Conducting a remote diabetes consultation in Africa: a how-to guide
The COVID-19 pandemic has had a tremendous impact on mindset and practices for healthcare professionals. In many respects, it has accelerated the transition to a more flexible provision of healthcare, particularly in Africa, where access to basic and specialised healthcare remains a challenge. Telemedicine is an effective tool that can be used to expand the reach and most importantly improve the quality of healthcare in Africa in these challenging times. However, conducting a diabetes consultation remotely requires specific skills and knowledge, as it is in many respects more challenging than a face-to-face consultation. Upskilling healthcare professionals to ensure that they are adapting their practice appropriately is key to improving health access with telemedicine.
The most important points to keep in mind when conducting a telemedicine consultation are:
- Ensuring patient consent and confidentiality;
- Following a consultation protocol to structure the conversation;
- Giving guidance for post-consultation care and follow-up;
- Recognising and managing emergency situations.
This article was written by Dr. Michael A. Olamoyegun (MBBS, FWACP, FACP, FACE, MPH, M.Sc).
First contact with telemedicine
Before the pandemic, healthcare professionals and doctors in particular had had very little opportunity to practice telemedicine. Many professionals learned on the go. It is no exaggeration to say that In Nigeria, where my practice is based, picking up the phone to speak to a person living with diabetes often made the difference between life and death.
Telemedicine is here to stay. It can help us address some of our most common challenges: for example, facilitating access to care for people living in remote rural areas or providing specialised medical advice despite shortage of medical personnel.
My general advice to healthcare professional is to seize the opportunities offered by telemedicine and consider it as an additional tool in the palette of services that they can provide. My second piece of advice is to research the topic and exchange views with colleagues who may be more familiar with technology and remote consultations.
I am sharing here a few lessons that I have learned from this experience and from my practice.
Telemedicine is essentially diagnosing and treating a patient remotely, be it on a phone using video and voice calls or by text messages. I would generally reserve text messages for regular patients that I know well, and who require quick advice after a reading, for example. I would discourage healthcare professionals to conduct an initial consultation over text messages.
Consent and confidentiality
Ensuring patient consent and confidentiality should be top of mind. Who’s listening and what are the rules?
The patient must be comfortable with the idea of a virtual consultation itself, and that they have the capacity to make their own decisions on the matter. The patient would need to give consent verbally or in writing prior to the appointment, for example. “Yes, I consent to a consultation via telemedicine”.
When onboarding a patient, it may be useful to highlight the benefits of a teleconsultation to them: these include a shorter waiting period, potentially a speedier diagnosis and the ease and privacy that comes with speaking to a doctor in your own home, and there being no need to travel to hospital. Managing a patient’s expectations is important as you will be performing a remote consultation. Point out that any clinical assessment done in this manner is not always as complete as it could be, but that you are using this method to try and alleviate their condition.
Privacy and confidentiality are of course paramount, as they would be in any consultation, virtual or not. When holding a video/voice call with a patient it is crucial that only those who have been onboarded are on the call, and no other person can be seen or heard in the background. Perhaps arrange for the call to take place in an appropriate setting such as a private office within the hospital, this will give the patient confidence that their information is being kept confidential. If the consultation is to be recorded for any medical record, consent for the recording must also be obtained and documented in the records.
If a patient is in a noisy public area when taking the call, and if you fear confidentiality cannot be respected, you can ask them to reschedule the call.
Consultation protocol and dialogue
When beginning the consultation, you can reassure the patient that the conversation is secure and confidential, if it is indeed the case. Start by confirming the patient’s details and follow this with an introduction of yourself and any other doctors or healthcare professional involved.
It is important to be aware of the patient’s medical history and any presenting complaints. You can ask the patient if they have any history of hypoglycaemia, for example. If the patient have type 1 diabetes, offer them advice about checking their ketones usually through a blood or urine test. If their ketones are high, the patient will need to report to emergency care. Encourage them to do this as soon as possible.
Find out about any allergies and intolerances. Make clear reference to these in the notes with an emphasis on any drug related allergies. Highlight these clearly for other healthcare professionals to be aware of.
Once all this has been done and the patient is aware of the limitations of a teleconsultation, simple examinations can be performed and relayed by video. Neurological examinations can be viable in this virtual format as well. In this case you should look closely at the patient’s facial asymmetry, asking them to both stand and walk. This can give you a fair idea about the state of their condition. Should you observe any foot lesions or abscess on any other visible lesion via video or photo, but perhaps the quality is insufficient, you must arrange a complete physical examination as soon as feasibly possible.
At the end of the consultation ensure there is a management plan easily summarised for the patient to understand. This will avoid confusion and misinterpretation. Explain the steps required going forward in terms of follow-ups plans.
It is important to allow ample time at the end of the consultation for the patient to address any questions or queries they may have. This is often the moment when crucial elements of information are shared. All remote consultations should allow risk stratification and if needs be a face-to-face appointment should be organised to allow further clinical assessment.
Post-consultation
Teleconsultation can be used again for follow-up visits or if the same patient suffers from a different ailment. However, there are several instances when you may need to arrange an in-person appointment for a patient in need. If there is a requirement for a face-to-face appointment, the patient must be informed and acknowledged.
You will need to arrange a face-to-face consultation in cases where a patient needs to understand how to administer their own medication, if doses or prescriptions require adjustments. It is easy to show them this via video. This might be the case for example, with a patient requiring more than two anti-hypoglycaemic agents or the initiation of insulin as treatment.
With COVID -19 and variants in mind, the patient should be given any necessary certification or permit allowing them to travel to their nearest hospital or doctor’s practice during any lockdown period to receive treatment without intervention of the authorities.
Special cases and emergencies
There may be a patient in an emergency or with special circumstances that require an in-person consultation or hospitalisation. Here are examples of some special situations below which you may come across during a virtual consultation and suggestions on how to manage these.
Gestational Diabetes Mellitus
If this is discovered during a first consultation, the patient may require the initiation of insulin along with detailed diabetic education and lifestyle advice. As this will have developed while the patient is pregnant, special care must be taken when walking them through the condition. After the first consultation, follow-up appointments should mainly consist of minor dose adjustment and can be managed with the use of telemedicine without issue.
New Type 1 Diabetes Mellitus Patient
A face-to-face consultation will need to be arranged to begin insulin treatment. The patient and their family must also be informed about the condition and given hypoglycaemic education. The patient must be advised that if they develop ketoacidosis (and this needs to be fully explained), then they must be admitted to hospital.
Finally, should the patient experience any emergency situations such as severe hypoglycaemia, foot infections, major foot Lesions and gangrene, a complete face-to-face consult or hospitalisation must be arranged immediately. A consultation in person must be given if the patient suffers from any acute deterioration of any organ functions.
Conclusion
As a diabetologist working with the Ladoke Akintola University of Technology (LAUTECH) in Oyo State, Nigeria, I have been part of pioneering telemedicine initiatives, including the design of applications to facilitate access to care for people living in remote areas. There is more to come with regard to telemedicine, and healthcare professionals should be encouraged to keep in touch with their patients by all means, especially during these challenging times. If used with care and by following good practice, I am confident that teleconsultations will improve the overall care of people living with diabetes.
To find out more about telemedicine and diabetes in Nigeria, read this article.
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