Implications and Contributions
During the COVID-19 pandemic, telemedicine use is increasing without practice guidelines
specific adolescent health. This study summarizes obstacles to the implementation
of telemedicine for adolescents, and proposed solutions. Observations made during
this process have implications for the continued use of telemedicine to improve healthcare
access beyond the current pandemic.
The Coronavirus Disease 2019 (COVID-19) pandemic is a rapidly evolving public health
crisis. Uptake of telemedicine has been one response utilized by providers to continue
caring for patients while minimizing risk of exposure or transmission of COVID-19.[[1],
[2], [3], [4]] The Centers for Medicare and Medicaid Services (CMS) defines telemedicine
as two-way, live communication between the patient and provider at a distant site
including audio and video equipment.[5] This may occur with or without the assistance
of peripheral medical examination devices (e.g. electronic stethoscope, etc) and can
augment but should not fully replace in-person medical visits.[6,7] Telemedicine has
been increasingly recognized in recent years as a tool to improve access to healthcare.[[8],
[9], [10], [11]] Despite successful expansion of telemedicine in some areas, persistent
barriers to widespread implementation include patient and provider acceptance, technical
connectivity challenges, infrastructure to support Health Insurance Portability and
Accountability Act (HIPAA) compliant care, and unavoidable deviations from clinical
standards of care.[7] Thus, the COVID-19 pandemic has challenged clinicians to rapidly
determine how to provide high quality care while addressing the public health needs
of the community. The appropriate response may vary by patient population, specialty,
practice setting, and local availability of resources. For providers caring for adolescents
and young adults (AYAs), the scramble to care for this vulnerable population in the
midst of a pandemic raises questions about quality of care, limitations of telemedicine,
and challenges with confidentiality that are yet to be fully understood.
Despite opportunities for improved access to care, telemedicine has not been widely
implemented or studied within the field of Adolescent Medicine. Telemedicine practice
guidelines are established for general pediatrics[12] and adolescent and pediatric
mental health care,[13] but there are no telemedicine guidelines specific to Adolescent
Medicine. Ethical and legal complexities remain, including concerns over privacy and
data security, inequity in access to technology and technological knowledge, and questions
regarding effects on the doctor-patient relationship.[7,14,15] Given this population’s
unique access-to-care issues (e.g. sexual/reproductive health, mental health & substance
use) and wide developmental variation in healthcare needs and literacy, additional
research and guidelines are needed to incorporate telemedicine into AYA care.
Some precedents do exist for remote provision of key components of adolescent medicine
including online platforms for reproductive health services[16,17] and mental health
telemedicine for the treatment of eating disorders[18,19]. Telemedicine for medical
monitoring in eating disorders care is emerging out of necessity during the COVID-19
pandemic.[3]
Despite limited evidence and lack of guidelines for AYA telemedicine, the COVID-19
pandemic has necessitated its rapid adoption in AYA-serving practices. The University
of California San Francisco (UCSF) Adolescent and Young Adult Medicine clinic provides
primary and sub-specialty care to local urban AYAs, and specialty care to patients
from communities across Northern California. This study reports on our clinic’s rapid
transition to audiovisual telemedicine without peripheral devices to decrease the
number of in-person clinic visits in response to COVID-19, and describes novel observations,
challenges, and opportunities for innovation.
Methods
Clinical Context
UCSF’s Adolescent and Young Adult Medicine Clinic is embedded in an urban academic
medical center. The clinic was established in 1974 and serves 12 to 26 year-olds.
In 2019, the clinic served 1,715 unique patients over 4,195 clinic visits. Patients
are 26% male and 32% publicly insured. The clinic provides full-spectrum interdisciplinary
AYA care including primary care for AYAs with complex medical conditions, management
of attention and mood disorders, sexual and reproductive health care, eating disorder
care, and addiction treatment.
