Telehealth in the Pediatric and Adolescent Population: Unique Considerations

Introduction

Telehealth, the remote delivery of health care via electronic platforms, has experienced tremendous growth in light of the Coronavirus 19 (COVID) pandemic. Market predictions anticipate an overall value beyond $55 billion by 2025 from $25.4 billion in 2020 [8]. Increasing ubiquity of and familiarity with digital communication technologies have contributed to a steady rise of telehealth over the past decade. These advances, coupled with social distancing practices and redistribution of health care resources, have encouraged musculoskeletal care providers to turn to telehealth as a surrogate means for continuing to deliver high-quality health care [4,9].

Initially introduced to provide health care services to rural communities, telehealth has demonstrated early benefit to orthopedic providers and patients alike. Evaluation of the utility of telehealth for perioperative care and consultations among traumatologists and arthroplasty surgeons have demonstrated equivalent patient satisfaction scores when compared with in-patient visits [2,5]. Notable challenges include patient and provider skepticism as well the inability to perform a remote physical examination [7]. As such, focus has turned to establishing an appropriate and robust, albeit surrogate, remote physical examination, as well as continuing to evaluate and meet patient expectations by establishing appropriate criteria for a telehealth visit [3,6,7], particularly within the fields of sports medicine, spine surgery, and pediatric orthopedic surgery.

Orthopedic telehealth for the pediatric population carries unique benefits, challenges, and opportunities for growth. While concern has been raised regarding the difficulties that older adults may face with technical unfamiliarity—the so-called “computer anxiety”—when using telehealth [1], the growing ubiquity of smart devices and its on-demand nature may make telehealth an enticing alternative for younger pediatric and adolescent patients. A pilot survey evaluating patient/guardian satisfaction of telehealth for pediatric fracture care suggested no-difference in patients’ satisfaction with their medical care between telehealth and traditional, in-person visits [6]. Similarly, decreased costs, work/school time away, travel, and waiting times are uniquely appreciated by both the patient and parent in the remote setting, further suggesting that telehealth practices may persist beyond the COVID-19 pandemic. As such, establishing best practices for pediatric orthopedic telehealth is critical.

The purpose of this focused review is to discuss the unique considerations, barriers, and technicalities musculoskeletal care providers must consider when using telehealth with a pediatric/adolescent patient. While recent literature has provided generalized recommendations for how best to implement this remote platform, various aspects of these guidelines must be re-evaluated when treating children. Our aim is to discern those visits/consultations that are most appropriate for a telehealth visit, as well as provide those technical aspects unique to the pediatric population.

Appropriate Visits for Telehealth Versus In-Person

In the authors’ experience, telehealth is found to be most beneficial for pre- and post-operative visits with established patients presenting for routine follow-up care, surgical decision-making discussion, imaging review, simple post-treatment range of motion evaluation, and discussion of milestone progression following surgery. Follow-up visits are most appropriate over telehealth when the patient is progressing as expected and are found to be especially beneficial for visits that do not require any re-imaging. Furthermore, most surgical incision evaluations not requiring suture removal can easily be performed by inspection over videoconference. Discussion of a treatment plan based on imaging studies can be reviewed over telehealth when a prior in-person clinical examination was performed and documented. Subsequent surgical discussions based on imaging results can also be performed using telehealth, particularly when the clinician is able to screen share and go over imaging with patients and families remotely. We have noted the added benefit, comfort, and convenience that patients may experience from being at home when these conversations ensue. All telehealth visits consist of a musculoskeletal examination. Visual inspection of the affected area and joint range of motion can easily be performed over telehealth. Other aspects of the physical examination, however, may pose greater challenges over videoconference.

There are some pediatric and adolescent conditions that are less appropriate for telehealth and should be addressed in an in-person meeting. Visits requiring an in-depth or focused physical examination, blood/fluid analysis, suture or pin removal, or repeat advanced imaging require a traditional in-person visit. In addition, initiating a new patient relationship is best established in person rather than over videoconference. While some portions of the physical examination are compatible with telehealth, including general inspection and range of motion, others are more challenging. For example, assessing manual muscle testing (MMT), reflexes, or a detailed vascular or sensory examination is unrealistic over videoconference. Therefore, the provider must evaluate which post-operative visits require an in-person physical examination depending on the surgical procedure performed. We note, however, that a caregiver/guardian may be able to assist the provider via telehealth. By providing straightforward, basic instruction, the provider may “coach” a parent through simple examination maneuvers, including direct palpation, assisted range of motion, patient positioning, and even some proactive maneuvers (such as glenohumeral or patellofemoral apprehension). With appropriate discretion and clinical judgment, a provider may be able to perform an effective, albeit surrogate, physical examination during a telehealth encounter.

