Four Ways to Get the Most Out of Virtual Visits

The COVID-19 pandemic has made virtual visits a necessity. And their utility as a service model — as well as patients’ expectations that they’ll have access to virtual options — are sure to remain after the pandemic is over.

This makes it critical for providers to resolve the unique challenges of conducting visits virtually, from how to examine a patient over video to how to deal with a bad internet connection.

The pulmonology team at Children’s Health℠ has completed more than 1,500 virtual visits since the start of the year, serving patients who are at risk of getting seriously ill from COVID-19 because of asthma, chronic lung disease or other lung issues. Along the way, the team has developed best practices that can help other providers make the most of virtual visits.

Tanya Martinez-Fernandez, M.D., Pulmonologist at Children’s Health and Associate Professor at UT Southwestern, has personally seen more than 100 patients virtually. Below she shares her tips for making virtual visits successful — during the pandemic and beyond.

Tip 1: Prepare the patient

While video communication is familiar to many people by now, virtual visits are unique and it’s important to set the right expectations with patients beforehand. This includes asking parents to make sure the child is present for the visit.

“I’ve had some appointments where the child isn’t there and the parents thought they could do the visit alone, but clearly that doesn’t work,” Dr. Martinez-Fernandez says.

It also helps to start the visit by explaining how it will unfold, including everything you’ll be doing differently than if you were in person. For example, rather than gathering patient history information first, Dr. Martinez-Fernandez likes to do visual exams right off the bat.

“That’s an important part of the visit, so I want to get to it first thing,” she says. “There’s always the chance the video connection falters or fails later on.”

For that reason, it’s also important to have a backup option ready to go. This can be a phone line or alternative video channel that meets your local regulatory requirements. At Children’s Health, regulations in Texas allow us to turn to Doximity or Zoom if our initial connection fails.

Tip 2: Change the execution of physical exams

A virtual exam isn’t as thorough as a true physical exam, but there are strategies for getting the insights you need. The first is to observe the child’s entire body for visual and behavioral cues.

For a pulmonologist like Dr. Martinez-Fernandez, that means looking for things like nasal flare and work of breathing, including mouth breathing and fast breathing. In younger patients, she’ll have a parent remove their child’s shirt to see how the chest wall moves during breathing.

She asks kids to hold their hands and feet close to the camera. A pink color suggests good perfusion, while the appearance of clubbing in the hands may be evidence of chronic lung disease.

“Their posture, level of energy and activity, and environment all communicate information as well,” she adds.

For example, whether a child is running around and playing, or sitting still and sullen, says a lot about their health and comfort. Dr. Martinez-Fernandez also looks for aspects of the home environment, such as pets, dusty blankets or old furniture, that may affect children with asthma.

“I remind myself I’m seeing patients in their natural setting, so I try to glean as much from that as I can,” she says.

To help with the exam, she invites patients to upload digital pictures — which are usually higher resolution than live video — to the health system’s patient portal ahead of time. She also asks parents to do hands-on tasks she can’t do herself.

“Parents see and handle their kids all the time, so they’re actually pretty good at judging things like whether the child’s abdomen feels tight or swollen,” she says.

Tip 3: Know which patients to see virtually

Dr. Martinez-Fernandez looks at a number of factors when considering a patient for virtual care. But no factor automatically translates to a good or bad fit. It’s a nuanced consideration weighing many pros and cons.

“The best candidates for virtual visits are kids I’m already established with and am seeing for follow-up needs,” she says.

She prefers to see patients who are actively sick in person, so she can make a careful assessment and order the right tests. On the other hand, complex patients who have home-health nurses can often be seen virtually, because the nurse is there to be the provider’s eyes and ears.

“Age is also important, because you depend on a child to verbalize and engage with you to some degree,” says Dr. Martinez-Fernandez. “Adolescents can be really good, because they're often tech-savvy and interactive.”

Patients who live in distant or rural areas may seem like good candidates, because meeting virtually saves them a long drive. These areas, however, can have poor or unreliable internet coverage. If possible, it’s important to gauge your patients’ connectivity before scheduling them.

Tip 4: Make It a Decision-Making Tool

Providers should avoid thinking of care as either virtual or in-person. Rather than competing alternatives, these can be complementary modes of care.

For example, one of Dr. Martinez-Fernandez’s patients who’d recently had a tracheostomy reported having secretions and difficulty breathing. Was it just an infection she could treat with antibiotics, or something requiring more serious attention? Through a virtual visit, she could see the child struggling to breathe and could talk to the parents about specific episodes the child was having. She told them to come into the clinic, where they confirmed it was an airway problem.

“There’s also the chance they can't wait a few days or a week for a clinic visit and need to go to the emergency room,” she says. “Virtual visits can help you make the right decisions more efficiently.”

Learn more about the innovative pulmonology care and research happening at Children’s Health.

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