Intervention
In the setting of the COVID-19 pandemic our practice sought to maximize AYA access
to health care while maintaining social distancing. As a result, we rapidly implemented
the use of telemedicine in all aspects of our practice. This required coordination
between providers, clinical support staff, and clerical staff (see Table One: Personnel
Involved in Implementation). All providers were trained to use Zoom©,[20] a HIPAA-compliant
audiovisual tool, for telemedicine purposes within one week of our initial faculty
meeting on COVID-19 (see Table Two: Timeline).
Nursing and administrative staff created new protocols for remote triage, scheduling,
and patient check-in. Because virtual visits required patients to have access to the
EMR patient portal, clerical staff had to develop new workflows to be able to enroll
minors and their proxies remotely while still maintaining confidentiality and obtaining
appropriate written permissions. A member of the clinical faculty met with support
staff daily throughout telemedicine implementation to identify challenges and facilitate
communication between providers and staff. The first two weeks of the intervention
focused on addressing logistical challenges to EMR patient portal enrollment, patient
scheduling, utilization of the telemedicine platform, and streamlining communication
between providers, clinical support staff, and clerical support staff. By week two,
providers began identifying challenges and lessons learned in practicing telemedicine
for general adolescent health care, reproductive health, eating disorders, and addiction
treatment as highlighted below. We received a letter of exemption from the UCSF Institutional
Review Board for this publication.
Results
The number of telemedicine visits in our practice increased from zero to 80 per week
as of March 30, 2020 (see Figure1
One). While the percentage of provider telemedicine visits increased from 0% to 97%,
the number of overall clinic visits did not decline when compared to one year prior
(337 visits in March 2019 vs 332 visits in March 2020) and no-show rates were comparable.
The clinic billed 518 Relative Value Units (RVUs) in March 2020, compared to 480 RVUs
billed in March 2019. Due to delays in insurance company adjudications, we cannot
report actual March 2020 revenue generated.
Figure 1
Clinic Visits per Week. AYA Clinic visit types (telemedicine visit, provider visit
in clinic, or nurse-only visit in clinic) by week in March 2019 compared to March
2020, illustrating telemedicine visits from zero per week to 56 per week by the second
week of March this year. By the last week in March, more visits were conducted via
telemedicine than total clinic visits in the same week one year earlier.
Overall, providers noted that telemedicine seemed acceptable to AYAs who generally
had competence with electronic communications platforms and welcomed the convenience
of meeting with providers remotely. Providers reported only two visits that were not
completed due to technical issues. When needed, providers were able to integrate certified
medical interpreters directly into telemedicine visits. Generally, patients arrived
on time and the structure of telemedicine encounters combined with our initial problem-focused
visits, led to timely clinic sessions which were well received by providers and patients.
Providers identified several common barriers to telemedicine across all clinical domains.
In some cases, privacy and confidentiality were challenges given the provider’s inability
to establish a quiet and private environment for the patient as they would in an office
visit. In response, providers encouraged AYAs to use headphones, utilized yes/no questions,
and leveraged the Zoom© chat function to allow patients to type replies to questions
while limiting disclosure to household members in close proximity. With these interventions,
providers only reported seven appointments in which the scope of care was overtly
limited due to patient privacy concerns. Lower socioeconomic status compounded privacy
challenges due to crowded living conditions. While some providers were also concerned
that patients with limited socioeconomic means might not have access to the electronic
devices needed for telemedicine (smart phone, tablet, or computer), all patients in
our clinic were able to access an appropriate device for their appointments.
Implementation efforts also revealed barriers to telemedicine related to limited provider
comfort with clinical decision making in the absence of a complete physical exam or
laboratory data. Providers explored evidence-based practices for treating common ailments
such as suspected uncomplicated urinary tract infections or strep throat with clinical
scoring and assessment methods based on limited objective data. Additionally, numerous
providers reported discomfort with asking patients to provide on-camera views of certain
body parts as part of their physical exam due to limitations in patient privacy as
well as provider-perceived impropriety (see reproductive health below).
In addition to these overarching issues, the practice also identified actual and potential
barriers to telemedicine (Tables 3 and 4
respectively) and solutions specific to each of its main clinical domains.
