Friday, November 29, 2024
Virtual Heart Care
Telehealth 

Rapid Rise of Pediatric Telehealth During COVID-19 in a Large Multispecialty Health System

Editor


Introduction

Rapidly upscaling a telemedicine program is challenging—especially during a health crisis. The coronavirus disease 2019 (COVID-19) pandemic prompted swift federal and state changes that brought virtual appointments to the forefront of outpatient care. Even with removing barriers to payment parity and state licensure,1,2 telemedicine programs still faced the challenge of rapid scalability.

Health care organizations responded to patient care needs during the COVID-19 pandemic by swiftly increasing virtual care.3–9 This is clearly illustrated by the U.S. Department of Health and Human Services briefing that revealed nearly half (43.5%) of Medicare primary care visits were provided through telehealth in April 2020 compared with <1% before the public health emergency (0.1% in February 2020).3 Similarly, the Center for The Epic Health Research Network (EHRN) reported a 300% increase in telehealth use from March 15, 2020 to April 14, 2020.10 This increase in virtual care has been observed across multiple specialties, with the greatest impact seen in gastroenterology, pulmonology, psychiatry, cardiology, and pediatrics.11

While there are many studies reporting the rapid rise in telehealth during the COVID-19 pandemic, there is little published data on the use of telehealth in outpatient pediatric specialty practices. Similarly, there is a paucity of data on the variation in telehealth utilization by subspecialty, rates of video visit completion (vs. cancellation or no-show), and the factors that facilitate successful rapid scaling of telehealth services. In this retrospective study, we evaluated telehealth utilization in a multispecialty outpatient pediatric practice during the initial months of the COVID-19 pandemic. We aimed to analyze the change in telehealth utilization rates over time, use of telehealth by specialty, and percent of video visits successfully completed. Metrics were compared over a 12-week period across three epochs that included pre-stay-at-home order (SHO), post-SHO, and reopening of the practice to in-person visits. We also describe how our telemedicine infrastructure and strategy facilitated successful rapid upscaling of video visits.

Methods

Study Setting and Timeline

Pediatric outpatient visits were studied during a 12-week time period (March 9, 2020–May 29, 2020) that encompassed substantial practice changes related to COVID-19 (Fig. 1). The 12-week study period was divided into three epochs. Epoch 1 (weeks 1–3, March 9, 2020–March 27, 2020) was 3 weeks before activation of the Minnesota governor’s executive SHO.12 During Epoch 1, on March 11, 2020, the World Health Organization (WHO) declared COVID-19 a global pandemic. Six days later, the Center for Medicare and Medicaid Services expanded telehealth rules and parity of coverage for telehealth visits.13 The same day, March 17, 2020, our health care organization issued a directive to change outpatient in-person visits to video appointments whenever possible. A week later, on March 25, 2020, the SHO was issued.12 Epoch 2 (weeks 4–6, March 30, 2020–April 17, 2020) was the 3 weeks immediately following the SHO. During Epoch 2, on April 6, 2020, our organization and pediatric practice began making workflow changes needed to allow for safe, in-person outpatient visits, which included universal masking of patients and staff, virtual visits before in-person visits to shorten patient’s time in clinic, and modifying waiting areas to ensure appropriate physical distancing. Epoch 3 (weeks 7–12, April 20, 2020–May 29, 2020) was the 6 weeks following the safe reopening of the pediatric specialty practice to in-person visits, which initiated at the end of Epoch 2 (April 13, 2020).

Fig. 1.

Fig. 1. Timeline shows key dates during each epoch for the 12-week study period.

Multispecialty Pediatric Outpatient Practice

Our multispecialty pediatric outpatient practice includes >95 specialty providers (physicians and advanced practice providers) working in 14 divisions and 70 programs that provide specialty care to children. In the course of a year, outpatient specialty providers collectively care for >33,000 patients, with average monthly outpatient visit volumes exceeding 2,700 visits per month. In 2019, 21% (3/14) of pediatric specialty divisions utilized telemedicine, and in the 6 months before March 2020, telehealth comprised only 0.36% of all patient visits to our multispecialty pediatric outpatient practice.

