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Since the COVID-19 pandemic, telehealth has been widely adopted in outpatient settings in the United States. Although telehealth visits are publicly accepted in different settings, little is known about the situation after the wide adoption of telehealth from the perspectives of adults with type 2 diabetes mellitus (T2D) and their providers.
This study aims to identify barriers and facilitators of maintaining continuity of care using telehealth for patients with T2D in a diabetes specialty clinic.
As the second phase of a multimethod study to understand missed appointments among adults with T2D, we conducted semistructured, individual, in-depth phone or Zoom interviews with 23 adults with T2D (14/23, 61% women; mean age 55.1, SD 14.4, range 35-77 years) and 10 providers from diabetes clinics in a tertiary academic medical center in Maryland. Interviews were audio-recorded, transcribed, and analyzed using thematic content analysis by the research team.
Adults with T2D and their providers generally reported positive experiences with telehealth visits for diabetes care with some technical challenges resulting in the need for in-person visits. We identified the following 3 themes: (1) “perceived benefits of telehealth visits,” such as convenience, time and financial efficiencies, and independence from caregivers, benefits shared by both patients and providers; (2) “perceived technological challenges of telehealth visits,” such as disparities in digital health literacy, frustration caused by unstable internet connection, and difficulty sharing glucose data, challenges shared by both patients and providers; and (3) “impact of telehealth visits on the quality of diabetes care,” including lack of diabetes quality measures and needs and preferences for in-person visits, shared mainly from providers’ perspectives with some patient input.
Telehealth is generally received positively in diabetes care with some persistent challenges that might compromise the quality of diabetes care. Telehealth technology and glucose data platforms must incorporate user experience and user-centered design to optimize telehealth use in diabetes care. Clinical practices need to consider new workflows for telehealth visits to facilitate easier follow-up scheduling and lab completion. Future research to investigate the ideal balance between in-person and telehealth visits in diabetes care is warranted to enhance the quality of diabetes care and to optimize diabetes outcomes. Policy flexibilities should also be considered to broaden access to diabetes care for all patients with T2D.
It is estimated that there are more than 37 million people in the United States with diabetes mellitus, and 90% to 95% of those cases are type 2 diabetes mellitus (T2D) [
Telehealth, the use of telecommunication technologies to provide health care remotely [
Specific to diabetes care, the transformation from in-person to telehealth visits has the potential to democratize routine diabetes care provision, such as providing care to those with limited transportation who otherwise could not be at the clinic regularly [
However, some endocrinologists believed telehealth visits were more helpful for people with type 1 diabetes mellitus (T1D) compared with those with T2D because people with T1D are more closely monitored by continuous glucose monitoring (CGM) and insulin pumps [
This qualitative narrative study took place in the Johns Hopkins Diabetes Center, a multidisciplinary team (physicians, endocrinology fellows, nurse practitioners [NPs], registered dietitians, and certified diabetes care and education specialists) providing comprehensive diabetes care across multiple locations in the greater Baltimore area affiliated with a tertiary academic medical center in Maryland. There were no telehealth (video or phone) visits before the COVID-19 pandemic. During COVID-19, appointments at the Johns Hopkins Diabetes Center were transferred to telehealth visits on March 23, 2020, after the expansion of coverage by the Centers for Medicare & Medicaid Services [
In normal circumstances, the telehealth visits at Johns Hopkins are through MyChart (Webex by Cisco). A medical assistant usually calls a day before the appointment to verify patients’ physical locations to meet individual state regulations. On the day of the appointment, vital signs and medical history are verified again through a phone call after a patient completes the electronic check-in through MyChart. Before the scheduled appointment time, the link to “start your video visit” appears to initiate the visit. The link for the video visit can be sent via text message if a patient does not use MyChart. A simple phone call may be used if the patient does not have devices with video capabilities [
The findings for this manuscript were the second part of a multimethod study focusing on missed appointments among adults with T2D. In short, the first part of the study used electronic health records (EHRs) to examine if predictors of missed appointments differ (1) between pre-COVID-19 (January 2019 to March 2020) and COVID-19 (March 2020 to December 2020) periods and (2) by health care delivery modes (in-person or telehealth visits) during COVID-19 among adults with T2D; more information is described elsewhere [
Based on the results of the first phase, the eligibility criteria for this qualitative study included a diagnosis of T2D, age greater than 18 years, residence in the state of Maryland, and at least one appointment with either a physician or an NP marked as a no-show in the EHR in the past year at the time of recruitment (February 2022 to July 2022). Adults who met the inclusion criteria were identified from the EHR and then were contacted via emails, phone calls, or text messages. We used purposive sampling with maximum variation to include adults from different physicians and NPs with diverse characteristics (eg, age [<60 years old, 61-75 years old, >75 years old], sex [female, male], race/ethnicity [Black, White, other], health care delivery modes [in-person or telehealth visits]) based on our quantitative results [
Potential provider participants were invited through a study presentation by one of the authors (CAS) at the monthly diabetes center meeting. CAS then emailed the study information to all potential provider participants. All physicians and NPs working at the Johns Hopkins Diabetes Center were eligible to participate.