Table 1
Personnel Involved in Implementation
Title
Role
Providers
Nurse Practitioners (NP)Adolescent Medicine Fellows (MD)Adolescent Medicine Attending
Physicians (MD)
Direct patient care via in-person appointments or telemedicine
Clinical Support Staff
Licensed Vocational Nurses (LVN)Registered Nurses (RN)Medical Assistants (MA)
Triage to telemedicine, in-person visit, or respiratory care clinicVital sign checks,
immunization administration, and point of care testing for in-person visits and to
augment telemedicine visits.
Clerical Support Staff
Front Desk StaffEating Disorder Program Coordinator
Scheduling including canceling appointments and rescheduling video visits.Facilitating
patient portal enrollment.
Other Health Professionals
Social Workers (LCSW)
Coordination of social support services, eating disorder programs, referrals for mental
health care, and health insurance advocacy.
Registered Dietitians (RD)
Dietary counseling for primary care and eating disorder patients and families
Table 2
Timeline
Date
Event or Intervention
1/22/2020
First COVID-19 case confirmed in the United States[32]
2/27/2020
CDC investigates first confirmed community spread of Sars-CoV-2 in the United States
which occurred in California’s Bay Area.[33]
3/6/2020
Initiative to explore the expansion of telemedicine begins at the health center level.
Intervention Week One: Zero telemedicine visits per week in Teen Clinic.
3/9/2020
First UCSF Primary Care Pediatrics COVID-19 Planning Meeting
3/10/2020
1-hour optional training course for pediatric providers on conducting video visits,
supplemented by online training videos
3/11/2020
First UCSF AYA faculty meeting to plan COVID-19 response and transition to telemedicine
for AYA Clinic.
3/12/2020
All Hands meeting of clinical faculty and staff across primary care pediatrics with
training in UCSF’s telemedicine platform.
3/13/2020
Plan for near total transition to telemedicine disseminated and revised by faculty
and advanced practice nurses with discussion of expected limitations of telemedicine
and a plan for weekly or biweekly evaluation of clinic protocols for all clinical
services.Meeting between AYA clinic leadership and hospital nutrition leadership to
establish a plan for telemedicine involvement of registered dietitians.First UCSF-wide
weekly town hall to disseminate regional and intuitional plans and update campus on
current and projected clinical demands.
3/13/2020 to present
Brief daily Division leadership phone calls and weekly calls with MDs and NPs are
implemented to facilitate rapid and responsive changes to the clinical services.
Intervention Week Two: 56 telemedicine visits per week in Teen Clinic.
3/16/2020
All attending physicians, fellows, and nurse practitioners in the practice are telemedicine
trained and ready.Daily telemedicine sessions begin for urgent care, mental health
(e.g. depression and anxiety assessments, medication management), eating disorder,
and addiction treatment follow up with established patients.Telemedicine clinics are
augmented by daily two hour in-person clinic sessions or nurse-only visits for vital
sign checks and laboratory work for select patients.
3/17/2020
Six Bay area counties become the first region in the nation to mandate inhabitants
“shelter in place” closing schools and non-essential businesses, and banning all non-essential
travel.[36]Addiction treatment program: first buprenorphine follow up visit via telemedicine
with established patient with opioid use disorder (OUD).
Intervention Week Three: 44 telemedicine visits per week in Teen Clinic.
3/23/2020
Clinicians continue to meet weekly to discuss challenging cases, creative problem
solving strategies, and plans for expanding telemedicine to a wider range of health
concerns and visit types.
3/24/2020
Addiction Treatment Program: first addiction psychiatry intake via telemedicine with
an established patient.
3/25/2020
Daily team huddles begin with the clinical staff, clerical staff, and one of the practices
attending physicians to allow for rapid problem solving and clear communication between
clinic providers and staff.
Intervention Week Four: 80 telemedicine visits per week in Teen Clinic.
3/30/2020
Department of Health and Human Services announces that it will not enforce rules against
using HIPAA non-compliant video chat software for telemedicine visits.[26]CMS modifies
its payment policies to encourage telemedicine or telephone encounters.[27]Clinic’s
daily telemedicine sessions continue with additional provider schedules added to meet
demand.Two hour in-person clinic sessions scaled back from 5 days per week to 3 days
a week due to low patient demand.Addiction Treatment Program: first new patient intake
via telemedicine (non-OUD).
