The Doctor Can See You Now

By Ian Anderson

Megan Lopez had already spent a month in the hospital prior to giving birth to her daughter Gracie, a micro-preemie weighing a mere one pound, six ounces. “She was 11 inches long, so not even the length of a ruler,” Megan recalls. “She’s a miracle.”

That was only the beginning. The June baby would stay in the hospital another four months before her parents could take her home. The underdeveloped infant needed round-the-clock observation and a host of neonatal therapies to treat complications common among preterm newborns, such as issues with breathing, digestion and eyesight. Even upon release, Gracie would require regular checkups to monitor her growth, and consultations with more than a dozen different specialists to track her development. In just the first six months after going home, the tiny child would have no fewer than 41 different doctor appointments.

Even under normal circumstances, all of this would have been taxing enough for the family. The fact that Gracie was born during the pandemic made everything more complicated. Every visit to a hospital or clinic felt fraught with risk. It became a greater challenge to find a babysitter for Gracie’s two older brothers, ages 4 and 6—particularly because the oldest has special needs of his own, and they had to rely solely on other family members during this time. Furthermore, the Lopez family lives in Murrieta. While Gracie’s primary care physician and a growing number of specialists operate out of the Murrieta Medical Plaza that Rady Children’s opened in 2018, many of the physicians the baby needed to see are at the main Rady Children’s campus, 60 miles away.

However, in one huge way, the impact of COVID-19  actually reduced the amount of time Gracie and her mother had to spend in doctors’ offices. That’s because, to limit the spread of the virus, medical networks across the country began to embrace telemedicine in a major way in 2020, and Rady Children’s was no different. Of Gracie’s 41 appointments in those first six months at home, only 28 of them required an in-person office visit. For the remaining 13, Gracie and her mother engaged with her doctors remotely, via video call.

Dial C for Care

The concept of telemedicine, or telehealth, has been around nearly as long as the telephone itself. The National Institutes of Health records early 20th century examples of doctors giving medical advice by radio to sailors at sea, or to patients in remote Alaskan villages. In the space age, NASA has used remote monitoring devices to track the physiologic data of astronauts in orbit. Rady Children’s looked to emerging technologies to give telemedicine a shot back in 2012 by deploying VGo robots to satellite NICUs. Each 4-foot-tall mobile robot was effectively a video screen and camera on wheels. Offsite specialists could operate them by remote control, moving them through Hospital corridors and using their two-way video feeds to monitor patients
from afar.

However, this and other pilot programs never really took off. And despite a proliferation of video calling technology that only got better (and easier to use) in the years following that VGo experiment, telemedicine failed to see widespread adoption—that is, until COVID-19 came along.

Rady Children’s administrators report that, prior to the pandemic, the number of weekly telemedicine visits averaged in the single digits. But over the course of 2020, the hospital logged a whopping 125,791 telehealth appointments, serving 92,341 patients!

Obviously, restrictions intended to curb the spread of the coronavirus were the driving force behind the explosive growth of telemedicine in 2020. But even though vaccination numbers are rising, and a return to normalcy appears within reach, the genie is officially out of the bottle. Now that circumstances have made it a more accessible and desirable choice, the inherent value of telemedicine has been made clear to all parties—patients, physicians and insurers alike. And even once we’re able to put the pandemic in the rearview mirror, the option to schedule certain types of doctor appointments at Rady Children’s as remote visits is not only here to stay: It’s just getting started.

Historically, both patients and doctors had been leery of telemedicine, mainly over concerns it would be less effective. But when Gracie left the hospital last October, Megan was grateful to learn that Rady Children’s was offering a wider range of telemedicine options due to the pandemic.

“It was a blessing in disguise,” she says, not only because she was anxious to protect her family from the virus, but because as flu season approached, Gracie remained vulnerable to any number of ailments most people don’t think twice about. “She is still more immunocompromised than other children, so if she doesn’t physically have to go into the office and be weighed or touched for some reason, I always choose to do it that way,
for her sake.”

