Background
The COVID-19 pandemic dramatically reshaped healthcare delivery in the United States, pushing telehealth to the forefront. With hospitals and emergency departments facing unprecedented strain and public apprehension about in-person healthcare settings escalating, telemedicine emerged as a crucial alternative for delivering urgent medical services remotely. In pediatrics, emergency department (ED) visits witnessed a significant drop in early 2020, raising concerns about delayed diagnoses of serious conditions due to fear of infection in healthcare facilities.[1-4] This shift underscored the urgent need for robust remote care solutions, particularly in pediatric urgent care.
Telemedicine, defined as “the use of information technology to provide clinical health care from a distance,”[5, 6] offered a viable solution. While telemedicine applications span various medical fields, from psychiatry to post-operative care, its role in acute pediatric urgent care, especially during a pandemic, required deeper investigation.[7-9] Data on the effectiveness of pediatric telemedicine and the frequency of necessary in-person follow-up were scarce. As telemedicine adoption continues beyond the pandemic, understanding its application in pediatric urgent care remains vital for optimizing healthcare delivery.
PM Pediatrics, a leading pediatric urgent care group, rapidly expanded its telemedicine services in response to the pandemic, conducting over 150,000 virtual visits. This experience provides a unique opportunity to characterize pediatric patients seeking telemedicine care during the COVID-19 pandemic. Furthermore, concerns about higher antibiotic prescription rates in telemedicine settings necessitate an evaluation of prescribing patterns in this specific pediatric urgent care telemedicine population.
Drawing inspiration from pioneering studies that defined the epidemiology of pediatric emergency medicine,[14] this study aims to establish the epidemiological landscape of acute pediatric telemedicine visits. Similar to how those earlier studies informed and advanced pediatric emergency care, this research seeks to contribute foundational knowledge to the evolving field of pediatric telemedicine. This study, approved by Solutions IRB, delves into the initial experiences and outcomes of a large-scale pediatric urgent care telemedicine platform during the COVID-19 pandemic.
Methods
TELEMEDICINE PLATFORM
PM Pediatrics Anywhere, our HIPAA-compliant telemedicine platform, is accessible via website or mobile app. This on-demand system connects parents with available, state-licensed urgent care providers immediately after they input their child’s information, medical history, insurance details, and pharmacy preference. The platform utilizes WebRTC protocols, ensuring high-quality, real-time audio and video communication. It’s important to note that peripheral devices like otoscopes and stethoscopes were generally not available to patients at home during these virtual consultations.
Patients were seen by a diverse group of providers: board-certified pediatric emergency medicine physicians, board-certified pediatricians, nurse practitioners, and physician assistants. All providers were also active in our in-person clinics, ensuring consistent application of evidence-based guidelines for pediatric diagnosis and treatment across both telemedicine and in-person settings. Our telemedicine program adhered to American Telemedicine Association guidelines[15] and achieved URAC accreditation in November 2020,[16] further validating its quality and standards.
In this study, pediatricians managed 57% of telemedicine visits, while pediatric emergency medicine physicians handled 20.7%. Unlike some telemedicine platforms,[17] PM Pediatrics Anywhere does not exclude patients based on their presenting complaint, allowing for a comprehensive evaluation of all pediatric patients seeking virtual urgent care. Providers obtained detailed histories from parents, guardians, and children, and performed visual examinations, often guided by parents, to assess for palpable signs. Parents received a complete visit record upon consultation completion.
SELECTION OF PARTICIPANTS
This study included all children aged 0-18 years who utilized the telemedicine platform. Exclusion criteria were patients 19 years or older and those with incomplete electronic medical records. The PM Pediatrics telemedicine service was available in 15 states: AK, CA, CT, FL, IL, MD, MA, NJ, NY, NC, PA, TN, TX, VA, and DC. PM Pediatrics had physical urgent care locations in all these states except FL and DC, where openings were delayed due to the pandemic. All physical locations were operational during the study period and offered COVID-19 testing. COVID-19 testing was available both via walk-in and after initial telemedicine screening.
TIMING OF STUDY
Launched on March 9, 2020, in response to the escalating COVID-19 pandemic, PM Pediatrics’ telemedicine platform rapidly expanded to all states with physical locations, as well as FL and DC, within two weeks. By May 15, 2020, the telemedicine program was fully operational. Telemedicine services were offered daily from 8 AM to midnight, alongside continued in-person urgent care services and COVID-19 testing at physical locations. This retrospective chart review analyzed the first 30,000 pediatric telemedicine visits, conducted between May 15 and September 16, 2020.
DATA COLLECTION
Data was extracted from eClinicalWorks electronic health records (v. 2020) and the PM Pediatrics Anywhere telemedicine application (v. 2020). Data aggregation and analysis were performed using Qlik Sense (v. 2020), Excel (v. Office 365 2012), and RStudio (v. 2021). Collected data points encompassed: age at visit, insurance type, state of residence, time of visit, preferred language, wait time, chart completion time, gender assigned at birth, chief complaint, and International Classification of Diseases (ICD)-10 diagnosis codes. We also tracked patients requiring immediate ED transfer and those referred for in-person urgent care. For in-person urgent care referrals, we recorded Current Procedural Terminology (CPT) codes and ICD-10 diagnosis codes from their subsequent visits. COVID-19 testing outcomes and patient satisfaction survey results were also analyzed. Furthermore, demographic data of the telemedicine patient population was compared to pre-pandemic in-office patient demographics from the four months preceding the pandemic.