3/31/2020
DEA and SAMHSA issue guidelines allowing credentialed providers to treat new patients
with OUD initiate buprenorphine using telemedicine.[24]
4/3/2020
California’s Governor Gavin Newsom releases an executive order to allow providers
to use video chat services to delivery health care without risk of penalty in alignment
with the federal Department of Health and Human Services guidelines.[37]
4/6/2020
Addiction Treatment Program: first new patient intake via telemedicine for patient
with OUD
Table 3
Identified Telemedicine Barriers and Solutions
Barriers
Solutions
General Issues
Limits to patient privacy and confidentiality
•
Use of ZOOM chat feature
•
Patient use of earphones with provider use of yes/no questions
Limited provider comfort with sensitive exams on telemedicine
•
Patients can upload relevant photographs via EMR patient portals
•
Practices & national organizations will need to develop guidance about best practices
related to use of sensitive exams in telemedicine.
Limited provider comfort with clinical decision making in the absence of physical
exams and point of care testing.
•
Point of care testing can be conducted in local laboratories or with nursing visits
•
Providers can share evidence based guidelines of clinical scoring modalities possible
with telemedicine exams.
Inability to assess recommended anthropomorphic data for annual preventive visits
•
Consider augmentation with nursing visits to collect vitals, high, weight, vision
screening, hearing screening, STI screening, and blood work (lipids, HIV screening,
etc).
Clinical encounters no longer co-located with interdisciplinary colleagues
•
Fully train social workers and registered diaticians to use telemedicine software.
•
Establish internal referrals to social work and dietitian staff with scheduling assisted
by clinic staff.
Mental Health
Need for ongoing screening and assessments of mood symptoms.
•
EMR based administration of PHQ-9 & GAD-7 prior to telemedicine visit.
Reproductive Health
Limited provider comfort with sensitive exams on telemedicine
•
Patient can take still photos of visible lesions and submit them via the EMR patient
portal
•
Practices & national organizations will need to develop policies about best practices
related to use of genitourinary exams in telemedicine.
Need for in-person encounters for LARCs, Papanicolau smears, and acute pelvic complaints
•
Hybrid model is needed with telemedicine visits to triage acute symptoms and in person
visits for diagnosis & treatment.
Eating Disorder Care
Inability to assess recommended anthropomorphic data for eating disorder visits
•
Train family members to collect weights at home.
•
Utilize hospital satellite clinics to collect vital signs.
•
Partner with local PCPs to collect weights & vital signs.
•
When possible, partner with therapists to trend weights from therapy visits.
Inability to assure parent privacy while disclosing patient weight or dietary recommendations.
•
Have parents and patient call in from separate devices so that one can be “removed”
from the visit to facilitate confidential discussions.
Table 4
Anticipated Barriers and Identified Opportunities
Anticipated Barriers
Future Opportunities
Patients might not have an appropriate device to engage in telemedicine
•
All patients in our practice had access to an acceptable phone or computer device.
•
Patients may have access to computers or tablets at school, through other community
programs, or via family members.
•
CMS and private payers could expand reimbursements for telephone only encounters
•
Consultations could occur directly in a Primary Care Providers office with clinic
equipment
Technology literacy gap within a family may lead to decreased engagement with caregiver
(e.g. an adolescent may be comfortable with telemedicine but the parent is not)
•
Initial consultations could be completed in office with training for family members.
•
Technical support could be provided in the form of online tutorials or phone support.
Patients may reject telemedicine due to lack of connection with providers or limits
of care.
•
As telehealth was well received it could be used to reduce geographic and travel-related
financial barriers to care (gas, missed work, etc.) and expand subspecialty care for
wider populations.
Language barriers could limit engagement in telemedicine
•
Standard phone interpreting services can be directly integrated in the telemedicine
platform.
