Providing virtual care during a pandemic: A guide to telemedicine in the paediatric office

By Raphael Sharon, MD, FRCPC, Board of Directors, Canadian Paediatric Society

When I started med school in the Netherlands in the 1990s, our first year involved a lot of cell biology and anatomy. We did not interact with any “live” patients until our third year. I was so excited once we were interns and saw real patients; I wanted to help each one.

As a paediatrician, my work became even more fun. Kids are wonderful to interact with, brutally honest (“doc, why don’t you have any hair?”), and so appreciative when you make them feel better. I love going to work every day, never knowing what the day will bring, what type of problem or story I will get to hear. 

But in the midst of this pandemic, we are “social distancing” (or “physical distancing with social engagement”), and we want to keep people home as much as we can. We are asking people to self-isolate after travel and when they are sick—which is odd for doctors since it’s our duty to see patients who are ill. Patients will continue to need our help during this difficult time, perhaps even more so.

How do we provide care when we can’t physically examine them? Cue telehealth/virtual medicine: We can help guide our patients and their parents by telephone and by videoconferencing, using apps such as Zoom and Doxy.

Here are some things to think about when using virtual care in your practice (examples refer to Zoom, which is what I have been using in my practice):

Scheduling a virtual appointment

Certain apps (like Zoom) allow you to schedule a virtual appointment. Patients receive an email with their appointment time and login data for the videoconference. Have your staff ask the patient to download the latest version of the free app on their smartphone or computer/laptop with webcam. 

The patient will arrive in a virtual “waiting room” before the appointment starts. When you are ready, you can admit the patient into the meeting.

Taking notes during a virtual care appointment

I have started asking my nurse to sit in on the virtual appointment with me. I introduce her on the call and she takes notes during the appointment. This allows me to give the patient my undivided attention.

If you typically take notes while talking to patients face-to-face, be sure to wear a headset or put the phone on speaker – it is difficult to take notes one-handed.

Use the parents to help facilitate the physical examination

Taking a thorough history is still one of the most important things in medicine, whether it is face-to-face or using telehealth. Videoconferencing still allows you to do large parts of the physical examination, provided the parents can help you manage the camera using their smartphone:

• You can observe the color of the skin, to see whether someone is jaundiced or pale.
• You can observe a congested patient for signs of respiratory problems: if they are tachypneic, have indrawings, if nostrils are flaring. 
• I have been able to look inside a patient’s throat to see if tonsils are enlarged, to see if pharynx is red or if there is any exudate.
• Kids can have lots of rashes, whether they are viral-induced, eczema or a drug reaction; these can be seen on video too. 

Who to still see in person in your clinic

Routine immunizations for children should be maintained as usual, because any delay or omission in scheduled vaccines puts children at risk for common and serious childhood infections such as pneumococcal disease, measles, and pertussis. Reserving times for this group may be a priority. Maintaining accurate, up-to-date health records and ensuring follow-up for missed vaccines is critical for children who may miss a vaccine given in school due to illness or school closure. Some provinces offer vaccinations in a paediatrician’s office, while others will be at public health centres.

Every paediatrician and clinic will have to make their own decision on who they must/can see in their clinic. Consider several factors, including the availability of Personal Protective Equipment (PPE). If your clinic does not have access to PPE, the following rules during the COVID19 pandemic should be considered: 

• See every newborn and baby up to 3 months of age.
• See babies > 3 months of age if there is a concern for failure to thrive.
• See patients with infectious symptoms only if they have a recent COVID-19 negative swab result.
• See asymptomatic patients for assessment and treatment of injuries to hopefully prevent them having to go to the ER.
• Always wear a mask and gloves when seeing patients (even asymptomatic ones).

In clinics with PPE, the same patients as above can be seen, as well as symptomatic infectious patients. In these cases:

• Make sure to give sick patients a mask.
• Don PPE when seeing patients.
• If possible, schedule sick patients at a separate time of the day. For example, checkups in the morning, and sick patients in afternoon. Or all sick patients at the end of the day.

Preparing your clinic for an in-office visit during the COVID-19 pandemic

• Be sure to have your staff call the patient ahead of time to ask about any symptoms (runny nose or cough or sore throat or fever or shortness of breath) or travel history, as well as whether they have been in contact with anyone who tested positive for COVID-19. Remember to ask the same questions of anybody who will accompany the patient. 
• Eliminate your waiting room if possible. If this is not feasible, space the chairs two meters apart.
• Ask patients over 2 years old (and their caregivers) if they could kindly wear a mask when they come into the office, as it is not always possible to maintain a 6ft distance within some exam rooms
• Escort your patient directly into an exam room upon arrival so they are automatically keeping their distance from others, including your staff. 
• Thoroughly clean your exam beds, surfaces, door handles (both sides), pens, etc., after each patient visit.
• Provide your patients with any prescriptions and requisitions in the exam room.
• Ask your patients to phone the office at a later time to schedule follow-up appointments so they don’t stand by the reception desk.

Virtual care allows you to work from anywhere

If you are in self-isolation or need to be home for another reason, virtual care allows you to work from home too. Here are some tips to make it work:

• Choose a private room in the house, so you can focus during work and to protect the privacy of the patient.
• Always dress as you would as if you were in your clinic. There is nothing more embarrassing than getting up from a chair, only to reveal you’re wearing pajama pants.

COVID-19 is presenting physicians with challenges that we couldn’t have predicted. We’re having to borrow some of the lessons of our first years of med school, working with patients more remotely than we are used to. 

Luckily, we have tools to help us. Learning to use these tools and developing new best practices is our new challenge. Consider this need to adapt an extension of our original medical education.

Stay safe. Stay healthy.

Dr. Raphael Sharon is an Associate Clinical Professor in the Department of Pediatrics at the University of Alberta

If you have questions about medical-legal aspects of providing virtual medical care during the pandemic, consult the CMPA website.

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The information on this blog should not be used as a substitute for medical care and advice. The views of blog writers do not necessarily represent the views of the Canadian Paediatric Society.