Center for Connected Care

The Mayo Clinic Center for Connected Care (CCC) was formed in 2014 to execute a system-wide strategy for the organization’s telemedicine programs, including outpatient video visits.14 A centralized infrastructure was adopted and vendor products were streamlined.15 Connected Care has subject matter experts and support in: legal/compliance, credentialing, revenue/billing, information technology, product (selection, deployment and support), government relations, training, education, and research. In May, 2019 the CCC initiated an Enterprise proactive installation of video hardware across provider private offices and select exam rooms, with the goal of outfitting 80% of Mayo Clinic’s clinical outpatient setting.

Telemedicine Equipment and Workflow

For outpatient video visits, providers used the telemedicine software embedded in the Epic Electronic Medical Record (EMR) (Zoom version 5.0; Zoom Video Communications, Inc., San Jose, CA). Desk Operation Specialists performed patient registration, insurance verification, check-in and virtual rooming using the EMR (Epic Systems Corporation, Verona, WI). To securely provide video visits from their home offices, providers were equipped with a Mayo provided desktop or laptop computer, or an iPad running Epic Haiku/Canto operating software. All care team members used VPN (Virtual Private Network) to connect to the Mayo Clinic network and access patient care systems and resources.

Telemedicine Implementation

On March 19, 2020, the multispecialty pediatric outpatient practice enlisted two physician champions and two operation managers to facilitate upscaling of its telehealth program. The champions’ efforts focused on: (1) staff communication, (2) efficient education, training, and personal coaching, and (3) prompt problem-solving—with emphasis on “good communication, early, and often.”

1.

Communication was primarily achieved through twice-weekly town hall meetings for outpatient staff, scheduled in response to the COVID-19 crisis.
2.

The CCC launched a self-service on-boarding tool kit for video to home appointments, which included a series of six, brief telemedicine tutorials that were deployed through e-mail. In less than an hour, providers could learn how to log on to the telemedicine portal, conduct and bill video visits. This allowed practice areas new to video appointments to rapidly on board during the onset of the pandemic.
3.

As needed, a physician champion provided informal consults to physicians to coach them on the workflow for team visits.
4.

Prompt problem solving was facilitated by the physician and operational champions who helped identify workflow changes needed for multidisciplinary video visits. For example, the 45-min time limit on video visits resulted in the longer multidisciplinary team visits being prematurely disconnected. The champions partnered with the CCC desk operations specialists to extend the time limit (1 day to implementation).

Study Design and Data Collection

We analyzed outpatient visit data for providers in 14 pediatric specialty divisions over 12 consecutive weeks, March 9, 2020 through May 29, 2020. The Child Advocacy division was excluded from the study as their staff did not conduct video visits due to privacy concerns surrounding child abuse evaluations. For each pediatric specialty outpatient visit, patient characteristics were abstracted from the EMR, including age, gender, race, ethnicity, and insurance status. The study period was divided into three Epochs as previously described. Appointment data for all pediatric outpatient specialty visits were abstracted from the institutional EMR and categorized as an in-person or video visit. Video visits were further categorized as completed, cancelled, or no-showed by the patient. The Mayo Clinic Institutional Review Board (No. 20-011578, Rochester, MN) deemed this study exempt from its review.

Statistical Analysis

Demographic characteristics were compared between two groups defined by their type of visit (in-person or video), restricted to one observation per patient in each group, using two-sided chi-square tests. The number of completed outpatient visits with pediatric specialists, overall and by type of visit was descriptively summarized graphically for each of the 12 weeks in the study period using Microsoft Excel v14.0 (Microsoft Corporation, Redmond, WA). These data were also stratified by specialty. In addition, the number of scheduled video visits by visit outcome (completed, canceled, or no-showed) was similarly summarized. For comparison purposes the weeks were collapsed into three Epochs as described above. The percent change between any two Epochs was calculated as the change in value between the two Epochs divided by the value in the starting Epoch, multiplied by 100. Proportions were compared between Epochs using a two-sided chi-square test determined using the JMP statistical software v.14 (SAS Institute, Inc., Cary, NC).