The Johns Hopkins Medicine Institutional Review Board (IRB; #IRB00231790) approved the study design and procedures. Verbal consent was obtained from each participant.
The study team developed a semistructured interview guide to explore perceptions among people with T2D and their providers regarding the barriers and facilitators of keeping appointments for both in-person and telehealth visits, with a focus on interpersonal relationships. The initial interview guide drafted by CAS was based on the findings of our previous quantitative study on missed appointments during the COVID-19 pandemic [
One-on-one 30-minute to 45-minute phone or Zoom interviews were conducted by 2 trained interviewers (CAS and ZS) from February 2022 to July 2022 until thematic saturation was reached. In total, we contacted 52 eligible people with T2D; 28 refused (ie, not interested in the study topics, no times to be interviewed, no replies after 3 calls or text messages), and 24 agreed to participate. Of those participants agreeing to participate, 23 completed the interview, and 1 participant was excluded due to a mislabeled T2D diagnosis on the EHR. Among 12 eligible providers, 10 (8 physicians and 2 NPs) agreed to participate and completed the interviews. All phone interviews were audio-recorded; all Zoom interviews were recorded using Zoom’s recording features. Only audio recordings were saved and sent to a professional transcription vendor approved by the Johns Hopkins IRB for verbatim transcription. After verifying the accuracy and removing identifiable information, transcripts were imported into f4analyse for coding and analysis.
The analysis began after the transcription of the first interview and continued throughout data collection. We conducted a thematic content analysis of the interview transcripts, a common method of analysis when coding categories are derived directly from data [
Reflexivity was achieved through discussions between interviewers and written notes after the interview. Trustworthiness was maintained through team discussions and audit trail documentation; all documentation was kept using Microsoft Word. The transferability of the study was enhanced by providing a thorough description of the study method, study setting, and our processes of data collection [
Details of characteristics of persons with T2D included in this study can be found in
Characteristics of persons with types 2 diabetes mellitus (T2D) at the time of the interview (n=23).
| Characteristics | Results | |
| Age (years), mean (SD; range) | 55.1 (14.4; 35-77) | |
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| Female | 14 (61) | |
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| Black | 12 (52) | |
| White | 10 (44) | |
| Other | 1 (4) | |
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| Medicare | 12 (52) | |
| Medicaid | 7 (30) | |
| Commercial | 4 (17) | |
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| Any insulin | 16 (70) | |
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| Ever used | 8 (35) | |
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| Activated | 20 (87) | |
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| Before March 2020 | 15 (65) | |
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| In-person visits only | 4 (17) | |
| Both in-person and telehealth visits | 19 (83) | |
Among 10 provider participants (8 physicians, 2 NPs), there were 7 female and 3 male providers, with an average service time at the institution of 7.2 (SD 4.54, range 1-14) years.
We identified 3 themes with 13 subthemes addressing patients’ and providers’ perspectives on telehealth visits in T2D care (see
In the following sections, we first describe the first theme, “perceived benefits of telehealth visits,” shared by both patients and providers, followed by the benefits noted by providers only. We then describe the second theme, “perceived technological challenges of telehealth visits,” shared by both patients and providers. Finally, we describe the third theme, “impact of telehealth visits on the quality of diabetes care,” as perceived by both patients and providers, though mainly from providers’ perspectives with some patient input. Direct quotes are presented in the following sections.
