While the rise of virtual care during the pandemic affected medical practices of all types, some specialties are more amenable to digital care than others. To learn more about the role of telemedicine in pediatric medicine – today and well into the future – SmartBrief spoke with Dr. Susan Sirota, a founding partner of Pediatric Partners, and chairperson of the Board of Managers at PediaTrust in Illinois.
SmartBrief: Could you share a bit of background about your practice and how telemedicine fit into patient care before the pandemic?
Susan Sirota: Pediatrust is a super-group that’s essentially a merger between 12 independent practices. We have 20 locations, including the legacy practice locations, and we have our own after-hours care. We think of the practice, PediaTrust, as a whole, but we also see ourselves as divisions, and there’s a lot of autonomy in each of those divisions or legacy practices.
We started the process of bringing telemedicine to Pediatrust approximately three years before the pandemic. We felt that this was going to be an important way to deliver care, and we like to stay on the front or leading edge of change and transformation in pediatric practice.
We practice under a medical home model. We’re level-three NCQA-certified, and we want to create the highest-quality experience for our patients that we can. We are very much patient-focused in our approach. So, it obviously took some time — there were not a whole host of options to choose from, at the time — but we chose a vendor, and because we were early adopters and early customers, we were able to grow with them and really inform the process of developing what we needed for pediatric telehealth care.
Before March 13, 2020, the number of pediatricians who were interested in telemedicine was very small. But we started with a pilot group of those of us who are interested in technology applications in medicine. And we were using telemedicine primarily for behavioral health visits and follow-up, medication management, and follow-up in general for behavioral health conditions we treat.
It was a challenge because we are in Illinois, and at the time, Illinois was one of a small number of states that did not require reimbursement for telemedicine care. But we launched anyway, and we offered it as a convenient option for care that a small number of families chose to pay for because the cost of driving to our office, missing a day’s worth of work and disrupting school was higher to those families than what they perceived as the cost of the visit.
In 2020, the number of telemedicine visits in our practice overall changed dramatically. But because we had already been using telemedicine, it was remarkable to know that in a day we could bring all of our physicians on board, including physicians who had told me they would never use it. And really, all of those physicians now recognize the value of having had this tool in place in the pandemic.
We knew we were nimble, in part because we’re pediatricians who make decisions for pediatricians and their pediatric patients. But the pandemic has really shown us just how incredibly nimble we are, despite the size of our overall group. And we were fortunate to have a very responsive vendor at a company that was started by a pediatrician. They recognized our need to see our patients, and they provided all the technical support so that we could very quickly add more clinicians to the platform we were already using.
SB: Can you talk a little bit about where telemedicine fits today?
SS: We were truly doing everything we possibly could virtually for the early period of the pandemic and only seeing patients in person for things that we had to do in person. And we created safe ways to have in-person care. But nearly all of our sick visits were virtual, at least to start, and many were virtual from start to finish. A good percentage of our well visits were also virtual, with the exception of in-person exams and vaccinations.
Today, some of that has shifted back. As you can imagine, for those who either were not very interested in technology or virtual care, or who brought biases about what works well for virtual care and what doesn’t, those people have shifted back. I also believe that just as people have grown tired of the pandemic and wearing masks in their personal lives, some people have needed to come back to in-person care that they perceive as more personal.
Today, we pivot back and forth in the context of COVID surges. So, for children who are at very high risk of bringing COVID into the office and some other sick care that can be done very well through a virtual exam, we generally use telemedicine. We have many families that prefer the convenience of virtual care.
Well visits are for the most part being done in person. But the vast majority of a well visit is spent answering questions and giving anticipatory guidance. So, when kids develop illness or COVID the day they’re supposed to come in for their checkup, we don’t have to cancel and create all these voids in our schedule. We do everything we can that’s part of the checkup virtually, and then we have them come in for a follow-up.
