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Late on a Friday afternoon in June, Rebecca Liu’s son’s face was flushed and he felt hot. Liu took Oliver’s temperature and saw that it was 102F. Liu, a first-time mom who lives in Newmarket, Ont., had a fleeting thought that it might be COVID-19, but she wasn’t too worried because she and her husband hadn’t seen anyone outside their family since the lockdown, and neither felt sick or showed any symptoms. She gave the 16-month-old Tylenol to help him get some rest, and the fever dropped. But when he woke up with a fever of 103F the next morning, Liu started to grow more concerned. She called their family doctor only to be told the clinic would not allow patients with a fever to be seen in person, but they were offering virtual doctor appointments for kids.
“When the doctor called back, she asked if Oliver had other symptoms, which he didn’t. And by this point, his temperature had dropped again. She advised me that if his temperature went up a third time, to 103F, I should take him to the hospital’s emergency department,” says Liu.
Oliver’s temperature spiked again by early Saturday evening, but she was reluctant to go to the ER unless it was truly necessary. “I didn’t want my son to be exposed to COVID,” she explains. Her sister, a nurse, suggested she call the virtual ER clinic at the Children’s Hospital at London Health Sciences Centre (LHSC), in London, Ont. (LHSC will take virtual patients from all over the province.) After phoning at 7 p.m. and giving some basic information, Liu received an email with instructions to download the Cisco Webex Meetings app and was on a video call with a paediatric emergency physician within 10 minutes.
The doctor reviewed Oliver’s symptoms, answered all Liu’s questions, reassured her that she could wait overnight, and advised her on what to do if his fever continued or worsened in the morning. To everyone’s relief, Oliver woke up totally fine.
Interacting with an emergency room doctor over a video call is just one example of the explosion in virtual healthcare that has resulted from the COVID-19 pandemic. Across the country, patients are using smartphones, regular phones, tablets and computers to connect with doctors and other healthcare professionals, such as nurses, psychologists and dentists, for everything from emergencies to routine physicals. A fringe service before the pandemic, virtual doctor appointments for kids has practically replaced regular in-person visits in many instances—and it’s likely here to stay.
When the world shut down due to coronavirus, doctors’ offices in Canada had to quickly adapt to seeing patients virtually, as it would be too risky to bring potentially infected patients into a clinic. Virtual doctor visits are now being offered in some form by many family physicians, paediatricians and children’s hospital emergency departments, and by more than 20 privately owned virtual healthcare apps and services, such as Maple, Babylon by Telus Health, Tia Health, and Lumeca in various provinces.
The virtual emergency clinic at the Children’s Hospital in London was launched in early May. “Our ER visits were down dramatically. We were very worried that parents were delaying seeking medical attention and risked hurting their children. In New York and Italy, there was delayed presentation of cancer and undiagnosed type 1 diabetes because parents were afraid to visit the hospital,” says Rodrick Lim, medical director in the paediatric emergency department at Children’s Hospital.
Private virtual healthcare services, which typically charge a fee per visit or offer a monthly or annual subscription fee, were around before the pandemic, but the use of them has increased. Some of these are now temporarily covered by provincial health plans for residents with valid health cards in certain provinces, but they charge users fees in other provinces. Private virtual healthcare services are an option for parents to consider at times when their primary care doctor or a paediatric emergency hospital virtual service isn’t available. It’s also a potential alternative for parents who don’t have a family doctor, if they’re able to pay the fees.
These companies typically hire licensed Canadian physicians to work for them part-time to supplement their practice, or in some cases to work full-time for the company. The service is like a virtual walk-in clinic. You are connected to an available doctor and will get some basic information about their name and credentials just before or during the visit. You can also ask for the virtual consultation report to be sent to your regular family doctor.
A key difference between private virtual care apps and seeing your regular family doctor virtually is that your regular doctor knows your child and their medical history and you know the doctor has expertise and experience caring for kids.
In some ways, the benefits of virtual healthcare are obvious—fast, easy and convenient access to medical advice is a big advantage. This is especially true for families who would have to travel long distances to see their family doctor or get to a hospital ER or for those who don’t have a family doctor. Private healthcare apps are often available 24/7, a bonus for parents when a kid spikes a fever in the evening. Of course, during the pandemic, virtual healthcare also means no risk of exposure to the COVID-19 virus for you or your children. Using virtual healthcare services appropriately can also free up time and physical space for in-person visits to doctors and ERs that are truly needed.
But not all conditions can be successfully diagnosed without an in-person examination. Some conditions, like a rash or minor skin infection, can be safely assessed and treatment can be prescribed over a video call, while other health problems, such as a possible bone fracture, ear pain (the doctor needs to look inside the child’s ear) or a serious cough (the doctor needs to listen to the chest with a stethoscope) require one.
