Pediatric Strategic Telemedicine Response Before and After the Primary COVID-19 Surge: Lessons Learned

Introduction: The year 2020 brought unparalleled challenges for maintaining safe access to pediatric care with a rapid expansion of existing telemedicine infrastructure, while allowing for cross-leveraging capacity for emergency and inpatient care of COVID-19 patients. Method(s): We examined telemedicine encounters across multiple specialties during fiscal years (FYs) 2019-2021, encompassing before and after the primary COVID-19 surge, as well as the infrastructure and processes created. Included in this analysis were age, gender, preferred language, zip code of residence, and primary insurance plan. Result(s): Telemedicine visits institution-wide increased from 220 in FY 2019 to 94,057 in FY 2021, representing an increase of 0.05% to 19.9% of total visits. Notably, total penetration of primarily Spanish-language telemedicine visits increased from 6.4% to 14.8% from FY 2020 to FY 2021. During that same time frame, our pediatric otolaryngology practice demonstrated a reduction of overall telemedicine visits (8% to 5.8%) in favor of a return to brick-and-mortar visits;this trend varied across numerous medical and surgical specialties, influenced by ability to optimally render diagnostic and treatment capabilities virtually. Conclusion(s): The COVID-19 pandemic necessitated technologic and process innovation to preserve care to our vulnerable pediatric population and created sustainable infrastructure for future postpandemic patient care. Barriers to telemedical care include clinical diagnostic limitations, low socioeconomic status with limited smartphone and broadband access, as well as nonprimarily English-speaking patients. Our institution rapidly scaled telemedicine access across the sociodemographic spectrum through the COVID-19 pandemic and is working across specialties to maintain and increase access to those within our diverse Southern California community, as well as in service to our international and rural families.

Rapid expansion of specialty practice telemedicine delivers timesensitive care during COVID-19

Background: The unprecedented impact of SARS-CoV-2/COVID-19 worldwide pandemic on healthcare hasbeen profound. At our large quaternary care pediatric healthcare system, in response to change how wedeliver care, a telemedicine strategy was rapidly developed with a priority to address the needs of patientsrequiring specialty time sensitive ambulatory care. One obvious opportunity was to rapidly expandtelemedicine capabilities to address the impact quarantines and stay at home orders would have on thedelivery of care to children with chronic conditions. We had some telemedicine capabilities in certainpopulations, however when our community shut down we responded with an immediate plan to expandtelemedicine services in a large multi-specialty practice. During the first week of the stay at home order, ourambulatory volumes drop by 69% reinforcing concerns regarding delays care (Fig. 1). Methods: We establisheda leadership model, task forces, and communication plan. We rapidly adapted to ongoing changes andaddressed specific needs including clinic workflow, patient populations, patient capabilities to utilize telehealth, education of clinical teams, and daily visible tracking tools. We measured daily telemedicinevolumes by practice, total visits, and proportion of telemedicine visits. Results: The 69% decrease inambulatory volume was countered with a 42,300% increase in telemedicine visits. Prior to COVID-19, weaveraged 4 telemedicine visits weekly and currently complete over 2,000. Through telemedicine, we aremaintaining a clinic volume of 57% of expected with 68% of all those visits being provided throughtelemedicine (Figure 2). All specialty services provide telemedicine. Certain specialty clinics adapted totelemedicine easier than others;allergy/asthma (98%;n = 581), pulmonary (97%;n = 390), neurology (96%;n =1,004), dermatology (95%;1,175), and otolaryngology (91%;n = 1,314) clinics experienced the greatest degreesof success over the past month while ophthalmology (55%;n = 531), cardiology (35%;n = 576) and orthopedics(14%;n = 1,713) faced challenges. Additionally, 30% of all completed telemedicine visits were for new referralvisits. Conclusion: We rapidly expanded telemedicine to provide time sensitive care in a large ambulatoryspecialty practice. Certain specialties were more amenable to telehealth for various reasons--vital signsavailable from home monitoring, ability to assess neurologic function in natural settings, etc. We realized thatevery specialty could do some aspect of telemedicine yet for others it was more challenging due to the needfor ancillary tests (Echocardiogram, x-rays, ophthalmology adjuncts, etc.) or lack of a good substitute forphysical exam findings (murmurs, abdominal exams, etc.). We successfully completed new referral visits (aprevious concern in specialty practices). Future steps to sustain our telemedicine practice are to continue torefinine best telemedicine practices, identifying appropriate populations and visit types, track financial impact,and measure patient outcomes.