Pediatric telehealth gets ‘trial by fire’ during COVID-19 pandemic
Many practices, if they did not have them already, set up telehealth services during the COVID-19 pandemic — one of several ways that clinicians have adapted to care for patients during ongoing social distancing measures.
Infectious Diseases in Children Editorial Board Member C. Buddy Creech, MD, MPH, associate professor of pediatrics and director of the Vanderbilt Vaccine Research Program at Vanderbilt University Medical Center, said he and his colleagues have been using telehealth services since before the pandemic and were prepared for the shift in practice.
“We always want in-person visits to be available to those who need them but we also recognize that in this time, there is a great deal of anxiety around coming to the medical center,” Creech said in an interview. “Our guiding principle for telehealth, whether pre-pandemic or during COVID-19, is that we want to provide medical care in the most efficient and effective way possible.”
Creech currently uses Vanderbilt’s system, My Health at Vanderbilt, which serves as a portal to allow families to access bills, check lab results, securely message doctors and providers and request immunization records. The portal also lets patients connect to their providers over Zoom.
“We have integrated an encrypted version of Zoom into our electronic medical record system and established workflows and standard operating procedures for video teleconferencing,” he said. “Through our EMR — Epic — I receive a notification on my phone that a patient has arrived at their telemedicine visit. In that way, it looks very similar to a visit I would have in my clinic.”
Although no one expected such a drastic shift to telehealth only 6 months ago, Creech said pediatricians and specialists have adapted well.
“We have been working on building telehealth into infectious diseases for several years, and we hope that it is here to stay,” he said. “I think the pandemic has catapulted the approach into a different place. It’s trial by fire, but it’s been successful for us so far.”
Judd Hollander, MD, senior vice president of health care delivery innovation at Thomas Jefferson University, told Infectious Diseases in Children that the university’s program, JeffConnect, began in 2009 as a neurostroke network but became an all-access telehealth network in 2015.
“I’ve said long before this pandemic that everybody likes to say telehealth will be great in a disaster, but if you don’t have one before a disaster, it’s really hard to invent it during a disaster,” Hollander said.
Infectious Diseases in Children spoke with Creech, Hollander and other experts about the usefulness of telehealth and the aspects of the technology that can take some time to master.
‘A good place to start’
According to findings from a Kaiser Family Foundation tracking poll, 48% of people have skipped or postponed medical care during the pandemic, and 11% of those who have skipped care said their condition got worse. Telehealth appears to have filled some gaps in care.
Data published by FairHealth.org showed that monthly telehealth visits increased 4,346% in March 2020 compared with the same month last year. In the Northeast, telehealth visits increased 15,503%.
Among the experts who spoke with Infectious Diseases in Children, the consensus was that the biggest challenge is not being in the same room as a patient.
Infectious Diseases in Children Editorial Board Member William T. Gerson, MD, FAAP, clinical professor of pediatrics at the University of Vermont College of Medicine, said it took some time to adjust to using telehealth, but in 3 decades of practice, he has built a level of trust with his patients, which made it easier. One potentially challenging aspect of telehealth is taking on new patients that way, he said.
“Starting it up from scratch with families, I think would be a little bit hard,” Gerson said in an interview.
Another challenge in more rural states like Vermont is that there is less reliable access to the internet and broadband connectivity, according to Gerson.
“Broadband is a concern, particularly since we went to home schooling. We had lots of situations with a sort of functional broadband capability for many,” he said. “When we have both parents telecommuting and three kids telelearning, adding video conferencing can be a challenge. Recently, they further relaxed the rules to allow us to use FaceTime or other ways of accomplishing the same thing. Overall, the technical side of it was easier than others.”
Gerson said some rashes are harder to identify on certain cameras, but the switch to telehealth was not as big of a hurdle as he had initially anticipated.
“Telehealth is not for everything. It’s one tool,” Hollander said. “One of the ways to think about it is like a stethoscope. It’s a tool the doctor will use to determine what the right test and the right treatments are. Sometimes it may begin with telehealth, but you need something else.”
As an emergency physician, Hollander said he has many available resources in the ED, but that does not necessarily mean he knows what is wrong with a patient right away. He may need an X-ray or CT scan — tests that telehealth cannot offer. After meeting with a patient using telehealth, he may need to refer them to their pediatrician or an urgent care center.
“It’s a good place to start, and most of the time, we can resolve it on telehealth,” Hollander said. “More than three-quarters of the time you need nothing else.”
Susan J. Kressly, MD, FAAP, an AAP fellow who runs her own practice in Warrington, Pennsylvania, recounted a telehealth visit in which a patient’s family helped her rule out appendicitis.
“I just saw a patient with abdominal pain in the middle of the night. Every family’s nightmare is that this is appendicitis and they have to go to the ER,” Kressly told Infectious Diseases in Children. “I conducted a telehealth visit and the kid did not appear to be sick enough or have the right symptoms. It’s interesting, because I actually had the parents guide me through the exam. I’m saying, ‘Press here, let go. Tell me what’s going on.’ It was a teenager, so they were very cooperative, and it saved that child an unnecessary emergency room visit.”
Still, Creech said it is important to be able to physically examine patients, “to see a child with my own eyes, examine the abdomen, examine the lymph nodes, and to do all of the things that I would like to do.”
“I think telehealth serves a role, but I don’t think it can ever replace the physical interaction between a health care provider and a patient,” Creech said.
The effectiveness of telehealth also can depend on the specialty, according to Creech.