Kathryn Pasma, a mother of four young children in Edmonton, connected virtually with her kids’ doctor when her three-and-a-half-year-old daughter had a severe rash on her chest and collarbone. She sent him a picture of the rash before their appointment. “I tried a natural moisturizer for dry skin, but the rash kept getting worse and she was scratching it all the time. Our doctor looked at the picture, asked some questions and prescribed a steroid cream for eczema that cleared up the rash,” says Pasma. She appreciated not having to take her daughter to the clinic and arrange care for the other three during the visit, something that has gotten more complicated during the pandemic.
But when you see a doctor over a screen rather than in person, there’s a possibility that your child’s health problem may not be properly diagnosed or treated, causing their condition to worsen, or that an important health problem the doctor would have detected in person will be missed. The extent of that depends in part on who is providing the healthcare. Is it a family doctor or paediatrician who sees your child regularly, a paediatric emergency physician from a children’s hospital you trust or a private virtual healthcare service? It matters how much experience and expertise the doctor has in treating children, how well they know your child and whether they have good judgment in recognizing the limitations of virtual care.
However, a lot can be accomplished by a physician with specialized assessment skills and experience. “We can do a modified neurological exam through video and talking to the parent,” says Sarah Reid, a paediatric emergency physician at CHEO, a paediatric hospital and research centre in Ottawa. “So much of paediatric assessment is around how the child is acting, looking and behaving. We can also coach a parent if a baby falls, for example, to touch and feel and move the body in certain ways to do an assessment. But any doctor doing virtual care needs to recognize its limits.”
In some cases, a virtual doctor's appointment for kids can lead to an in-person one—and that’s OK. Lim says that at the London virtual ER, 30 to 40 percent of families using the service ultimately go to the ER for tests and treatment of conditions such as sepsis infections, wounds that need stitches, bone fractures, or head injuries with concerning symptoms like vomiting or confusion. “Virtual visits ease parents’ anxiety about whether they need to see a doctor in person or not. For me, it also harks back to the days of house calls. There is something very personal about seeing a parent in their own home just after their kid falls,” he says.
Like many doctors, Raphael Sharon, a paediatrician and associate clinical professor of paediatrics at the University of Alberta, only started providing virtual care during the pandemic, using apps such as Zoom and Doxy. His nurse sits in on the appointment and takes notes so he can give the parent and child his full attention. He also gets parents to help facilitate certain aspects of a physical examination by using their smartphone to observe the colour of the child’s skin, whether it’s jaundiced or pale, or look inside the throat to see if the tonsils are enlarged.
Sharon has done about 80 percent of visits virtually and 20 percent in the office since the pandemic started. He sees every newborn and baby up to three months of age in person, and babies older than three months if there is a concern about failure to thrive, as it’s important to weigh the baby and keep a close eye on growth and development. Regular immunizations for children are also important to maintain as usual to prevent common and serious childhood infections, he says.
“I think virtual care is a wonderful addition for advice, care and as an initial screening tool. But I don’t want it to replace my in-person practice, and there are many situations where you need to see the patient in the clinic. If you have a five-year-old kid who is often tired, peeing more than normal and drinking excessively, you want to bring them in to check their glucose on the spot for possible diabetes. It’s also important to see kids with developmental delays. You need to examine them to make sure there isn’t a neurological problem, such as autism,” says Sharon.
Pasma, whose children are patients of Sharon’s, values the convenience of virtual care and is comfortable knowing she can rely on her doctor’s judgment to determine whether and when her children need to see him in person. “He was also able to do a nine-month and one-year checkup virtually on my twins and was just as thorough as he would be in person. I don’t think I need to go into the clinic as often now that I know how easy and efficient this is,” she says.
The popularity of virtual healthcare among patients and doctors ensures that it is here to stay as a complement to in-person care, especially if governments continue to fund doctors to provide the service. And it will be a necessity as long as we’re still dealing with COVID-19. “I’ve become a big believer in the future of virtual care based on our experience. Parents are ecstatic about the virtual emergency service and our patient satisfaction rate is over 95 percent,” says Lim.
Rebecca Liu echoes that view: “There is a gap where you might have urgent concerns in the evening or on the weekend, but you don’t have access to your family doctor,” she says. “Injuries and illness don’t stop just because your family doctor isn’t in the office.”
Not all private healthcare apps are created equal. When using a private virtual healthcare provider, it’s important to do your research to find one you can trust. Here are some questions you should consider:
Tip: If possible, talk to other families that have used these services, and ask your family doctor for their opinion or recommendation about using any specific apps.
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