Reimbursements may be low or unavailable for telemedicine
•
State, federal, and private payor expansions of telemedicine coverage were ongoing
during the pandemic and may provide opportunities for future telemedicine reimbursement
General Adolescent and Young Adult Health Care
Our initial roll out of telemedicine focused on general AYA acute health complaints
that did not require respiratory triage for COVID-19 evaluation. Issues that were
particularly straight forward to treat via telemedicine included follow up for established
problems such as chronic headaches, dermatologic issues, and some musculoskeletal
complaints. Initially we did not offer well care visits due to our inability to monitor
height, weight, blood pressure, vision, and hearing as recommended by Bright Futures,
though we later established a protocol for obtaining at home weights for those patients
with a scale.[21] Additionally, vaccines and screening for Human Immunodeficiency
Virus (HIV), STIs, and dyslipidemia could only be completed in person with the help
of nurses or phlebotomists. However, many aspects of adolescent and young adult care
recommended by Bright Futures were possible to implement via telemedicine including
screening for depression, substance use, psycho-social development (e.g. the HEADDS
Assessment), and general anticipatory guidance.[21]
Another limitation of our initial telemedicine rollout was that our social workers
and dietitians were not available in real-time as they had been in the clinic’s former
practice model. Telemedicine visits began with one registered dietitian. An additional
dietitian and social worker were on boarded by the second week of implementation.
To facilitate internal referrals, we created a shared list of patients requiring consultation
with these providers in the EMR. Ongoing efforts aim to further integrate our social
work and dietitian colleagues into our telemedicine practice.
Mental Health
Providers identified that medical management of mood disorders and maintenance of
attention deficit hyperactivity medications were all easily managed via telemedicine.
We utilized built-in EMR questionnaires, including the Patient Health Questionnaire
9 (PHQ9) and the Generalized Anxiety Disorder 7 (GAD7), which patients could complete
prior to their appointments to screen for and monitor mood or anxiety disorders. The
rapid implementation of telemedicine for mental health services was critical as we
saw an influx of college-aged youth returning home abruptly from campuses and requiring
mental health support and medication refills due to loss of college-based providers
or new onset of acute stress responses secondary to the pandemic. One challenge providers
faced was how to appropriately manage medications for conditions typically managed
by psychiatrists (e.g. antipsychotics, mood stabilizers, benzodiazepines). We chose
to bridge patients with prescriptions as we facilitated appropriate local referrals.
Reproductive Health
Despite limitations to physical exams via telemedicine, providers identified contraception
counseling and provision of combined hormonal contraceptives (pills, patches, and
vaginal rings) as feasible for telemedicine with a plan to reassess blood pressure
at the patients’ next in-person clinic visit given the low occurrence of clinically
significant hypertension with these methods. Additionally, consults for dysmenorrhea,
menorrhagia, and oligomenorrhea were completed via telemedicine with supporting visits
for blood work or imaging as indicated. Specific to reproductive health, providers
expressed concern about the possibility of reproductive coercion given limitations
to patient privacy via telemedicine.
Despite the ease of telemedicine for some contraception visits, many other reproductive
health issues required physical exams (e.g. suspicion for pelvic inflammatory disease)
or laboratory tests (e.g. STI screening, testing, and treatment; HIV screening and
Pre-Exposure Prophylaxis (PrEP)). Likewise, in-person visits are essential to the
provision of Long Acting Reversible Contraception (intrauterine devices and Nexplanon),
injectable medroxyprogesterone, treatment of ascending pelvic infections, and Papanicolaou
smears. Patients requiring these services were offered appointments during the clinic’s
abbreviated in-person sessions. We also transitioned collection of pregnancy tests,
STI screening, HIV testing, and PrEP monitoring serologic tests to nursing or laboratory
visits either at UCSF or commercial laboratories.
In some cases, when physical exams for reproductive health complaints were possible
via telemedicine, providers in our practice struggled with the propriety of virtual
genital or breast exams. For example, one patient described a classic genital herpetic
lesion by history, but the provider did not feel it was appropriate to ask the patient
to point his camera at the lesion and instead asked the patient to come to clinic
for an in-person visit. Other providers chose to complete similar exams via telemedicine
or ask patients to submit photos of their lesions via the EMR patient portal.
