Expanding Telehealth in Adolescent Care: Moving Beyond the COVID-19 Pandemic

Before the COVID-19 pandemic, adolescent-focused telehealth programs were seen primarily in school-based health centers and behavioral health programs. A 2016 survey identified that only 15% of pediatricians had used telehealth in the previous 12 months, and the equipment costs and limited reimbursement were the most significant barriers to use.⁶  Between 2008 and 2017, the use of telehealth in school-based health centers increased by 271%, with most of the growth occurring in rural schools and sponsored by hospitals.⁷  Several other promising models of telehealth care emerged before the COVID-19 pandemic. One such focus has been on children and adolescents with medical complexity. A 2019 study of the use of in-home telehealth devices that included a stethoscope in children and adolescents with medical complexity revealed a lower rate of ICU admission in the intervention group, resulting in a cost savings of $9425 per patient over the course of the 4-month study with high levels of caregiver and medical team satisfaction.⁸  There have been several models of delivering asthma care at school,⁹  with evidence that the use of telehealth for rural students with asthma decreased the use of emergency departments by 20%.¹⁰  Despite emerging evidence of the benefits of telehealth for adolescents before the pandemic, concerns regarding the lack of evidence supporting its use and questions regarding the scope of health issues that were appropriate for care via telehealth persisted.¹¹ 

Physicians are receiving support from major medical organizations to implement telehealth in their practices, including the American Academy of Pediatrics,¹²  American Medical Association,¹³  and the American Academy of Family Physicians.¹⁴  Despite this support, information regarding the quality of care provided to adolescents via telehealth is still lacking and continues to be a significant barrier to compensation for care.¹⁵  The American Academy of Pediatrics Section on Telehealth Care Supporting Pediatric Research in Outcomes and Utilization of Telehealth has consolidated multiple national evaluation frameworks into 4 domains: (1) health outcomes, (2) health delivery: quality and cost, (3) experience, and (4) program implementation and key performance indicators¹⁶  Although not every physician will be engaged in research, considering the potential impact of a practice’s telehealth program on these domains will assist in assessing its value in all 4 domains.

Current research is focused more on adolescents’ access to and experience receiving care via telehealth than on clinical outcomes for specific conditions. Surveys of adolescents and young adults, along with caregivers, when appropriate, have identified tremendous support for the use of telehealth. A survey of adolescent patients (n = 55) at an academic adolescent medicine subspecialty clinic and their caregivers (n= 123) identified that telehealth was “highly acceptable” and noninferior to in-person care for confidentiality, communication, medication management, and mental health care.¹⁷  However, adolescents in this study had a higher degree of concern about confidentiality than their caregivers, and one-quarter of patients had technical difficulties. An online survey of 13- to 17-year-olds focused on mental health care utilization during the pandemic revealed that parental support increased the likelihood of having private space for a virtual visit.¹⁸  Additionally, the research revealed that text-based care was more prevalent among “minoritized” adolescents; Black adolescents were less likely to report in-person visits, and, among those unable to receive care, Black adolescents preferred in-person care. In a mixed methods study, 13- to 17-year-olds who had completed a telehealth visit with their pediatric practice (n= 48) and their parents (n= 104) described telehealth as confidential, convenient, useful, and private. The study also revealed that only 31% of the adolescents had alone time with the provider, and those that did found themselves more comfortable discussing private issues.

Although there is great promise in improving access to care with telehealth, there is also the chance to exacerbate health care inequities. For telehealth to serve as a tool for improving health equity, multiple aspects must be considered, as outlined in the Digital Health Equity Framework, which promotes multisector efforts for resourcing of, and access to quality digital health care for all social groups to reduce digital health disparities.¹⁹  At the practice level, examining how to implement virtual care and increase health literacy is essential²⁰  Community-level work should be focused on providing access to care where adolescents, especially those with limited access to technology, can find privacy and free broadband access. These locations may include schools, libraries, and youth-serving organizations. Advocacy must also focus on improving access to broadband in all communities, assuring reimbursement for multiple modalities of telehealth, and connecting telehealth care to the medical home to ensure continuity of care.

