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Abstract
Recent advancements and adoption of telemedicine have affected all aspects of healthcare including paediatrics. While telemedicine has the potential to increase access to paediatric care, the limitations of this service in its current iteration bring into question its usefulness for direct replacement of in-person care, particularly in an acute or urgent care setting. This retrospective review demonstrates that only a small percentage of in-person visits to our practice would have resulted in definitive diagnosis and treatment if facilitated via telemedicine. There is a need for better and more widespread data collection techniques and tools suitable for paediatric remote care implementation before telemedicine becomes a useful diagnostic and treatment tool in an acute or urgent care setting.
- Data Collection
- Technology
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Introduction
During the COVID-19 pandemic, telemedicine saw over a 600% increase in usage as the healthcare industry transitioned away from in-person care.1–3 Outside of a pandemic setting, telemedicine, particularly in the paediatric space, also has the potential to provide broader reach and access in areas without these resources.4
Additionally, telemedicine has shown equal efficacy compared with in-person visits in certain cases as demonstrated by a recent systematic review.5 It is important to note, however, that this systematic review examined conditions that do not rely heavily on objective data collection such as mental health evaluations or chronic condition management where an in-person visit would have been a part of the management plan. For the acute conditions included in the analysis, data collection tools such as cameras or cellular device otoscope attachment were part of the study design.
Telemedicine also comes with several drawbacks, not least of which is that healthcare systems are largely based on in-person interactions.2 Additionally, quality telemedicine encounters are based on access to costly and non-widely distributed technologies, which tends to favour those with privilege.6
Our hypothesis is that telemedicine is likely ineffective in terms of definitive diagnosis and treatment in the acute and urgent care setting and that in the absence of data collection tools, most of the visits presenting to our clinic could not be definitively managed via telemedicine alone.
In order to evaluate the effectiveness of telemedicine in the acute and urgent care setting, we retrospectively reviewed 2019 visits to our paediatric primary and urgent care clinic in Portland, Oregon, pre the SARS-COV-2 pandemic from 2019 to early 2020. Our clinic provides routine and urgent (non-emergent) care to paediatric patients aged 0–21 years. As the majority of our practice is acute care, telemedicine at our practice is almost entirely used to address new acute concerns or injuries.
Methods
A retrospective chart review was conducted for all in-person visits at our paediatric primary and urgent care office located in Portland, Oregon. The current study includes 4 months leading up to the start of the COVID-19 pandemic (November 2019 to February 2020). Each patient visit (n=2019) was first categorised into groups deemed automatically incompatible with telemedicine such as need for a procedure or additional workup. Due to the hours of operation and lack of a pre-existing relationship with our patients, sending them to an outside centre for blood work or imaging is not practical.
The remainder of the visits were reviewed by an experienced paediatric clinician and divided, based on the available documentation in the note, into whether definitive treatment via telemedicine was likely of value, potentially of value, or not of value. Information on data validation can be found in online supplemental file 1.
Supplemental material
Results
Our study included 1567 distinct patients representing 2019 visits. The majority of patients (n=63.15%) were under 5 years of age.
Telemedicine would not have led to definitive diagnosis and treatment for 1350 visits (n=66.86%). Telemedicine would have been potentially useful for definitive diagnosis and treatment for 578 visits (n=28.62%) and would likely have been useful for definitive diagnosis and treatment in 91 visits (n=4.51%). The diagnoses most likely to have been definitively treated with telemedicine are rashes and head/eye/ear/nose/throat/mouth concerns (table 1).
Visit counts by category grouped by likelihood that telemedicine would lead to definitive diagnosis and treatment
Discussion
Our findings support our hypothesis that the majority of paediatric patients who visited our practice during the study period could not have been treated definitively via telemedicine. Rather, telemedicine is of most utility as an augmented triage tool.
Given the recent surge in telemedicine services and utilization around the COVID-19 pandemic, it is clear that a significant portion of the proliferation energy in telemedicine solutions could be better used perfecting remote data gathering tools geared specifically towards paediatric patients. We would expect that a substantially higher portion of our visits could have been definitively diagnosed and treated with telemedicine if some basic exam and laboratory data could be obtained at home.
There are several limitations of our study. Selection bias by retrospectively analysing in-person visits is one such limitation. In addition, despite analysis by expert paediatric clinicians, there is some subjectivity to judging whether a patient might or might not have been definitively diagnosed and treated via telemedicine. Another limitation is that our clinic almost entirely caters to acute and urgent illnesses and concerns. It is likely that due to the nature of the presenting complaints, telemedicine alone would not be sufficient for diagnosis and treatment without additional patient data. Finally, due to its retrospective nature, our study cannot comment on whether the patients who were deemed to need in-person treatment would have been fine without a visit and vice versa.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Pearl IRB, IRB Protocol #20-BRAV-101.
Acknowledgments
The authors would like to thank Maryam Taheri for her support in gathering the research team, Ash Pine and Jason van Reken for their contributions to the data collection and analysis, Juli Moore of Oregon State University for advisory support, and Anamara Ritt of the University of Southern California for advisory support.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors ZZS was critical in the planning of the study, data collection and analysis as well as manuscript preparation and revision. CF additionally finalised the study design, collected and analysed data and was responsible for the final manuscript preparation and submission.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.