Eating Disorders
The medical monitoring of eating disorders includes regular assessment of weight,
vital signs, dietary history, electrolyte monitoring, and coordination with the patient’s
psychotherapist.[22] Given the need for regular anthropomorphic measurements for these
patients, providers expressed particular concern about transitioning these patients
to telemedicine. As such, we collaborated with our psychiatry colleagues to refine
a protocol for family members to calibrate home scales and take blind weights prior
to telemedicine visits. In other cases, therapists or primary care providers measured
weights and vital signs and forwarded these data to our team. Finally, when a patient
was clearly engaged in concerning behaviors (e.g. increased restricting, purging,
over exercising), or the provider, therapist, patient, or family member had a high
index of suspicion for medical deterioration, the patient was asked to come in for
one of the clinic’s limited in-person sessions for measurement of weight, orthostatic
vital signs, and any indicated blood work (e.g. electrolyte monitoring). When admission
was required due to vital sign instability, it could be coordinated from that visit.
Providers noted that our eating disorder patients particularly benefitted from the
convenience of telemedicine as they are referred to our clinic from a much wider geographic
range than our primary care patients. By working with our hospital’s satellite clinics,
local primary care providers, and therapists we were able to spare these patients
and their families the financial and time burdens of travel to our clinic, in addition
to minimizing potential transmission of COVID-19 between communities.
Our providers identified unique challenges to telemedicine in this patient population.
Concerns about privacy arose again, including concerns of patient distress related
to overhearing specific weight numbers or nutrition interventions that providers would
otherwise discuss confidentially with parents or guardians in an in-person clinical
setting. Providers encouraged parents to use headphones in these encounters. Conversely,
telemedicine created flexibility for some families, allowing increased parental participation
in medical visits (e.g. among parents with separate households or for working parents).
Addiction Treatment
The UCSF Youth Outpatient Substance Use Program (YoSUP) is embedded in the Adolescent
& Young Adult Medicine Clinic and provides treatment to youth with opioid use disorder
(OUD) and other substance use disorders. Initially, we limited these telemedicine
visits to established patients. We expanded care to new patients after March 31, 2020
when the Drug Enforcement Administration (DEA) in partnership with the Substance Abuse
and Mental Health Services Administration (SAMHSA), issued guidelines allowing appropriately-credentialed
providers to admit and treat new patients with OUD and to prescribe buprenorphine
using telemedicine platforms without initial in-person assessments during the COVID-19
public health emergency.[23] As a program funded by SAMHSA, YoSUP is legally required
to complete structured intakes that include demographic, diagnostic, physical health,
and mental health information.[24] To ensure that new patients completed federally
required intake interviews, our program support staff began conducting these via Zoom©
before each patient’s first physician telemedicine visit. We asked that, whenever
possible, youth and their parents log in to visits from different devices or have
access to separate private spaces to facilitate separate but co-occurring confidential
meetings with clinicians and social workers. For youth in need of psychiatric assessments
for comorbid disorders, our providers also transitioned to telepsychiatry. As most
components of the clinical opiate withdrawal scale can be assessed via video connection,
we plan to conduct buprenorphine inductions using telemedicine for youth who can enlist
a loved one to provide support. We will offer in-clinic inductions to youth who do
not have access to a support person.
Discussion
This study describes one AYA medicine practice’s experiences quickly implementing
telemedicine without peripheral examination devices in response to a pandemic. Many
observations are widely applicable to other AYA medicine practices, while some may
be unique to our group. Because our practice is based in San Francisco, where strict
shelter-in-place mandates were announced early in the COVID-19 pandemic (March 16,
2020),[25] we adopted changes in our practice earlier and more rapidly than many other
practices in the U.S. This rapid shift required us to continuously re-assess balancing
adherence to social distancing while preserving our commitment to high-quality AYA
care. Given the dearth of telemedicine guidelines specific to AYA, these changes were
uncomfortable for our providers, but necessary in the face of unprecedented circumstances.
