Children’s hospitals care for many of the nation’s sickest and most medically complex kids, but in some cases during the COVID-19 pandemic, they were abruptly unable to see patients in person.
During the boom in virtual care, clinicians and hospital leaders scrambled to expand infrastructure for telehealth, adapt to technology and learn new ways of providing care to pediatric patients.
“Prior to the pandemic, there was hesitation to try telehealth among providers and families,” says Natalie Pageler, M.D., MEd, chief medical information officer at Stanford Children’s Health in Palo Alto, California.
“It’s a new skill for clinicians. But what happened during the pandemic is the risk-benefit balance shifted significantly. Providers were willing to jump in because they needed to maintain contact with their patients. Any contact was better than none.”
As children’s hospitals ease out of COVID-19 surges, they have space to reflect on what went well in virtual care last year and what the future holds. Now, attention turns to how to make the most of it.
“We have an opportunity now to look at everything we do in medicine through a new lens,” says Robert Ball, M.D., medical director, eHealth at Texas Children’s Hospital in Houston.
“E-health can help us improve so much in health care: how we communicate with patients, how we look at quality, how we meet patients in the place they want to be met. It’s like doing a reset on patient interactions.”
Getting patients online
Telemedicine can remove some barriers to care, particularly for families who travel long distances, rely on public transportation or must take off work for appointments.
But for many low-income families, it shifts the challenges.
“You hope that telemedicine would eliminate some barriers the underserved have connecting with health care, but it’s just changed the barriers,” Ball says.
Families with private or commercial insurance typically have the economic means to support a telehealth appointment with the right devices and sufficient internet bandwidth.
Often, if one device fails, there is a secondary smartphone, tablet or laptop to use as backup.
Many of Stanford Children’s Health vulnerable patients received laptops through school at the start of the pandemic, which helps but doesn’t solve internet access issues.
Ideally, a family would be able to connect from a device that allows for the full virtual experience—reliable connectivity, audio, video, screensharing and portability for appointments that require privacy.
“There are still plenty of children out there who don’t have the proper internet access or devices,” Pageler says. “Right now, we are working on a project to get a better handle on the disparity, then develop focused efforts to address those challenges.”
In low-income households, families are more likely to have outdated devices and weak connectivity, especially while others in the household are doing virtual school or work.
And families on data plans use up so much of their allotted balance for a virtual appointment that “it’s absolutely devastating because they can’t afford it,” Ball says.
Children’s hospitals are looking for ways to alleviate these burdens. Short-term solutions include Texas Children’s allowing families to use a clinic’s Wi-Fi from the parking lot or come inside and use the practice’s telehealth set-up while the provider joins from elsewhere.
“We’re working hard to break down those barriers because telehealth is not a magic wand,” Ball says. “I dream of having a bandwidth infrastructure for education and medical needs.”
Also on Ball’s wish list: issuing iPads to children with chronic health conditions who will see the most benefit to virtual care.
He says just like any other medical device, access to an iPad and consistent care could lead to better outcomes and a better experience with the health care system.
Even for families who have the right technology, accessing the appointment can be a challenge. Many health care providers have now added a line item on their resume: tech support during appointments.
Pageler says clinical staff felt unprepared for the demands of the digital environment, so Stanford Children’s Health developed telehealth champions in each clinic to quickly field basic how-to questions from providers during appointments. For more complex support needs, the clinician can direct families to a patient-facing help desk.
Pre-visit materials detail how to get connected to the appointment, and, at the beginning of the pandemic, a family outreach group conducted tech checks the day before every initial virtual visit to reduce troubleshooting during the appointment. “We made sure they could get on and know how it worked,” Pageler says. “That was important in helping with the success of those first-time visits.”
Providing quality care
With telehealth, the clinical environment is mostly beyond the control of the physician. In the shift to virtual care, certain disciplines were unable to get the basic patient information they were used to having.
“We replicated our in-person visit over telemedicine and that didn’t work,” says Andrew Savage, M.D., Pediatric Cardiologist and Ambulatory Director at MUSC Shawn Jenkins Children’s Hospital in Charleston, South Carolina. “We stressed about, ‘I can’t listen to their heart, how can I do this?’ At first we had very few patients who shifted to telemedicine because we were trying to replicate our appointments.”
But creativity has helped clinicians and patients get more out of a visit than initially thought possible. Parents are learning to be the eyes, ears and hands for the provider, taking photos and examining certain spots at the physician’s direction.
And providers who are invested in the future of telehealth are discovering ways to leverage the technology to better coordinate care. Stanford Children’s Health is working toward uploading patient data to the patient portal prior to the appointment, including any vitals parents collect. Endocrinology has had success with data uploading for diabetics using continuous glucose monitors, not skipping a beat in care when things went virtual.
In the last year, some of the best candidates for virtual care have been chronic patients who rely heavily on the health care system. Savage’s proposal for telehealth going forward shifts the strategy of a medical visit toward quick touchpoints to make sure medication adjustments are working or symptoms are improving, rather than treating every visit as a full visit.
