Telemedicine and Diabetes with Dr Sarper Tanli – Dia-Logue Podcast Episode 07

Pam Durant speaks with Dr. Sarper Tanli about what is telemedicine and how it can be used to help manage diabetes and other health conditions. We go deep and we get technical at times! You won’t want to miss this discussion about the future of healthcare, telemedicine and diabetes.

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Dr. Sarper Tanli has over 28 years of experience in medical and healthcare management, planning, and development, and operations.

He holds a Medical Doctor and a Masters in Healthcare Administration degree from Istanbul University as well as a Ph.D. degree in Healthcare Management from Marmara University. He worked in the international divisions of Houston Methodist Hospital Global and Harvard Medical International in the region over the last 15 years. Dr. Sarper pioneered the first home health and disease management company in Turkey in early 2002. He has held key positions in the development of Dubai Healthcare City. He recently founded Diginova Health Solutions a leading platform that incubates, supports and invests in the most promising digital health startups.

Episode 07: Telemedicine and Diabetes with Dr Sarper Tanli

Pam 0:02

Hello and welcome to Dia-logue, the Diapoint podcast. I’m your host Pam Durant. Today I will be speaking with Dr. Sarper Tanli, who is an experienced senior healthcare executive with years of experience in the GCC region. He has worked for many years in different models of healthcare, even those that were once considered alternative before COVID-19, including digital health and home health care. And actually in this episode, I’m going to speak to him about telemedicine.

He is the founder of Diginova Health Solutions, which is located in Dubai. He is also trained as a medical doctor. He has a Master’s in Health Care and Administration. And he also has a PhD in Healthcare Management as well.

About a year ago when we were all in lockdown. Here in Dubai, I started a series where I interviewed several experts about different topics, largely focusing on diabetes, but I also interviewed Dr. Sarper Tanli at that time about telemedicine because many people were asking a lot of questions about it. Some people had never heard of it before, even though telemedicine had been around for many years. And some doctors and clinics were embracing it. But because we were not able to get out and go to clinics, many places started to use it or started to think about using it. And I’m happy to say now that more and more do, but this discussion, although a little bit technical at times, gives you a lot of insight to the power of what exactly telemedicine can do. We talk about what it is, how it can support treatment in diabetes and other conditions. And also we talk about what we need to know and how to prepare when our doctors suggest a telemedicine consultation. So I hope you enjoy this episode.

Thank you everyone for joining us today. I am Pamela Durant, the Founder and Managing Director of Diapoint Middle East, the place for people with diabetes. And as we’re all sitting here working from home, in light of COVID-19, I thought it would be really nice to speak about telemedicine because that’s something that affects people with diabetes, but it will affect every single one of us and how we interact with our doctors, nurses and other health care providers in the future. And I thought what better person to ask to come and speak with me today in this webinar series, Dr. Sarper Tanli.

He’s been in the region working in Dubai for 16 years, before that working in Turkey, and in the US and he has a very deep background in healthcare technology. And I will turn it over to him, so he can further introduce himself, and then we’ll start our discussion about telemedicine.

Dr. Sarper Tanli 2:56

Great. Thank you, Pam. Thanks, everyone. Thanks for joining, I hope it will be a good interactive session for all of us. A little more on what Pam said, actually, I’m a physician and trained, but I’ve been in Healthcare Management for 28 years, and half of it here – and more than half of it actually in the region. And mostly in the management side. So I’m not a practising physician, just a disclaimer, I’m not an endocrinologist or infection control specialist. But been probably in many projects in the region that some of you probably use as a healthcare facility from like Dubai Healthcare City. I was instrumental to set up that place, and Dubai Mall MediClinic Center, Valiant Clinic and many others to count. But the last three years, my interests switched to new ways of doing things in terms of healthcare services.

How we can bring the services to people much more efficiently and much more effectively. And therefore that I had a chance to work heavily in the region, again, not only for Dubai, but Saudi Arabia and Kuwait and other places to work on services at home or out of the hospital or out of a clinic and using different technologies to be able to do that. So as a person, I guess it’s the been there done that and still working on it very heavily. Hopefully, that’s my experience of what I know, and what’s coming up in the healthcare space for all of us to utilize and use for ourselves and for our loved ones. Hopefully, it will be helpful.

Pam 4:36

Thank you. Okay, so why don’t we just start with a general overview. Some people in this call are in healthcare and have a healthcare background. Others are not working in the healthcare sector. So, and I think for even those of us that do work in the healthcare sector, there’s a lot of confusion around what exactly is telemedicine?

