AAP Voices Blog

After a full day of telemedicine appointments, I noticed that a patient had missed her scheduled video visit. I know Tiana well. She’s a 7-year-old who had missed two recent appointments despite several requests for rescue inhaler refills over the past year.

When I called her home, Tiana’s mom sounded flustered. “Hi, Dr. Lazerov! I’m glad you called!” I learned that her smartphone’s limited storage capacity wouldn’t allow her to download the Zoom app for the visit. Troubleshooting commenced and eventually she logged in using Tiana’s brother’s device, but their internet bandwidth supporting a sibling’s virtual classes caused the video to freeze and the audio lagged. It had now been almost 20 minutes since we began.

Situations like this are not uncommon for my patients in Southeast Washington D.C. Like many other organizations, our institution rapidly expanded our virtual capacity last year as telemedicine became part of the patient-centered medical home. But despite our considerable efforts, there are those who have been left behind. Barriers to access are not new, and not surprisingly, my patients who have struggled to access their medical home in the past are often those I see struggling to access virtual care.

So, how can we do better?

To start, we need to prioritize easy-to-use platforms for those with varied broadband access and technological expertise, and interpreters must be accessible when needed. Also, it is critical to invest in administrative support to provide real-time assistance for families preparing for their virtual visit, especially for first-time visits.

“If our goal is to reach our most under-resourced and historically marginalized families better than we do now, we must truly listen with humility to those we intend to serve.”

But despite significant challenges, there are opportunities that telehealth can offer that in-person care cannot. In my experience, patients and families are far more comfortable in their own homes, avoiding stressors such as traveling to our office, clinic wait times, missing school or work, and the fear of coronavirus exposure. As such, our conversations are often more meaningful, and encounters feel more productive.

Even one successful virtual visit has the potential to strengthen the patient-provider relationship and empower families as they access their medical home differently, which could translate into improved outcomes and healthier patients.

Telemedicine also gives us a glimpse into our patients’ daily lives, homes, routines, and struggles in real time in ways office visits cannot, though attention to privacy means we must ask permission to view their home environment, obtain appropriate consent prior to virtual care, and ensure privacy for teens.

My glimpses into my patients’ worlds have been invaluable, often giving me profound insights into how we approach acute and chronic disease mitigation.

For one child struggling in virtual school, I was able to assess her learning space. I suggested moving distracting toys to another area and turning her desk away from a window looking onto a busy street corner. A welcome bonus was that she only missed 15 minutes of school time during our telehealth visit.

For three siblings struggling with unhealthy weight gain, I completed a kitchen tour with their permission, evaluating the contents of their cupboards and fridge, and eventually finding those sneaky, healthy-looking foods that were sabotaging their considerable lifestyle-change efforts. I was also able to document their weight displayed on their bathroom scale.

For a patient with eczema not responding to topical steroids, I asked during our virtual visit if we could take a “medicine cabinet field trip.” We discovered that the ointment he had been using was an antibiotic with a red label that looked quite similar to the tube of ointment I had prescribed.

As for Tiana, we reviewed her symptoms and she and her mother showed me her medications one by one. Together, we developed a plan to store her controller medicine somewhere else to improve twice-daily compliance. With permission, I assessed Tiana’s bedroom. Her neatly made bed sat under an open window, complete with a superhero comforter topped with several carefully arranged stuffed animals. With Tiana’s documented pollen and dust mite allergies as her main asthma triggers, this was a great opportunity to discuss how to reduce her exposure to triggers.

With time, patience, and an already strong therapeutic relationship, a successful virtual visit that day was possible. But for so many others in the community like Tiana, the barriers to virtual care can seem insurmountable.

Despite telemedicine’s benefits, committing to reducing health disparities means that equity must be top of mind as we design and implement patient-facing technologies; retrofitting for equity is insufficient. Otherwise, we risk perpetuating or further widening the health equity gap. Because telehealth’s enduring role in care delivery is likely going forward, it is essential that this virtual care is not only of the highest quality but also becomes integrated into the patient-centered medical home.

If our goal is to reach our most under-resourced and historically marginalized families better than we do now, we must truly listen with humility to those we intend to serve. For parents who would like more information, HealthyChildren.org has several articles on how telehealth can work for their families. 

I ended my visit with Tiana with a “virtual high-five.” “I’m so happy you got to see my house!” Tiana giggled as her mother beamed. When asked if they would consider telemedicine in the future, her mother said: “Definitely! It’s like you were here and gave us VIP treatment!”