Telehealth lessons learned during the COVID-19 pandemic

Contemporary Pediatrics sat down with Andrew J. Schuman, Editorial Advisory Board member, clinical assistant professor of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and practicing pediatrician, to discuss what he’s learned about utilizing telehealth during the COVID-19 pandemic and how it’s shaped his practice.

Q. Now that you've done both telephone and telehealth visits for 2 months from home, can you compare the 2 in regards to effectiveness?

Dr. Schuman: Pediatricians are used to interacting with patients via telephone for years, decades. It's our traditional way of providing care to patients. Interestingly enough, it's services that we have provided free of charge. If you need to communicate small bits of information, telephone communication is more than adequate.

Ideally to mimic a real in-person visit you'd like to do a telehealth visit. There are many advantages in virtual video visits that are not present in telephone encounters. It's very important for physicians to interact and see facial expressions, to see how their recommendations are received, to perceive attitudes among patients. The telehealth visit is in many ways superior but not necessary.

In my own practice, I've found that it depends on the need of the patient, their technology capability, the software that your practice is using. There are many factors that go into the decision which to use, but both have their advantages as well as disadvantages.

Q: Do you have any new recommendations for selecting a telehealth service?

Dr. Schuman: Yeah, I do. There are many platforms available. The one that my institution uses patients continue to have problems with because they have to download applications, put in passwords, and so forth. There's lots of glitches that make 50% to 60% of our telehealth visits ineffective. I've done a little research and I find that there are 2 apps that I like to recommend for first time telehealth users.

One is Doxy.me, which is inexpensive, and is a web based application. Pediatricians, primary care providers can just enroll for a reasonable fee. I think it's $35 a month per individual. You merely send a link to a patient, they click on it, and you're there in a reasonable good quality video visit.

What's perhaps even more easy to use is a new application from Doximity, which at the moment is a smartphone-based application. You launch the application and you do nothing more than put in a phone number and send a link to the patient, they click on the link, and you're there. It's very simple, straightforward and it just works. The majority of my calls these days are by way of the Doximity app. I think in terms of technology, simple is probably better at the moment.

Once we emerge from this crisis, this pandemic, then one can decide what platform you want to use. It will depend on reimbursements and a number of different factors, but we'll have to see what happens.

Q: During the pandemic, have you seen a change in your management of ADHD (attention-deficit/hyperactivity disorder) patients and those patients with anxiety and depression via telehealth?

Dr. Schuman: I have indeed, for a variety of reasons. Patients are home with their parents; parents are home with their children; and parents have the opportunity to observe firsthand the activity level and the focus of their children. Whereas before the pandemic, they were getting reports from the teacher who had to pay attention to 20-30 kids. Now parents know firsthand if the medication is effective at the dosages we prescribe. It's also a very stressful situation for parents and children. So I've had to initiate medication and recommend video counseling for a lot of patients. I've had to adjust a lot of medications to more suit the environment that we're seeing in the midst of the pandemic. It's very interesting.

Q: Do you have any new recommendations regarding deciding whether to prescribe antibiotics during a telehealth visit?

Dr. Schuman: Yeah, I do. I have made some general recommendations and made the observation that pediatricians who have been doing pediatrics for a number of years, have acquired a skill set that enables you to look at a patient and without touching the patient, determine many things whether the patient has respiratory distress, is the child really sick or not. These are the basics that we know.

Over the course of many weeks, I've been surprised how few antibiotics I've prescribed. High quality video visits are ideal. It's easy to diagnose certain things by video, including certain rashes, impetigo, diaper rash, conjunctivitis, and so forth. I've been very surprised how well one can visualize the throat of a patient by video to the point of looking for tonsillar hypertrophy, exudate, and so forth.

Although one can’t auscultate the lungs, you can look for signs of respiratory distress. Audible wheezing is very apparent. There are lots of things pediatricians can do to continue to prescribe antibiotics judiciously. You cannot do a strep test, you know remotely, but sometimes symptoms indicate whether the patient may be at risk for strep or not. If a patient has a cough, then it's unlikely that it's strep, but ultimately, it's your decision to err on the side of caution and prescribe an antibiotic.

I think the most challenging is the febrile patient with a cough, you need to of course eliminate COVID as a possible cause. In that instance, particularly for an asthmatic child, or one with some early signs of respiratory distress, I've been erring on the side of prescribing antibiotics.

The last thing is if someone complains of ear pain, then if a child is able to do a Valsalva maneuver or equivalent, if they can blow a whistle, if they can blow into a party horn, or actually do a Valsalva, if they're old enough. If there's fluid in the middle ear space, they're going to have pain with that maneuver that would lead me to believe they have a middle ear process going on. In that instance, I would tend to prescribe an antibiotic so it's a surrogate, not ideal.