Dr. Sarper Tanli 4:56

Yeah, it’s really good. Actually, telemedicine is quite a large terminology that covers many different services under it because when we say telemedicine, it’s been around for many, many years, and it started with more of a physician-to-physician connectivity. So when you need a specialist or a much more sub-special person to look into a certain diagnosis or care plan, we usually use it to connect. And there’s still an existing service of course for that, and so we call it really practitioner-to-practitioner telemedicine services. And a perfect example of that is when you have your X-ray is taken or an MRI, that MRI specialist, that radiologist might be sitting somewhere else. They might be in India or South Africa or Europe, and in many different places. So that’s really a part of telemedicine. A lot of academic medical centers, a lot of small centers, but that want to really provide good quality care, use that technology to make sure that they have a sub-specialty area to be able to provide. So that goes under telemedicine. And some of you probably know it that when you go to a clinic or diagnostic center that they have a telemedicine service or not. But you can ask always, if they have such services to go to the sub-specialty area, when it comes very much at a certain time in a chronic diseases or in some critical illnesses, to really make sure that they are the ones actually getting the second opinion, not you. So that goes on the telemedicine, it requires a quite high level of technology, connectivity and all that. The other one is more on the very much of a finally in UAE, came into effect in our lives lately with COVID-19, which is teleconsultation. Teleconsultation is you to get on the tele, by the name, on the phone or on a video called like this, to talk to the physician to be able to get their feedback in terms of your complaints. So the reason I said finally because there are other countries in the UK, in Europe, and of course in the US, there was quite widely used services in place, specifically for the last five years or so. And because there are regulations in place, and last year, we had a regulation. And now with COVID-19, it was opened up because there was a lot of red tape from the government. And now that that service is available. We’ll talk more about that I think it is very important to discuss later. That what exactly that teleconsultation works – how does it work?. Because when you talk about that technology, you’re in front of a screen, not only the physician, obviously you can work with many different healthcare professionals, your nutritionists, your education specialists, and nurse and diabetes nurse and everybody else that in the circle of providing the care, could be online working with you for the care plan. So we’ll talk more about that, how it works, what we need to look for. The third category that I will call it is the telemonitoring. Telemonitoring is under still telemedicine or telehealth. It’s that we, as a healthcare specialist, use certain devices to see what’s going on with you at home or wherever you are. So those are possible with specific devices that either helps you to test whatever that we’re looking at that day, or small devices that are basically part of you and connected to your body that measures regularly your biological data. I’ll give you an example that actually, Fitbit in a sense that you use if it is connected to someone, that someone can look at it, that data and I give you feedback, it becomes telemonitoring. If the Fitbit data stays with you, it’s your self-monitoring, right? But a better example of this is, for specific for diabetes, are glucometers. So some of you may know that there are technology and glucose meters available. This is what very old technology actually for last 20 years, maybe more with the Bluetooth technology, whenever you measure the blood sugar, blood glucose, that data can go to the front of a specialist, either your nurse educator or physician to look at the data in a real-time basis. They can really decide what needs to be done in terms of your care for the day, and for the long term as well. And if you think of this, then there are many different devices that we’re able to add to this, because the technology is embedded in healthcare now. Think of it, as a blood pressure cuff, I can check your blood pressure, whenever you measure it at home, I can see it. A scale – whenever you get on a scale, I can see it specifically for obesity, or congestive heart failure, that we measured the weightage on a daily basis, this is very important. Or specifically these days, your temperatures, and whenever you measure your temperature or someone under suspicion of quarantine, obviously temperature is important to monitor, I can see it every time that you measure it or that person. And we can see what’s happening with that person. We can expand that more, for now obviously, COVID-19 is a respiratory disease. The measurements of the oxygenation are an important pulse oximeter, which we used to measure the oxygen level in the blood. And we can see that whenever you measure it, and your lung capacity by spirometers, that simple device in our hand, then we can connect the device. And literally, that you can think of any device that we can use at home with us, that could be monitored and those condors and telemonitoring hence we call telemedicine.

Pam 11:18

And we just had a question come in the chat, and please feel free anytime if you have a question, just pop it down in the chat box, is an in-home ultrasound scan done by us and sonographers at home and sent to the doctor considered as telemonitoring?

Dr. Sarper Tanli 11:31

It is considered telemonitoring and the perfect definition as used in the question is done by an ultrasonographer is important here. However, there is also new technology in place, coming in, not in the market yet, that uses artificial intelligence. And with that you can do the ultrasonograph by yourself with the guidance of the device, and using certain data to help the physician on the other side to be able to read that ultrasound properly. And so but today of course the ultrasonographic going through the physician is under telemedicine.

Pam 12:09

So it sounds like almost any condition could be monitored or could be beneficial from having telemedicine. So to break it off into like you said the physician to the patient I just want to focus on that piece for a minute. So because now, lately, particularly in Dubai, we’re getting text messages, we’re getting emails from our clinics and hospitals, saying hey, we now have telemedicine, schedule your appointment. And if we work in healthcare, we might have an idea of what that means. But what does that really mean? What can I expect? If I’ve been going to a clinic and I’ve been seeing a doctor and suddenly I have a message and they say we’re gonna have your next appointment through telemedicine, could you just kind of give us an idea of the steps of what to expect from that process?

