What Telemedicine Means for Pediatric Health Care

As part of an effort to flatten the curve of COVID-19 and maintain physical distancing, Mass General for Children and many other health care providers shifted their practices towards offering more virtual visits for patients and their families. This method of care allows patients to still be seen and cared for remotely where feasible, while reducing the exposure of patients and providers. With pediatric health care, however, there can also be some unique challenges that providers should keep in mind when meeting with their patients virtually.

Katie Brigham, MD, a pediatrician in the Adolescent and Young Adult Medicine Clinic at Mass General for Children addresses some questions and important differences providers should consider when caring for their pediatric patients via virtual visits.

Q: What are the benefits of virtual visits for pediatric patients?

Brigham: The big benefit is that it allows us to still see patients who need to be seen in a way that’s safe for both the patient and the provider. In some cases, there may be concerns that a family member might be contagious, so it would not be safe for that child to be seen in the office. But with virtual visits we can still provide medical care for these children and adolescents. In addition, having these types of visits also decreases the number of patients seen in the hospital, which decreases everyone’s potential exposure, too.

That said, we’re still taking incredible infection control measures to make sure that if someone needs an in-person visit, we are able to do so safely and effectively. We have spaced out appointments, avoided having large groups together in rooms, separated chairs in waiting rooms, and added barriers between the reception desk and patient checking in.

Q: How might pediatric telemedicine visits differ from adult telemedicine?

Brigham: With pediatric visits, it’s often not just the child or adolescent present, but generally there is also a parent or guardian as well. This can also happen with virtual visits, where in addition to the patient, caregivers or other adults might also be on the Zoom or telephone call.

Another thing that's very interesting is we get to see our patients “at home” in their home environment through these types of visits. It can be scary for children to see a doctor because they're worried about getting a shot or it's just a new environment, but they’re generally quite relaxed when participating in a virtual visit from home. As a result, it can actually be easier to assess children’s developmental milestones—on a video visit you can see them doing things like playing in their own home—so you may get a more accurate picture of their developmental stage than you would have had it be a more typical in-clinic visit.

Q: Are there ever situations where, while it may not be as accurate as what you might get in the hospital, you can ask a caregiver or an older sibling to take someone's pulse, or use a scale at home to get a general weight, for measurements you would normally do in person?

Brigham: Yes, we often ask patients or caregivers to check the patient’s vital signs. One of the things I treat is eating disorders, so for virtual visits, we will ask the patient or parent to weigh the patient prior to the virtual visit. I’ve also discovered that many families have blood pressure cuffs at home, perhaps used for taking care of a grandparent or because a parent is in a medical field. This has been very helpful for adolescents, but most families probably don’t have the right cuff size for an infant or a small child. I’ve taught patients how to check their own pulses, and I often will watch them breathing to count their respiratory rate. We are getting creative in ways that I think none of us anticipated doing, but it's been really rewarding.

Another thing that’s surprised us all is how much of a physical exam we can do without physically touching a patient. While I’m not able to use my stethoscope to listen to someone's lungs or heart, but I can observe the way they're breathing while they're talking to me, and I can look at their chest and see if they're working harder to breathe. For patients who are acutely sick, virtual visits can act as an initial triage step to figure out which patients really need to be seen in person, and where is the safest place for this patient to then be seen. We can keep treating most children at home but for the ones who do need to be seen, we are then able to facilitate arranging an in person evaluation.

Q: Some patients or caregivers may feel more comfortable answering some personal health questions in writing versus speaking to another person. Do you have any suggestions for techniques to address this and get patients in virtual visits feeling more comfortable with the video calls?

Brigham: Over Patient Gateway we are able to assign patients the questionnaires that we would normally have them fill out either on an iPad or on paper in the clinic before seeing their provider. I have also had patients message me over Patient Gateway ahead of virtual visits to give me a “heads up” about issues that they want to make sure we address, which is incredibly helpful if they’re hesitant to initiate these conversations.

In March 2020, when quarantine started, virtual visits felt very new for a lot of people—for both providers and patients. I think for people who have tried the technology and have been using it for a few months, it’s not as big of a deal now. Once you get over the initial difference of being on a zoom call versus being in the office, most are quite comfortable with it. I think what worries us a lot more is that there are some patients who don’t have enough data on their plan to video call in with us, or don’t have  WI-FI in their house and aren’t able to participate in a video visit. We do offer telephone visits, but then a lot of the visual cues you can pick up on from a video call are lost. We are concerned about this “digital divide” that we know already exists, and that this is could be worsening outcomes for patients who don’t have access to these technologies.

Q: With pediatric virtual visits, there may often be a guardian or someone else in the room during the call. This can be helpful or prevent the patient from feeling comfortable speaking fully about their health or questions. This can also happen in a clinic room, but you then have a lot more control over who comes in and out. How do you manage this with virtual visits?

Brigham: I will often just ask the patient, “[child’s name], who else is in the room right now?” That way I know who might overhear what we’re discussing. If it’s just the case where there are other people in the room having lunch, for example, and not actively participating in the virtual visit, I might suggest the patient go to their bedroom or another location. However, this sometimes this isn’t doable if for example there is only one spot in their home that gets good  WI-FI, but you can suggest that they use ear buds so that way other people can’t overhear the conversation. You have to be careful that you don’t say anything that breaches their confidentiality.

I have also had patients use the chat function with me to tell me things that they don't want to say out loud, or to warn me to not mention something. However, if you feel that the patient is being supervised in a way that you can’t ask a particular sensitive question, unless it is something you feel absolutely sure you need to address and that is going to significantly change your management of the patient, I wouldn’t ask them at that visit, and would wait for the next one.

Q: In addition to the chat function, is there any other advice you have for patients who may need to signal the need for a more private visit, but can't overtly state it?

Brigham: With Mass General for Children, you can always send a follow up question on Patient Gateway and tell the patient to check their account that evening or the next day. I sometimes send messages like this just to make sure that the patient understood instructions I gave on a call.

Q: When the provider and parent or patient don't share a common language, are there any additional considerations to make with virtual care?

Brigham: At MGfC, we can use interpreter services. If there is an interpreter at Mass General who can translate that language for us, you can add them into the video call. For any languages where we don’t have an available Mass General interpreter, we use a confidential outside interpreter service, and in those cases I will call them on my phone and put them on speaker right next to my computer so the interpreter speaks through my phone and the patient can hear over my computer. We can help patients in every language for virtual visits.

Q: Despite the safety initiatives the hospital has in place to ensure a safe environment for everyone, many parents and children may be hesitant to come for care that cannot be done virtually. How do you have conversations about the importance of in-person care when that’s needed?

Brigham: I usually review the screening process before a patient comes in and reassure them that everyone who comes to the hospital gets the same screening. I explain that we screen for symptoms, such as asking if anyone has a fever or a sore throat, and if they do, we don't have them come into the regular care areas of the clinic. The hospital has designated sites for patients who need to be evaluated for COVID-type illnesses or who may have COVID-19 but need care for a non-COVID related illness. These sites are separate from where typical clinic patients are seen. I also explain that everyone is given a mask and sanitizes their hands upon entering. I feel very confident when I ask my patients to come in that we are taking effective precautions to keep everyone safe.