Pandemic Generates Best Practices for Pediatric Telehealth
By their very nature, pandemics stress healthcare networks, as providers are constantly adapting to new best practices that drive quality patient care. In the case of COVID-19, the challenge of providing preventative, acute and chronic treatment has been complicated by the risk of respiratory spread.
The obvious solution? Telehealth, where secure video capabilities allow for families and providers to experience medical appointments from two different locations.
The catch? General telehealth models for most community members don’t readily apply to pediatric patients, which means exploring new ideas and innovation to best care for children and serve families.
CHOC, which serves a handful of Southern California counties, started using telehealth about five years ago. The initial focus was helping outside emergency departments manage critically ill children and facilitate their transport for specialized care. Two years ago, our Population Health division began exploring the use of telehealth with subspecialists. This division includes after-hours nurse triage, developmental screening, and care management and telehealth relationships with community organizations, including schools.
Population Health was on track for 400 telehealth visits a year, with limitations – shared by healthcare systems across the country – related to insurers’ preference to reimburse only for in-person appointments. Then the coronavirus appeared in mid-March. With government insurers such as Medicare and Medicaid quickly authorizing insurance reimbursement for telehealth, private insurers soon followed.
In just 48 hours, CHOC’s telehealth team stood up nearly 500 primary and specialty providers on the hospital’s virtual appointment platform. Simultaneously, the hospital worked to promote expanded telehealth services to community members and launched a 1-844-GET-CHOC nurse advice line, open 24/7 to triage incoming calls and warmly hand off families to a doctor or nurse practitioner for an immediate telehealth visit if needed. Working from 6:00 a.m. to midnight for two straight weeks, including weekends, we dramatically upscaled our telehealth program using valuable evidence-based protocols available at the time.
Over the next eight months, our CHOC network provided 63,000 telehealth visits across 25 pediatric primary and specialty disciplines. As a result, we embraced innovation and assessed our outreach to further enhance our offerings to meet both the demands of and opportunities for telehealth, with a particular eye on caring for children and their families.
Lessons Learned from the Pandemic
Just as pediatric disciplines in in-person healthcare differ, they also display unique elements in the telehealth environment. Through the dramatic increase we’ve seen in virtual visits, the CHOC team has identified several key learnings to facilitate effective telehealth appointments.
- Providers need training. Providers are not trained to conduct telehealth visits. They are trained to be doctors, and they know how to be very good doctors. Through innovative online education modules, resource materials and even e-coaching, CHOC armed providers with best practices in telehealth, starting with basic setups, including lighting and how to engage on screen.Because the traditional in-person examination cannot translate directly to the virtual experience, the team focused on helping providers explore and gather other data that they don’t empirically think about but that can contribute to an effective telehealth session. That might be counting respirations while a child sits in a mother’s lap, teaching a parent how to count a pulse, determining alertness, and even looking at a child’s gait. You can even look at a child’s eyes and mouth to assess hydration.
- Talk to parents. The youngest patients can’t tell you what hurts. Even an older child who’s not feeling well can struggle to put their symptoms into words. Interaction with parents and guardians becomes even more critical in a virtual setting.We prepare providers to demonstrate their engagement by looking into the camera – not to be distracted by note-taking, for example – and be prepared with a different set of questions than they use in the in-person approach. Again, they’re picking up clues from observing the child over a video monitor and asking the right questions to help hone in on the proper diagnosis.
- Treatments are unique. Providers are more cautious in prescribing medications, particularly antibiotics, for young patients. Remember, pediatric practitioners have long relied heavily on physical exams to treat their patients. In the virtual exam room, the fact that you must care for essentially two patients – the parent and the child – can be even more pronounced. Greater attention must be given to collecting the right patient history from parents so providers can make sense of the child’s virtual examination and arrive at the correct diagnosis and treatment plan.
- Determine the right kinds of visits for telehealth. At CHOC, we know there’s a sweet spot in determining which cases to direct to virtual care. The first gate to get through is the discretion of the physician. If the provider – or the family – isn’t comfortable with a virtual visit, we’ll see that child in person.We quickly learned that you can’t assign cases to telehealth purely by symptoms related to expected diagnoses. Take two kids with stomachaches. One has no fever or vomiting; it might turn out he ate five pieces of candy and his belly is sore. But another kid has right lower-quadrant pain and a low-grade fever. You might be looking at appendicitis. Quality telehealth becomes about looking at the whole picture.In our first eight months of telehealth appointments, we diagnosed two cases of appendicitis – getting those kids seen in-person and operated on before the organ perforated – and our providers identified a neonate with a very serious blood infection.We know that well-child visits aren’t appropriate for telehealth, because you can’t deliver a vaccine virtually. Likewise, surgical and orthopedic specialties often require in-person appointments. However, CHOC is handling many cases in gastroenterology, endocrinology, speech therapy and mental health through virtual visits.
- You can assess the quality of care. At CHOC, we, like our peer institutions, are conducting appropriate research to confirm the quality of telehealth. Our innovation in this space is asking all children who come to our Emergency Department whether they’ve seen a doctor in the last seven days. If they answer yes, we ask if it was a telehealth or in-person visit. We want to seek out any trends in ER visits following telehealth visits.In the first six weeks of our study, we’re not seeing any surge, which is encouraging. We are aligned with new pediatric research that identifies four domains for identifying quality: health outcomes, health delivery, cost, and provider and patient experience. My mantra is that it’s incumbent on us to demonstrate quality in an objective way and that, perhaps, we can even deliver some care at a lower cost than through face-to-face visits.
A significant benefit of telehealth is improved access to preventive, chronic and acute medical care for underserved populations. But some obstacles remain with continued adoption of telehealth, including family access to internet services. For patients who need ongoing treatments, such as dialysis, our hospital is working with community partners to try to provide hotspot services for those families.
And there are some easy wins with telehealth, including easier in-the-moment language translation services with families. Another gain is streamlining scheduling of team-centered visits for CHOC’s high-risk patients; those teams start with a physician and case management nurse, but could extend to a social worker, a therapist, a school representative and others, as appropriate. We’re able to use technology to have multiple people in the same virtual room to interact with the family. Additionally, we’ve provided medical leadership on COVID-19 topics for local public health and school divisions.
Families have embraced the concept, as telehealth offers a convenient and safe way – particularly during a pandemic – to get initial access to healthcare. Patient satisfaction is 90% at CHOC, which helps demonstrate that we’re meeting families where they need us.
Do you have other best practices to share on improving pediatric telehealth? Contact the Lab to speak to someone from our team.
Dr. Mike Weiss is Vice President of Population Health at CHOC, a member owner hospital that is part of The Innovation Institute. CHOC taps into the resources of the Innovation Lab, which works closely with administrators, providers and staff to ignite innovation that improves healthcare.