Our rapid transformation to a primarily telemedicine practice was facilitated by multiple
factors including institutional support for telemedicine as well as access to the
necessary technology and training for providers and clerical staff in their adjusted
roles. Not all AYA practices have the same systems-level supports in place, and different
creative strategies will be required to resolve barriers to telemedicine.
State and national policies regarding telemedicine are undergoing rapid changes. CMS
has modified payment policies to encourage telemedicine[26] and private payors are
following suit, announcing elimination of co-payments for telemedicine visits.[27]
While payment and privacy laws vary by state, many states have reduced policy barriers
to telemedicine.[28] Similarly, the Department of Health and Human Services announced
that it will not penalize the use of HIPAA non-compliant video chat applications for
telemedicine during the COVID-19 emergency.[29] In other countries, telemedicine implementation
is also being fast-tracked with adjustments to privacy laws and systems-level supports.[2]
While expansion of AYA telemedicine continues under these emergency policy changes,
it is unclear if this expansion would be sustainable should these be reversed. For
example, practices may no longer be able to effectively bill for telemedicine, clinicians
currently using HIPAA non-compliant applications may need systems-level supports to
transition to different platforms, and addiction medicine providers may no longer
be able to prescribe medications for treatment of OUD using only telemedicine.
Serving AYAs through telemedicine poses many unanswered questions. For AYA primary
care, the extent to which health supervision via telemedicine is appropriate remains
unclear. While many aspects of routine AYA preventive care can be done via telemedicine,
some components are not feasible.[21] It remains to be seen how advancing technologies
(e.g. wearables or smart phone accessories) and the shifting culture of Adolescent
Medicine might overcome some of these challenges. A lack of research or practice guidelines
on telemedicine for AYAs leaves providers in this field with patients who largely
have access to the necessary technology[30] and are likely eager to take advantage
of virtual visits,[31] but with no clear evidence or recommendations on applying telemedicine
in this population. This study was limited to anecdotal provider experiences and short-term
data. More research is needed to understand the patient and family experience of AYA
telemedicine.
Along with the possibilities offered by telemedicine, it is crucial to consider its
current limitations and how they can be addressed. Barriers to telemedicine still
exist for AYAs who lack access to internet or required technology; or who have no
private place to conduct a visit (e.g. due to homelessness or overcrowding). Additionally,
it is well documented that young adults have worse clinical outcomes than adolescents
on a variety of health issues and it remains to be seen if telemedicine may impact
these disparities.[32] Furthermore, as we push the limits of what can be done via
telemedicine, our patients’ safety must remain paramount. For example, AYAs may live
in unsafe conditions involving abuse or violence, where discussions during a telemedicine
visit at home could put them in danger or they may not be able to safely disclose
all of their concerns. In-person clinic visits must remain available for patients,
and providers should utilize in-person appointments if they suspect telemedicine may
be inappropriate for these reasons.
As noted, our providers struggled with the propriety of genital exams via telemedicine.
Strategies for collaborative decision-making with patients about limitations of telemedicine
exams balanced with patient inconvenience and risk (e.g. risk of infection in the
COVID-19 pandemic) will need to be explored through further research with patients
and providers. Best practices in this regard are also likely to have implications
for sexual maturity ratings for adolescent preventative health care visits.
There is particularly urgent need to better understand the efficacy of telemedicine
for the medical management of patients with eating disorders and addiction. While
telemedicine has potential to expand access to specialty care for both, research is
needed to understand the safety, efficacy, and acceptability of telemedicine for these
disorders. For eating disorder care, research is needed to assess the accuracy of
home weights, hospitalization rates, and long-term recovery outcomes when eating disorders
are managed via telemedicine. AYA subspecialists can expand access to care by collaborating
with primary care providers via teleconsultation.[7]
There is a sense that many of the changes that we have described here are not just
temporary responses, but rather that they represent a “new normal.” While we are by
no means proposing that telemedicine for AYAs will replace seeing patients in person,
the field can look at this quick shift to telemedicine as an opportunity to reach
our patient population in new ways, both in this time of crisis and beyond.