Results

Over the 12-week study period, 4,914 outpatient pediatric specialty visits were completed. This included 3,296 (67.1%) in-person appointments and 1,618 (32.9%) video appointments. Patient gender and ethnicity distributions were not significantly different between the two groups; however, we did observe statistically significant differences in race, age, and type of insurance (p < 0.001). A higher proportion of patients in the video visit group were Caucasian (87.0% vs. 83.1%) or had commercial insurance (75.8% vs. 70.8%) compared with patients in the in-person appointment group. In addition, there was a smaller proportion of patients in the video visit group who were older than 18 years of age (11.2% vs. 16.2%) (Table 1).

Table 1. Demographic Characteristics of Patients Seen by In-Person Visits and Video Visits
CHARACTERISTIC UNIQUE PATIENTS WITH AN IN-PERSON VISIT(N = 2,066)a UNIQUE PATIENTS WITH A VIDEO VISIT(N = 1,335)a pb
Gender
 Female 1,090 (52.8%) 685 (51.3%) 0.33
 Male 976 (47.2%) 649 (48.6%)  
 Not disclosed 0 (0.0%) 1 (0.1%)  
Hispanic ethnicity
 Yes 144 (7.0%) 75 (5.6%) 0.28
 No 1,876 (90.8%) 1,232 (92.3%)  
 Unknown or not reported 46 (2.2%) 28 (2.1%)  
Race
 Caucasian 1,717 (83.1%) 1,174 (87.9%) <0.001
 Black or African American 112 (5.4%) 41 (3.1%)  
 Asian 57 (2.8%) 36 (2.7%)  
 All others 151 (7.3%) 73 (5.5%)  
 Unknown or not reported 29 (1.4%) 11 (0.8%)  
Age group at visit (years)
 0 to <6 503 (24.3%) 375 (28.1%) <0.001
 6 to <12 489 (23.7%) 369 (27.6%)  
 12 to <18 740 (35.8%) 442 (33.1%)  
 18+ 334 (16.2%) 149 (11.2%)  
Type of insurance
 Commercial 1,463 (70.8%) 1,012 (75.8%) <0.001
 Government 560 (27.1%) 295 (22.1%)  
 Self-pay 29 (1.4%) 26 (1.9%)  
 Other 14 (0.7%) 2 (0.1%)  

Video visits increased rapidly from the beginning of Epoch 1 (week 1) to the end of Epoch 2 (week 6), representing a robust 4750% increase in the number of completed weekly pediatric outpatient video visits (Fig. 2). During week 1, only 0.84% (6/717) of outpatient pediatric specialty visits were conducted through video. By week 6, 82.0% (291/355) of visits were by video. The practice initiated a safe reopening to urgent in-person outpatient visits at the end of Epoch 2 (week 6). By week 12, 19.4% (97/500) of outpatient pediatric specialty visits were conducted through video. When comparing week 12 to week 6, there was a 66.7% decrease in the number of video visits and a 76.3% decrease in the proportion of visits conducted through video. Although video visits decreased during Epoch 3, the percent of outpatient visits completed by video during weeks 10–12 remained higher than in Epoch 1 (21.6% vs. 4.9%, respectively, p < 0.001).

Fig. 2.

Fig. 2. Percent of total visits performed by video and number of total visits performed by video in the outpatient pediatric specialty practice, March 9, 2020 to May 29, 2020, illustrates the rise and fall in both the percent of total visits performed by video and number of completed video visits before the governor’s stay-at-home order, during the 3 weeks following the stay-at-home order, and the subsequent 6 weeks during the safe reopening of the outpatient pediatric specialty practice to in-person visits.

