Paediatric diabetes care during the COVID‐19 pandemic: Lessons learned in scaling up telemedicine services

Paediatric diabetes care relies upon a multidisciplinary approach for the education of and collaborative medical decision-making with patients and families. It involves healthcare providers, diabetes care and education specialists (formerly known as certified diabetes educators), registered dieticians, medical assistants, nurses, social workers and behavioural health specialists. Behind the scenes, administrative assistants and schedulers also contribute to making this care possible. Across the world, the COVID-19 pandemic has upended routine outpatient care, placing new demands on healthcare systems to meet the needs of their patients. Many facilities, including our own, rapidly expanded telemedicine services to facilitate patient care.1 Though telemedicine has been utilized for both paediatric and adult diabetes care before,2-11 current endeavours by many institutions are now on an unprecedented scale. In some cases, health systems may have limited existing infrastructure due to previous state law limiting telemedicine services, such as in Pennsylvania. Prior to COVID-19, our large, academic centre had minimal telemedicine services for subspecialty care, including diabetes. We present lessons from our experience embarking in telemedicine for routine diabetes appointments and outpatient education. These lessons reflect the feedback received by all members of the division. Physicians, advanced practice providers (APPs), fellows, certified diabetes care and education specialists, nurses and administrative staff provided their viewpoints at their routine meetings to their co-ordinators/managers who in turn brought back this input to the division leadership. Using this approach, our centre was able to rapidly and successfully scale up our telemedicine services in order to continue providing care to our patients (Figure 1). Our diabetes centre follows ~2200 patients, (~55% females, ~88% White, 35% with public, 10% with private and 55% with public and private insurance). Prior to COVID-19, our typical weekly schedule included approximately 200 diabetes appointments, with an average of 80% completed visits (all in-person). In our first week of telemedicine, we completed 76 of 157 (48%) scheduled visits virtually; by the third week, this increased to 126 of 166 (83%) visits. Since that time, we continued to have more than 80% of ~200 scheduled diabetes visits virtually, reaching almost 90% by the fifth week (Table 1). In some cases, offering virtual visits during this time may have improved our typical no show/cancellation rate by increasing communication with the family in advance of the visit and removing possible barriers to families from inclement weather, transportation or work/education obligations. We summarize key points in Table 2.

ers. These providers are supported by a large team of nurses, medical assistants and administrative staff. Rapidly scaling telemedicine services required a joint effort among all personnel and support from leadership to ensure seamless continuity of care. The initial planning phase involved identifying a representative among each of these groups. As we created a framework for transitioning to telemedicine, each of these stakeholders had a role within a series of planning and feedback meetings. This facilitated clear avenues for communication both among and between different groups, allowing for continued reassessment and collective problem solving of emerging issues. As a result, we were able to cohesively develop a uniform approach to telemedicine services in a very short period of time.
It is important to note that no adjustments in the schedules were made when converting from in-person to virtual visits. The same appointments were kept. The administrative staff contacted patients and families the week ahead of the visits to let families know what to expect, instruct them on the process and give them thorough instructions on how to participate in the portal-based virtual visit.
Instructions on how to join the portal were also provided by emailing them directly to families and posting on the hospital website.
Patients that could not be reached initially were called at least two more times.

| LE SSON 2: CON S IDER D IFFERENT PL ATFORMS
included usability and accessibility, ability to have multiple participants, HIPAA compliance, privacy for providers working from home, screen sharing and visit-tracking metrics. Our hospital system endorsed several platforms to use on a temporary basis while working to embed a platform into our electronic medical record (EMR). Many systems do not offer all desired features in one platform. For our centre, we found one system was straightforward for both providers and families, but lacked the capability to have more than two participants on the call, limiting the ability to involve trainees, ancillary providers (eg, education specialists and dieticians) or additional caregivers (eg, two parents in separate homes with a shared custody agreement). Another system allowed for multiple participants but was more cumbersome to access. Still other HIPAA-compliant platforms required using personal accounts that may have compromised provider privacy (ie, cell phone number or email address). Other desirable features that some systems offered included screen sharing to view growth charts and device reports from insulin pumps or continuous glucose monitors (CGM), smartphone compatibility and time tracking for billing purposes.
Our hospital opted to prioritize use of the EMR-embedded system, which operates via our patient portal and requires minimal provider training. Though simple and convenient to use, this platform does not yet include all our desired features, and it requires that families are registered for the patient portal. To accommodate different scenarios or technical issues that might arise, we promoted a flexible decision tree of back-up web-based platforms for providers. The decision tree was simple but effective: our preferred option was our EMR-embedded system which operates