A traditional office visit exposes both the patient and caregiver to the full scope of a practice, including the administrative team, nursing and ancillary staff, and physician. While a parent may benefit from this transparency, younger children are often apprehensive in this setting. As such, while parents/guardians may feel skeptical toward establishing care via telehealth, the patient may actually prefer the ability to “see the doctor” from their own home. In addition, new patient visits in pediatric orthopedics are not typically an appropriate way to use telehealth, as the initial evaluation almost universally requires radiographic imaging and a detailed physical examination.

Camera and Setup for Physical Examination

To perform an effective telehealth visit, patients must have access to a computer, smartphone, or tablet with audio and a camera. If using a smartphone or tablet, a basic stand is recommended for stability. We have found smartphones (Apple iPhone, Samsung Galaxy) to be most effective given their 2-way facing camera and dual Wifi/cellular network capabilities. The patient should be informed in advance to wear appropriate athletic-wear for observation of the affected area during the physical examination. We recommend that the patient use a bedroom or living room with adequate space and a chair, bench, or other flat surface, to allow for both gait examination, range of motion inspection, and potential evaluation in sitting or supine positions. With a mobile device, patients can undergo visual gait analysis in an adjacent hallway with the parent or guardian holding the camera.

For younger patients, we recommend that a parent hold the patient in the lap, or assist the patient to stand if they are already ambulatory. The patient’s area of question (ie, tibia, distal radius) can be placed in the center of the screen to allow the provider to obtain a 360° inspection. The provider should remain consistently vocal throughout the visit, guiding the patient to correct their field of view as needed. A quiet environment (eg, without siblings, other family members, or pets), is essential to minimize distractions that could result in missed findings. Implementing these processes are likely to result in a more effective and efficient visit between the patient and provider.

Administrative Tips and Challenges

Some of the most crucial steps to ensure a convenient and effective telehealth appointment happen prior to the actual visit. Before the telehealth appointment, the pediatric patient and their parent proxy must have access to the hospital-affiliated patient portal. At our institution, patients and their proxies require an active hospital patient account, and proxy access is set up over the phone with the help of office staff. Parents are asked for the following information to set up an account: full name, date of birth, zip code, and e-mail address. It is imperative that the office staff ensure that the parent knows to provide their information rather than their child’s. All paperwork, such as updated physical therapy prescriptions and school notes, can be securely e-mailed to the family after the visit is completed.

Most administrative challenges arise as a result of the parent inability to create an account on the portal before the appointment. For example, at our institution, if the parent does not create a portal account within 48 hours of receiving the setup e-mail, the unique activation code will expire. The office staff will then need to create a new activation code and send it to the parent, which can cause confusion and a sense of being rushed if delayed until the time of the appointment. If the parent does not use their name and date of birth while creating the account, often they use their child’s name and date of birth instead, resulting in the inability to create an account. It is crucial that administrators take the necessary steps before the appointment to guarantee that the parent successfully makes a portal account prior to the appointment. Finally, parents and guardians must be aware that they both need to be present for the telehealth visit, just as they would need to be present for a traditional in-person visit. In the event a caretaker other than a legal guardian is physically present with the child, a legal guardian must be available to 3-way conference into the video call so they can be virtually present for the visit. Informing the parents/guardians of the patient of this regulatory element is of the utmost importance.

Conclusions and Future Directions

The COVID-19 pandemic posed new obstacles for families trying to balance the need for seeking health care with decreasing exposure risk. A telehealth visit can be helpful for families who are unable to determine the urgency of an orthopedic issue (eg, initial screening) or for routine follow-up care. Establishing the best practices for pediatric orthopedic telehealth is of paramount importance to the pediatric orthopedic surgeon, not only during the COVID-19 pandemic but beyond this period as well. While there are certain situations in which in-person visits are more appropriate than telehealth visits, telehealth visits provide accessible and convenient health care without decreasing the level of patient care, satisfaction, or patient outcomes. Telehealth appointments may also help the provider determine the specific imaging needed prior to the in-person clinical visit to ensure that the in-person visit is quick and effective. The initiation of telehealth has not only helped mitigate the spread of COVID-19, but it has also offered an additional way to provide patients with high-quality care.