key: cord-0697719-a1ni77zh authors: Raina, Rupesh; Nair, Nikhil; Sharma, Aditya; Chakraborty, Ronith; Rush, Sarah title: Telemedicine for Pediatric Nephrology: Perspectives on COVID-19, Future Practices, and Workflow Changes date: 2021-03-28 journal: Kidney Med DOI: 10.1016/j.xkme.2021.01.007 sha: 54e64e64d1d8581b8fc1515366de7e1176256839 doc_id: 697719 cord_uid: a1ni77zh While the use of telemedicine in rural areas has increased steadily over the years, its use was rapidly implemented during the onset of the COVID-19 crisis. Due to this rapid implementation, there is a lack of standardized workflows to assess and treat for various nephrotic conditions, symptoms, treatment modalities and transition processes in the pediatric population. In order to provide a foundation/suggestion for future standardized workflows, the authors of this paper have developed standardized workflows via the Delphi method. These workflows were informed based on results from cross sectional surveys directed to patients and providers. The majority of patients and providers were satisfied, 87% and 71% respectively, with their telemedicine visits. Common issues that were raised with the use of telemedicine included difficulty in procuring physical laboratory results and a lack of personal warmth during telemedicine visits. The workflows created based on these suggestions will both enhance safety in treating patients and allow for the best possible care. The swift rise of telemedicine in the age of COVID-19 has had large implications for the current and future practice of medicine. While the growth of telemedicine has been slow over the past few years, the sudden onset of the COVID-19 pandemic has led to the rapid growth of telemedicine. Not only can telemedicine be used as a direct virtual contact between the physician and the patient, known as the tele-visit, but it can also be used to triage patients with mid-level provider virtual visits through the use of "telesupervision" (1) . Since much of the care delivered by pediatric nephrology is based on laboratory results, many of the in-person visits can be conducted through telemedicine. Although the physical examination, an important part of each visit, can not be done with telemedicine, recent studies have shown that the use of telemedicine is associated with positive outcomes as outlined in Table 1 . However, deciding when a patient is an appropriate candidate for a telemedicine visit and how to evaluate and treat via telemedicine have not yet been standardized in pediatric nephrology. Therefore, we discuss the benefits and drawbacks of telemedicine, as well as perspectives on the standardization of workflows for common pediatric nephrology pathologies. The literature search, article review, data extraction and results were completed by the authors, who submitted their results to the workgroup for discussion. All individuals were responsible for reviewing and proposing recommendations for the telemedicine workflows. Disagreements between members were resolved by quantifying votes using the RAND Corporation/University of California Los Angeles (UCLA) appropriateness method and subsequently calculating a disagreement index (2, 3) . The Patients were given the survey by the authors of this manuscript along with help from providers who were approached to fill out the physician questionnaire. Consent to publish the de-identified findings was obtained with the completion of the survey through an informed statement at the beginning and conclusion of the survey, gathering the consent of the parent/guardian in situations where necessary. Data was collected and underlying components were identified using principal components analysis. Questions that measured the same concepts were loaded onto the same factors. Factor loadings range from -1.0 to 1.0 with factors being grouped together when they are ±0.60 or higher. Internal consistency of questions loading onto the same factors were checked by the Cronbach's Alpha (CA) test, with values of 0.60 to 0.70 being acceptable to the research group. The results of the principal components analysis found that Questions 7, 11, 14, 16 , and 17 were loaded onto the same factor that was determined to represent practice pattern in our cohort. The Cronbach's Alpha for questions representing personal commitment to practice pattern and geographical location was 0.91, indicating excellent internal consistency in the responses. Data was analyzed and gathered among the different partner institutions and all results were analyzed anonymously for the purpose of the article. reduction in missed appointments when using telemedicine services versus in-person consultations (5) . As such, telemedicine has proven to be a developing alternative to inperson visits. In the field of pediatric nephrology, the traditional in-person visit often includes establishing patient rapport, meeting with families, discussing laboratory results and prognosis, much of which can be