“Telemedicine may be beneficial in shorter, more frequent visits,” Savage says. “A quick check in to see how things are going could prevent big complications. This is important for our highest-risk families. And chronic specialists, like our rheumatologists and endocrinologists, appreciate seeing families in their home environments.”
Virtual care also adds the possibility for reduced wait times for specialty and sub-specialty care appointments. For clinical areas that often have long waiting periods, Savage says telemedicine could facilitate quick initial visits.
“You can wait two weeks to see a cardiologist, but what you may actually need is an electrophysiologist who specializes in rhythm,” Savage says. “Now you have to wait again for your next appointment. Instead, you could have a 10- minute virtual visit with a provider within the first week of the referral. They’ll direct you to the correct sub-specialist, and while you wait get the testing you need.”
If the process works, by the time the patient sees the correct sub-specialist for the in-person visit, they’ve already received the right referrals and completed necessary tests to maximize the visit. Ball agrees telehealth gives providers an opportunity to rework patient flow.
“We can reflect on our own experiences as patients,” he says. “For example, I know whoever did my ultrasound knows the result as I’m walking out the door. Wouldn’t it be nice to have an answer and not hear, ‘Your provider will contact you in 48 hours?’ Even if it’s just, ‘Everything is OK.’ There’s so much we can do with telehealth to improve the family experience and close those clinical loops.”
It’s not for everyone
A virtual environment introduces unfamiliar technology, new workflows and different provider-patient dynamics. For some, the transition to virtual care was easy. Others struggled to adapt to the abrupt changes to their practice.
In Texas, Ball noticed providers were so focused on if the virtual format was going to work that they weren’t on top of their clinical game. He calls it practicing under the influence of telemedicine: some impairment in conducting a patient encounter due to new technology.
“They were distracted by how they were doing it that they forgot the decades of skill they have caring for patients,” Ball says. “Professors felt like medical students and interns. That is hard.”
Ball found a caregiver’s level of comfort with telemedicine had to do with a mix of technology and diagnostic confidence. Newer physicians are typically more comfortable with the technology, adapting quickly to new processes and systems. However, determining a diagnosis virtually is harder.
More experienced providers have clinical assurance but, if they weren’t using telehealth prior to the pandemic, are more prone to having difficulty with the technology. Success lies in the provider’s willingness to embrace telehealth paired with diagnostic and technical confidence.
The divide among which physicians perform well with telemedicine reinforces the need to allow individual practices and providers to decide if—and how—they use virtual care. Hospital leaders believe telehealth has a role to play in delivering care and achieving positive patient outcomes, but how virtual strategies are implemented and for which patients may look different depending on the provider.
“It’s not for everybody,” Ball says. “If you push somebody to do it and they’re not comfortable, the patient experience will be subpar. As we emerge from the pandemic, give providers the flexibility of backing away from it.”
The cost of care
Virtual care reimbursement typically varies by state. States like California have already established reimbursement rates for telehealth through Medi-Cal, its statewide Medicaid program. With the public health emergency declaration, there were additions to telehealth coverage for services like physical therapy and occupational therapy, which Pageler calls “a huge win.”
“There’s a little bit more certainty for us that for our basic telehealth visits, we expect to continue to get reimbursed,” Pageler says. “Some of the expanded coverage is an ongoing question. We’re trying to get better coverage for counseling appointments with just parents, which is a perfect use for telehealth.”
For states like South Carolina, there is more uncertainty. Recent changes implemented by some payers could reduce reimbursement payments to providers to be 75% of in-person rates, versus the one-to-one parity during the pandemic.
“We are prepared to adapt to the change, though it would decrease telehealth utilization and inhibit the innovative progress in enhancing access,” says Emily Warr, M.S.N., RN, interim administrator, Center for Telehealth at MUSC. “We remain optimistic the future reimbursement environment will be a positive one for continued telehealth services.”
As telehealth services are utilized now, hospitals still have the cost of maintaining clinical space, which positions virtual care to be an additional cost. Warr says the current cost analysis between technical needs and staff involvement for a telehealth appointment is about equal to an in-person visit.
But to Savage, telehealth offers a better clinical experience. “From a personnel standpoint, virtual care often requires more coordination,” Savage says. “But telehealth also prevents hospitalizations. There are some real advantages that could be advantageous to payers.”
With the continuation of telehealth programs post-pandemic, the process for providers and families should become more efficient. But efficiencies often come with a price tag, requiring software and hardware improvements as these programs grow. Maintaining high utilization of virtual visits will facilitate enhancements and demonstrate value.
“We’ve decided as an institution that telemedicine is important to our families and we need to continue to provide it as long as there is a market,” Savage says. The hospital finance team is supportive of moving forward with telehealth and currently partnering with each clinical area to identify needs going into the next fiscal year.
As children’s hospitals and health systems emerge from the chaos of pandemic telehealth implementation and move toward balancing in-person care and virtual visits, they begin to set their sights on identifying clear guidelines, staffing needs and making progress toward an improved health care experience.
“It’s not a perfect science and things will change, but we’re helping with planning and figuring out who we need to support and in what ways,” Pageler says. “We are doing it service by service coming up with next steps. This is the model we want to get to because we think it provides more continuous, supportive and proactive care while minimizing the disruptions in our patient’s lives.”