Dr. Sarper Tanli 13:02

Yeah, absolutely. So I think Dubai is a good example because it now is a controlled example. So I was always worried about that, the need sometimes to be able to communicate to the doctor is always there. And some doctors do that through WhatsApp messaging, if the WhatsApp Video was open in the UAE, it would have been also possible to do that on the video, too. I was always worried about that, even as simple quick questions and checking in maybe it’s okay. But when it comes to medical consultation and without a recording, and that not necessarily recording the call, but recording the results of it somewhere, is extremely dangerous in terms of your or medical course of actions. So I will tie into the question, one of the things must be, when you have an online visit or televisit with the physician, is basically a consultation instead of going to a clinic, you’re doing that visit online. And we have to make sure that a physician or the clinic is using an approved solution that is applicable to be able to collect medical information that goes into your medical records. So the personal or medical information protection becomes very important. As in Europe for the GDPR which data protection rules, and here as well in UAE. So not every solution should be used. Like for example, I wouldn’t use Zoom for a physician consultation. The physician needs to be able to put your complaints and to be able to also prescribe medicine. So it’s a very important point. Not every country, that physicians online consultation allows to provide for prescription, but the UAE is a unique country, one of the not many in the world, that physicians can write a prescription. So in UAE when you have teleconsultation, with the proper place and with the physician, they will be able to provide you with a prescription, and you will be able to get that prescription by your insurance company. Some of these insurance actually are now paying for televisits by teleconsultation. And hopefully maybe even depends on the insurance of your pharmacy, they can even deliver to your home. So we actually now start to see the full circle of providing that service online. But also there are limitations, right? And not everybody or every case, that could be consulted on the phone. Because there are limitations. So what we were looking at in the video consultation or teleconsultation with the physician is more like primary care, like your first and you know, immediate needs that you might need to ask a question. For example, you might have a runny nose and a bit of a headache. And that usually with you know, the body ache, etc. The things that you want to go check in the clinic, a quick check and what’s happening with me, are the things probably right to consult with a teleconsultation. So not every condition will be, so the physician, actually based on your complaints, will tell you that you should really go see a physician in the hospital in a real face to face exam and it will be necessary. And also maybe we’ll see the specialist or maybe they will recommend going to the emergency room. It depends on your condition.

Pam 16:44

So then that leads me to a question. If telemedicine is used in this way, is it more for just like a pre-assessment where we really get a full doctor’s appointment out of a telemedicine consultation as like as a patient, rather than just what we would call in an emergency room like a triage? If I’m not feeling well, and let’s say I have just a general case of flu, I’m not talking any COVID-19 or anything like that, and I don’t have a chronic condition, I’m not feeling well. So is it that telemedicine is going to be used just as a general like, okay, these are your symptoms, and then go here go there, rather than really have a good thorough full kind of checkup? Is it possible to have a checkup and telemedicine?

Dr. Sarper Tanli 17:38

It will be there. And the technology is available, but I don’t think that anybody now has it in the UAE. What I mean by that is technology-wise, for example, there’s a very simple, like my mouse size of a device, that I can send to your home. And by putting it on your chest, I can get your EKG taken. I can listen to your heart from the other side, I can you put on your monitor, I can see you, you know, go to the examination. So that technology is available. And once that’s done, and most of the electronic exam, I call it will be done right? As well as that we can today, it’s possible to do laboratory at home, someone can come in, get your blood and your entire blood profile could be done at home. So if a doctor has all of these data coming in, I think that most of the checkup could be done, other than you know if you need other interventional things in your checkup like colonoscopy, mammography, etc. But most of it could be done with the technology in place. And is it available? Anybody providing now in UAE? I don’t think so. But it’s possible very soon, we’re going to be able to do that as well.

Pam 18:53

Okay, we have so many questions coming in. I love it. This is like the most interactive call that we’ve had. And some of these questions are questions I have for you as well. So I want to make sure we get to those. So you mentioned in one of my questions was security right? And you mentioned that Zoom is not, probably the safest way to be doing this. So what would you suggest other than Zoom to have a call?

Dr. Sarper Tanli 19:17

Right I mean, I don’t want to put Zoom on the spot, I meant by even like WebEx or you know, GoToMeeting, and you know, Hangouts, etc. So those are the ones that we on the physician side cannot really connect to our medical record system. So what I have to use, they say that I’m a physician now today I’m doing consultation. And if I see you, whatever that I see, I will. I should be able to connect that information to your medical records. And if you don’t have a medical record with me, your file, I need to be able to open a new one. And I need to be able to put my prescription in it to be able to send it to you. So none of this is available in Zoom. That’s what I meant by that. And so what we use, we use a specially designed application or solutions, either in the clinical management systems that all of you have electronic records here in UAE, and acquired. So you know in advance in that sense. So we are all, you know, paperless in most of the places. And so it needs to be either inside of that or needs to be a separate application that connects to that. So that way your data protection is much more clear for the authorities for also for us, for the healthcare professionals,

Pam 20:38

Right. So there are specifically dedicated programs that would be used, and then from the patient side, if I’m a patient, does that mean I have to download something extra? And do I need to be really technologically savvy to be able to do all this? I think that’s a concern for a lot of people.

Dr. Sarper Tanli 20:56

Yeah, most of the solutions are that they’ll give you a link that you download from a, you know, Apple Store or Google Android store, and pretty easy to use. So you can do this through the app, some of the places that they go through online through web, their online websites. So either way that you can do it. But obviously, we use so many applications now easy to download to do it on your phone.

Pam 21:24

Okay, so then continuing on that question, which actually, there are two questions that relate to insurance. So it’s kind of looking at it from both sides. So one, do insurance providers here, are they covering telemedicine yet? And the second part of that is, what is the requirement for the insurance providers to cover teleconsultation?

