Wow have things changed! My daughter, Gretchen, who has two children younger than age 3 years, recently called me for advice on well-child visits and immunizations. Is it safe to take them to their pediatrician? Are well visits necessary during this coronavirus disease 2019 (COVID-19) pandemic? My response was that, although staying at home as much as possible is important right now, she should take them for their well-child checkups and immunizations, which unfortunately cannot be done virtually.
Given the need to socially distance for the foreseeable future, what aspects of pediatric and adolescent health care can be accomplished via telehealth visits? And what exactly is telehealth/telemedicine/virtual visits?1 Telehealth includes all care models that use an electronic transmission of health care data. Telehealth can be further defined as synchronous, meaning there is real-time communication or transfer of data, or asynchronous, where there is non–real-time data transmission. “There are two principles that guide all forms of telehealth: (1) the standard of care for any given condition is the same regardless of whether care is provided in person or via telehealth; and (2) the site of care is the patient's physical location at the time of the telehealth encounter.”1
With this framework in mind, particularly given the ongoing efforts by the American Academy of Pediatrics (AAP) and other organizations to encourage private insurance and Medicaid payments for telehealth visits to continue for at least 90 days after the public health emergency declaration expires,2 it is important to explore what tools might facilitate primary care through a telehealth medium. Practicing clinicians are already equipped with the basic tools (ie, phone, tablet, computer) to conduct telehealth virtual visits. However, there are some newer technologies available such as digital stethoscopes and otoscopes, remote home-monitoring devices to track glucose and pulse oximetry, and even devices that can capture an electrocardiogram or conduct a sleep study virtually.1
Given the availability of different technologies, it is interesting to see what types of medical and preventive health issues have been accomplished virtually by using telehealth. They include remote interpretation of radiology studies, echocardiography, and toxicology; acute care visits at day care centers; pre-transport assessment and stabilization of infants who are critically ill and children at community hospitals; remote monitoring of patients in their homes and long-term care facilities; subspecialty consultation, especially in rural and remote care areas; global health programs; primary care pediatric visits; mental health visits; remote monitoring of patients; and newborn weight checks.
To process this new virtual world, the AAP has provided a compendium of online resources offering general and technical information for pediatricians to help set up and incorporate telehealth into their practices.3 As the issue of future reimbursement for tele-health becomes clearer, it will also be important to consider implications for malpractice coverage for this new form of medical care.1
Only time will tell whether tele-health will maintain its current ubiquitous presence, but our patients have certainly taken notice. Dr. Benjamin Kornfeld, a practicing pediatrician who writes for our “Healthy Baby/Healthy Child” column, has observed first-hand the tremendous appeal of telehealth from the patient perspective: “It's a really interesting topic and I think the most fascinating aspect for me is to see how much of this all ‘sticks around’ as a millennial generation of parents gets used to this sort of way to conduct visits. I've heard from many parents how much more they like and value the ability to do certain things from the comforts of their home.”
In addition, Dr. Bridget M. Wild, who is a pediatric hospitalist and also writes for our “Healthy Baby/Healthy Child” column, has provided her thoughts about the utility of telehealth in her practice and that of her colleagues: “It's worth mentioning that the benefits of providing care in place are bi-directional. As many subspecialists cover consultation at multiple hospitals, the ability to limit exposure and triage patients to the appropriate level of care from the ER to avoid multiple transfers is helpful. While there remain nuances to communication and examination that the screen cannot replace, the more comfortable our sub-specialists have become with the virtual platform, I have noticed the frequency of check ins with the family has been able to increase from baseline availability. Without traveling, they are able to round in the morning and late in the day.”
What is clear to primary care, subspecialty, and community and tertiary care practitioners is that telehealth has become and will continue to be an integral part of ongoing clinical care of pediatric patients and their families.