Your doctor's ready: Please log in to the videoconference
The coronavirus has prompted many medical centers to switch from in-person appointments to video visits. A new study from UCSF Benioff Children's Hospitals suggests that for some hospitals, video visits may become a permanent feature of the patient-provider landscape.
Prior to March 2020, all patients at the UCSF Adolescent and Young Adult Clinic received medical care through in-person visits. By the end of March, 97 percent of visits—approximately 80 appointments per week—were done via videoconferencing with physicians or nurse practitioners, according to the study publishing June 3, 2020, in the Journal of Adolescent Health.
"This has been a complex transition because we have had to navigate the uncertain waters of parent and adolescent/young adult involvement and confidentiality," said senior author Marissa Raymond-Flesch, MD, of the UCSF Division of Adolescent and Young Adult Medicine. "However, after the current coronavirus crisis, we expect to maintain telehealth in many areas.
"Patients will be able to complete video visits from school or work, or any setting that they identify as adequately private," Raymond-Flesch said. "This is a new domain in our field, and we are excited about reducing disparities in care in underserved areas such as rural communities."
The clinic serves patients ages 12 to 25, of whom three-quarters are female, from a catchment area spanning 400 miles north to the Oregon border and roughly 100 miles east to the Central Valley. Service includes both general health care and specialty care in attention and mood disorders, sexual and reproductive health, eating disorders and addictions.
Virtual Waiting Rooms Protect Patient Privacy
In their study, the UCSF researchers used a videoconferencing platform that was compliant with the Health Insurance Portability and Accountability Act, which protects the privacy of health information and security of electronic records. To prevent third-party access, they created a virtual waiting room, requiring a doctor to authorize entrance for each visitor. The visits were streamed—like FaceTime or Google Hangouts—rather than recorded. They also identified ways for patients to share information without risking disclosure to people within earshot, such as by using headphones and responding to sensitive questions with "yes" or "no," as well as using the chat function to type responses.
"The telehealth visit is a new reality and one that presents unique challenges," said Raymond-Flesch. "While you can see the patient's face, you cannot make direct eye-contact and you cannot demonstrate compassion by offering a tissue or a gentle pat on the arm. I found it meant that I had to exaggerate facial expressions or offer more verbal assurance than I would have done in actual visits."
The researchers reported that virtual visits did not present a barrier in screening patients for depression, substance use or psycho-social development. Additionally, clinicians were able to provide contraceptive counselling and appropriate follow-up for established diagnoses like headache, acne and back pain; and they reported that they were comfortable managing mood disorders and medication maintenance for attention deficit hyperactivity, with referrals made to psychiatrists for some conditions.
More challenging were appointments that required exams and procedures. Patients needing vaccines or tests for pregnancy, sexually transmitted diseases, urinary-tract infections or high cholesterol required an in-person visit with a nurse or phlebotomist. While the researchers have not considered using devices such as electronic stethoscopes, which enable providers from a second clinic to stream data directly to the consulting site, they said patient-owned devices such as an Apple watch or blood pressure monitor and upper-arm cuff may be used in the future, pending tests for accuracy.
Weight Checks a Challenge for Patients with Eating Disorders
Virtual care for patients with eating disorders, who make up about a third of the clinic's patients, required significant workarounds to provide regular monitoring of weight, vital signs and electrolytes. Weight checks, in particular, can be very stressful for these patients and many prefer to not know their weight. In some cases, primary care providers or therapists were able to weigh patients and take vital signs, which they shared with the clinic. In other cases, a parent or trusted adult was tasked with weighing the patient and relaying that information in private to the clinician.
"There were concerns that patients would overhear their weight or learn of nutritional interventions that normally parents would discuss confidentially with the physician during an in-person appointment," said Raymond-Flesch. "But on the upside, many families travel significant distances to reach us. Telemedicine may have allowed for increased parental participation," she said noting that patients with eating disorders were referred from a much broader geographic range than primary-care patients.
In addition to improved accessibility, telemedicine also opened the door to collaboration with primary-care providers. "It's something that has been considered before but never implemented," said first author and clinical fellow Angela Barney, MD, of the UCSF Division of Adolescent and Young Adult Medicine.
"There's a sense that many of the changes are not just temporary responses, but rather the new normal," she said. "We are not proposing that telemedicine for adolescents and young adults will replace in-person visits, but we can look at this quick shift as an opportunity to reach our patient population in new ways, both in this time of crisis and beyond."
More information: Angela Barney et al, The COVID-19 Pandemic and Rapid Implementation of Adolescent and Young Adult Telemedicine: Challenges and Opportunities for Innovation, Journal of Adolescent Health (2020). DOI: 10.1016/j.jadohealth.2020.05.006