The vast majority of patients we are seeing on telemedicine are being seen for behavioral health care and consultations with families — things that really do not require an in-person interaction. We also developed and launched a telemedicine program with about a dozen overnight camps in a neighboring state. This is our third summer doing that. When kids need care from a doctor that is amenable to virtual care, we can provide that care while keeping the kids in the camp and not sending them into towns where there is a high rate of COVID. It started as a COVID initiative, but we’ve continued to provide support to camp nurses through virtual care.
I can tell you personally, I use telemedicine on call. For example, when a child is developing croup for the first time, that’s very scary to a parent. It comes on late at night, and their child sounds like they can’t breathe. When that happens, I’m able to say, “would you like to do a quick video visit so I can see your child?” And croup is a great example of a situation where we can look at a child and say, yes, they have stridor, the sound of croup, but they do not appear to be in distress. And then we can proceed with treating, and the child is better in a matter of hours. The parent is reassured, and they didn’t go and wait in an emergency room for hours. So, it’s also a very efficient way to meet patients where they are, give high-quality care and reduce the overall cost of care.
SB: Looking back on your shift to integrating telemedicine, are there things that you would do differently or other takeaways that might be useful to other practices?
SS: One thing I would say is, if someone implemented telemedicine as sort of a spare tire or a Band-Aid during the pandemic without the ability to develop a plan or a process, it’s great to really go back to the starting board, look at this as a method of delivering care and really develop the plan. We piloted telemedicine pre-pandemic for that reason, so we could really figure out, where were the challenges? Where were the bottlenecks? What were the parts of our process that needed improvement? And I think when you develop a process, it’s always good to involve members of every part of the team in the office. So, starting with scheduling the appointment and using the computer to schedule. Then, what is the role of the nurse and what is the role of the clinician, and where are these visits going to happen? Who has video access? Is it just the physician or is it everybody?
To do this well and have high quality, the process really needs to be the same process that you have for a patient who’s coming into the office. So, from a business perspective, you do need to schedule the appropriate time, you need to collect co-pays, you need to register. You need to have those processes happen the same way they do for in-person visits. And I think when you can give video access to all points along the way of the patient journey, it can be very effective. So, from a nursing perspective, a nurse should go into the virtual visit, see the patient and collect vital signs. Parents can weigh kids at home, they can take temperatures at home, they can be trained how to measure a pulse or breathing rate at home, or a nurse could do that by watching a child on a video. If there are screening tools that are being used, like the GAD-7 for anxiety, those things should be collected ahead of time.
We should also learn to think of this as a patient experience that should parallel whatever the in-office experience is. I would also go as far as to say, physicians can set up computers on wheels, like a telemedicine stand. And, then that patient can be taken into an exam room, because you have to have private space for these visits. And many doctors share their workspace when they’re not in an exam room. So, you can take the patient into the room and do what you normally do as a nurse or medical assistant, and then the physician can come in and just move like we do all day long as pediatricians from room to room.
I think my biggest tip is to think about how you approach this now. Because if you got into telemedicine overnight in the pandemic and you started out with FaceTime on your phone, you probably never developed a process that really made this a highly valued and high-quality patient experience.
SB: Sometimes telemedicine presents a data-flow issue. Can you talk about the level of integration you have between virtual and in-person care? If you’re seeing patients in person, then virtually, and then in person, does everything just go into the record regardless of setting? Or is there a data issue that you have to solve for?
SS: There really isn’t. We actually use two telemedicine platforms. We have an EMR system as an offering through a big children’s hospital in our area. That’s a fully integrated process for us. Patients are scheduling the same way they schedule for in-person care. They show up in our schedule, and then we just click on a particular link when we open up their chart to go into that visit.
But the telemedicine platform we use most often is not integrated. So, you are working in essentially two windows on a computer and documenting at the same time. One of the things that I started using — and I find this very helpful for the mental health visits where there’s a lot of talking, especially initial evaluations — is a virtual scribe that relies on AI. So, I go into the visit. I have my laptop with me that I carry all day as I see patients. I turn on a separate monitor and open up my telemedicine visit, and then within that browser I have an extension that also links to my schedule. When I turn it on, it records the visit, but then AI is used to create a note. It’s not a dictation or transcription, it’s the kind of note any physician would write, and it’s in the style I like, because I create the templates. Then I just copy the note right into my EMR.