Themes and subthemes from patients' and providers' perspectives.
| Themes | Provided quotes | ||
| Patients | Providers | ||
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| Diabetes care “in the comfort of your home” at a time of one’s convenience | Yes | Yes | |
| Saving money and time due to no need for transportation | Yes | Yes | |
| Relief from relying on one’s caregiver and less “juggling to get it into our schedule” | Yes | Yes | |
| Efficient visits, fewer delays, and more time with adults with T2Da | No | Yes | |
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| Disparities in digital health literacy and lack of devices as barriers to telehealth visits | Yes | Yes | |
| Frustration caused by unstable internet connection | Yes | Yes | |
| Phone visits not encouraged | No | Yes | |
| Difficulty sharing glucose data | Yes | Yes | |
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| A double-edged sword for care continuity | No | Yes | |
| Perceived incomplete visits due to no diabetes quality measures | Yes | Yes | |
| Compromised care quality due to unavailability of glucose data and/or unpreparedness of their patients | No | Yes | |
| Needs for and preferences of in-person visits | Yes | Yes | |
aT2D: type 2 diabetes mellitus.
The majority of persons with T2D and provider participants described positive experiences with telehealth visits due to several benefits, mainly noting increased convenience and efficiency as compared with in-person visits. We identified the following 5 subthemes: (1) diabetes care “in the comfort of your home” at a time of one’s convenience; (2) saving money and time due to no need for transportation; (3) relief from relying on one’s caregiver and less “juggling to get it in our schedule”; (4) efficient visits, fewer delays, and more time with patients; and (5) a good fit for data-driven diabetes care.
Regarding the first subtheme (diabetes care “in the comfort of your home” at a time of one’s convenience), many adults with T2D specifically cited the convenience of being able to conduct telehealth visits from their homes or at a private location conducive to their schedule. Similarly, from providers’ perspectives, many providers acknowledged the added convenience of telehealth visits for their patients, citing reasons largely in alignment with what patient participants mentioned:
It's really convenient, I don't have to take off from work, I don't have to park. Based on the time of the day, any time prior to like 3 o'clock, the parking garage is pretty well filled up. So, it just really alleviates a lot of additional stress, and a lot of the times, I can either do it at work in a secluded area. I think it's just great, very convenient.
I think the benefit of telehealth is patients who are not coming in because of either distance or they can't find the time to come in at least we have this as a resort to say, “Well, if you can take 20 minutes out of your workday even at work, we can at least still see you and try to do some management.” I think it's useful in that sense.
Regarding the second subtheme (saving money and time due to no need for transportation), people with T2D who drive to in-person visits expressed contentment about not having to pay for parking or gas. Adults who take public transportation to attend in-person visits were satisfied with telehealth visits due to saving money and decreased wait times for both transportation as well as in the provider’s office. Many providers empathized with people’s economic and time constraints that often hindered in-person visit attendance. The following quotes from a person with T2D and a provider reflect the mutual understanding of the perks of being able to conduct diabetes care visits irrespective of their physical locations:
Yeah, I do like the video visits. I mean, because it saves money. You know, you don't have to worry about transportation to and from. You know, you could be in the comfort of your own home.
I think it (video visit) is a fantastic way to extend care to people who don't have to drive into our clinic, don't have to park, don't have to waste probably an hour to 2 hours of their day.
Regarding the third subtheme (relief from relying on one’s caregiver and less “juggling to get it into our schedule”), several people with T2D shared their emotional burden of having to rely on their caregivers (ie, family) to attend in-person visits for a variety of reasons. For them, sharing one vehicle meant that family members had to miss time from work or skip their own medical appointments to help people with T2D with transportation to in-person diabetes visits, or sometimes the adults with T2D would need to skip their visit in lieu of their caregivers. Hence, when telehealth visits were available, these adults with T2D felt content as they no longer needed to rely on others for in-person visits. This quote highlights the experience of 1 participant who had a right leg amputation:
To me, it’s convenient that you don't always have to go into the hospital because my fiancée works 9 to 5, which is most of the time that appointments are, so she doesn't have to miss time from work to take me. Normally I could drive, but now with this amputation, I can't do that myself. So, they help a lot, that everything can be done right through a video call, don't actually have to be there.