The percent of pediatric outpatient specialty divisions that conducted video visits in week 1 was 14.3% (2/14) (Fig. 3). This peaked during Epoch 2 (week 5) when 100% (14/14) of divisions completed video visits. There was a modest decrement in the percentage of divisions completing video visits in Epoch 3, with 78.6% (11/14) of divisions completing video visits during weeks 11 and 12. The percent change in completed pediatric specialty outpatient video visits varied by specialty (Fig. 4). From Epoch 1 to 2, the greatest percent rise in completed outpatient pediatric specialty video visits was in Developmental (5,300%), Rheumatology (2,200%), and Pulmonology (1,850%).

Fig. 3.

Fig. 3. Percent outpatient pediatric specialty divisions completing video visits, March 9, 2020 to May 29, 2020, illustrates the rise and fall in the percent of outpatient divisions completing video visits before the governor’s stay-at-home order (Epoch 1), during the 3 weeks following the stay-at-home order (Epoch 2), and the subsequent 6 weeks during ramp-up of in-person visits (Epoch 3).

Fig. 4.

Fig. 4. Percent change in video visits between Epoch 1 and 2 by specialty division (March 9, 2020–April 17, 2020). Illustrates rise in the percent of completed video visits pre- to post-governor’s stay-at-home order. For divisions not conducting video visits during Epoch 1, a percent of increase could not be calculated.

A total of 1,954 outpatient pediatric specialty video visits were scheduled during the study period, of which 82.8% (1,618/1,954) were completed, 9.1% (178/1,954) were cancelled, and 8.1% (158/1,954) were no-showed by the patient. Neither the completion rate (80.7%, 81.6%, and 83.6%; p = 0.47) nor the no-show rate (3.6%, 7.5%, and 8.7%; p = 0.21) was significantly different between the three Epochs (Fig. 5). However, the cancellation rate decreased significantly during the three Epochs, from 15.7% to 10.9%, to 7.7% in Epochs 1 through 3 (p = 0.008).

Fig. 5.

Fig. 5. Percent completed outpatient pediatric specialty video visits versus cancelled and no show visits March 9, 2020 to May 29, 2020, is on a bar graph. It illustrates the consistently high percent of completed video visits versus cancelled and no-show appointments during Epochs 1, 2, and 3.

Discussion

The COVID-19 pandemic had a substantial and measurable impact on this multispecialty pediatric outpatient practice. We observed a significant 4,750% increase in outpatient video visits, from a baseline of <1% of total visits in week 1 to >80% of visits in week 6. As the practice prepared for and then implemented safe in-person care in the setting of the pandemic, video visits declined by 66.7%. However, at the end of Epoch 3, video visits accounted for a larger proportion of the outpatient practice than was observed before the pandemic. Most pediatric specialties saw an increase in video visits, with the greatest increases seen in Developmental, Rheumatology, and Pulmonology. Even with the rapid transition, the rate of completed and no-show video visits did not significantly change throughout the study period. In fact, the cancellation rate decreased significantly during the study period.

Other health care organizations have reported significant increases in their telemedicine programs during the COVID-19 pandemic, with percent increases ranging from 237% to 2,255%.6,16 Our 4,750% increase in completed video visits in a 6-week period appears to be unique in its magnitude and focus, as our data did not include phone calls or other nonsynchronous forms of telehealth. As modifications were made to our outpatient practice to provide safe in-person care during the pandemic, we observed a decrease in telehealth usage. Similar findings were reported by the EHRN that demonstrated national telehealth use dropped from a peak volume of 69% of total visits in mid-April to 21% of total visits by August 2020.17 It is interesting to note that both our data and that reported by the EHRN show ∼20% of visits continued to be conducted through telehealth even as organizations adjusted to the new practice environment. In our study, use of telehealth remained higher than prepandemic usage rates, with the majority of providers continuing to conduct video visits even after reopening to in-person visits. Furthermore, our 83% video completion rate compares favorably with other health systems that also report completion rates of ∼80%.4,7

