Implementing Telecommunication Services in the Medical Home

The American Academy of Pediatrics (AAP) 2021 policy statement, “Telehealth: Improving Access to and Quality of Pediatric Health Care,” calls medical telecommunication “a critical infrastructure to efficiently implement the medical home model of care and provide high-value, coordinated, and unfragmented health care.” Supporting use of medical telecommunication “within the medical home recognizes that the medical home offers continuity and the prudent use of health care resources, avoiding fragmented and episodic care delivered without such coordination (Ibid.).

Medical telecommunication has the potential to transform pediatric health care by expanding the reach of the medical home, especially for youth with special health-care needs and youth who have not had access to high-quality care, according to the AAP’s 2022 technical report, “Telehealth: Opportunities to Improve Access, Quality, and Cost in Pediatric Care.” However, “implementation will require significant efforts to address the digital divide to ensure that telehealth does not inadvertently exacerbate inequities in care (Ibid.).

The technical report adds that “addressing barriers, such as language, digital literacy, disability, and access to and payment for technology infrastructure, is required to avoid furthering disparities.”

The AAP offers guidance to primary care providers about using medical telecommunications, including reducing barriers in the medical office, preparing families for a virtual medical appointment, and ensuring equitable access to medical telecommunications in diverse and underserved communities. Find links to the AAP’s “Telehealth Tips for Pediatricians” and the AAP Toolkit: Promoting Telehealth in the Appendix.

Keys to providing telecommunication services include:

• Identify staff to address administrative, financial, clinical and technical issues
• Determine what services will be provided and establish a schedule
• Select a technology platform that is compliant with the federal Health Insurance Portability and Accountability Act and has sufficient speed and bandwidth to meet your needs
• Develop a system for documenting telemedicine visits
• Prepare and train staff
• Market to patients (the AAP Toolkit offers social media graphics and other marketing tools)

Medical telecommunications can establish links between doctors and their patients who may be located at home or in a child-care center, preschool, school or other location. Well before the COVID-19 pandemic, the AAP (2015) enumerated some benefits of this virtual method of practicing medicine:

The advantages of such links include an enhanced medical home in which personal physicians care for children; reduced health care system costs, as well as fewer school absences for the children; less money spent by parents on travel; less time away from employment for parents; and less crowding in emergency departments.

Virtual clinical encounters can augment in-person care provided in a patient-centered medical home between primary care providers and patients. Medical telecommunications in the medical home:

Permits providers making decisions to have full access to the complete medical record and an established relationship, both of which are conducive to making appropriate care decisions for the patient on par with the level of care afforded during an in-person visit. In addition, telepractice in the context of the medical home has the advantage of being able to convert a tele-enabled visit into an in-person visit when medically necessary. Typically, this is not possible with telehealth-only providers.

(AAP, 2015)

Provider satisfaction also may increase because less time and money are spent traveling to satellite clinics, and care coordination can be managed at shorter intervals (Ibid.).

Webside Manners

Interacting with children and adolescents via medical telecommunications is different than remote health care for adults. For example, because parents are involved in the appointment, they need to be briefed in advance about what to expect and what information they need to provide. An administrative or clinical staff member may contact a parent before the appointment to provide such information, take a medical history and answer questions.

In addition, young patients may prefer less formality—both in setting and speaking style—and may have more questions about where the provider is located and why a virtual visit is taking place.

“Whether the visit is in person or virtual, empathy is a vital part of the encounter and requires the same communication skills” (Cleveland Clinic, 2018). “The ability to express empathy through carefully chosen words and nonverbal communication is a key to successful connection with patients.”

The following communication tips for health-care providers can build rapport and provide an appropriate clinical environment:

• Acknowledge that a patient or family has invited you into their personal environment: “Thank you for inviting me in your home today. It’s good to see you.”
• Many children are familiar with video chats, but it may be new to some patients. Explain telecommunications in a developmentally appropriate manner. Tell young children that you can see them just as they can see you. “I see you are wearing a red t-shirt.” Ask them to describe what you are wearing. This simple exercise builds rapport.
• If the patient seems apprehensive of the virtual medium, acknowledge the newness of the situation. “I realize this visiting style is new, so thank you for giving it a try.”
• Explain why you are using telecommunications.
• Provide time for questions before the appointment begins and explain how the visit will unfold.
• Acknowledge that you may be typing during the visit but that you are listening. “I want to make sure I capture your story accurately, so I’ll be typing as we talk.” Continue to show you are fully engaged. “I hear concern in your voice. Tell me more about this.”
• When you are not typing, try to maintain a constant gaze into the camera. Use visual communications, too, such as “high fives” or “thumbs up”.
• Reduce distractions in your office space. Children can be distracted by items that wouldn’t catch the attention of adults such as a wall poster or stethoscope. If they are curious, offer to give a virtual tour of your workspace and invite them to show you something from their surroundings such as a favorite toy, book or blanket.
• Use open-ended questions to glean information.
• Employ patience and humor when technical difficulties occur.
• Remember to simply have a conversation with the patient and family. Research has shown that is a reliable way to build rapport, even when using medical telecommunications.

Sources: American Psychological Association; Cleveland Clinic; and Seager van Dyk, Kroll, Martinez, Emerson, & Bursch (2020).