Improving Efficacy of Telemedicine in Outpatient Pediatrics

Purpose/Objectives: As the epidemiology of COVID19 and its impact on pediatrics evolved, we abruptly converted acute visits to virtual encounters in our pediatric teaching clinic. Initially providers engaged virtually with each caregiver and triaged the need to upgrade to in-person encounters. Provider and caregiver time was inappropriately utilized through repeat visits for the same complaint when a virtual visit was converted to in-person (sometimes with a different provider) and when caregivers were unavailable to answer their phones. In addition, providers were not consistent with approach to information gathering and documentation of care provided. Our objective was to optimize physician availability and minimize time wasted for all and standardize approach to virtual visits within the teaching environment.

Design/Methods: Our plan was to task shift administrative roles to the call center (CC) appointment clerks and triage nurses. We used the Plan-Do-Study-Act model for quality improvement to implement sequential cycles of change. The intervention began with a baseline survey and interviews of residents and attending providers to determine the impact on resident education and which complaints would be best completed in a virtual vs. in-person setting. We then developed a CC triage algorithm to guide virtual or in-person appointment assignment (Figure 1) and a provider guide to standardize virtual visits (Figure 2). The CC gave caregivers a specified time to expect a call back and instructions to transmit relevant images to the provider in advance.

Results: The baseline survey revealed provider calls were often not answered by caregivers, providers had difficulty perceiving patients’ complaints, and providers were unclear how to document virtual visits. The impact to resident education included decreased opportunities to practice physical exam and decreased protected educational time, as attending providers spent most of their time on phone calls. Educational benefits included having more autonomy in developing the assessment and plan on the phone rather than first confirming with a preceptor. After the triage algorithm was implemented and provider guide was distributed, provider feedback included less time wasted with call attempts, patients were less inappropriately appointed for virtual encounters when requiring in-person appointments, caregiver complaints decreased with respect to callback time, protected educational time was reinstated, and preceptor availability during clinical time improved.

Conclusion/Discussion: Learners noted this transition to telemedicine improved their communication skills as military pediatricians communicating with their patients and with sub-specialists. In addition they learned how to triage which patients need to come in to clinic when resources are limited. Our next steps include completing a chart review to show number of virtual visits which resulted in a repeat in-person visit over time to determine further changes to the algorithm. We intend virtual encounters and utilization of these tools to be an enduring process beyond the pandemic.