Dr. Sarper Tanli 21:48

Yeah, not every insurance provider, but some insurance providers are already covering telehealth. Some insurance companies, actually international ones, have their own physicians, family medicine physicians to do that. I’ll give you, I hate to give you names. But for example, Aetna, here. They have their own department, does that specifically, but others are also covered. So I will suggest checking with your healthcare provider, which insurance company does it. But major big ones are really covering now. What is required? Think of a simple physician visit, you call your provider and then you ask for teleconsultation, you get a booking, and they put you on the spot and then you get done that day, and you have the call. So that’s how the teleconsultations are now done today, in overall. But also you can always say that you can also some insurance companies, check your insurance company, have some numbers, you can call any time. This means some of them are available 24 hours and depends on the insurance company. And you can call a physician to get a consultation online immediately.

Pam 23:00

Okay, great. And so this is an interesting question, how would you define monitor? and Khristian says, ‘what I understand is that monitor, means definition needs active engagement, reading the data continuously and actively follow up, I have a feeling the word monitor is used too lightly or is that just me?’

Dr. Sarper Tanli 23:21

No, monitor is absolutely the definition, as someone looks at your data in continuous spaces. That’s what then becomes real monitoring. That’s what I was trying to say that if I receive your data, and it comes in front of my screen, that I look at it, and I’ll make some clinical decisions or suggestions to change the course of action for your care. That’s called monitoring. If the data comes in a place and goes in the cloud, or wherever, but nobody looks at it, it means nothing to us. So when you look at it from the diabetes point of view, and when you visit the doctors, whatever the frequency, you go every hopefully maybe every three months, every six months or whatever, this was the only time the doctor gets your data, from the whatever the tracking mechanism you use, maybe manually, maybe through the pump, maybe other methods. So then they look at it retrospectively, what happened you lost x months, but when you do real-time telemonitoring, that day and in that week, I see what’s happening with you. So every time that you check your blood glucose, I can see it, then the interaction is the following. The person looking at that data should be able to send you or talk to you, send you a text message and remind you of something or maybe things are not going well and then you keep reading a high like the last couple of days. Maybe they’ll immediately schedule a quick call to see what’s going on, to support you. That’s real telemonitoring. And this service is available, not in many places, but actually, the company I use for work for that has since I left, has that service, so they can really follow and then they can provide support by the nurse educators. Even sometimes if someone, elderly forgets to check the blood glucose that morning, sends a message to tell you that you forgot, this is the time to check your blood glucose.

Pam 25:32

Great. Yeah. And from actually where I’m looking at it, I’m actually happy that this is finally happening. Because of the really amazing doctors, I don’t think we have any of them on the call. But there’s a lot of endocrinologists in Dubai that follow their diabetes patients that use Dexcom, which is a particular continuous glucose monitor that’s constantly measuring your blood sugar. And that has a share option with an app and you can see it through your phone. And particularly when it comes to new Type 1 patients, those doctors are following those patients. They’re giving feedback to the patient or the parent and they’re already doing this. And like 24-hours a day, just one doctor or a doctor and a nurse in the clinic. It’s amazing. So the fact that it’s now kind of coming together to be more of a comprehensive institutionalized thing is so much better for doctors and patients because it’s exhausting for the doctors that were doing it without the support.

Lori says, If you know someone has a blood pressure monitor, glucose monitor, and thermometer at home plus the physician seeing you on the video screen as well, then she can see how it can be very effective. And she also says the same for specific conditions that are safe to monitor daily heart failure, diabetes, kidney disease. Are there any conditions that have already been really studied that it’s best to do them with telemonitoring, or it’s safer? Or you get better results if you do it? Would you say that there’s any conditions that it’s a perfect match for and are there any conditions? I mean, you pointed out a few procedures like colonoscopies and stuff like that. But are there any conditions where you would say it’s not very common to do telemonitoring?

Dr. Sarper Tanli 27:22

Well, I will tell you diabetes, hypertension and COPD, chronic obstructive pulmonary disease are really the ones who get the most benefit from this. And the studies in the US and Europe and the UK shows many different ways of not only cost-saving matters for the healthcare system but especially for the clinical outcomes. Even with the program that we had, we did a very quick small study for the patients that we’ve followed at home. So those are the patients, adults, with diabetes, and they have a nurse with them 24/7, and when we start using the telemonitoring, with the nurse educator, diabetes specialists are on the screen looking at it. Their hemoglobin A1C level, within three months drops on average 1.5 within three month. So you can imagine that you already have some caregiver with you, but specialist access is not that immediate. When you put that immediate access, the results are immediate. And so maybe, we’re going around nine and we were able to bring it to seven within three months’ time. So the effect on the clinical outcome is amazing. As long as that monitoring is done by the individual in the proper hands and continuously. The problem we have in the UAE, this service or this year, I mean this has not been covered by the insurance yet, unfortunately. So that’s why the endocrinologist and other doctors are doing it on their extra time, through maybe quick messaging it looking at results and giving feedback, but really is not sustainable at the end of the day. So we’re pushing really hard the payers, the government, to include that the service is also for, you know, covers so you don’t have to worry about it and you can really go get it from wherever companies are providing it.