A provider also acknowledged the barriers of in-person visits, saying:
The patients, I think, though, have more of a struggle (doing in-person visits) than we do because of transportation and coming in. If they’re older and they don’t drive, and yet they need to be driven there, that kind of thing.
The fourth subtheme (efficient visits, fewer delays, and more time with adults with T2D) was unique to providers. Providers described how telehealth visits can be conducted more efficiently than in-person visits, thereby reducing delays in their daily schedule and allowing them to maximize their time spent with each patient. One provider participant contrasted their use of time during in-person and telehealth visits and the beneficial impact on their daily workflow:
The person has to get transportation to (the clinic), and then maybe if they have a vehicle, they have to park it. There’s the process of getting signed in, and my 1:00 patient who arrives a couple minutes after 1:00, and then the medical assistant is a little busy, may not get them in the room until 1:25, which can then set my schedule behind. Whereas on telemedicine, I'm running it, I can say to a patient, if we need to wrap-up, like “We only have 5 more minutes,” and I know I’ll have somebody coming into the queue, who will be ready to go ahead and have their appointment. It’s easier to structure the patient to the amount of time you have and also make use of that full amount of appointment time, because you immediately sign onto them, so there’s no delay at all.
The fifth subtheme (good fit for data-driven diabetes care) was unique to providers. Most providers mentioned that diabetes care was suitable for telehealth visits as it focused more on the behavioral and cognitive perspectives. However, providers also specifically expressed the requirement of having home blood glucose data to provide optimal diabetes care and a treatment plan to their patients. This practice is particularly important in telehealth visits as most adults might not have an available glycated hemoglobin (HbA1c) measurement for the telehealth visits as compared with in-person visits, where a point-of-care HbA1c is taken. Advances in diabetes technology allow most people with diabetes to share their blood glucose data before telehealth visits.
Diabetes care, half the time, I don’t even put my hands on a patient, other than to look at their toes and maybe recheck their blood pressure. It really is whatever they say, a cognitive specialty. If they (adults) can share their readings from home, it can be just as good and preferable from the patient’s perspective.
Despite the aforementioned benefits, patient and provider participants all faced some challenges related to technology during telehealth visits. To complete a successful telehealth visit in diabetes care, people with T2D needed to have a digital device, know how to get online, navigate the patient portal to the nested telehealth platform, upload their glucose data via a cloud or patient portal, and have familiarity with manipulating the video camera and volume. Any disruption could happen during this process, which could result in a suboptimal experience. We identified 3 subthemes related to technological challenges from both adults and providers and 1 subtheme unique to providers.
Regarding the first subtheme (disparities in digital health literacy and lack of devices as barriers to telehealth visits), when navigating technology aspects of telehealth (eg, using a digital device, patient portal, telehealth platform, uploading glucose data) throughout COVID-19, some people with T2D were proficient from the beginning, while others required additional support from staff at the diabetes clinics or other family members. For other patient participants, the repeated practices over time made them more comfortable with telehealth-related technology:
I've got a desktop that we've had for some time, and my wife is a technical genius in the house, she helped me get it set up three times now, I'm an old veteran; I could do it solo now.
However, 2 people with T2D specifically cited computer illiteracy as the reason for not utilizing the patient portal (Adult06, Adult18). In this case, they would rely on providers to contact them using alternate video platforms (eg, Doximity, FaceTime) without going through the patient portal. All providers acknowledged that the use of telehealth required digital health literacy and were prepared to use different ways to connect with their patients. A provider discussing the limitations of telehealth visits mentioned the following:
Not everybody has a computer at home, which is a problem. Or they don’t have iPhones, so, we can’t do a Facetime call with them. (...) Any of these technical issues mean that we can’t cover as much in that half an hour as I would if I saw them in person because you don’t have those limitations in person.
Both people with T2D and providers acknowledged that the lack of digital devices was a barrier to telehealth visits. At the time of the interview, 3 adults did not have a digital device with a camera capacity (Adult02, Adult07, Adult15). Of these adults, 2 had only phone visits during the peak of COVID-19, while the other person had only in-person visits as he established care after in-person visits resumed. One person who only had experiences with phone visits stated the following:
No. I don't even know how to work that (video visit), uh-uh. I just have telephone calls. I don't know how to do none of that virtual stuff. (...) I just upgraded my phone, but I'm saying I still don't know how to work it real good.
