Using the Electronic Health Record to Conduct Adolescent Telehealth Visits in the Time of COVID-19.

Adolescent telehealth visits present opportunities for improved health-care access. However, owing to concerns of maintaining confidentiality for adolescents within the electronic health record (EHR), EHR access (often needed for telehealth) remains challenging for this group [[1], [2], [3], [4], [5]]. At Stanford Children's Health, we have been practicing telehealth for the past four years. Thus, we were in a fortunate position to rapidly expand our telehealth services when our Bay Area location was one of the first counties in the United States to declare a shelter-in-place (SIP) order because of coronavirus disease 2019 (COVID-19). Within 1 month after the SIP order, our institution's telehealth utilization jumped ∼600% to nearly 17,000 visits.

Similar to many other institutions with EHRs, our telehealth system is integrated into our EHR platform (Epic). Benefits of this embedded method include having a secure, Health Insurance Portability and Accountability Act of 1996 (HIPAA)-compliant platform, as well as having a provider- and patient-friendly modality that is easy to navigate by a single “click” on a telehealth link. To complete a telehealth visit within the EHR, two major access points need to be available for patients: the patient portal and the “Upcoming Appointment” view. The patient portal is essential as it is the means for a patient or proxy to access the EHR. The "Upcoming Appointment" view is where the secure link for the telehealth visit resides. Without this view, the patient will not be able to see a list of scheduled appointments, nor view the link necessary to connect to the telehealth visit. Unfortunately, for adolescents and their parents/proxies, these two access points are often limited because of concerns around confidentiality. In the following commentary, we will describe the development of our institution's policies to support adolescent telehealth and discuss specific opportunities to improve adolescent health-care utilization.

Portal Access

EHR portal access is a critical step to enabling secure telehealth visits. Because of the many legal and ethical considerations that vary by state, no single uniform approach to portal access for adolescents and their parent/proxy exists [6,7]. Our portal development was guided by two general ideas: (1) principle of equivalency between accounts and (2) congruency between access to information via the EHR and our institution's Health Information Management Services (HIMS). For equivalency, adolescent and proxy accounts have the same information availability to minimize any coercion by a proxy to access the patient's account. To parallel HIMS′ approach to information, we developed a two-tiered adolescent account that requires parental consent for an enhanced level of information, similar to obtaining medical records via HIMS. With parental consent, an adolescent aged 12 years or older may have his/her own portal account which allows access to messaging, appointments, nonsensitive laboratory results, and after-visit summaries. However, upon turning 13 years of age, an adolescent may sign up for a basic account, without parental consent. This age was chosen to be compliant with the Children's Online Privacy Protections Act which requires parental consent for information to be collected for a minor younger than 13 years [8]. With the basic account, an adolescent may message providers, in a confidential manner, and access the appointment view.

To support provisioning of adolescent accounts, basic accounts can be activated by the front-desk staff, back-office staff, or clinicians during a visit. Once parental consent, via a signed form, is obtained, a programming point enables the adolescent account to “flip” from a basic to a more enhanced level of information access. Although adolescent accounts require in-person activation because of identification concerns, proxy accounts are able to be remotely activated to expedite telehealth access during COVID-19.

Allowing Access to Upcoming Appointments

As the link for telehealth visits resides within the “Upcoming Appointments” view, access to this schedule is critical. In the past, we blocked this feature because of a concern that the presence of specific appointments might break confidentiality. However, families were vocal in their reliance on an appointment list to manage their children's medical needs, particularly for those with complex medical conditions. Also, as our needs for telehealth were realized, access to the schedule became essential. Subsequently, we met with multiple stakeholders to develop a filter that would block specific appointment types but allow access to all others. Interestingly, the types of appointments to filter were few (confidential family planning services, in-person psychiatry, and obstetrics), and thus, access to most appointments could be opened for patient portals.

With portal access and the ability to view upcoming appointments, we have been able to quickly increase telehealth visits for our adolescent patients. Notably, within our adolescent medicine clinic, we have maintained approximately 90%–95% of our typical patient volume, by using telehealth, since SIP was ordered.

Telehealth Use Cases: The Confidential Visit

While telehealth has improved access to care for patients and their families, being mindful of how these visits differ from in-person visits with regard to confidentiality is paramount. To acknowledge confidentiality needs for adolescents, providers can ask if there is a private space available for the patient to have a confidential part of the visit. Giving examples of spaces can help prime a patient to think about nontraditional options (e.g., their closet/bathroom, their car, their backyard, and so on). Providing a 360° “sweep” of their space with their video camera ensures that both the patient and provider understand who is in the room. To add an additional layer of privacy (or if the patient is unable to move to a separate space), providers can encourage patients to use headphones and/or background sounds (e.g., turning on a fan) to limit the ability of others to hear the conversation.

Ongoing provision of contraception, including long-acting contraceptive methods, is essential during this time and should not be deferred. Resources from multiple professional societies exist with guidance on provision of comprehensive reproductive health care during the COVID-19 pandemic [9,10]. These guidelines emphasize using telehealth for screening and comprehensive counseling and review ways to safely provide contraception while minimizing direct patient contact.

Telehealth Case Uses: Eating Disorder Care

Another unique patient population requiring ongoing medical care while needing to follow the SIP order comprises patients struggling with eating disorders. As an institution with a large eating disorder program and a wide catchment area, we have been providing medical follow-up via telehealth for over a year. After SIP, we were quickly able to convert almost all our clinic visits to telehealth while maintaining high-quality care.

For patients who live near our clinic, we use nurse-only visits to obtain weight, vital signs, and urinalyses. Staggering visits minimize the number of patients in clinic at the same time. Patients are then seen via telehealth later in the day. For patients who live far from clinic, we leverage primary care providers and urgent care centers to obtain the necessary clinical information, which is then faxed (or viewed through a health information exchange) to our clinic. We are able to coordinate medical visits with our dietitian who is also able to provide telehealth visits. This workflow has been adapted to our new patient intakes and includes coordinated telehealth visits with psychiatry. Anecdotally, providers have noted these visits are often quite efficient, and families often comment on the ease of the telehealth visits.

The explosion of telehealth during the COVID-19 pandemic has truly changed the way we are providing care for our patients. By being cognizant of broader issues around portal access and EHR confidentiality, as well as patient-level strategies to maintain privacy and use clinic workflows that minimize time spent in-person, we have been able to provide efficient, high-quality care for our patients and families.