Pam 30:12

And David has a question. He said he’s heard that drones can be used for medical support. Can you share your view on this technology?

Dr. Sarper Tanli 30:22

Yeah, drones are definitely used mostly now for medication delivery, and specifically for remote areas. But in specific, when the COVID-19 came in, it became a hot topic for us to use drones more and more to be able to send medication to homes. So there’s one area that I know is widely planned and used. And, and also, you know, obviously, that you need to have someone on the other side to be able to put in, so you can actually put some lab specimens as well. So, let me explain it a little bit. So technology, you know, came to a point that I do not have to send you a nurse to draw your blood for many tests, you know, that is we can do it by you know, finger prick, very quickly, not only for glucose, for many, many things, even for the gene testing. So you can imagine very simply, that drone brings you a quick laboratory kit, you do the test by yourself, put it back on and it sends it back. So that’s the technology that’s how it’s gonna come into our lives. And very soon, not far actually.

Pam 31:33

Yeah, I think it will come soon as well. Yeah, Alisa knows of an example of where doctors immediately following up with the patient with, you know, blood sugar, that it might be out of range. And Linda has a question, how do providers or hospitals, clinics, how are they getting a patient signature, to process a claim or even to get consent? How does that work? Because you know, when we go to the clinics, we have to sign so many papers about everything. How are they then getting the permission from the patient, if you don’t have the actual paperwork there?

Dr. Sarper Tanli 32:08

Yeah, that’s a good point. So that these are actually now covered in the regulations here in GCC. We have in the UAE and Dubai, the regulations for telemedicine and Saudi Arabia has regulations for telemedicine. In those regulations, this clearly says that you have to obtain electronic consent for the patients before you start. So the system that I was mentioning is why WhatsApp, Zoom will not work. The system should be able to send you electronic consent, you can check and sign and that you will be able to get that service otherwise, it’s not really secure. It’s not really approved. It’s not something that you should really rely on. These are the only services that we should look after.

Pam 32:52

Okay. And another question just jumped in. Hi, Rudy. In your opinion, what are the steps that healthcare institutions and healthcare systems need to take, in order to encourage the patients to trust and adopt telehealth services? That’s an excellent question. I’ll let him answer that one first, and then I’ll read your second question.

Dr. Sarper Tanli 33:13

Sure, I think that a couple of things that we need to do first of all education training, about what really telehealth means and what are the things that you need to pay attention when you get to telehealth services. For example, maybe you know, or you don’t know, but telehealth services are licensed here in the UAE. So not everybody can provide telehealth services. They need to be licensed by the authorities. So that means it brings a lot of those consent forms where you keep the records, etc. Also the other thing that it brings that you have to as a healthcare provider, I have to train my providers whoever that is that’s gonna sit on the other side of the screen. So then those are the physicians who must be trained for telehealth services. So the reason is, when I went to medical school, even like recent graduates, they were not trained to do the consultation on the screen with the patient but we were taught to touch the patient to you know, listen in, etc. So now we’re talking about totally different technology even to be able to capture certain information from a patient. This is basically the art of, you know, medicine. It is very different than sitting down next to each other than when you are on the screen. So that training must be there. The healthcare organizations must provide the training and then tell the public that their physicians or whoever is providing the telehealth, is trained, they need to train for that. They need to roll it out and give the security to the public that their information is protected as they were in the hospital. Anytime they do whatever the security, cyber security we’re talking about here. Certifications, medical records, everything must be there. So healthcare providers, hospitals also inform the public what precautions they take to be able to provide a service.

Pam 35:09

That’s great. And then his second question: telemedicine-centered programs have proven to help in chronic disease management. However, telemedicine services rely a lot on the engagement of the patients. No engagement means no data, no monitoring, no database consultation. So if your patient’s not doing anything, or not really interested in their health care, particularly in a diabetes context, how can you overcome that obstacle? And that people want to think less about their disease and not be reminded of it? Because diabetes is super nagging. Like all the time.

Dr. Sarper Tanli 35:46

Right. So that’s an excellent question. This is the next problem that we’re actually trying to bring some solutions to it. We absolutely recognize the fact, we’re talking about behavioral change. And that’s a very long, you know, battle but we’re going to have to do it. But some of the ideas and solutions are in place now. Because exactly the reason that the patients are not engaged or they might not get on in front of a screen, or they want to do things. So now there are, we call it patient-facing applications. So those are the applications that will keep them and these are age specific, by the way. And for children and different types of applications for other different applications, to keep them engaged with their applications, maybe put a little quick gaming into that app, so they can keep using the app. The way that they will not forget pulling their data because data collection for the chronic disease is the most critical thing for us. And whatever data we can get is not necessarily glucometers. If you have the Fitbit then I should be able to get that data as well. If you’re sitting down and do a video game, the technology’s available by the way from your hand gestures. I can capture the data, your movements and what you do. So any data related to you as long as you allow me to look at this you know, underlined very important, I should be able to get it to manage. You’ll be able to change your approach to the disease and all that so I can intervene in different things. But this is the next problem that you’re trying to look at. There was no solution yet, ideas, some small anecdotal pieces in place, but not in complexity yet.