| LE SSON 3: FIND CRE ATIVE SOLUTI ON S TO MEE T REQUIREMENTS WHILE PROVIDING E XCEP TIONAL C ARE
With changes in the way we deliver, care came changes in how we bill for and document that care. Regulations governing telemedicine procedures and billing varied by state prior to COVID-19, and national and regional guidance has evolved rapidly during the pan- It is important to note, that even with virtual visits, there were some patients that still did not show. In most cases, these were patients that had a history of not showing to the face-to-face visits and we were not able to reach to reschedule. In other cases, lack of connectivity was an issue and some of these families were accommodated using other platforms such as phone. Multidisciplinary telemedicine care with trainees and ancillary providers is possible and essential

Opportunities for improvement
Establish patient-centred systems to share glucose data with our clinic regardless of device Tailoring of virtual platforms to suit clinical needs (eg screen sharing)

Creating workarounds to enable completion of needed examinations or laboratory studies
System-wide administrative processes to facilitate patient enrolment into the EMR portal and streamline communication Developing an evidence-based approach to target telemedicine services to certain populations moving forward with formalized patient feedback Continue to understand how issues with state licensure as well as telemedicine coverage will be addressed in a long-term care model. the provider felt that there was a greater need, a message was sent to the social workers through the medical record system to have them call the families. Acknowledging the significant financial hardships faced by many families as a result of COVID-19, we attempted to be proactive in supporting our community when possible.

| LE SSON 5: ENG AG E FELLOWS AND AN CILL ARY PROVIDER S
Many academic centres incorporate learners at all stages, including medical students, residents, fellows and APP fellows. While reducing in-person visits and scaling up telemedicine services, it can be difficult to keep medical trainees engaged in both patient care and learning activities due to social distancing and billing requirements. In addition to trainees, certified diabetes care and education specialists, registered dieticians and social workers are integral members of the care team. Staff communicated regarding patient needs in real-time using our EMR. Education specialists were preassigned to provider schedules; prior to the clinic, they reviewed glucose data in order to provide suggestions to the clinician. During the appointment, they were also available to address any diabetes education needs. Our dieticians created a daily 'on call' schedule for both annual evaluations and referrals. The on-call dietician was able to follow-up with the family either the same day or shortly thereafter to schedule a virtual visit. Our social work team employed similar methods to offer support or behavioural health services. This network enabled our institution to continue a multidisciplinary approach to care undisturbed.

| LE SSON 6: IDENTIF Y REMAINING BARRIER S
Despite our success, there are remaining challenges that are likely to be common among institutions implementing telemedicine. In some cases, poor cell phone or Internet service affected the connection leading to delays or interruptions; in others, patients lacked access to a smartphone, tablet or computer that would enable them to complete video visits. If this was the case, we did offer telephone visits to ensure continued access to care for all our patients (<10% of the visits). An additional technological concern is translation services. Pittsburgh is fairly homogenous, and the great majority of the families speak English. However, our institution has a built-in system for remote translation via telephone if there is no provider within our practice who speaks the native language.
Administrative challenges include a shift in daily responsibilities.
To increase portal registration, we worked with the information technology group to simplify the sign-in process and make avail- We are taking a moment to reflect on the many ways in which this experience will influence patient care for the better, even after the restrictions necessitated by this pandemic are lifted. We have sig- In summary, the COVID-19 pandemic has generated incredible challenges around the world. Healthcare systems have needed to care for an influx of ill patients while still attempting to deliver care for patients with chronic medical conditions. Telemedicine has become a new standard of care. Despite hurdles and some remaining challenges, the infrastructure developed for telemedicine on a large scale will leave a lasting imprint on many diabetes centres. Moving forward, the experience we have gained will continue to drive innovation in developing and evaluating new strategies to optimize care for children and adolescents with diabetes.

CO N FLI C T O F I NTE R E S T
The authors are all employed by UPMC Children's Hospital of Pittsburgh. They have no significant financial conflicts of interest to disclose.

AUTH O R CO NTR I B UTI O N S
All authors participated in the telemedicine committee, and IL, RM, CM and AF conceptualized this manuscript. CM and AF drafted the manuscript. ER contributed the clinical data, which IL reviewed, summarized and assimilated into table format. All authors reviewed, edited and agreed upon the final version of the manuscript.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from