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Timely Topic: Is Virtual Health Here to Stay?

Virtual health visit

Virtual health, telehealth or virtual doc. It goes by many names, but as health professionals know, telemedicine services have been around for more than a decade. That’s true for some Cook Children’s specialists who have been serving families in rural areas virtually for more than 15 years.

In addition to specialty care, Cook Children’s offers school-based virtual health, virtual lactation services and virtual urgent care. But while this technology has been available, physicians and families alike preferred an in-person health care visit. It wasn’t until COVID-19, that video conferencing became the only way most physicians could visit with their patients.

Almost overnight Cook Children’s Virtual Health grew from only 5 percent utilization of virtual visits to nearly 100 percent. The experience was, at first, a steep learning curve for patients and physicians alike, but for some physicians and families, this method of health care is here to stay.

In a virtual interview, our physicians shared their experience practicing medicine via Cook Children’s Virtual Health during the pandemic and what they think the future of medicine may look like post-COVID-19

In Neurology, visits for seizures are particularly suitable for virtual health because the majority of the visit is concentrated on history with the exam being secondary. Neurological diagnoses that require a physical exam to drive treatment decisions – like spasticity management, weakness, sensory changes, are more challenging because the exam is important to diagnosis what the problem is and where it is localized in the nervous system. – M. Scott Perry, M.D., Medical Director, Neurosciences

With regard to psychiatry, the majority of our conditions may be seen by virtual health, including ADHD, anxiety, depression, aggression and self-injury. – Kristen Pyrc, M.D., Psychiatry

One of the biggest challenges to treating patients virtually is not being able to see all of their nonverbals. Another is not being able to see the patient’s whole body to assess for things like self-harm, unless specifically asked for it. Finally, determining privacy can be an issue. The provider cannot always be sure the parents or guardians aren’t in the same room or listening when asking difficult questions, and the patients may alter their answers due to the parent or guardian’s presence. – Mary Kathryn Nader, LPC, TCU/RCU Clinical Therapist

For primary care, virtual visits are great for rash without fever, minor bumps and bruises, allergies, behavior and developmental concerns, ADHD, anxiety and depression. – Vanessa Charette, M.D., Cook Children’s Pediatrics Fort Worth Magnolia

Therapeutically, the biggest challenge for me is when there has been a critically ill infant that might die. Those therapeutic moments/times when no words or few words are exchanged. When the presence of the Clinical Therapist is literally the intervention. – Helen Thomas, LCSW, NICU/NEST Clinical Therapist

My teenage patients have responded best to virtual health. I think being in their home environment where they are more comfortable has allowed them to be more open in their responses to questions about their mood. Younger kids, especially with ADHD have been more challenging due to hyperactivity, but that is also diagnostic! – Kristen Pyrc, M.D., Psychiatry

The lack of a good physical exam on the issue. For primary care and urgent care, this is huge as we are the first line seeing the patient. Specialty has the benefit that they frequently can review the physical exam provided by the PCP to support their virtual visit but we need to examine for quality work. – Alice Phillips, M.D., Cook Children’s Pediatrics Fort Worth Cityview

There are some things that simply require a physical exam such as a need to look in an infected ear, listen to the lungs someone who is coughing, palpate the abdomen of someone who may have appendicitis. – Jason Terk, M.D., Cook Children’s Pediatrics Keller Parkway

Time is the great benefit. A visit for a rash may be a 10 minute visit with the doctor, but if the family comes to the office then their time spent is much more (driving, parking, checking in) on a virtual visit it is truly 10 minutes for them. I have loved seeing kids in their own home, it helps us know them better. They are relaxed. They can show us their toys or room if they want. For older kids and teens being able to talk virtually about anxiety and depression while they are at home seems beneficial in that they may be more comfortable at home talking about difficult topics. – Vanessa Charette, M.D., Cook Children’s Pediatrics Fort Worth Magnolia

I see virtual health as minimizing the burden of time and money in attending appointments in person. I am hopeful that this will allow students to stay in school longer since they will not have to commute to the clinic. Hopefully the minimized burden will improve our no-show rate as well. – Kristen Pyrc, M.D., Psychiatry

Providing care to patients who face real challenges coming to sessions in person. Family dynamics, lack of transportation, living outside of the Dallas-Fort Worth area, are all reasons that a patient might “fall between the cracks” through no-shows or inability to get to the clinic for a session. Connecting with them virtually provided continuing of care and consistency of appointments. – Lisa Nichols, LPC, TCU/RCU, Clinical Therapist, Psychology