Regarding the second subtheme (frustration caused by unstable internet connection), once people with T2D and providers were connected, echoing in voices and delay in transmission due to unstable internet connection were other issues that undermined the quality of conversation and sometimes caused frustration for both parties involved. As most of the allotted time was spent on nonmedical issues (ie, trying to get connected with each other), people did not have enough time to ask questions, and providers were unable to properly deliver care. A provider provided the following quote when discussing the disadvantages of telehealth visits:
It really comes down to the connection and the person’s savvy with it. I had a lady, lives in Virginia, and she’s elderly, and a friend had to drive her over the line into Maryland. So, they were in the car trying to get a connection with me, and where they were, it wasn’t good connection. So, I’m seeing her frozen face, she sees my frozen face, we halfway hear each other, and finally it had to degrade into a phone conversation.
A person with T2D discussing this frustration in her previous telehealth experience mentioned the following:
It (video visit) didn’t go through. We were talking and then it kept disconnecting. The call kept dropping, so we had to wind up just texting. So, 1 out of 5, I’d give it a 1. (...) I will not give it (the video visit) a try.
The third subtheme (phone visits not encouraged) was unique to providers. At the time of the interview, phone visits were not encouraged due to the complexity of the reimbursement and compliance issues. Although phone visits were the least preferred method for providers to connect with their patients, it was a necessary backup when connection issues or the other abovementioned technical issues persisted.
You can't bill for phone visits. (...) Or you can bill for it, but you won't get reimbursed for it. So, then why did I go to all that trouble? Then, I can just have my secretary set up a phone call, and I can just have a phone call, which will work easier, instead of doing this thing of getting onto EPIC—it's a nightmare. Not good.
Regarding the fourth subtheme (difficulty sharing glucose data), both people with T2D and providers mentioned the potential obstacles of sharing glucose data in telehealth visits. Depending on the devices (ie, CGM or glucometer) a person uses, sharing glucose data can be either easy or very troublesome. Patient participants with a CGM generally reported a smooth and easy process for sharing data compared with those with a traditional glucometer. However, not everyone with T2D was eligible for insurance coverage for a CGM, which is expensive for a person paying out of pocket. Many adult participants using a glucometer reported sending handwritten documents ahead of the telehealth visits or reading their daily glucose data in the past few weeks aloud during the telehealth visits. A person with T2D with experience using both glucose monitoring systems shared his experience:
Before, it (sharing glucose data) was really easy. Now that I've got different insurance, it's not as easy as it was before, because before I had a CGM and it could just upload the information. So, I just uploaded the information to my dock . Now I'm back to pricking my finger (glucometer), I can't (upload my data), it (the glucometer) didn’t do the same. I've got to keep a record of it myself and share it with my doctors.
Sometimes, if a person did not have their glucometer with them, a provider would rely on the person’s memories of their glucose trends to decide on the treatment plan. Either way, this process took extra time for providers to make sense of the glucose data (eg, time in range, average, trends) before a clinical judgment was made. Those practices specific to telehealth visits either increased the time needed by providers or limited the length of a visit to address adults’ questions and concerns:
I had to have them (during telehealth) grab their glucometer and scroll through the numbers and read to me what those were, but for a 20-minute visit, if they're doing that for more than 10 minutes, it really leaves us not much time to go over other things.
The aforementioned benefits and challenges of telehealth had clinical implications for diabetes care. We identified 4 subthemes mainly from providers’ perspectives with support from patient input, including “a double-edged sword for care continuity,” “perceived incomplete visits due to no diabetes quality measures,” “compromised care quality due to unavailability of glucose data and/or unpreparedness of their patients,” and “needs for and preferences of in-person visits.”
The first subtheme (a double-edged sword for care continuity) was unique to providers. With all the needed information on hand, telehealth visits allowed providers to offer more frequent quality diabetes care to adults with T2D who traditionally could not attend in-person visits often due to geographic barriers or other transportation-related issues:
I think this model (telehealth setting) has some advantages in that way, I mean they can touch base more frequently, they might be shorter communications, but they're more frequent as opposed to spaced out longer in-person visits.