It works very well. I teach Northwestern Medical students in my office, and one time I told a student who was in a virtual visit with me, “we’re going to use the AI scribe, and you’re going to compose your note, and then we’re going to compare the two.” They were virtually identical.
SB: That raises another interesting question. Does physician training need to change to accommodate the rise of virtual care? Are there skills that you use in virtual care that are different or that you need to lean more heavily on?
SS: Absolutely. Delivery of virtual care is something that needs to be part of medical education. Things like understanding how you should be set up, where should your camera be? Where do you look in a visit? Because you don’t look at the patient on the screen when you’re talking to the patient, you need to look into the camera. Having a professional presentation and establishing the privacy of the visit. I’ve done visits with teenagers where they’re in their bedrooms, and I’ll say to them, give me a 360 view of your room. Because if you don’t ask, they might not tell you that someone else is in the visit with you. And you also need to be aware of what’s on your desk or what’s behind you, because you could have something visible that is protected health information from another patient. Developing those standards and understanding how best to do a virtual exam, what’s appropriate, what’s not appropriate, having chaperones, etc. And understanding the limits. So, it’s really not OK just to say to a resident or a physician in training, “go see that patient on telemed.” There should be education around that type of visit.
SB: Let’s close by talking about the future. What do you see in the future for pediatrics, with respect to telehealth?
SS: I personally believe that telehealth will have a prominent role. What that means in terms of patient visits, I’m not sure. Over time, maybe 20%, 25% of visits in the near term, and then long-term, we just have to see where this goes. The more parents do this, the more they learn it’s very effective for them. Also in pediatrics, so much of the care parents seek from us is conversation, not hands-on physical exams. And then for mental health care, it can be very useful. We had a mental health crisis going into the pandemic, and now there is this exponential growth of patients being treated for mental health care. I think it’s going to take on a very big role.
So, I see growth. I see, like everything else in medicine, some physicians are not interested in change. So, I think that growth will come faster or slower, depending on how interested physicians are. But I do believe that those practices that don’t keep up and don’t implement some telehealth program in their practice will be left behind. There are just too many other large organizations moving into health care or established health organizations that are there to provide that care, including what’s being referred to as virtual-first primary care. This is what will take our patients out of the medical home if we don’t keep up. So, I think if you practice in a true medical home model, it makes no sense not to have telehealth as part of what you offer in your medical home. Obviously, I have a strong bias, but my biggest bias is keeping up and providing really up-to-date care for patients and keeping them in the medical home. I think telemedicine is something that lets us do that.
However, we have to keep health equity in mind. The digital divide has been very blatant throughout the pandemic, and that divide has really determined who can access telehealth and who cannot. Language barriers can be an issue for the ability to read instructions, and these systems are fairly dependent on speed or consistent connection. It does create a health inequity when we don’t have the opportunity to offer this care to everyone, so I think it’s something physicians have to keep in mind, and health systems and insurance companies need to recognize this, so we don’t increase inequity as we increase adoption or shift too quickly without ensuring access.
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Dr. Susan Sirota is a founding partner with Pediatric Partners and Chairperson of the Board of Managers of PediaTrust. She’s been practicing for over 25 years.
Dr. Sirota is an Assistant Professor in Clinical Pediatrics at Northwestern University’s Feinberg School of Medicine, and she has been a speaker for local and national organizations, including the American Academy of Pediatrics. She also volunteers with the Stand Strong Coalition.
Dr. Sirota received her undergraduate and medical degrees from Tufts University. She completed her pediatric internship and residency at Ann & Robert H. Lurie Children’s Hospital of Chicago (formerly Children’s Memorial) where she served as a Chief Resident in pediatrics.