Telehealth – Where Are We Now?

Mother and daughter on a video call with a doctor for a online medical consult

Claudia Gamez and Jesus Zazueta used to make frequent trips from Yuma to Phoenix Children’s Hospital due to their daughter Aileb’s complex medical conditions. They would pack up Aileb’s medical equipment and rescue medication, and leave sometimes at 3 a.m. depending on her appointment times. If Aileb needed a diaper change or had a seizure, her parents pulled off the highway to attend to her needs. After one of these trips, it frequently took Aileb, now 7 years old, a few days to get back to her regular routine.

In spring 2020 when the COVID-19 pandemic forced doctors’ appointments online, it was a game-changer for families like Aileb’s. While the technology to see patients via video call has been around for years, COVID-19 forced this option into the mainstream. Insurance companies also started covering telemedicine for most visits.

Many parents and medical professionals call telemedicine the “silver lining” of the pandemic and have learned strategies for successful visits. But is this level of telemedicine here to stay?

Arizona’s executive leadership indicates that it is. In May 2021, Arizona Governor Doug Ducey signed legislation related to telemedicine. According to a statement from the governor’s office, House Bill 2454 expands access to telemedicine for patients and ensures that doctors receive equal compensation from insurance companies for telemedicine services compared to in-person visits. The bill also allows out-of-state healthcare professionals to provide telemedicine to Arizona residents.

BRINGING HEALTHCARE TO THE PATIENT
The Centers for Disease Control and Prevention define telemedicine as the use of electronic information and telecommunication technology to get the healthcare you need while practicing social distancing.

One unexpected advantage of telemedicine is that it brings doctors into patients’ homes. Instead of being confined in an examination room, patients stayed in familiar environments. Parents wouldn’t want their children with mobility challenges to crawl around on the floor of a doctor’s office. However, during a video appointment, a child can move around at home for the doctor to observe via camera.

“Much can be gained from a video visit because we get a glimpse of what it’s like in the patient’s home,” said Wendy Bernatavicius, MD, division chief for primary, complex care and adolescent medicine at Phoenix Children’s Hospital. “In the office, it can seem sterile, rehearsed and a less involved conversation. As a doctor, during a video visit you’re reminded of other things going on in a family’s life.”

Before the pandemic, Claudia, Aileb’s mom, was not as open to telehealth visits. “I wanted doctors to check my daughter and make sure they caught everything,” she said. “COVID gave us the opportunity to reach another level of telemedicine. During a clinic visit I might talk about things Aileb can do at home, but with telehealth I can show the doctors.”

Telemedicine can also allow parents to join an appointment from two different locations. Aileb’s dad Jesus often connects to her telehealth appointments while at his job. “It’s amazing!” Claudia said. “He can take part in medical decisions for our daughter without physically being there.”

Families can sometimes see unexpected cost savings with telemedicine. Trudy Billy, Tribal Program Manager for Raising Special Kids, spoke with parents who said they would previously travel from remote areas such as Tuba City to Maricopa County or Flagstaff for doctors’ appointments. Food and lodging are frequent additional expenses for these families but telemedicine appointments can save them both time and money. One family in Tuba City started with virtual visits to their son’s doctor, ultimately needing to travel to Phoenix for ankle surgery. But over time, the family saved several trips and enjoyed their virtual appointments. They did caution other families to research their insurance coverage for telemedicine because their private insurance only covered a specific number of visits.

COMBINING TELEMEDICINE AND IN-PERSON VISITS
While telemedicine seems to have its place, it’s not necessarily the best option for every doctor’s visit. During well checks, the child’s weight, height, blood pressure and other vitals need to be collected, which is certainly easier to do in person. In-person visits are also needed to ensure that children’s immunizations are kept current.

“What would be fantastic in the future is if we had a telemedicine kit that parents could buy or that insurance could cover with a scale, blood pressure cuff and other tools,” Dr. Bernatavicius noted, to enable well checks via telemedicine. “Maybe that’s in the future?”

Sometimes parents can take their children to off-site labs for blood draws or lab work before a scheduled appointment, and then use a virtual appointment to discuss concerns or surgery preparation with their child’s doctor. Adam Turner, 15, sees an endocrinologist in Phoenix for hypothyroidism. His family lives in Scottsdale and his mom Louise was able to take him to a nearby clinic for blood work before an electronic visit with the endocrinologist. “It definitely saved us driving time and we avoided in-person contact during the pandemic,” Louise said.