Successful rapid scaling of pediatric specialty outpatient video visits was in part due to fundamental changes our organization made in its approach to telemedicine over the last several years, specifically the formation of the Center for Connected Care (CCC). The CCC described eight components for a robust telemedicine program.14 Of those components, the most relevant to our rapid scaling were practice champions, quality education programs, and an efficient system for rapid deployment. With the foresight of developing a centralized infrastructure for telehealth, most of the changes our organization implemented to upscale rapidly in March 2020 were not high-tech—but high-touch.

We observed that physician champions helped to facilitate the rapid upscaling and adoption of pediatric telemedicine services as found in other studies.18–20 A pediatric telehealth research network’s national survey found that the presence of clinical champions was a significant variable in helping ensure program success.21 Professional willingness to embrace telemedicine has been identified as a key factor for program success.22 At one university practice, clinicians had previous telepsychiatry training and supervision, which the authors suggest reduced barriers to acceptance and helped the rapid scaling from 2% to 100% telehealth visits in 3 days.9

Starting March 17, 2020, we made concerted efforts to ensure accessible resources for education and quick upskilling of providers. Our toolkit was critical to quickly and effectively upskilling, which has been observed in previous studies. Smith et al. demonstrated that toolkits facilitated rapid implementation of their urology telemedicine program in 3 days.8 A 20-year longevity study of a pediatric cardiology service in Portugal supported the importance of education and found effective upscaling requires a “clear commitment to building and improving digital literacy.”23

Another variable for efficient and rapid deployment of telehealth appears to be a pre-existing telehealth infrastructure.4–6,8–9 In our health system, this was imperative as it enabled the CCC to rapidly assemble support services in response to the COVID-19 pandemic. This included organizing and implementing the Provider Call Center in March 2020 to reduce excessive wait times due to high demands for video appointments. The CCC was also able to reallocate staff to supplement the Customer Assistance team. Rapid telehealth deployment may also be facilitated by organizational commitment to this model of health care delivery. Our expansion of pediatric outpatient video visits was aligned with our organization’s 10-year strategy that focuses heavily on digital health. One comprehensive cancer center committed to Relative Value Unit credits for telehealth use and reported a rise from 7%–18% to 76%–86% in ambulatory video visits within 11 weeks.4 The circumstances created by the COVID-19 pandemic may have allowed organizations that were already committed to telehealth to effectively scale up services when the crisis hit.

The COVID-19 pandemic radically changed the world’s perception and use of telemedicine. Whether this level of telehealth will be maintained after the pandemic abates is unclear. Telehealth may become the new norm of future health care.5 The convenience and accessibility that telehealth offers to patients and providers has raised expectations that may be challenging to reverse.5 Recently, Rametta et al. found that 86% of patients and caregivers using telehealth were interested in telemedicine for future care.7

Strengths and Limitations of the Study

Strengths of the study included examining variations in video visit use by specialty among a cohort of outpatient pediatric specialty providers, which has not been reported previously. This allowed for more specific data analysis such as percent change in video visits by specialty. This detailed look at use of video visits by individual pediatric specialties provides early data about specialties that may be most amenable to telehealth. By comparing only in-person and video visits (vs. including telephone consults or other asynchronous telehealth services), we clearly captured the dynamics of a significant paradigm shift in patient care during the pandemic. Moreover, we demonstrated that the rate of completed video visits over a 12-week period was stable, which illustrates the sustainability and acceptability of telehealth for the organization, providers, and patients

This study has limitations. We did not directly evaluate patient and family experience, patient outcomes, or provider satisfaction with the video visits. However, when reviewing Press Ganey survey data, our percent top box quarterly trend for “Likelihood of Recommending Practice” remained high during the first and second quarters of 2020 (January 1, 2020–June 30, 2020). Given few of our pediatric specialists had telemedicine experience before the pandemic, a provider satisfaction survey would offer valuable insights. Future studies could evaluate the long-term impact of pediatric specialty outpatient video visits on patient experience, equitable access to care, and health outcomes.