Telemedicine Pros and Cons

Aside from obvious advantages of telemedicine, such as not having to drive, find parking or spend time in waiting rooms, Megan points out that it’s helpful not necessarily having to cancel an appointment if the baby is sick. Specialists tend to book appointments months in advance, and there’s always a chance Gracie won’t be up for a trip to the doctor’s office when the day finally arrives. “I can’t even bear the thought of waiting for months and then having to skip our appointment,” she says. “Sometimes I’ve called in the morning and said, ‘I’m so sorry; Gracie is sick, but I don’t want to cancel. Can we convert this to telemedicine?’ That, to me, has been incredibly valuable.”

Not every in-person doctor visit can be substituted with telemedicine, of course. Most diagnostic tests require a patient’s physical presence, for instance if it relies on expensive medical equipment, such as an MRI, or is by definition hands-on.

But some types of doctor visits are particularly well suited to online video sessions, like mental health counseling. Prior to the pandemic, most Rady Children’s telemedicine visits involved counseling sessions with psychologists or psychiatrists. These have been helpful to adolescents experiencing anxiety. For a generation innately comfortable with technology, being able to access therapy from a place of comfort—such as their bedrooms—may allow them to open up to a degree they wouldn’t otherwise.

Other visits that rely on conversation also make prime candidates for telemedicine. Seeing a doctor to discuss test results, for example. Or postoperative follow-up visits, or those concerning the management of chronic conditions—routine situations where little or nothing may have changed with regard to the patient’s health, and the physician needs only to ask a few questions or make a simple visual assessment.

For these types of visits, one begins to wonder why it even took a pandemic to make telemedicine the norm. It’s possible that most physicians haven’t been comfortable conducting remote visits due to a lack of experience with the format, or out of concern they won’t be able to provide the same quality of care over video. Patients have shown reluctance for similar reasons, including concerns that they won’t get as much face-to-face interaction with their health care provider.

But after the crash course in telemedicine that Rady Children’s doctors and patients experienced in 2020, most found it to be a success. The Hospital has received generally positive feedback, and data shows the amount of time doctors spend with each individual patient is comparable to in-person visits—in other words, switching to telemedicine didn’t change the number of patients a doctor can see in a day, nor did patients (or the parents of patients) generally feel they were missing out.

After experiencing Gracie’s mix of in-person and video appointments over her first six months at home, Megan reports very little difference in how the doctors conduct the visit. “They’re still just as thorough,” she says. “They hit on all the topics that they normally would.”

Building the Way Forward

Probably the biggest logistical hurdle for telemedicine before the pandemic was a mundane aspect of hospital business—namely, that many insurance providers, whether private or public, offered only limited reimbursement for telemedicine visits, compared to the amounts paid for in-person visits.

But the urgent need to accommodate social distancing practices last spring spurred federal and state governments to address this right away, expanding reimbursement for a wide variety of telemedicine services. This newly created parity means that, rather than public or private insurers paying only for the time a doctor interacts with a patient by video, they instead must reimburse the hospital as they would for a normal visit. This also accounts for the time a doctor takes to perform routine yet crucial tasks, like reviewing patient charts, analyzing lab results or documenting
the visit.

Some of these expanded reimbursements—such as for audio-only telehealth visits—are temporary, and likely to expire with the pandemic. However, others will stick around, thanks to California legislation requiring payment parity that went into effect this January. Although this legislation applies only to private insurers, the political will to expand telemedicine reimbursements for public health coverage seems to be growing, at both the state and federal levels.

In the meantime, patient access to telemedicine is increasing as the technology improves—and we’re not just talking video quality. There’s also tech that increases patient access to health care providers and to their own medical records. When Megan describes how positive her experience with Rady Children’s has been, she gives some credit to the MyChart app, where she’s able to view all of Gracie’s test results, appointments and prescriptions in one place, whether they originated from Rady Children’s or from Gracie’s birth hospital. Just as importantly, she’s able to connect to the long list of providers contributing to Gracie’s health care, and they’re able to view her ongoing treatments and appointments across specialties.