“For the specialties that are not procedural, it can be very effective,” he said. “Infectious diseases, endocrinology, genetics — these are specialties where the history and review of laboratory studies are often the most critical aspects of the visit.”
Telehealth also is convenient when parents are unable to take time off work for an in-person visit, especially one that will take not longer than 15 to 20 minutes, Creech said. Telehealth may be advantageous for families that travel long distances for routine follow-up visits. For these and other reasons, “I think telehealth will remain,” he said. Still, Creech has a preference for in-person visits.
“I think an important take-home message is that regardless of the technologies available to us, in-person visits are still preferable for many patient encounters,” Creech said. “I think that should still be our default posture for most visits.”
Mental health care
Experts have expressed concern over the potential negative mental health effects in children who have been in lockdown at home during the pandemic.
Telehealth has allowed pediatricians an opportunity to connect with their patients and check in with them to assure them someone is there, if needed. But this is not necessarily a new mode of care.
“One aspect of telehealth that has always been available, but we never really used it, was mental health follow-up and care,” Gerson said. “That’s been really quite good to do via telemedicine, being able to see the patient — particularly adolescents — face to face and being able to follow up more frequently because it’s easy to get to them.”
Kressly said telehealth visits to check in with patients who have anxiety or depression “have been very well received” in her practice.
“We said, ‘OK, we’re all stuck at home. Let’s take this opportunity to connect to see how you’re doing,’” Kressly said. “Especially with those kids with anxiety and depression who are locked in at home, it’s been amazing what we’ve [seen with] the added stress of not being in school and being socially locked down.”
Virtual mental health follow-ups can be “very enlightening,” she said.
“Getting a look at what is happening inside the family’s home, at least periodically, for all follow-ups gives you incredible insight when you’re talking to a depressed teenager. They’re talking to you from their bedroom, you ask them where they sleep and where they study, and you get a much better insight into them.”
Kressly said most patients have been more honest and open with her via telehealth.
“They are connecting with me on their terms,” she said. “I’m coming to them; they’re not coming to me.”
However, every advantage can bring a disadvantage, Gerson said. As much as he appreciates the convenience of telehealth, he noted that there are also confidentiality issues in some cases.
“You never know who is listening in the background,” he said. “You can ask, but you don’t know who’s on the other side of the closed bedroom door. It makes some of that a little awkward. We can control that a little better in our offices, but for some mental health care, it’s a little tricky over telemedicine. The idea of distance and confidentiality is a little bit more challenging, but I think overall it would be a nice change to be able to offer telehealth on a more frequent basis.”
‘What will happen down the road’
In the same way that people may no longer see business travel and working from home in the same manner after the pandemic, health care delivery may be altered in some way, Creech said.
“What will happen down the road,” Hollander said, “is both physicians and patients will get more comfortable with [telehealth]. We have great data — because we’ve been doing this for half a decade or longer — that show patients who do it, love it, and have an extremely high rate of returning to it, and are much less likely to feel the need to go to an in-person visit all the time. Now that patients are forced to use telehealth because they have little to no other options, they’re going to get an experience with it and they’re going to get used to it.”
Gerson agreed. Convenience is a major factor that will make more patients and families open to telehealth, he said.
“I think we have arrived at a way of seeing patients that’s been very convenient and efficient for physicians. It’s become quite clear that it is very convenient for families to access us over telemedicine,” Gerson said. “It’s sort of like our experience on cell phones.”
One issue has been cost. In general, CMS changes enacted prior to the pandemic have allowed for telehealth consultations and follow-up, according to Creech.
“In general, telemedicine visits do not reimburse at the same level as in-person visits do,” he said. “But it is certainly better than what could have happened during the pandemic, which is that we could have been trying to provide care but have no mechanism by which to seek compensation for that care.”
However, according to the AAP, some insurance carriers plan to stop covering telehealth services at the end of June after expanding and increasing payments. The AAP urged insurance companies and Medicaid programs to continue the payments for at least 90 days after the expiration of the U.S. public health emergency declaration, calling telehealth “a vital way for pediatricians to care for patients.”
“Telemedicine has played a critical role in expanding access to care for many patients, including those who live in rural areas or in areas without access to reliable public transportation during the pandemic,” AAP President Sara H. Goza, MD, FAAP, said in a statement. “Those needs will not end in June. Nor will the needs of children with complex medical conditions, for whom the ability to interact with pediatric subspecialists and pediatric surgeons to guide their follow-up care is critical for their long-term health.”
Hollander said that all companies should make sure their insurance policies provide access to telehealth.
“Not only will it drive down overall expenses over time, it’ll keep your employees at work more,” he said.
- AAP. AAP urges unsurers to extend telehealth payments during COVID-19 pandemic. https://www.aappublications.org/news/2020/06/03/covid19telehealthcoverage060320. Accessed June 4, 2020.
- FairHealth.org. Monthly telehealth regional tracker, March 2020. https://www.fairhealth.org/states-by-the-numbers/telehealth. Accessed June 4, 2020.
- Hamel L, et al. KFF health tracking poll – May 2020. https://www.kff.org/report-section/kff-health-tracking-poll-may-2020-health-and-economic-impacts/. Accessed June 4, 2020.
- For more information:
- C. Buddy Creech, MD, MPH, can be reached at firstname.lastname@example.org.
- William T. Gerson, MD, FAAP, can be reached at email@example.com.
- Judd Hollander, MD, can be reached via firstname.lastname@example.org.
- Susan J. Kressly, MD, FAAP, can be reached at email@example.com.
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