Advertisement

Can You See Me? Can You Hear Me? Best Practices for Videoconference-Enhanced Telemedicine Visits for Children

Published:August 28, 2020DOI:https://doi.org/10.1016/j.pedn.2020.08.015
      Pediatric nurses have used telehealth for over a decade to respond to telephone calls from caregivers at Poison Control Centers and After Hours call centers. Today telehealth is evolving to videoconference-enhanced visits or the “use of real-time videoconferencing between sites to provide medical care to a patient” (
      • American Telehealth Association [ATA]
      Operating procedures for pediatric telehealth.
      , p.17). Caregivers can use virtual visits for their children who live in pediatric medical homes to make virtual appointments with medical subspecialists and surgical specialists (). Videoconference-enhanced telemedicine is also useful for providers and caregivers of children with chronic medical conditions who live at a distance from their providers and children living in rural areas who do not have ready access to a pediatric care provider. Virtual visits are also available to children in school settings.
      The COVID-19 pandemic has created the need for increased use of virtual assessment technologies (,
      • American Academy of Pediatrics [AAP]
      State notices on telehealth policy in response to COVID-19.
      ;
      • Ohannessian R.
      • Duong T.A.
      • Odone A.
      Global telemedicine implementation and integration within health systems to fight the COVID-19 pandemic: A call to action.
      ). The rapid shift to videoconference-enhanced telehealth visits due to the pandemic has left little time to consider the practical needs of both providers and children in a virtual environment. Pediatric healthcare providers find ways they can interact safely with children and their families, from traditional practice locations, while the information on the virus continues to evolve. Concerns about children's infection potential, transmission and infection rates, and severity of illness are all part of the decision whether children can visit a pediatric practice setting. Current evidence changes daily from differences in symptoms in children to concerns surrounding the continuation of timely well-child care (
      • Center for Disease Control and Prevention [CDC]
      Information for pediatric healthcare providers.
      ). All of these factors have led to significant delays in vaccinations and well-child visits where pediatric providers deliver anticipatory guidance, appropriate screenings, and referrals (
      • American Academy of Pediatrics [AAP]
      State notices on telehealth policy in response to COVID-19.
      ).
      Social distancing, state, and local stay at home orders, as well as concerns based on the spread of COVID-19, have increased the need to use videoconference-enhanced telemedicine for well-child visits enabling evaluation of patients at a distance (
      • American Academy of Pediatrics [AAP]
      State notices on telehealth policy in response to COVID-19.
      ). Tools such as videoconference-enhanced telemedicine visits can ensure that prompt healthcare is available for children. This article will provide guidelines that support safe and effective videoconferencing-enhanced evaluation for children.

      Patient privacy and security

      Videoconferencing interactions are generally required to comply with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. There are many HIPAA compliant video-based systems available at different price ranges and features, all of which provide encryption between the devices involved in the interaction (
      • Burke B.L.
      • Hall R.W.
      Telemedicine: Pediatric applications.
      ;
      • Davidson G.
      11 best HIPAA-compliant video conferencing software.
      ). Some systems integrate with electronic medical records, patient billing systems, or scheduling systems, providing a robust platform for practice efficiency (Davidson).
      Because COVID-19 is a public emergency, the
      • U.S. Department of Health and Human Services
      OCR Issues guidance on telehealth remote communications following its notification of enforcement discretion.
      “exercised an enforcement discretion to not impose penalties for HIPAA violations against healthcare providers in connection with their good faith provision of telehealth using communication technologies throughout the pandemic” (para. 2). HHS recognizes the importance of removing barriers to care to those people most at risk; older persons and those with disabilities. Just as essential as HIPAA, pediatric providers need to comply with the Children's Online Privacy Protection Act [COPPA] (2013), which puts parents in control when it comes to the collection of personal information from children under the age of 13 (Federal Trade Commission (
      • Federal Trade Commission
      Children's online privacy protection rule: A six-step compliance plan for your business.
      ). COPPA protects young children's personal information by requiring providers to inform parents if their child's data are shared publicly over the Intranet.
      Before a videoconference-enhanced telemedicine visit, the provider must obtain consent for telehealth services from caregivers and deliver HIPAA and COPPA information to them (
      • Federal Trade Commission
      Children's online privacy protection rule: A six-step compliance plan for your business.
      :
      • U.S. Department of Health and Human Services
      OCR Issues guidance on telehealth remote communications following its notification of enforcement discretion.
      ; ). In the consent, providers must include information that is specific to telemedicine, such as recording encounter information and any potential for technology equipment failure (FTC;
      • Burke B.L.
      • Hall R.W.
      Telemedicine: Pediatric applications.
      ).

      Providers tips for videoconferencing and telepresenting

      Utilizing videoconference-enhanced telemedicine visits, the pediatric provider has the added advantage of visualizing the child. Providers can best leverage videoconferencing to virtually assess and evaluate children by understanding how to engage with children and caregivers while using technology tools.
      Children under the age of two years of age should not receive care through telehealth services (ATA). Regardless of COVID-19, caregivers must continue to bring children less than two years of age to their pediatric primary care provider, in-person in a clinic or office setting. Telehealth services are the exception for children under two when the child's primary provider or surrogate is providing the service or when there is a need for the caregiver to consult with a specialist.
      As providing videoconferencing-enhanced evaluation becomes more mainstream for children, practitioners must be qualified to treat children (). If the telehealth provider is not the child's primary care provider, the provider should send a visit summary to the child's primary pediatric provider.
      Health care providers must only use diagnostic tools designed for children when conducting a virtual assessment; adult-sized tools will provide inaccurate measurements and may injure the child. Special tools designed for children are available for use in the home and include blood pressure cuffs, otoscopes, pulse oximeters, etc. ().