Pam 37:33

Amazing. It’s like we’re in the future but not we’re living the future. Right, the hand gestures and monitors and the gaming and all of that. I have one more question here right now from Kristian. Not related to telemedicine really: is traditional finger – it’s kind of related because – is traditional finger pricking better, or is it more effective to use a continuous glucose monitor in diabetes? I have an answer, but I’ll let Dr. Sarper go.

Dr. Sarper Tanli 38:03

Please answer this. Okay.

Pam 38:05

So, so what we’re always taught, yeah, I’m so sorry, but because my son wears a continuous glucose monitor, and at the end of the day, that’s another technology and someone even in a group this morning that I support, they’re all moms with newly diagnosed and some moms not newly diagnosed, but there’s a mom in there with a newly diagnosed child. And one mom from the UK and the first diabetes team that she had, the rhyme they taught her was when in doubt pull the glucose meter out. So continuous glucose monitors, if they’re showing a real high or a real low, they may need to be recalibrated. Sometimes yeah, you might be really high and it’s good to double-check, always the best source of truth is the finger. But the beauty of the glucose monitor is that you continuously know what your blood sugar is so you can make decisions. For us, what I go by of course I’m looking at the number and if I have any questions I will double-check with a fingerprint but the glucose continuous glucose monitor the valuable information for that for me is the arrows up or down you get 1-2-or 3 arrows up or down depending on how fast it’s going. That is usually correct but still, we always double-check, with our fingers, so yeah.

Dr. Sarper Tanli 39:30

For me personally, I love continuous glucose meters now, but also the way that we need to look at this and for everyone at different solutions will work. The importance is the outcomes, so as long as we have below the targeted hemoglobin A1C we may want to see we do not have any side effects coming up throughout the years. Maybe you know what, two fingerprints pricks a day might be okay, but it depends on you know, what the level is. But specifically in Type 1, you’re going through so many ups and downs, and during the day and it’s not stable yet. But it seems like CGM is much more effective to be able to manage that quick changes.

Pam 40:14

And also, if you’re talking about it in a telemedicine context, it’s so much better because data is information at the end of the day. And the doctor can make decisions about your insulin or other medications or your care and what you need to do. And also you can make decisions as well. So it just opens up a whole new dialogue, the more data we have, the better decision making we can do. Does the double-checking happen often? No, no more than usual. The particular CGM we use is required to be calibrated every 12 hours. And we rarely need to do it more than that. And then so and also another thing that I’ve been told that really helps to get CGMs. And any device that you might have accurate, is making sure that you’re really hydrated. So if anyone here is being monitored with some device, hydration is important.

Do Type 2s wear CGMs? They do, I think it’s more common with Type 1. But there are Type 2s, if they’re insulin-dependent, they wear CGMs. Or sometimes they may not wear it for a long time. They may wear it just to understand over a short period of time. A trend, what’s happening with them, maybe to fine-tune something, but they certainly can, at the end of the day, they probably use it less because it is more costly. And with Type 2s, the body is still producing some insulin, it’s not as volatile as a Type 1. Type 2s don’t have a higher chance of having a DKA for example, those kinds of things. So it’s more common for Type 1s to be monitored.

Hmm, okay, here’s a good question about telemedicine. What is the cost expectation like as a patient? And of course, it will vary from country to country. But what do you, or is there any data or indication of what we can expect the cost will be like? Will we be paying the same price that we would if we’re going to our doctors, or will we be paying less because we’re not actually going to a building now?

Dr. Sarper Tanli 42:23

Yeah, so it should be less. But today, because of COVID-19 prices are not settled yet. You can get a teleconsultation, depends on the hospital for AED200 to AED300. But if insurance pays for it, obviously that’s okay. If your insurance doesn’t cover and then they have a payment mechanism quickly, either you send a bank transfer or you do a quick credit card payment online. And then they’re okay. But this is for a one-time consultation. So there are also models that are available that you sign up for an annual subscription for teleconsultation, you pay a certain fee a month, and that is as low as, it could be, $20 or $15 a month. And then you have access to a physician to be able to talk to, so there are subscription models like that. We will see more and more of those coming to the UAE. I think there’s, I heard one that you can pay very minimal amounts, but you need to commit like 12 months commitment for that monthly payment. But even access, so there’s an unlimited number of calls that you can make to the doctor with that. So yeah, I think that the pricing will be set a little more. Normally, it shouldn’t be AED 200 to 250 shouldn’t be in my opinion, not more than AED100 or maybe even 70/80. But it will come through because more people are going to be providing this. Almost every clinic I can tell you, they’re either trying to create their own or looking to the companies that can bring and put it into their clinic to be able to do it. Telemedicine actually interesting enough. You can even imagine that your dentist will do teleconsultation with you very soon.

Pam 44:12

How will that be? I was just one, honestly because I was thinking of this interview last night. I was like well I guess in my head, I said I guess that won’t work for dentistry. Please tell me how that will work.

David’s got a demo.