completed through the use of telemedicine, with the exception of the physical exam. During a telemedicine visit, providers need to learn to remain "present". If the provider and patient are together in a room and the provider happens to look away or move a short distance away, the patient will generally still have a sense that the provider is "present" (6) . However, when the clinician can only be seen on the monitor and he or she looks away, the patient may feel like the provider is no longer "present." To avoid this, it is particularly important to be sure to review the patient's chart before the televisit, instead of doing so while on screen. One way to maintain a presence is to have proper eye contact. Providers can practice looking at the camera, instead of at the image of the patient on the screen, so that the patient feels that the clinician is "looking them in the eyes". Conveying emotional support over a screen is harder to achieve than in person (7) . Pediatric nephrology consultation often involves delivering difficult information. J o u r n a l P r e -p r o o f 6 Sitting silently for a few moments with a patient can be helpful if the clinician is sitting in the same room. With technology making great leaps and bounds, accessibility to patients via the virtual world has become a bourgeoning reality. The development of multiple videocapable applications and technologies has made communication better than ever before. In response to the COVID-19 pandemic, nephrologists at Mt. Sinai have utilized all technologies that allow for video communication, including Facetime, Zoom, and WhatsApp (8) . We recommend the use of these services as they are free to patients and are easily accessible to use. In our survey the majority of providers utilized Zoom or EPIC to conduct their telemedicine visits. In order to examine the experiences with telemedicine of both pediatric nephrologists and patients, we conducted a survey with 197 pediatric nephrologists and 400 pediatric nephrology patients from February 28 th , 2020 to June 30 th , 2020. The results showed a positive response among both pediatric nephrologists and patients alike. The majority of physicians expressed satisfaction with the capabilities of telemedicine visits, with only 10% expressing dissatisfaction with the clinical aspect of telemedicine and 4% expressing disappointment with telemedicine overall. In addition, patients reported their experiences with telemedicine to be as good as if not better than the traditional in-person visit ( Table 2) . One of the primary limitations posed by telemedicine is the relative lack of billing coverage from Medicare and private insurance companies throughout the United States. While telemedicine has been utilized for many years, a more widespread adoption of these services has occurred as a result of the COVID-19 pandemic. Given the diverse nature of hospital systems and insurance coverage, finding a standardized method of applying telemedicine will pose a challenge in the near term. As both provider and patient comfort with virtual care increases, delivery will continue to become more refined and established as a routine component of health care practice. Inclusion of metrics around quality of telemedicine encounters will also be critical. We have developed generalized suggestions and workflows via the Delphi Method that can serve as the foundation for standardized telemedicine workflows. We believe that the implementation plans we present can serve as guides to assist with standardization of workflows in the future practice of pediatric nephrology. The first step for any patient with CKD is to determine their clinical status and the extent to which treatments can be conducted virtually. Virtual visits are more feasible Given the pandemic, the process of transitioning patients from pediatric to adult care can be disrupted and impact the patient's ability to conduct disease selfmanagement. Our suggested protocol for transition is derived from the RISE (Recognition, Insight, Self-reliance and Establish) protocol from the Akron Children's Hospital, which is based on previously stated survey findings and literature review (Figur e 7) (11). This protocol specifies four main competency areas for patients to achieve prior to transition: 1. Recognition of their disease process, reason for transplant, and the healthcare system; 2. Insight into the short-and long-term impact of their disease, therapy, non-adherence, and emotional needs; 3. Self-r eliance in scheduling and attending appointments, refilling medications, and identifying urgent/emergent changes to their health on their own; 4. Establish healthy lifestyle choices, life-long adherence to medications and follow-up, psychosocial skills, and educational/vocational goals. For patients who are on peritoneal dialysis, COVID-19 has created a roadblock to routine office visits. Furthermore, nephrologists are unable to see each patient's dialysis cycle information