      Preparing a professional environment

      When virtually assessing and evaluating children using videoconferencing, the provider should have a working Webcam turned on and facing them (). Children and caregivers need to establish a sense of trust with their health care provider. When using a Webcam, ensure that the lighting in the room is in front of the provider. Minimize intense light by avoiding bright windows behind or next to the provider. Add coverings to windows and add lighting throughout the room.
      Position the camera and adjust it so that it is level with the top of the provider's head; this prevents the appearance of looking up or down into the camera (NTRC, n.d.). Allowing for some distance between the camera and the provider will give the impression that the provider is looking directly at the patient and caregiver (
      • Farcase B.
      How to look your best on a video call: Five tips for looking (and sounding) great. The Verge..
      ,
      • Walden J.
      Best practice tips for using zoom.
      ). It is critical to remember that Webcams provide a wide-angle view. Getting too close to the Webcam will distort the image-making assessment more difficult. During the evaluation, the provider will need to look at the screen; this may seem as if the provider is not looking at the patient and caregiver (
      • Walden J.
      Best practice tips for using zoom.
      ). Consider informing the patient and caregiver that the provider's eyes will appear diverted. When reviewing care recommendations and instructions; however, the provider should look directly into the camera so that they appear to be directly speaking to the patient and caregiver.
      To create a professional environment when videoconferencing a simple, uncluttered background is best (). Providers may also consider using a virtual background available in some videoconferencing systems. Depending on the system, virtual backgrounds can reflect the individual's practice environments, such as the office or clinic that the patient and caregiver regularly visit (Farcase, 2020;
      • Walden J.
      Best practice tips for using zoom.
      ). The appearance of the healthcare provider during the videoconferencing evaluation matters; patients and caregivers expect to see providers dressed professionally, wearing clothing consistent with the practice area where they see patients ().
      Sound is also a consideration when assessing and evaluating children using videoconferencing. Find a quiet space for the evaluation, being careful to ensure that noise is limited, and privacy is maintained (). Test whether an internal microphone on the computer or a headset provides the best sound quality. Be mindful that the microphone can pick up other sounds in the room (e.g., keyboard, cell phone, other people in the room, etc.). The provider may elect to mute their microphone while the patient or caregiver is speaking to help minimize background noise.

      Preparing patients and caregivers

      The provider needs to have an understanding of the child and caregiver experience to optimize the use and effectiveness of videoconferencing-enhanced evaluation. It is helpful to create instructions for caregivers on how to access the virtual system, how to get started, and navigate. Send caregivers the requirements for the type of device necessary for the videoconference, the need for a working camera on a machine, and audio capabilities. A best practice is to send an email invitation to the patient and caregiver before the scheduled session; include instructions on how to access the videoconferencing program and any program downloads required for using the system (). Providers may want to consider including a short instructional video, along with screenshots of the technology interface, navigation buttons, as well as technology self-checks. Keep in mind that if there is a loss of Webcam function, the advantage of videoconferencing-evaluation is lost. Including instructions for caregivers for how to access text chat functions and telephone communication through the application are also important. Sending a reminder message to the patient and caregiver before the videoconference can also help facilitate a smooth session.
      Sound is also a consideration during the videoconferencing-evaluation on the caregiver's end. Ask the caregiver to find a quiet space for the evaluation, ensure that noise is limited, and privacy is maintained (). To minimize background noise due to microphone feedback or other sounds from home, ask the caregiver and patient to mute their audio while the provider is speaking (
      • Walden J.
      Best practice tips for using zoom.
      ).

      Conclusion

      Advances in technology provide the opportunity for pediatric providers to conduct videoconference-enhanced telemedicine visits. Telehealth, however, is not advanced enough to take the place of an in-person appointment for children under two years of age due to the need for vaccinations, anticipatory guidance, appropriate screenings, and referrals. The benefits of videoconference-enhanced evaluation are that it affords children and their caregivers with access to providers, whether they in rural areas, home, or at school. By addressing provider presence with a plan for how to best leverage videoconferencing technology, along with ensuring a user-friendly experience, a more robust virtual visit of children is possible.

      References

        • American Academy of Pediatrics [AAP]
        Guidance on providing pediatric well-care during COVID-19.
        • American Academy of Pediatrics [AAP]
        State notices on telehealth policy in response to COVID-19.
        • American Telehealth Association [ATA]
        Operating procedures for pediatric telehealth.
        Pediatrics. 2017, August; 140: e20171756https://doi.org/10.1542/peds.2017-17
        • Burke B.L.
        • Hall R.W.
        Telemedicine: Pediatric applications.
        Pediatrics. 2015; 136: e293-e308
        • Center for Disease Control and Prevention [CDC]
        Information for pediatric healthcare providers.
        • Davidson G.
        11 best HIPAA-compliant video conferencing software.
        HIPPA Compliance, Jot Form2020, July 9
        • Farcase B.
        How to look your best on a video call: Five tips for looking (and sounding) great. The Verge..
        • Federal Trade Commission
        Children's online privacy protection rule: A six-step compliance plan for your business.
        • McSwain D.S.
        Telehealth services for children.
        Healthychildren.org, 2017
        • Northeast Telehealth Resource Center [NTRC]
        Tips for professional videoconferencing & telepresenting.
        • Ohannessian R.
        • Duong T.A.
        • Odone A.
        Global telemedicine implementation and integration within health systems to fight the COVID-19 pandemic: A call to action.
        Journal of Medical Internet Research: Public Health and Surveillance. 2020; 6e18810https://doi.org/10.2196/18810
        • U.S. Department of Health and Human Services
        OCR Issues guidance on telehealth remote communications following its notification of enforcement discretion.
        • Walden J.
        Best practice tips for using zoom.
        Generation Digital. 2019, July 9;