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Telemedicine: new technique for initial office visits

Virtual appointments become the first-step practice for pediatric visits


Doctors shift to telemedicine to assess pediatric and other patients by way of virtual appointments.

With medical practices now limiting their in-office visits to help combat the spread of COVID-19, many parents are concerned about their kids’ medical care. Some wonder if they should delay their youngster’s immunizations and wellness visits. Or whether a cough or sore throat merits an office visit. And what about a toothache or their child’s regular dental cleaning? It can be hard to know what’s necessary and how to stay safe.

I interviewed three of our Five-Star Docs, Dr. Geri-Lynn Waldman, pediatric dentist and owner of Hudson Valley Pediatric Dentistry, Dr. Stuart Tashman, a pediatrician at Middletown Medical and Dr. Marc Habert, a pediatrician with The Children's Medical Group. 

Remote office visits. Medical practices and professionals are helping fill the in-office gap for their patients with telemedicine, where they see some patients by way of digital conferencing and other remote technologies.

Hudson Valley Pediatric Dentistry in Middletown, which treats infants through teens, now offers teledentistry through Emergency Tele-Dental Services, said Geri-Lynn Waldman, DDS, a pediatric dentist and owner of the practice.

“I was lucky,” said Waldman. “When there was talk about closing the dental offices, a member of a Facebook group for pediatric dentists that I am a member of mentioned that he had created a system that could be used online for remote consultations. He offered to install it on our system.”

Since the beginning of the shutdown of her office, Waldman has been using teledentistry as a tool for screening patients to assess their dental care. Parents can upload photos of what they see as a problem and include a description of the issue of concern.

“The system works beautifully,” says Waldman. “When a patient signs up for the service from our website, they are actually giving me permission to use the system as an assessment tool. And all the information they provide automatically uploads into their child’s chart.”

The Children's Medical Group has been offering telemedicine through an app created by Healow. According the Habert, they find that telemedicine doesn't work well in all situations. "Works well for things we can see like pink eye and also we are having great success dealing with mental health issues and ADHD questions that arise. 

But how do you diagnose ear pain remotely? "At this point, we have been practicing a little looser. I will prescribe medication for the pain, and do follow ups to see how it is working. If the child is feeling better then we have avoided the need for a visit."  

Virtual versus in-office visits. Another practice, Middletown Medical has been using telemedicine for about a month, said pediatrician, Stuart Tashman, who practices out of the group's Wurtsboro office.

“I am as busy now, as I was before the Corvid-19 outbreak, maybe even busier,” says Tashman, who uses telemedicine for everything, from the initial review of a patient’s Corvid-19 exposure to questions about poison ivy and tick bites. “In the morning I see children who need well-visit care,” he said. “Children come in to update their immunizations, and I make sure they are reaching their natural growth milestones.”

Those measures are in-line with those of the American Academy of Pediatrics (AAP), which encourages medical professionals follow up pediatric televisits, as possible, with in-person appointments for comprehensive physical exams; laboratory testing; hearing, vision, and oral health screening; fluoride varnish; and immunizations.

Middletown Medical uses WhatsApp, a free service owned by Facebook, to link to the practice’s telemedicine program, an application that Tashman said seems easier for younger people to manage than for senior patients. He and his practice’s administration also have been discussing doing curbside visits to update immunizations, especially for babies.

“The is a service I want to introduce for new parents who are afraid to bring their baby to the office,” he says. “In any case, parents should try to maintain their child’s immunization schedule. People may remember that last year we had many cases of the measles,” a situation, he said, that he doesn’t want to see repeated.

In fact, the World Health Organization (WHO) offers new guidelines aimed at sustaining immunization practices through the COVID-19 pandemic as appropriate to help maintain protections against widespread diseases, like the measles.

Safety practices. Besides morning wellness checks and telemedicine visits, Tashman sees sick patients in the afternoon. No sick patient comes into the office. Instead, there is an outside tent set up for those visits.

“I dress in a complete hazmat suit, with head gear and double gloves,” says Tashman. “I am covered from head to toe. We change gloves between visits, wash hands extensively and use hand sanitizer frequently.”

When the day is over, he removes his gear, changes his clothes, drives home and showers before changing into other clothes, all to keep him, his family and patients safe.

Habert says that 10 of their 26 docs were infected with Covid-19. In fact, Habert and his family were all infected but are all doing well now. 

"Early on there was no quick testing being done and it was impossible to get protective gear right away." After that first week, they have not had a Covid-19 incident. 

The Children's Medical Group began their telemedicine program in mid-March, no one waits in the entry rooms, and a complete office cleaning is done every night. They do well visits in the morning. Take a break. And then see sick patients in the afternoon. "The fact is we only see 5 to 9 sick patients daily across all 8 offices," says Habert. 

Habert says that all docs wear face masks and wash their hands frequently instead of wearing gloves. The system seems to work perfectly. They have not had any additional infection occurrences. 

At The Children's Medical Group, some docs only conduct the group's remote visits. Telemedicine helps them assess kids' conditions before having to see them in the office.  "Even if I feel a child may have the virus, I have them stay at home in isolation," says Hebert.  "I don't send them for testing because we have found that there is a 30% false reading and there is no medication for the virus." 

Before Waldman used telemedicine, if there was an after-hour or weekend dental emergency, she met the family at her office. Now she uses Emergency Tele-Dental Services as a first-step assessment tool, which saves many patients from having to drive to the office.

Parents call with the same occurrences that Waldman usually sees in the office, including pain, trauma, chipped teeth and other issues. She arranges for an office visit when she feels that the child should be seen and, like other doctors who are seeing patients, allows more time for each patient and longer periods between patient visits.

“Parents call us when they arrive in the parking lot at the office complex,” says Waldman. “We review a screening application they have to complete before allowing them in the office. One parent and one patient are allowed in the office at a time.”

The power of prevention. Waldman has invested about $15,000 in equipment to ensure that she, her staff and patients are treated safely, including protective over-garments for the dental team, even though, the doctor admits, they are hot to wear.

“One strange thing is that we have always encouraged parents to maintain regular checkups and routine exams to prevent cavities,” says Waldman. “But now with social distancing, parents are calling only when there is a problem.”

That’s a challenge, she says, especially for children with baby teeth.

“A mom sees a problem but holds off until there is lots of discomfort,” says Waldman. “By then the baby tooth can become abscessed and have a large hole. Then it is an emergency. There is not a lot of time between the start of the problem until it reaches emergency proportions.”

While Tashman says patients can use an Android Phone Samsung Health app for key indicators, like blood pressure and blood oxygenation, there is no substitute for a doctor’s hands on examination.

“I find things at an office visit, that I probably would not pick up with a remote visit,” he said.

And, Tashman said, although remote medical services are likely to become an integral part of society’s medical landscape, in-office visits are best. Habert agrees. Likewise, the Centers for Disease Control and Prevention (CDC) reports that in-person medical care appointments for babies and youngsters are optimal, with some practices, alternating times for well and sick visits and/or physically separate sick patients from well ones.

“I must admit, that telemed is no substitute for in office baby checkups,” Tashman said.

Terrie Goldstein is the publisher of Hudson Valley Parent