without such visits. A solution to this has been Sharesource, an online platform that allows for medical professionals to remotely monitor each patient's dialysis information (8) . Sharesource has been widely implemented by nephrologists at Mt. Sinai, where 80% of patients are now being monitored remotely with this technology. This can provide nephrologists access to dialysis information, and with virtual office visits providing an opportunity to meet with patients, the ability for nephrologists to remotely monitor and treat patients on peritoneal dialysis has now become a reality. There are a few limitations that can serve as avenues for future research. In the survey released to both patients and providers, data on demographics and relative access to internet was not gathered. This information could be used to better tailor workflows to various communities and minimize health disparities. As of yet there is no preliminary data, beside with peritoneal dialysis, on the efficacy of these workflows in practice. Future research and analysis of their implementation will allow for adjustments to be made to improve their quality. In order to deliver the most effective treatments for patients, the standardized telemedicine workflows are imperative. With the COVID-19 pandemic continuing for an indeterminate amount of time, coupled with the impending flu season, there is an everincreasing need for telemedicine services. We believe adaptation of these workflows can clinician was better with the inperson setting in 60% of cases; not comfortable sharing confidential information in 30% of cases; patients (n=400) reported inability to show a clinician a physical problem 80% of times; the cost of the visit was better for the in-person clinic visits 33% of the time (36%) followed by the inability to perform physical exams (30%) or laboratory tests (18%), unfamiliarity with telemedicine (9%), and being uninformed about billing (7%); the 321 responders stated that telemedicine services were not connected to the electronic health record in 60% of cases, had no waiting room feature to queue in patients in 32% of cases, and had restrictions in performing telemedicine services in 24% of cases Cost 65% of patients were definitely willing to co-pay $ 10-25 dollars; 28% were definitely willing to pay $ 26-50 dollars and 18% were definitely willing to pay the full cost of the televisit r m a ti o n a d a p te d fr o m S p e c i a l C o d i n g A d v i c e d u r i n This includes persons who have been tested for COVID-19 and are awaiting test results and persons who have not yet been tested for COVID-19 This includes persons who have been tested for COVID-19 and are awaiting test results and persons who have not yet been tested for COVID-19 Avoid having health care staff change dialysis shifts to avoid cross-contamination and infection; dialyze in place with rigorous use of personal protective equipment (PPE) and isolation; defer dialysis and refer a patient to a hospital for testing and/or treatment A hospitalization from hell: a patient's perspective on quality The EXTRIP (extracorporeal treatments in poisoning) workgroup: guideline methodology The RAND/UCLA appropriateness method user's manual Two-year experience with telemedicine in the follow-up of patients in home peritoneal dialysis Telehealth monitoring decreases missed treatments in new dialysis patients Telenephrology: a novel approach to improve coordinated and collaborative care for chronic kidney disease Perspectives from the Kidney Health Initiative on Advancing Technologies to Facilitate Remote Monitoring of Patient Self-Care in RRT Telenephrology with Remote Peritoneal Dialysis Monitoring during Coronavirus Disease 19 Interim Additional Guidance for Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed COVID-19 in Outpatient Hemodialysis Facilities Outpatient Management of the Kidney Transplant Recipient during the SARS-CoV-2 Virus Pandemic Pediatric Renal Transplantation: Focus on Current Transition Care and Proposal of the "RISE to Transition Home-based preventative care in highrisk dialysis patients: a pilot study Health-related quality of life in patients undergoing peritoneal dialysis: effects of a nurse-led case management programme Effects of post-discharge nurse-led telephone supportive care for patients with chronic kidney disease undergoing peritoneal dialysis in China: a randomized controlled trial Telehealth: Acceptability, clinical interventions and quality of life in peritoneal dialysis Testing the Feasibility and Usability of a Novel Smartphone-Based Self-Management Support System for Dialysis Patients: A Pilot Study Effect of Nurse-Led Telephone Follow ups (Tele-Nursing) on Depression, Anxiety and Stress in Hemodialysis Patients Special coding advice during COVID-19 public health emergency Differences in Online Consumer Ratings of Health Care Providers Across Medical, Surgical, and Allied Health Specialties: Observational Study of 212,933 Providers