Conclusions

The COVID-19 pandemic radically changed the use of telemedicine, making “In-Person Health Care as Option B” a reality.24 Our organization’s telemedicine program, designed for long-term scalability, proved to be sufficiently agile for rapid response to the public health emergency. Our physician and operations champions excelled at “good communication, early, and often” with our clinicians, IT department, and operations team. Our experience and that of others suggest health care delivery through telemedicine is sustainable during and beyond a health crisis.

Authors’ Contributions

F.H. conceptualized and designed the study, carried out the analyses, coordinated and supervised data collection, drafted the initial article, and reviewed and revised the article; B.L.K. conceptualized and designed the study, collected data, carried out the analyses, critically reviewed the article for important intellectual content; A.R. assisted with the acquisition of data, critically reviewed the article for important intellectual content; T.L. assisted with design of the study, critically reviewed and revised the article for important intellectual content; M.D.H. assisted with design of the study, critically reviewed the article for important intellectual content; J.L.F. conceptualized and designed the study, interpreted the data, and critically reviewed and revised the article.

Acknowledgments

The authors thank Kendra Ask-Carlson and Tari Errthum for their assistance with data abstraction. They also thank Lana Christian for her editing expertise. They are grateful to Maxwell Cain for supporting this study with his knowledge of information technology and to Alison Larson for assisting with data collection and review.

Disclosure Statement

J.L.F. has licensed intellectual property and earns royalties from Teladoc Health. F.H., B.L.K., A.R., T.L., and M.D.H. have no conflict of interests to disclose.

Funding Information

No funding was received for this article.

