In the space of only six weeks we obtained a drop in the HbA1c of 1 percent, which turned out to be a significant number.

We submitted the project for presentation at the American Diabetes Association annual meeting. Although the ADA published my project in the program, I was not allowed to present it.

The comments explaining why no presentation was allowed were sent to me for my review. Two of the three reviewers said something to the effect that "the Internet is not an appropriate place for medical care."

I persisted in the concept of telemedicine because I felt that diabetes was uniquely positioned for an information-rich disorder that only needed data for good management. I convinced others of this concept as well, which enabled me to get venture capital in the early part of the "bubble" to fund DiabetesWell. Unfortunately, like many other institutions, it disappeared in the downturn and no longer exists.

Endocrinologists always have whined that their discipline was not as hands-on as others. We have no procedures, merely looking and listening. But the information that we have to dish out seems inexhaustible. Patients just can’t learn enough no matter how long we talk with them.

I also realized then that the nursing staff did a better job, took more time, and used this time more effectively than I when treating patients. In diabetes care, this observation has subsequently become true throughout all levels of care. I put nurses in charge of talking to the patients on the Internet. The patients accepted their stewardship easily.

I now refer to this as "continuous care." Patients tell their story in comfort, on their own time, and are remarkably frank about what’s wrong and what they want. It has been accepted overwhelmingly. With the teleconferencing we have today, we now have the "office visit" compensated under the California Telemedicine Law, which was passed first in 1996 with frequent updates.

Patients want and feel they need quality medical care on their terms. Information that is action oriented and of value for them seems to transcend all the feelings physicians have had that face-to-face is the only real way to practice medicine.

As we know, millions of diabetics are not receiving the basic level of care that is necessary to maintain a healthy life. Lack of adequate medical insurance for their situation keeps many from receiving necessary care. Doctors’ offices are impacted with routine visits, reducing ability to take on new patients, particularly those who need intense care. This results in increased health and disability issues—read increasing complications and health care costs—that impact the medical system with loss of health and ability to work.

We are wary of change. The idea that one of us could become as rich and famous as Bill Gates is unthinkable. In the main, Internet care in some form will increase your income and increase your stature in the patients’ eyes, but Bill Gates will not see you gaining on him. The ever-present concern about malpractice in this setting will necessitate your talking with your carrier to learn the company’s view of the rules of the road for you in this situation.

Laws favor knowledge-based practice. As one attorney told me however, "Even though you have impeccable electronic records, even though you have documented all your decisions well, even though you have presented a plan for care, I’ll still sue you."

Large companies are asking for this type of care because it is the only change that will reduce costs and increase quality. Many companies feel it has been proved to reduce costs. I received the Recognition of Excellence Award from the American Medical Association in 2005 for the ability to take 19 diabetic Hispanics, who were frequent ER visitors, and in three and a half years have no ER visits.

Internet care does improve outcomes and allow easy reporting with electronic records. My present electronic records system does not have the easy capability that can be expected from the next iteration of electronic records. But our data indicate the majority of patients significantly improve measurable risk factors.

In 12 years of using this system, no patient has raised the issue of privacy. We do have patients sign a paper that says the system will not be secure and privacy could be violated, which might head off any concerns. Patients feel the Internet improves their outcomes and quality of life.

So what’s the downside? Cost of technology infrastructure is obvious, but as we all know the cost of a computer is declining rapidly. Inadequate time for each patient is in the first line of physicians’ concern, but it is something that we can learn to do. Fear of losing income because of preoccupation with a new system and substitution of the time you would have spent seeing patients in the office can easily be confronted by just working on it later when the office is ordinarily closed. This won’t take forever; just time enough to be comfortable with the process.

Decreased doctor-patient contact may be one of the true things that we miss most of all. I have found it very satisfying to use something like Skype—a computer program that allows free calls over the Internet and just recently added video calls—to actually see the patient’s face and have a nice chat. It’s way more relaxed, they are so pleased they’re not driving anywhere, and we reduce the cost of the "office visit." What a deal!

Patients’ fear of technology is something I do not know how to handle. Older folks often just say they are never going to have anything to do with computers, and they don’t want to start now. If it is important in the course of their medical care, I often see their children step forward and take over the communication part.

Cost of equipment for patients is only important if they think it is. Most people feel that communication by computer is just plain part of life. Software management problems usually only occur after you master the basics and are ready to soar as an Internet physician and start exploring new features.

At some level we think of change as just exploitation of patients. After all, heroic medical chart narrative involves the purity of professionalism, a pleasurable idleness woven into the texture of life. We all have put together our office practice as an elaborate construct for immobility, not another expression of medical genius. It’s our time to do something special.