Virtual health is efficient, very convenient and economical. Even before COVID we were facing a lot of competition from companies like Teladoc® and Virtual Care for Kids, not to mention local competitors like Children's Health and HCA. Like Amazon's effect on retail, virtual health is an innovation that is too effective to stop. So we needed to make this transition, and COVID accelerated this process. – Robert Gillespie, M.D., Medical Director, Nephrology and Kidney Transplantation

For psychiatry, I think virtual health has been a positive change. Teenagers have been more open in their responses, students will miss less school, parents will miss less work, and I am hopeful that our no show rate will decrease to reflect the decreasing burden of attending appointments. – Kristen Pyrc, M.D., Psychiatry

It is driving the patient desire for immediate care. Patients want quick and convenient and virtual health offers that. – Alice Phillips, M.D., Cook Children’s Pediatrics Fort Worth Cityview

The barriers really boil down to whether insurance will adequately compensate for virtual visits. – Joel Steelman, M.D., Endocrinology

It would be beneficial to be able to continue virtual health for those who are interested, or those unable to get to the clinic for appointments. It gave me the opportunity to provide counseling to three patients who would have been referred to an outside provider and likely not engage in counseling at all. And, for another patient who does not have transportation. I would like to continue to utilize my registered therapy dog in virtual sessions. The children and teens really enjoyed seeing him and his tricks (magic card trick, identifying his feelings with cards, etc.) It built instant rapport and was the first time I saw some patients smile. It allowed me to do some animal-assisted activities that I am trained to do but have never done at Cook Children’s. – Lisa Nichols LPC, TCU/RCU, Clinical Therapist, Psychology

We’ve also learned how crucial it is to continue to provide mental health services as many emotional symptoms were increased due to the pandemic crisis. Personally, it helps me cope with the crisis because I am able to do my job, have my work routine, and stay engaged in something I feel confident in. – Lisa Nichols LPC, TCU/RCU, Clinical Therapist, Psychology

It is doable and physicians can see a lot of patients efficiently if they have a good process in place. In our experience this requires a nurse/PSR to be in touch with family prior, and have them checked in and ready so you can hop online and get started with the patient. – Blake Palmer, M.D., Pediatric Urology

Although I can build rapport over a screen, I still prefer face-to-face sessions. I do like the convenience of being able to do a session from anywhere I can bring my computer. I also like the flexibility for the patients that they do not have to leave their home to participate in a session. – Rachel Grimes, LCSW, Pulmonary Clinical Therapist

Patients have loved it. It has created instant rapport for some, allowed them to utilize natural self-soothing techniques from home. It has provided insight into patients’ daily lives. I’ve had several children show me stacks of journals they keep about their feelings and medical journey … something they would not bring to a clinic appointment. Parents have told me they are "so grateful" that counseling was not stopped [during the pandemic] because they saw their children decompensating with a new crisis to deal with. I have several patients who are difficult to transport due to their medical conditions and those parents have said virtual health was "a godsend" for them. – Lisa Nichols, LPC, TCU/RCU, Clinical Therapist, Psychology

I was using virtual health health prior [to the pandemic] just not for home visits. I love it and look forward to coming up with more ways to be creative with its use. I’ve used it in multi-disciplinary visits so other providers don't have to be waiting around clinic. – Blake Palmer, M.D., Pediatric Urology

I think we'll continue to see the increased use of virtual health after the pandemic. Many physicians and patients have realized the usefulness of video visits and patient messages as a convenient means of receiving care when an in person visit is not necessary. – Justin Smith, M.D., Cook Children’s Pediatrics Trophy Club

There will be much more use of virtual health and its use will become almost universal. It will be a common part of the continuum of care, where people will see doctors they know and have a relationship with, in both virtual and in-person settings. – Robert Gillespie, M.D., Nephrology

I've been using telemedicine telemedicine in various forms for 13 years, but the proportion of virtual health visits has increased greatly and that's here to stay. The patients love it for the convenience, but the doctors also find it very convenient. It lets us deliver quality care with excellent patient satisfaction. – Robert Gillespie, M.D., Nephrology

I am certainly doing more of it and the market will demand that we continue to provide this service. – Jason Terk, M.D., Cook Children’s Pediatrics Keller