Doctors and patients can also use online visits to discuss surgery preparation. “We might have a lengthy clinic visit to discuss indications for surgery and why a child is a good candidate,” said Emily Andrisevic, MD, orthopedic surgeon at Phoenix Children’s Hospital. “As we get closer to a surgery date, the family can gather questions. We’ve had some really good perioperative discussions over telehealth.”

Another advantage of telehealth visits for pre-surgery discussion is that the child is less nervous, not needing to go to a doctor’s office, Dr. Andrisevic noted. “The children are in their home environment so it’s a lower-stress situation.”

TELEMEDICINE IN ACTION
As parents gain more experience with telemedicine visits, they learn strategies to make these appointments more successful.

Cheryl Gilroy has five children, four with special needs. Before the pandemic, taking one child to an appointment frequently required her to either get a sitter for her other kids, or bring everyone along with plenty to do so the other children wouldn’t become restless.

Her son Jacob, 7, is bilaterally deaf, and cochlear implants enable him to hear. He participates in speech therapy sessions at home through video calls. During speech therapy, he needs to be in a quiet room without distractions, at a computer with the door closed and Cheryl by his side. She alerts her other children ahead of time that she will be unavailable during those sessions. Cheryl sometimes provides specific toys or games that his siblings can play with only during Jacob’s telehealth therapy appointments, making the time special for her other children too.

Amanda Akey participates in her son’s occupational, speech and physical therapy sessions through telemedicine. She uses her phone instead of a computer during these appointments, which enables her to reposition to show the doctor or therapist how things are going. Otherwise, she uses a phone stand to keep the view steady during appointments. The whole family gets involved with the therapy sessions. She has four children, including Leonard or LJ, age 3. LJ has a genetic condition resulting in hypermanganesemia, acquired brain injury and movement disorders including dystonia.

Telemedicine proved especially helpful when Amanda struggled with positioning for LJ in the bathtub. During a session with LJ’s occupational therapist, Amanda could bring the phone into the bathroom while LJ, in swim trunks, was in the bathtub. “You can’t do bath time at (the doctor’s office),” Amanda said. “When his therapists could see him at home, they could brainstorm with us and coach me so I could use the skills we learned during telehealth in our own environment.”

Parents seem to agree that telemedicine visits work best when the family already has a good relationship with the doctor. Any particular needs like language interpretation services or sign language can be requested before an appointment, but these requests will already be known if the child is an established patient.

FROM THE DOCTOR’S POINT OF VIEW
During the height of the pandemic, Barrow Neurological Institute at Phoenix Children’s Hospital saw 80 to 85 percent of their patients via telemedicine visits. As of late May 2021, 60 to 70 percent of visits still use telemedicine.

“People have latched onto this, providing a positive experience for child and family,” said P. David Adelson, Chief of Pediatric Neurosurgery and Director of the Barrow Neurological Institute at Phoenix Children’s Hospital. Telemedicine has proven to be effective for simple neurologic exams and discussing results like imaging, allowing the doctor to share a screen while going over the findings.

In addition, parents of children who will undergo surgery from a new physician want to meet the doctor beforehand. With telemedicine they can do this online instead of taking a day off work and school and traveling to a doctor’s office, which for some may mean hours in the car and arranging childcare for other siblings, Dr. Adelson noted.

The institute did an informal quality audit to investigate if there was an increase in the number of patients coming to the emergency department after telehealth visits compared to in-person visits. They did not see an increase. If doctors or medical assistants saw specific concerns during electronic visits, they could still recommend that families schedule in-clinic visits.

Like many specialists, Banner Children’s Pediatric Endocrinology department did most visits via telemedicine through the height of the pandemic. Although once the state began reopening, most patients of the pediatric endocrinology clinic wanted to return to in-person visits, said Rachel Calendo, RN, Nurse Practitioner and Diabetes Program Manager. The department still frequently uses telemedicine for training, including helping patients and families learn more about using continuous glucose monitors or insulin pumps, she added.

The best of both worlds seems to be a combination of in-person appointments and telemedicine visits when appropriate. “Telemedicine is absolutely here to stay,” Dr. Adelson said. “It’s now so widely accepted by patients, families and healthcare providers. It’s not the end-all, and in-person visits are still needed, but telemedicine is an opportunity to expand patient access and provides the opportunity for patients to receive high-quality care, even from a distance.

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