Provider participants also noticed that telehealth visits decreased missed appointments, which increased care continuity. Adults with T2D scheduling a telehealth visit received at least one extra reminder because current regulatory requirements mandated the verification of a person’s location before the visit. Additionally, due to the unpredictable nature of technical issues in telehealth visits, providers were more likely to outreach to adults despite an initial absence on the telehealth platforms. Most of their patients were able to remotely engage immediately in telehealth visits when prompted by a provider’s phone or video call. A provider described missed appointments and provided the following quote:
I will say, with telemedicine, it’s easier, because you can just call them and say “Hey, you have an appointment, let’s just talk right now.” A lot of people will say “Okay, that’s fine.”
On the other hand, the current telehealth workflow in the diabetes clinics requires adults with T2D to take the initiative to schedule their next appointment after a telehealth visit, instead of scheduling the next appointment at the front desk on the way out of the office after an in-person visit. Although it did not bother people with T2D in this study, a person described how her other health conditions delayed her scheduling the next appointment:
I know I need to schedule an appointment. In fact, I was gonna call this week, but I'm getting a medical procedure, so Monday I was seeing other health care providers, so probably next week, I'll call the scheduling line and set up something or try and do it through MyChart to set up (the next appointment).
The delay in scheduling the next appointment could sometimes lead to discontinuity in diabetes care because there was no follow-up mechanism at the time of the interview by the clinics after each visit. A provider discussing the impact of telehealth in diabetes care described this phenomenon:
Often, I will say they fall through the cracks, because we don't have the staff to follow-up on every patient and see if they scheduled a follow-up, and so it's sort of like I tell them “Please schedule a follow-up,” and I put in the order so that they'll get a prompt in MyChart, but beyond that we're not following-up to see what happens, and so they may not schedule it themselves.
Regarding the second subtheme, (perceived incomplete visits due to no diabetes quality measures), both people with T2D and providers viewed being unable to complete a thorough physical evaluation as a major limitation of telehealth visits. The American Diabetes Association recommends each person with T2D undergo a physical exam (eg, foot exam) and biofeedback (eg, BMI, blood pressure, HbA1c, lipid panel, microalbumin) quarterly or annually [
I mean, I think that’s (video visits) good, but I can’t come in getting my instant test, how “boom,” they give you the A1c. It was awesome. I liked that.
Providers admitted the same limitation, adding this additional effort sometimes led to incomplete diabetes quality measures. Without the information, providers might not be able to provide timely treatment recommendations, which could ultimately compromise their patients’ health outcomes. When comparing in-person and telehealth visits, a provider provided the following quote:
We can’t do a point-of-care A1c at those visits, and those are problems because we care about all of those and it impacts our decision making . (...) We try to reach out to patients who haven’t had labs done in a while to try to get their labs before their (video) visit, but that’s challenging because the point-of-care A1c makes it very (easy)—it’s a 5-minute test result.
The third subtheme (compromised care quality due to unavailability of glucose data and/or unpreparedness of their patients) was unique to providers. Although telehealth visits had the potential to enhance care continuity through proactive outreach from a provider, provider participants felt that sometimes their patient was distracted during a telehealth visit—they might be driving with an intermittent internet connection, walking down the street, or having other commitments—so it was difficult to assess their lifestyle management during that environment. In addition to the inattention, people with T2D might not have their glucose data ready to share, as mentioned previously. Therefore, provider participants sometimes felt that a telehealth visit could compromise the care quality. A provider discussing frustration in telehealth visits mentioned the following:
There are times when telehealth visits are not productive. It really, I think, depends on patient engagement. I certainly have had patients who are taking the call while they're driving, or they forgot that they had a visit with me. So, in some ways, people take the telehealth less seriously, in which case, it's a waste of their time and so they're not ready for the visit and so sometimes they don't have labs, no glucometer data (...).