Dr. Sarper Tanli 44:27

So he’s obviously like, you’re gonna have to put the camera in your mouth and all that, so that’s more of our like initial quick exam to help you and make some decisions do you really need to go now or later? But now I think the one clinic started, another one is about to start in UAE, so check it out.

Pam 44:47

Okay, amazing. Oh, I’ll find out which clinics those are guys, and I’ll send a follow-up and let you know, that’s very cool. David has a very interesting question. But I think that’s a good question to be the last one but I’ll go ahead and ask it. David’s wondering, Has anyone here had a telemedicine consultation before? I did. Sarper has, okay. Anyone, anyone else? I guess, the emails that I used to get after my son’s diagnosis, because when Erin was diagnosed, there was no pediatric endocrinologist in the UAE that I knew of at the time, um, and a doctor from the US, I was emailing him. I don’t think that really quite counts, but I was consulting with him through email, that’s not telemedicine, but it was life-saving for me at the time.

Dr. Sarper Tanli 45:38

To add, some people might be hesitant to get in front of a camera to, you know, pick a physician that they have never met before, right? So you don’t have to turn on your camera. There’s another thing, right? You can still…

Pam 45:55

From a security perspective, because would the doctor not need to confirm that it’s you that he’s really talking to you, to make sure for patient verification. How would that work?

Dr. Sarper Tanli 46:07

Through the signature of the consent, they are doing before they start.

Pam 46:12

Okay, yeah, I have quality questions. But that’s another call. And I’m sure my fellow former quality colleagues on this call know where I’m going with that.

Rudy: Teleconsultation and telemonitoring are driving away the traffic from hospitals, which means less revenue generation for hospitals. How will we be, excellent question, how will we be able to get the healthcare institutions on board and not scare them away with telehealth, and consequently have them push the patients against adopting this technology?

Dr. Sarper Tanli 46:45

Yeah, that’s a perfect question. You know, again, how we convinced that with the payment systems, because now in UAE, the clinics and hospitals, they get money. Everything they do every additional test, every time they see you, they get money, but there are payment systems in the world, that they do not get extra money when they see you extra time, based on the disease that they have to follow. So through that payment mechanism coming into a country, which I already actually come in, by the way, their interest will be for you to not to go, even for a follow-up or not simple visit. Or rather, they will focus on much more complex cases to really treat much deeper things. If you look at the hospitals and clinics in UAE, other than the much major big facilities, they don’t really do complex cases that are very rare. So that’s why I suspect that pooling their resources to more that are actually in such that telehealth will even improve in their competency and complexity in what they provide. But how we convinced them is with the payments and that is already coming. So if I am in a hospital, I’m already to get paid only for one price, I want to get you out faster. I don’t want you to come back for another follow-up, I rather do my follow up on teleconsultations even simple with that they will even push and say don’t come we’ll do teleconsultation with you. You will love it. You don’t have to drive, you don’t have to wait an hour and whatever half an hour. It is a two-hour minimum visit if you look at the time from your life and at the end of the day, when you do follow up, the doctor just looks at you. Do you have any complaint? Nothing. Then thank you very much and repeat the prescription, maybe. This could all be done now online.

Pam 48:39

Okay. Lori has an excellent question, and so many patients. This is one of the top questions from patients about telemonitoring. Does the convenience of telemedicine mean the quality of the consultation has the risk of being lower? Like, you’re not going to get a quality checkup, and some patients they even fear, when they see telemedicine that it may not even be the doctor, that they usually see that they’re going to see. So they worry that it’s not going to be as good as seeing the doctor in person.

Dr. Sarper Tanli 49:09

Right? I mean, I think that, that suspicion should be the same, until we build our trust in the system and trust in the doctors that we work with. But look at telemedicine as more of your first step into healthcare. So what would I lose at the end of the day? Because if I have a simple pain, and simple things going on, your doctor is going to be able to give you a prescription to say you know what? You know take this, in a couple of days, see what goes on, call me back tomorrow. I think that’s already happening in the clinics. Anyway, what will be the difference? So I look at it that way if the doctor sees that you really need to go and see him or see somebody else. They will say so, and that’s why it comes to the responsibility of the healthcare organizations when they put the telemedicine programs like this. They put actual guidelines for physicians and those guidelines are international ones like those done for by Mayo, Oxford and all are available that when they ask a question when you answer this, and they should actually look into the next question. So there are a lot of guidelines for physicians to try to create standardization, so certain levels. And so, that’s also another question we should ask those providers, what guidelines do your physicians use? And that will build more quality as well as our trust also.

Pam 50:33

I’m sure in time there will be special, in a very short time, telemedicine kind of quality certifications that people will be very quick to embrace. So, how will telemedicine work for say ear, nose and throat exams? If you have, you know, an ear problem or something like that, can this be discussed or diagnosed or is telemedicine good for this?

Dr. Sarper Tanli 51:04

So again, there are already devices available, and we call them home kits. That I can send to your home and that device that actually checks the ear, nose and throat with the connectivity with clear directions from the physicians: how to hold it, put it, etc. An initial example can be done today. I can send you a very simple EKG device home, you can even take your EKG electrocardiogram, and I can see it as well. So those are available in the UAE today. So yes, you can do that EMT but obviously, it does not leap to diagnosis or a live exam, but an initial quick exam any family medicine doctor does when you go to the clinic, you know otoscope etc. It could be done.

