Time for Telehealth

Name: Time for Telehealth
Creator: Alison Boast and Allison Hempenstall
Published: 2020-03-29T00:59:45Z

Alison Boast and Allison Hempenstall · Published 29 March 2020 · Updated 22 September 2024

As the COVID-19 pandemic continues to spread and utilize more of our health resources, many clinicians are being asked to minimize in–hospital clinic appointments. While it may seem simple to switch to telehealth for routine clinic appointments, a number of factors need to be considered to make the process as smooth as possible for yourself, your patient, and your family.

This post will help you transition from face–to–face clinic appointments to telehealth. Stay tuned for even more tips and tricks for assessing children with acute illnesses via telehealth!

Is your patient suitable for telehealth review?

If the answer is yes, then continue! There are some factors to consider, though.

Need for clinical examination – if a clinical examination plays a key role in decision-making, telehealth may not be appropriate, e.g. features of heart failure in a child requiring correction of a congenital heart defect.

Multidisciplinary clinics e.g. cleft palate clinic – it may not be possible for clinics with multiple providers to be shifted to telehealth.

Need for procedures – in some clinics, procedures are essential, such as dressing changes or immunizations and therefore may not be possible via telehealth or community services.

Collaborating with your patients, their families, local general practitioners, and nurse practitioners may overcome some of the above barriers; it is worth exploring this option.

Does your patient and their family have the right technology?

In general, the technology required for telehealth includes:

Reliable internet connection (remember that the weather, location and other users online at the time can impact your connection speed)
Computer, tablet or smartphone
Web–camera (built in many computers, tablets, and smartphones)
Secure program to communicate through (e.g. Skype, Zoom, FaceTime)

Telehealth consultations are inherently different from face-to-face ones. It’s really important to acknowledge that your consultation has shifted to a two–dimensional format, which poses unique challenges.

Voice or video – which should I choose?

Voice is more accessible, particularly for the elderly who may not have phones or computers with video capabilities. It requires lower bandwidth and is less susceptible to disruptions. Unfortunately, you can’t see the patient (duh!), so you can’t use your ‘end–of–the–bed–o–gram’ to see if they are well or unwell.

Video provides visual information on whether your patient appears ‘well’ or ‘unwell’. It is ideal for patients and families with hearing impairment, as nonverbal communication is preserved, as is the option to lip–read. With the increased use of the internet during isolation, quarantine, and social distancing, connectivity can be slow at times. Some governments have advocated for online streaming services downgrading from HD format to help preserve bandwidth.

Regardless of the method chosen, it is important to ensure the lighting optimizes illumination of your face and that sound is adequate with minimal background noise.

How should I run the consultation?

Before you start make sure you have your information technology support team phone number in case issues arise that you can’t troubleshoot. Check the patient’s identity, sound, and vision (if using video) and consider having a set of earbuds/ headphones handy.

Ensure that your patients and their families are holding the consultation in a private, safe space. Clarify the amount of time available for the consultation. With telehealth, nonverbal cues that the consult needs to end are more challenging.

Limit distractions – if the family has lots of children or pets, it is worth asking at the beginning of the consultation if they can play in another room (safely) or have a quiet activity to get on with. Communication with noisy siblings is even harder via telehealth than in real life.

If you need an interpreter before to organize this in advance, either by phone or in person

At the end of the consultation, take a brief moment to ask your patient and their family for feedback about the telehealth consultation.

Did your patient hear/ see you throughout the consultation?
Was your patient happy with the care they received?
Would your patient be happy to have another telehealth consultation in the future?

But how do I examine the patient?

A major barrier to telehealth is the inability to perform a physical examination. However, you can gather more from video telehealth than you realize.

General Inspection – probably the most important part of the paediatric examination :

Does the child look well or unwell?
Are they active and engaged or quiet and withdrawn?
Do they look well-grown? (remember to review your patients’ growth charts!)
Do they look like their parent(s)? Do they have dysmorphic facial features?

Observations – In most teleconsultations, you won’t have this information. Some patients and their families may have:

A thermometer to take their temperature (although generally not required for a routine clinic appointment unless the child is acutely unwell)
A smartwatch or app on their smartphone which can take their heart rate and or oxygen saturation for older children with comorbidities (e.g. chronic lung disease)
If a blood pressure is important for decision-making (e.g. chronic kidney disease) the cuff must be fitting correctly; few families have at–home sphygmomanometers, so they may be able to visit the local practice nurse for an accurate measurement.

Respiratory – A wise professor once said that most of respiratory examination only requires your eyes.

If the video quality allows it, what is the respiratory rate? Are there signs of increased respiratory effort? Is the respiratory cycle normal, or is there a prolonged expiratory phase?

Development – assessment requires some assistance and props from parents, but this in itself gives you information about the parent-infant bond and social skills:

Gross motor – stacking blocks, throwing a ball, sitting/walking/cruising/running and jumping
Fine motor – picking up raisins, scribbling or drawing
Speech and Language – can the child point out pictures in a book? Read you something?
Social – difficult to assess via telehealth; it’s easier to obtain from history and parental/teacher questionnaires.
Questionnaires filled out ahead of time can help gather more objective information on the developmental domains of concern (e.g. Ages and Stages Questionnaires)

Neurological – this is very challenging to assess via telehealth. Only gross assessments of tone and coordination will be possible (see above for gross and fine motor)

Financial Considerations

Many Medicare item numbers in Australia have recently become available to bulk-bill telehealth sessions. This includes quarantined/isolated doctors who can still provide telehealth from home. It is worth checking with the relevant agency in your area to see what options are available to support telehealth and what the surrounding rules and regulations are.