telemedicine area Share vision of need for redesign care Align and remind project goals and scope Create early goals and metrics for the program |
Selecting patient population |
Technology challenges for patients Is it a right fit for the program? Identify clinical metrics that can be improved with the virtual program Keeping a sustained patient engagement virtually |
Need to clearly identify patient population Mock previsit training for patients enrolled in the boot camp Embed virtual boot camp in the electronic health record and workflows Identify compatible platforms and apps Leverage the electronic health record to use metrics to identify and track patients Minimal data entry for patients Provide real time feedback and measure progress with patients |
Selecting pilot site |
Pilot a clinic that can be model for the organization The practice must be ready to be an early adopter and work with challenges Rapid change can cause disruption in clinic workflow |
Identify early a pilot clinic enthusiast of the new program Plan frequent communications and updates as the program evolves Designate program champions that can help adoption |
Workflow |
Multiple different workflows and platforms can hinder adoption Must be efficient to ease transition Virtual documentation templates can be different |
Engage the telemedicine or electronic health record team to keep workflows succinct within the same electronic health record Design patient support and education material Plan remote virtual training for providers and staff Collaborate across disciplines to enhance system changes |
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 (
Demographics of patients who completed the full 12-week virtual program.
Characteristics | Values | |
Age (years), mean (SD; range) | 53.4 (13.9; 22-78) | |
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Male | 14 (38) |
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Female | 23 (62) |
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White or Caucasian | 30 (81) |
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Black or African American | 7 (19) |
We demonstrated a quick 3-month implementation of virtual diabetes boot camp with the enrollment of over 100 patients. Our program intervention made an improvement of diabetes in a majority of patients (75%) who completed the program. Our proposed practical steps on guiding strategies can be used for quick implementation solutions for digital health programs. Telehealth has been used in diabetes care since 2000. The IDEATel (Informatics for Diabetes Education and Telemedicine) project, a randomized trial conducted over 5 years in New York, compared usual care with telemedicine among older Medicare beneficiaries [
Previous telehealth and diabetes care trials have studied the effectiveness of virtual nurse coaching and mobile health to improve physical activity [
Our successful holistic interventions for patients with diabetes included a mobile app, diabetes education, nutrition guidelines, lifestyle intervention, therapy adjustment with integrated decision support system, and a dedicated telemedicine help desk phone for support and guidance. Though we faced a few challenges, specifically a quick timeline, we were able to use practical approaches to overcome them (
Consistent barriers remain such as manual data entry by patients with diabetes, with automation and immediate feedback identified as enablers [
The virtual diabetes boot camp was launched to improve the overall health of our patients with diabetes and to reduce the need for in-person visits during the pandemic. We successfully launched the program within 3 months, with promising early clinical results and patient satisfaction. The program facilitated frequent engagement between the providers and the patients, decreased the burden for the providers, and increased communication between members of the provider team.
We recommend aligning organizational goals to strategies (
We launched the program quickly in the endocrinology clinics, but it took sustained educational and communication efforts by primary care clinics to improve adoption across the organization. Sustained effort is needed to successfully roll out a new virtual program and to engage physicians and patients in a multispecialty, large clinic organization. Frequently highlighting the program benefits and continuously monitoring progress is vital to adoption. We were able to use our dedicated patient telehealth help desk to support patients struggling with the telehealth platform. In our experience, a previsit education intervention led to an easier and more successful virtual visit by patients, as confirmed by others [
glycated hemoglobin
electronic health record
Informatics for Diabetes Education and Telemedicine
low-density lipoprotein
mobile health
University of Pittsburgh Medical Center
None declared.