The American Academy of Pediatrics advocates that telehealth is most valuable when provided by the medical home.²¹  Yet, integrating multiple modalities of telehealth into the care of adolescents may be beyond the reach of many medical homes. A more practical approach would be acknowledging that innovation moves quickly, whether in school-based telehealth or disease-specific apps and digital therapeutics. Hence, the ability to collaborate in the care of an adolescent with a curated number of these services, instead of needing to support the entire infrastructure in practice, would allow for more rapid and appropriate adoption. Key to this collaboration is the principle that all information flows back to the medical home.

Telehealth already creates a risk for fragmented care, and, as more entities enter the world of telehealth, the potential exists for these silos of care to further develop and evolve. We must find the balance between improved access to care through telehealth and the fractioning of care due to a lack of coordination. For example, access to reproductive health care or gender-affirming care may only be needed by some adolescents via telehealth; however, the medical home must have the information necessary to provide longitudinal care for an adolescent.

Another challenge of telehealth is ensuring that adolescents receive developmentally appropriate and confidential care essential to reducing disparities and improving health outcomes.²²  Confidential care must be provided regardless of the modality used to communicate with the patient. Ensuring that physical space, chats, and patient portals are properly secured is an important consideration to optimize quality care. There is a clear role for adolescents and providers of adolescent health care to work with technology companies to ensure that telehealth products are developed with a focus on maintaining adolescent confidentiality.

In a future state in which multiple telehealth modalities are integrated into adolescent care, we can reenvision how we provide more relevant preventive care and anticipatory guidance. Instead of the snapshot provided by the annual well visit, we collect data through scales, questions, screening laboratories, and a brief physical and then act on it through brief intervention, anticipatory guidance, and handouts. Telehealth may allow an ongoing, adaptive conversation focused on adolescent wellness. For example, periodic risk behavior and mental health screening could be conducted with short, chat-based questions delivered at regular intervals. The provision of care in this manner would allow access to a private space and increase confidentiality. Responses would trigger timely, developmentally appropriate, and culturally sensitive anticipatory guidance through a secure app or an immediate video visit with a medical team member for an acute crisis. Additionally, when appropriate, parent-focused health information could be delivered immediately.

For adolescents with limited access to a physician’s office, an annual physical examination (excluding the genitalia) would be accomplished by sending a peripherally enabled telehealth device to the home or collaborating with a community-based telehealth access point. Immunizations would be provided through school nurses or pharmacies, allowing them to be administered according to the recommended vaccination schedule and increasing access for adolescents unable to come to the office for a physical examination. Once a health issue, such as acne, is identified, the physician may employ a dermatology app that analyzes weekly images through artificial intelligence to evaluate the benefit of a new treatment regimen. Increasing the utilization of multiple telehealth modalities is a low-barrier model for improving adolescent access to care.

Telehealth can also be used outside of the direct clinician-patient relationship. Geography and capacity limits have reduced access to subspecialty care for adolescents, including with the Adolescent Medicine subspecialist. In the United States, the average distance an adolescent must travel to receive care from an adolescent medicine specialist is 35 miles. For an adolescent living in Alaska, the average distance is 1429 miles.²³  Additionally, only 4.6% of Adolescent Medicine subspecialists practice in rural communities²⁴  Virtual visits have tremendous potential to decrease geographic barriers; however, the number of Adolescent Medicine specialists is still limited. E-consults, or provider-to-provider consults, can potentially increase access to care. Using an e-consult system in an urban adult practice safety net study decreased referrals by 25% and the wait time for a subspecialty visit by 17.4%.²⁵  Although the pandemic has bolstered opportunities for interstate clinical practice, e-consult networks are often tied to large health systems, potentially making them less accessible across state lines.

Finally, it must be recognized that adolescents need physicians and other health care providers to interact with them on their terms and their schedule. Telehealth has the potential to transform how adolescents engage with the health care system; however, it is the responsibility of clinicians to adapt practice styles to meet the needs of adolescents and adhere to the expected standards for high-quality, confidential, and comprehensive models of care. Accomplishing this will require that clinicians redefine how they practice, advocate for changes in payment systems to allow for reimbursement for innovative care approaches, and extend partnerships beyond the medical home to virtually connect adolescents to the best services to meet their individual health needs.

COVID-19

coronavirus disease 2019