For instance, when Gracie’s gastroenterologist was ordering lab work and ultrasounds, she noticed the child also had an upcoming appointment with a hepatologist. So the doctor reached out to her colleague to ask if they wanted to add any blood work to the order, in anticipation of their appointment later on.

Megan says the app has also given the family direct access to Gracie’s primary physician, Steven Griffin, MD, whom they see at the Murrieta clinic as well as remotely. “I’ll message him, and he always gets back to me the same day,” she says. “Sometimes it’s eight o’clock at night and he’s emailing me back through the app.”

Dr. Griffin explains that, while young parents have always tended to reach out to their pediatricians often, advances in technology have made it easier. “Over the past 10 years or so, as we’ve gotten more electronic, we have a lot of messages from patients,” he says. “A new parent will be very nervous, and they’ll send us 20 different messages.” However, he notes that he’s found using telehealth visits to address such concerns to be far more effective. “It’s very much appropriate for having a longer discussion, instead of going back and forth with messages.”

New Frontiers and Possibilities

Dr. Griffin explains that the past year has presented a learning curve for practically everyone at Rady Children’s, as they’ve had to adjust to telehealth appointments on the fly. “This is a new frontier,” he says. “We’re all trained to keep our hands on people, and to figure things out with a physical exam.”

He reiterates that, more often than not, an in-person visit is still preferable, especially for evaluating the nuanced distinctions of symptoms such as abdominal pain or respiratory distress. And when it comes to writing prescriptions—even for medications as common as antibiotics—the physician will still want to examine a patient hands-on. For occasions when a telemedicine appointment reveals issues that can’t be diagnosed remotely, he and his colleagues at Rady Children’s work quickly to schedule an in-person visit for the patient, usually the same day.

“But,” he adds, “it certainly does have its place for those other problems that don’t necessarily need a head-to-toe physical exam.” In addition to monitoring behavioral health, Dr. Griffin has learned that a variety of common skin problems, such as rashes, may be examined remotely, allowing a parent to address minor issues without leaving home. In some cases, a recurring issue requiring a prescription modification or renewal can be more quickly and easily accomplished with a video call than an office visit.

“We’ve learned a lot over the past year with this, just seeing how it works,” Dr. Griffin says, “because before, nobody really knew how it would work in practice.” As the COVID-19 vaccination numbers rise, he’s finding more patients willing to schedule in-person appointments, but based on his experience over the past year, he anticipates a greater embrace of telemedicine in the months and years to come. “The technology is going to improve,” he says, “and our use of it, and how we deploy it.”

The experience has also encouraged Rady Children’s to keep telemedicine options available moving forward—and potentially, to make some exciting investments to improve upon it. The rapid expansion of telehealth protocols last year was made possible by a collaborative effort between Hospital physicians, administration and information technology staff seeking to create a standard of best practices. Administration and physician leaders have been closely monitoring patient access to care—and reviewing patient and family satisfaction—to make informed decisions about future telemedicine applications.

One possible outcome involves finding ways to provide patients with web-connected medical devices, so their doctors can collect vital signs remotely. Rady Children’s currently has an audiology department program that supplies patient families with digital otoscopes, which allow their doctor to look into the ear canal remotely. With the advent of each new smart medical device, more and more of these standard examinations will be available and reliable for in-home appointments.

Rady Children’s is actively looking to provide technology for use in patient homes, such as digital stethoscopes to monitor the heart, digital spirometers to measure lung capacity and integrated pulse oximeters to check blood oxygen levels (both of which are crucial measurements for monitoring COVID-19 infection).

The pandemic may have pushed the medical community into telemedicine out of necessity, but in doing so, it’s given us a glimpse of how this technology can be used to make our health care system more efficient, more effective and more user-friendly, especially for the vulnerable children and families Rady Children’s cares for every year.

Published in Healthy Kids magazine, Summer 2021