Editor's note:For the latest news on coronavirus disease 2019, visit https://www.aappublications.org/news/2020/01/28/coronavirus.
Some pediatricians have been using telehealth to provide primary care to patients and families virtually for several years, but they have been the explorers in the technology world. Telehealth also has been used by health systems to improve patients’ access to specialists and by schools to provide care to underserved populations.
And then the coronavirus disease 2019 (COVID-19) pandemic hit, and everything changed overnight.
As cases of COVID-19 spread across the country and regional social isolation regulations were implemented, pediatricians en masse raced to adopt telehealth solutions so they could provide care to their patients where they are (mostly home) and sustain their businesses.
Many pediatricians who had been reluctant to adopt telehealth prior to the pandemic were swayed by patient need, relaxation of regulations and adequate payment. State-level payment parity has been instrumental in driving adoption, but there were many hold-out states. As the COVID-19 crisis spread, the Centers for Medicare & Medicaid Services relaxed regulations on patient location (not limited to a health care facility) and expanded payment, paving the way for private and public payers to get on board. In many cases, payers had no choice or patients simply would not have access to care.
Many practices got their feet wet by having nurses screen patients who called for an appointment to determine whether a telehealth visit was appropriate. Other practices created a virtual walk-in clinic and had one or more dedicated telehealth providers waiting for patients to initiate requests for care. As time goes on and practices get more comfortable, many are adopting both models.
What types of visits lend themselves to telehealth?
Mental health follow-up visits and dermatology complaints are amenable to a virtual visit with audio and visual synchronous components.
Many pediatricians, however, are uncomfortable using telehealth for other common pediatric complaints. We are trained to lay our hands on patients and listen to them to get the most information possible so we can provide safe and effective care. But when that is impossible, what does appropriate care look like?
Pediatric care often is centered on listening, reassuring and providing education. All of that can be accomplished effectively via telehealth.
When seeing a child with vomiting or diarrhea, for example, you can visually assess hydration status, reassure caregivers and discuss appropriate home care. If needed, you can refer to a higher level of care, which might be your office for an in-person visit.
Ear pain is challenging for most pediatricians performing telehealth. However, evidence-based guidelines state that in a child who is not ill-appearing, watchful waiting and pain relief is appropriate care even when you affirm a diagnosis of otitis media on visualization of the eardrum. Reassuring families that the child is not ill-appearing, reviewing home treatments and inviting them to follow up with an in-person visit if the child does not improve in 48 hours is consistent with best practice guidelines.
At the time of this writing, it was unclear when the COVID-19 crisis would end. So how does a pediatric practice continue to provide great care?
A reasonable place to start is to recall patients with chronic conditions who are due/overdue for appointments and perform them virtually. Some practices have set up virtual visits with all of their patients with asthma to review asthma action plans and medications on hand to make sure they are prepared if they had COVID-19 or other respiratory illnesses in the home.
What about well visits?
The Current Procedural Terminology code for well visits includes in its definition a comprehensive physical exam, which cannot be accomplished via a virtual visit. Yet, much of the well visit is history, review of surveys (developmental, depression, adolescent behavior risk, etc.), anticipatory guidance and education. Some payers are allowing the use of the well visit CPT codes without a comprehensive exam in this crisis period, but advocacy around telehealth well visits is ongoing. Furthermore, immunizations should be prioritized wherever they are safe to administer.
What does the medical home look like on the other side of this crisis?
Depending on the length of the crisis, we also must plan for the surge on the recovery side. Most practices will not be able to accommodate all missed well visits after the crisis has passed. That may be especially difficult if practices had to lay off staff during the crisis and need to replace them.
The mitigation phase of disaster management often includes improved infrastructure. It is unclear whether that will include adequate payment after the crisis period has passed so telehealth can become an integral part of the medical home.
There are times when we need to touch patients, and the virtual visit will never be the right answer for all pediatric visits. What will its place be in your medical home in the future?
Dr. Kressly is chair of theAAP Payer Advocacy Advisory Committee.