Regarding the fourth subtheme (needs and preferences for in-person visits), both patient and provider participants shared the need for in-person visits. Although people with T2D in this study generally perceived that the conversations and interpersonal relationships during both telehealth and in-person visits were similar, only 5 participants noted a preference for telehealth visits; more than one-half of the participants specifically noted a preference for in-person visits because of the challenges and clinical implications discussed above:
Personally, I like face-to-face with my doctors, a checkup to see how you’re doing, with diabetes care. (...) It’s not like I have any kind of feet issues or circulation issues, hopefully never, but it’s good to go through that kind of stuff (check my feet) and just have them check that stuff, and it’s hard to do that with a virtual visit.
Similarly, provider participants also mentioned that adults with T2D should have an in-person visit at least once a year:
I do think that patients do have to be seen at least annually, in-person, for a comprehensive foot exam, and other parts of the exam that need to be done as well. (...) What I was finding with telemedicine is that a lot of time, though the visits were great and the recommended frequency would continue, often, the labs would lag behind. Patients wouldn’t feel comfortable going to get their labs done.
This qualitative study outlined the perspectives of both providers and patients with T2D on the benefits and challenges of telehealth in diabetes care. Although people with T2D and their providers acknowledged the convenience and efficiency of telehealth visits for promoting care continuity in diabetes care, telehealth also had challenges that could compromise the quality of diabetes care.
Consistent with previous literature [
Given health care systems’ rapid increase in telehealth capacities since the COVID-19 pandemic [
Several temporary policy flexibilities broadened access to diabetes care during the COVID-19 pandemic [
Our study revealed concerns about glucose data availability impacting the quality of diabetes care in telehealth visits. Of the patients in this study, 70% (16/23) used insulin at the time of their interview, and glucose monitoring is integral to guiding individualized treatment plans in this population [
Both patient and provider participants in this study acknowledged that telehealth visits promote care continuity because of convenience and efficiency, but both indicated the need for in-person visits in T2D care. Attending in-person visits allows people with T2D to check diabetes quality measures (ie, foot exam, BMI, blood pressure, HbA1c, lipid panel, microalbumin [
This study has a few limitations. All participants were from diabetes clinics within a large urban academic medical center in the mid-Atlantic region of the United States. Additionally, the study was designed to focus on missed appointments and interpersonal relationships, and thus, themes presented in this study might not apply to the people with T2D who do not miss appointments. Last, this study collected data from participants who spoke English and responded to our phone calls, text messages, or emails. Although we maximized variations in recruiting participants (eg, based on age, race, and lengths of provider-patient relationship), the themes derived may not apply to people lacking a working phone number or who do not speak English.
In summary, telehealth implementation during the COVID-19 pandemic has expanded access to diabetes care. Adults with T2D and providers generally reported positive experiences with telehealth visits, although some definite technical challenges exist. To ensure equitable access to diabetes care, legislation should provide more flexibility regarding geographic boundaries and telehealth delivery modes (audio-only versus video-audio visits). Telehealth-related technology design also needs to consider user experience and user-centered design to optimize the use of telehealth; a person-oriented telehealth workflow has the potential to address concerns about the negative effects of telehealth visits on the quality of diabetes. Future research to investigate the ideal balance between in-person and telehealth visits in diabetes care is warranted to enhance the quality of diabetes care to optimize diabetes outcomes.
Interview guides.
continuous glucose monitoring
electronic health record
hemoglobin A1c
institutional review board
nurse practitioner
type 2 diabetes mellitus
We would like to thank the participants who kindly took part in this study. We are also grateful for Drs. Nestoras Mathioudakis and Thomas Donner for their support in this study and for Dr. Brian Hasselfeld for his expertise in digital health and telemedicine.
This study was supported in part by the American Association of Nurse Practitioners, Austin, TX, and in part by the Translational Science Award from the National Institutes of Health (NIH) National Centers for Advancing Translational Sciences (NCATS; #TL1 TR003100).
CAS, SR, NM, NP, SL, and HRH conceptualized the study, and CAS and HRH designed the interview guides. CAS, ZS, HRH, and SZ performed the formal analysis. CAS, ZS, and SZ wrote the original manuscript draft, and CAS, ZS, SR, NM, NP, SL, and HRH reviewed and edited the manuscript.
SL is an employee of Beckman Coulter, a company that develops clinical diagnostics and clinical decision support solutions.