The use of telemedicine during the COVID-19 pandemic has been omnipresent and its potential effects on clinical care—for better or for worse—cannot be ignored. Pediatric rheumatologists have long struggled with ways to provide continuity and access to patients12 and telemedicine may have a place in routine ambulatory care moving forward. Barriers to telemedicine use in pediatric ambulatory care have included limitations in policy and reimbursement, technology13–14 and understanding the appropriateness and potential impact on patient health outcomes. Due to sheer volume of ambulatory telemedicine use with COVID-19, we have the opportunity to understand the real-world use of telemedicine in multiple specialties including pediatric rheumatology. This brief study asked a large cohort of pediatric rheumatology providers to detail their real-world experience of telemedicine use during a time where telemedicine, for many providers, was the dominant modality of care. We were able to observe specific trends amongst clinical care domains including exam reliability, visit type appropriateness, and the ability to make a clinical assessment, but also determined potential areas of disagreement amongst providers surrounding adolescent confidentiality, patient engagement, and provider burnout. As providers, we have a responsibility to our patients to optimize the integration of telemedicine care and address equity and disparities, identify tele-amenable issues, and measure quality and safety.15
With respect to visit type appropriateness, we found that in general, providers felt telemedicine was most appropriate for routine follow-up or follow-up due to ancillary needs such as injection teaching or lab result discussions. Generally, providers felt that urgent needs—whether flare of disease or patient concern regarding disease activity—were best suited for in-person clinical assessment. Interestingly, the majority of providers in this survey felt that components of the musculoskeletal exam, minus strength testing, were amongst the most reliable exam components done via video visit and the majority of providers were using a modified approach of standardized exams (such as the PGALS) with caregiver assistance to make their assessments. Virtualization of the standard musculoskeletal exam is necessary in pediatric rheumatology telemedicine visits.16 Regardless of visit type appropriateness or ability to conduct a reliable exam, the majority of providers (63.5%) felt that they were not able to elicit all the needed information from a telemedicine visit to make a complete clinical assessment. Further investigation needs to be done to outline the components that contribute to these perceived shortfalls of the telemedicine clinical assessment. Areas of further investigation may include the impact of diagnosis and disease state, patient-reported outcomes in a virtual visit, and components of the exam that are not able to be reliably assessed via video. Ultimately, controlled clinical studies evaluating in-person versus telemedicine visits may be required to understand the complete impact of telemedicine-related factors on the ability to make a sound clinical assessment.
Regarding patient engagement, the results appeared split between no change and less patient engagement despite providers reporting that patient caregivers were directly participating in the physical assessment tasks. Over a third of providers felt that patient engagement was worse when compared to in person clinical visits. This is an important finding in a specialty which provides chronic disease management because improved patient engagement and shared decision-making have been suggested to correlate with improved health outcomes.17–18 Beyond health outcomes, there may be important correlates surrounding patient engagement and communication in the health care transition of patients from pediatric to adult rheumatic care.19
An additional area of interest in pediatric rheumatology and in pediatrics in general, is teenage and young adult confidentiality. A benefit of telemedicine may include being able to take note of the patients’ environment and the potential implications of that environment on health, however, patients may have limited ability to be able to engage confidentially with their provider. During an in-person visit, there is no question of who is and is not in the exam room and it is less clear in a telemedicine visit. Though 41.2% of providers felt that confidentiality was not changed via telemedicine, over a third (37.5%) of providers felt that it was worsened when compared to an in-person visit. Providers must learn how to adapt their practice to ensure adolescent confidentiality and integrate new approaches to ensure this in telemedicine visits.20
Lastly, this survey acknowledges the potential of telemedicine to impact physician burnout. Physician burnout is multifactorial, though there is some suggestion that COVID-19 has introduced new stressors.21–22 Given the rapid deployment of telemedicine, the change in the care delivery model, and the increase in volume of visits, telemedicine may inevitably be associated with provider workload or stress versus increases in provider productivity and worktime saved. Though burnout was increased in approximately a third of survey respondents, we cannot exclude other confounding factors and stressors related to the COVID-19 pandemic that occurred simultaneously with the increase in telemedicine care. The rapid implementation of technology in the health care system may place added stress on providers as they navigate novel roles of information technology and should not be overlooked. Further qualitative studies need to be performed to assess physician burnout in relation to telemedicine.
This survey was intended to identify specific clinical domains related to telehealth for further study and as such, is subject to several limitations. This study did not examine external factors such as lack of validated assessment tools, patient environment, provider telemedicine education, visit follow-up completion or intrinsic factors such as patient diagnosis, patient disease activity, and communication barriers. Further in-depth qualitative studies regarding the physician experience and additional clinical studies involving telemedicine visits in pediatric rheumatology are needed. Most of the providers surveyed in this study were pediatric rheumatologists which may have impacted specific findings related to reliability around certain aspects of the physical exam; therefore, these results may not directly apply to other pediatric subspecialties. In addition, this study does not involve the patient or caregiver perspective which is necessary when considering reliance on patient or caregiver reported outcomes via telemedicine. Lastly, this study does not separately evaluate the impact of COVID-19 or the rapidity of telemedicine deployment on the physician experience.
A potentially unique finding in this study is that most pediatric rheumatologists surveyed felt that telemedicine use increased patient health access. Understanding the impact of telemedicine on access and addressing disparities in care is vital; a major challenge in pediatric rheumatology remains patient access to care, and telemedicine may be one avenue to address this. However, social inequities may introduce unforeseen disparities of care in through the application of telemedicine. This survey did not specifically address this, and further work, particularly on the patient-facing side, is needed to understand this implication of telemedicine care.