The coronavirus pandemic has forced an experiment in virtual pediatrics telemedicine. Are virtual physician visits the modern version of house calls?
Long gone are the days when doctors, bulging black bags in hand, spent their working hours going home to home making house calls. Yet modern technology may be able to bring back some of that nostalgic practice in the form of virtual house calls.
In her lecture “Virtual Visits to the Pediatrician's Office,” now available for CME credit through AudioDigest, Dr. Linda D. Meloy of the Virginia Commonwealth University (VCU) School of Medicine's department of pediatrics shares her experience with virtual pediatrics telemedicine, pondering whether virtual physician visits are the new house calls or simply “fancy phone calls.”
The novel coronavirus pandemic has placed many physicians and health systems into a forced experiment in telemedicine. While direct-to-consumer telemedicine companies have offered virtual visits, often covered by insurance plans, for years, those of us practicing in more traditional settings such as primary care offices, hospitals and academic medical centers now often find ourselves seeing our patients virtually, separated by screens and with limited ability to do a physical exam or get prompt testing, relying on our skills of history-taking and observation.
Perhaps we can see these strange times of pandemic as an opportunity to expand our telemedicine skills and figure out how virtual visits can make our practice better.
The advantages and limitations of telemedicine
Virtual physician visits do offer advantages. Dr. Meloy cites benefits including family convenience, increased access to care (particularly for patients with limited transportation or who live far from their physician), an increase in patient volume without the need for expanded physical space and reduction in harmful exposures for vulnerable populations such as infants and immunocompromised patients.
Like house calls, virtual physician visits allow a helpful peek into our patients’ home environments, something an office visit does not allow. Seeing a child's crib helps evaluate for safe sleep practices. A peek in the fridge can help counsel children with weight issues. A look into the bathroom can help troubleshoot toilet training difficulties. A kitchen demonstration of formula mixing can ensure proper infant feeding.
Yet the limitations of virtual visits are significant. Without a proper physical exam or point-of-care testing, our evaluations are limited, especially for common pediatric illnesses such as streptococcal pharyngitis, otitis media, pneumonia and urinary tract infection. The American Academy of Pediatrics has expressed particular concern with commercial direct-to-consumer telemedicine, which can employ providers who lack pediatric expertise, don't have access to patients’ medical records, have increased rates of inappropriate antibiotic prescribing and do not provide continuity of care.
Incorporating virtual visits into our own practices can provide our patients with convenient access to care and keep them in the medical home.
VCU test case
Dr. Meloy shares her experience of incorporating virtual physician visits into VCU's Department of Pediatrics primary care practice. She offered patients virtual visits for a limited set of chief complaints, including simple headaches, mild respiratory or GI illnesses, rashes and lactation support. While Dr. Meloy notes the technology took some adjustment - she kept wanting to touch the screen to palpate a belly and had to navigate occasional poor internet connections â€” the virtual visits were a helpful tool, with high satisfaction scores from participating families and pediatricians.
Virtual visits were particularly advantageous for new mother-infant dyads, who could have newborn rashes or breastfeeding issues handled without leaving the home, and for routine follow-up of conditions such as ADHD, obesity and constipation. By offering virtual visits with the child's pediatrician, VCU was able to practice antibiotic stewardship, with less than 10% of virtual visit patients receiving oral or topical antibiotic prescriptions.
Beyond a “fancy phone call,” Dr. Meloy and colleagues found virtual physician visits could be the modern version of the house call, with computers replacing the proverbial black bag. When done thoughtfully within the medical home, telehealth visits can provide continuity of care, family convenience, patient satisfaction, a glimpse into the home environment and protection for our most immunologically vulnerable patients. That last is a particularly key advantage during our current coronavirus pandemic.