Introduction

With the start of the COVID pandemic in early 2020, the use of telehealth expanded quickly within healthcare, and pediatric surgery was no exception. According to a recent publication in the Journal of Pediatric Surgery, while only 20% of pediatric surgeons utilized telehealth before the pandemic, an additional 62% began using it during the pandemic [1]. Although in-person clinic visits are the cornerstone of the patient-doctor relationship, telehealth offers certain advantages that are likely to outlive the immediate needs related to the pandemic. Some types of patient-healthcare provider interactions lend themselves well to virtual visits, while others are simply not possible. There is also a vast gray zone of encounters whose adaptation to the virtual world may seem counterintuitive and will require us to rethink our practice. This guide is intended to offer a taxonomy of sorts for the virtual patient visit in pediatric surgery.

Advantages to a Virtual Visit

• The risk of direct contamination is eliminated (in these pandemic times, but also when a patient or caretaker is suspected or known to have a transmissible disease; think measles and a pediatrician’s office, for example).
• In the right circumstances, it can be less disruptive and expensive for families: travel time, parking (time/cost), and time off from work/school.
• Having patients remain in their own environment can be less stressful for them – and sometimes more helpful for the clinician.
• It can be more efficient – and cheaper – for the clinical office, and scheduling can be more versatile.

Disadvantages to a Virtual Visit

• The main drawback is the inability to perform a physical examination, which obviously precludes many encounters that require it. However, telemedicine still allows observation, and that can be sufficient in specific cases. Furthermore, technology now allows monitoring of vital signs and other clinical parameters, depending on the network and set-up.
• While the patient and the family can remain in their own environment, there is a potential risk to privacy: neither the clinician nor the family can be entirely secure in the knowledge that the encounter is confidential, and clear measures to safeguard the protection of personal health information must remain in place.
• Language barrier remains an issue, both in face-to-face and virtual encounters. While technology should allow easier access to translation services, it is currently better developed in physical settings than in virtual ones.
• Some patients/parents may have difficulties with technology, which can limit which patients can be seen via telemedicine.
• May reduce the surgeon-patient bond that in-person visits may facilitate.

General Guidelines on the Appropriateness of Telemedicine Visits

Virtual clinical encounters can be appropriate in the following situations:

1. When a physical examination is not an essential part of the encounter.
   1. Prenatal consultations. For example, surgical consultation for a fetus with a diaphragmatic hernia, gastroschisis, lung lesion, or omphalocele. Provided medical records, including ultrasound and other imaging results, are available, a prolonged discussion with the future parents can be done virtually.
   2. Discussion about treatment options with the patient absent, or when a physical examination is not essential to the encounter. This can either be a follow-up encounter for a known patient, or a preliminary encounter with the parents or caretakers, with or without the patient present. For example, discussion about surgical options for Inflammatory Bowel Disease, cholelithiasis, or lung lesions (e.g., pulmonary sequestration).
   3. Known surgical patient requiring a yearly follow-up focused on history, behavior, diet, etc. This will depend on the level of acuity and the availability of external records. Examples include long-term follow-up for esophageal atresia, omphalocele, or diaphragmatic hernia.
   4. Upon reviewing labs or imaging studies, and the presence of the patient is not deemed necessary.
   5. Multidisciplinary discussions with other healthcare providers for complex cases (with or without patient/family present).
2. Straightforward postoperative check-up when physical examination can be limited to wound check. Examples include visits s/p appendectomy, hernia repair (epigastric/inguinal/umbilical), and excision of skin lesions. In addition to wound check and overall assessment, this may be a perfect opportunity to communicate pathology reports and other test results and plan for future encounters or treatment, if needed.
3. Office procedures. While it seems counterintuitive to perform minor procedures remotely, there are some notable exceptions that can occur when a parent or caregiver is familiar with the procedure but needs monitoring or reassurance by the clinician, provided that the necessary supplies are available. Examples include routine change of a gastrostomy button, a wound dressing change, or silver nitrate cauterization.

Remember, these are guidelines only. For each category, individual circumstances and preferences may preclude a virtual visit – or, conversely, make a face-to-face visit more appropriate for telehealth.

* Any of these indications depend on the personal preferences of the clinician, patient, and parents/caregivers, the available supplies and equipment, if indicated, and the availability of necessary records and test results. This list is far from exhaustive but gives a general idea of what types of encounters can lend themselves to telemedicine.

_{¹Requires an established relationship with a primary care provider or other specialist(s).}

_{² May require the ability to obtain vital signs.}

_{³ May require access to diagnostic imaging and/or other test results.}

_{⁴ May require specialized equipment or supplies.}

To further explore quality improvement initiatives pertaining to telehealth, please refer to the APSA Quality and Safety committee Telehealth Toolkit Projects.

References