References

  • 1. Hare N, Bansal P, Bajowala SS, et al. COVID-19: Unmasking telemedicine. J Allergy Clin Immunol Pract 2020;8:2461–2473.e3. Crossref, Medline, Google Scholar
  • 2. The Center for Connected Health Policy. Telehealth coverage policies in the time of COVID-19. 2020. Available at https://www.cchpca.org/resources/covid-19-telehealth-coverage-policies (last accessed November 29, 2020). Google Scholar
  • 3. Bosworth A, Ruhter J, Samson LW, et al. Medicare beneficiary use of telehealth visits: Early data from the start of COVID-19 pandemic. Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, 2020. Available at: https://aspe.hhs.gov/system/files/pdf/263866/HP_IssueBrief_MedicareTelehealth_final7.29.20.pdf (last accessed November 29, 2020). Google Scholar
  • 4. Lonergan PE, Washington SL III, Branagan L, et al. Rapid utilization of telehealth in a comprehensive cancer center as a response to COVID-19: Cross-sectional analysis. J Med Internet Res 2020;22:e19322. Crossref, Medline, Google Scholar
  • 5. Mann DM, Chen J, Chunara R, et al. COVID-19 transforms health care through telemedicine: Evidence from the field. J Am Med Inform Assoc 2020;27:1132–1135. Crossref, Medline, Google Scholar
  • 6. Punia V, Nasr G, Zagorski V, et al. Evidence of a rapid shift in outpatient practice during the COVID-19 pandemic using telemedicine. Telemed J E Health 2020;26:1301–1303. Link, Google Scholar
  • 7. Rametta SC, Fridinger SE, Gonzalez AK, et al. Analyzing 2,589 child neurology telehealth encounters necessitated by the COVID-19 pandemic. Neurology 2020;95:e1257–e1266. Crossref, Medline, Google Scholar
  • 8. Smith WR, Atala AJ, Terlecki RP, et al. Implementation guide for rapid integration of an outpatient telemedicine program during the COVID-19 pandemic. J Am Coll Surg 2020;231:216–222. Crossref, Medline, Google Scholar
  • 9. Yellowlees P, Nakagawa K, Pakyurek M, et al. Rapid conversion of an outpatient psychiatric clinic to a 100% virtual telepsychiatry clinic in response to COVID-19. Psychiatr Serv 2020;71:49–752. Crossref, Medline, Google Scholar
  • 10. Epic Health Research Network. Expansion of telehealth during COVID-19 pandemic. Available at https://ehrn.org/expansion-of-telehealth-during-covid-19-pandemic (last accessed November 29, 2020). Google Scholar
  • 11. Epic Health Research Network. As office visits fall, telehealth takes hold. Available at https://ehrn.org/as-office-visits-fall-telehealth-takes-hold (last accessed November 29, 2020). Google Scholar
  • 12. Emergency Executive Order 20-20 Directing Minnesotans to Stay at Home, No. 20-20 (2020). Available at https://mn.gov/governor/assets/3a.%20EO%2020-20%20FINAL%20SIGNED%20Filed_tcm1055-425020.pdf (last accessed April 14, 2020). Google Scholar
  • 13. The American Journal of Managed Care. A timeline of COVID-19 developments in 2020. Available at https://www.ajmc.com/view/a-timeline-of-covid19-developments-in-2020 (last accessed November 29, 2020). Google Scholar
  • 14. Lokken TG, Blegen RN, Hoff MD, et al. Overview for implementation of telemedicine services in a large integrated multispecialty health care system. Telemed J E Health 2020;26:382–387. Link, Google Scholar
  • 15. Kreofsky BLH, Blegen RN, Lokken TG, et al. Sustainable telemedicine: Designing and building infrastructure to support a comprehensive telemedicine practice. Telemed J E Health 2018;24:1021–1025. Link, Google Scholar
  • 16. Schulz T, Long K, Kanhutu K, et al. Telehealth during the coronavirus disease 2019 pandemic: Rapid expansion of telehealth outpatient use during a pandemic is possible if the programme is previously established. J Telemed Telecare 2020; [Epub ahead of print]: doi: 10.1177/1357633X20942045. Crossref, Google Scholar
  • 17. Epic Health Research Network. Telehealth: Fad or the future. Available at https://www.ehrn.org/articles/telehealth-fad-or-the-future (last accessed August 18, 2020). Google Scholar
  • 18. Contreras CM, Metzger GA, Beane JD, et al. Telemedicine: Patient-provider clinical engagement during the COVID-19 pandemic and beyond. J Gastrointest Surg 2020;24:1692–1697. Crossref, Medline, Google Scholar
  • 19. Fang JL, Asiedu GB, Harris AM, et al. A mixed-methods study on the barriers and facilitators of telemedicine for newborn resuscitation. Telemed J E Health 2018;24:811–817. Link, Google Scholar
  • 20. Yang L, Brown-Johnson CG, Miller-Kuhlmann R, et al. Accelerated launch of video visits in ambulatory neurology during COVID-19: Key lessons from the Stanford experience. Neurology 2020;95:305–311. Crossref, Medline, Google Scholar
  • 21. Olson CA, McSwain SD, Curfman AL, et al. The current pediatric telehealth landscape. Pediatrics 2018;141:e20172334. Crossref, Medline, Google Scholar
  • 22. Lennon MR, Bouamrane MM, Devlin AM, et al. Readiness for delivering digital health at scale: Lessons from a longitudinal qualitative evaluation of a national digital health innovation program in the United Kingdom. J Med Internet Res 2017;19:e42. Crossref, Medline, Google Scholar
  • 23. Maia MR, Castela E, Pires A, et al. How to develop a sustainable telemedicine service? A pediatric telecardiology service 20 years on – an exploratory study. BMC Health Serv Res 2019;19:1–16. Crossref, Medline, Google Scholar
  • 24. Duffy S, Lee TH. In-person health care as option B. N Engl J Med 2018;378:104–106. Crossref, Medline, Google Scholar





Source link