Pam 51:55

Excellent. Hmm Aysen’’s a pioneer. She sent a video of her daughter’s mouth to a dentist, he prescribed some medicines, and now she’s fine. So okay, and I assume that video was even with an iPhone, unless you had some other special thing. Amazing. Question from Asla, do you think there will be independent telehealth apps? Or will it go through a clinic always?

Dr. Sarper Tanli 52:22

There are independent apps now in the UAE. Those are approved apps by the government. There are seven approved telehealth solutions applications now, separate applications. And the clinics get the license to use those applications for their physicians as well.

Pam 52:42

Yeah, also another area that reminds me that, you know, we’re talking a lot about the physical but I think also a lot of psychology clinics are embracing telemedicine as well.

Dr. Sarper Tanli 52:55

There are many important points. So when I was talking earlier, that I keep saying the healthcare professional provided the other side. So mental health is very, very critical. Your coach or your psychologist, you can do those sessions, again through teleconsultation or video consultation is very important. But again, all the security safety things in place, as long as it’s a medical it needs to be a medical record, but it’s simple advice like a coaching etc is from the case, it could be the premise of the medical records, and if it is a psychotherapy session it needs to be recorded. So then their angle, but another thing that I will tell you in telemedicine, what we can do now is tele-physiotherapy. So once you diagnose that musculoskeletal disorders are quite common. And for not only elderly, for active people as well. So instead of going all the way to the clinic, three/four times a week for physiotherapy sessions. Once that physiotherapist puts your program together, there are certain applications that you can use at home without going to clinics. So that’s also come into our life.

Pam 54:13

Okay, great. Yes. Ozlem, I agree. We can have a quality brainstorm about well, how to review telemedicine, that would be great and it would be fascinating and detailed and it’s necessary going forward. So Ozlem is on the call. She works for the Joint Commission International and she is a hospital surveyor. So she’s looking at this from a quality perspective. She’s actually one of the people that is out there responsible for making sure the hospitals that we go to are of very high quality.

So Lori is asking, so are you saying telemedicine is great for acute and chronic illnesses but not for someone with an ongoing complaint or multi-symptom complaints that are persistent and undiagnosed also, this is being used for injury assessment?

Dr. Sarper Tanli 55:03

Ah, not necessarily. I never, I didn’t hear that this is done for injury assessment. Usually, when someone calls with injuries and for just a quick understanding, teleconsultants usually ask them to go to hospitals, it’s the routine answer. So I don’t think we’re there yet Lori.

Pam 55:27

Ah, but it’s a good segue actually to Della’s question because, so Della’s with David, she says for housebound patients, could you have a nurse with them when they speak to the doctor?

Dr. Sarper Tanli 55:39

Yes. And that is available in the UAE now. In some of the Saudi companies I set up, the service has nurses. So you can have a couple of ways to do that. Either if there is someone with that bed-bound patients 24/7, we can train that person to start with, to be able to talk to the doctor, or a nurse can make a visit with actually much more complex devices. Even we call it like mobile home kits, or something that nurses can use, and then with that data, the consultation will be much more complete.

Pam 56:20

Excellent. So it is four o’clock. And I didn’t have to ask them any questions because most of what I had to ask you all asked and then some. It was amazing. I want to be mindful of the time because some people are working or fasting during Ramadan hours and different things. Thank you all so much for joining. It was great to see your faces and thank you so much for the interaction. And we will look forward to seeing you all maybe again virtually, but hopefully face to face very, very soon. Yes, thank you and a special thank you to Dr. Sarper Tanli for joining us today, and giving us so much insight into telemedicine and what we can expect from our doctors, hospitals and clinics and health care providers going forward. Thank you. Bye, everyone. Take care. Be safe.

I just want to thank Dr. Sarper Tanli again for joining us for that discussion back in 2020 where we talked about what exactly telemedicine is, how it works, how it can support the treatment in diabetes and other conditions and some really fascinating things like dentistry and other things that you wouldn’t even think of could be done remotely. But it’s really great, you know, in the times of COVID or not, that we’re able to do this because it can help more people in a much shorter time. Or if you’re far away from an area of expertise that you don’t have access to, it helps open up access for a lot of people. So thank you all very much for joining us today. Please don’t forget that anything you hear on Diapoint you should follow up, ask your doctor, ask your diabetes team and other medical providers. If you like what you heard, please leave us a comment or share it with somebody that you know. I look forward to seeing you again next week.

Show Notes and Links

Disclaimer: It should go without saying that the Diapoint podcast is not intended as or should not be used as personal medical advice. You will hear us interview medical experts and others, but please always always ask your qualified doctor, diabetes team or other expert about your health. What works for one person does not always work for another person. What you should always do when you discover any new health information is ask YOUR doctor about it. This information should empower you to have a discussion with your healthcare providers about it. Diapoint, our guests, sponsors and business partners are not here to replace that advice. Living a full, healthy life means taking the proper medical advice from your qualified physicians, diabetes team or other healthcare providers.

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