ANALYSIS
This descriptive study employed descriptive statistical methods. Continuous variables are presented as means and medians, while discrete variables are shown as counts and proportions. Methodology was modeled after the Alpern et al. study, which significantly contributed to defining pediatric emergency care epidemiology, to ensure comparability and build upon existing knowledge in acute pediatric care.[14]
Results
PATIENT POPULATION
The study population comprised 30,000 telemedicine visits, with 51% male patients and a mean age of 7.25 years. This demographic profile was similar to the pre-pandemic in-office patient population (mean age 6 years), with a statistically significant but minimal age difference (p < 0.001) (Table 1). Private insurance covered the majority of telemedicine patients (74.1%), while 21% had public insurance and 4.9% were uninsured. A significantly higher percentage of telemedicine patients had private insurance compared to pre-pandemic in-office patients (65.9%, p < 0.001).
Table 1.
Demographic Data
| VARIABLE | N | PERCENT OF TOTAL |
|---|---|---|
| Male patients | 15,292 | 51 |
| Age | ||
| Infants (0–2) | 4,391 | 14.6 |
| Childhood (2–12) | 17,576 | 58.6 |
| Adolescent (12–19) | 8,033 | 26.8 |
| Insurance status | ||
| Private | 22,233 | 74.1 |
| Public | 6,284 | 21 |
| Self-pay/uninsured | 719 | 2.4 |
| Unknown | 764 | 2.5 |
| Patient’s home state (no. of offices) | ||
| Alaska (1) | 296 | 1 |
| California (1) | 689 | 2.3 |
| Connecticut (1) | 511 | 1.7 |
| Florida (0) | 190 | 0.6 |
| Illinois (1) | 72 | 0.2 |
| Maryland (9) | 4,169 | 13.9 |
| Massachusetts (2) | 819 | 2.7 |
| Michigan (0) | 1 | 0.003 |
| New Jersey (10) | 7,457 | 24.9 |
| New York (19) | 8,201 | 27.3 |
| North Carolina (2) | 2,328 | 7.8 |
| Pennsylvania (4) | 1,802 | 6.0 |
| Tennessee (1) | 15 | 0.05 |
| Texas (4) | 1,129 | 3.8 |
| Virginia (4) | 1,899 | 6.3 |
| Washington, DC (0) | 422 | 1.4 |
| Preferred language other than English | 298 | 0.01 |
| Time of day of visit | ||
| 8:00–12:00 | 6,675 | 22.3 |
| 12:00–16:00 | 10,331 | 34.4 |
| 16:00–20:00 | 9,037 | 30.1 |
| 20:00–0:00 | 3,957 | 13.2 |
| Patients with repeat visits | 2,463 | 9.1 |
| Visits referred for in-person COVID-19 testing | 17,864 | 59.6 |
| Wait time | 25,437 | 84.8 |
The majority of telemedicine visit volume originated from NY (27.3%) and NJ (24.9%), states with the highest concentration of PM Pediatrics physical locations and longest-established presence. This mirrored pre-pandemic in-office visit distribution, where 44% and 22% of visits were from NY and NJ, respectively. A significant majority (95%) of telemedicine patients resided within 20 miles of a PM Pediatrics clinic. Repeat telemedicine visits within the study period accounted for approximately 10% of total visits. While the telemedicine platform primarily operated in English, interpretation services were available, yet only a small fraction (0.01%) of patients identified as non-English speaking or deaf.
Telemedicine services were available from 8 AM to midnight, with peak utilization (64.6%) occurring between 12 PM and 7 PM. Median wait time to connect with a provider was 2.7 minutes, and 84.8% of patients were seen within 15 minutes. Median visit duration, from start to chart completion, was 16.3 minutes. A substantial portion of visits (59.5%) were for COVID-19 testing screenings at urgent care centers. Table 1 provides a comprehensive overview of the study population’s demographic characteristics.
CHIEF COMPLAINT AND DIAGNOSES
COVID-19 related concerns dominated chief complaints (Table 2). Screening for COVID-19 testing or seeking care for suspected COVID-19 constituted 55.4% of visits. The mean age of patients seeking COVID-19 related care was slightly higher (9.3 ± 5.4 years) than the overall telemedicine population (7.6 ± 5.4 years, p < 0.001).
Table 2.
Most Frequent Chief Complaints
| CHIEF COMPLAINT (30,000) | N | % OF TOTAL | % OF TOTAL EXCLUDING COVID-19 | % MALE | MEAN AGE |
|---|---|---|---|---|---|
| COVID-19 | 16,633 | 55.4 | — | 50.5 | 9.3 |
| Fever | 2,044 | 6.8 | 15.3 | 52.5 | 4.1 |
| Rash | 1,950 | 6.5 | 14.6 | 53.6 | 4.3 |
| Ear pain | 1,083 | 3.6 | 8.1 | 49.2 | 7.3 |
| Insect bite | 822 | 2.7 | 6.1 | 49.8 | 4.8 |
| Red eye | 567 | 1.9 | 4.2 | 54.7 | 5.3 |
| Skin infection | 557 | 1.9 | 4.2 | 50.4 | 5.9 |
| Sore throat | 465 | 1.6 | 3.5 | 43.4 | 8.8 |
| Cough | 384 | 1.3 | 2.9 | 54.7 | 5.8 |
| Allergy | 338 | 1.1 | 2.5 | 57.1 | 4.7 |
Analysis of ICD-10 diagnosis codes revealed COVID-19/COVID-19 screening as the most frequent diagnosis (52.1%). For this study, several ICD-10 codes used for COVID-19 screenings (Z11.59, Z20.828, Z20.89, Z03.818, and Z 20.9) were combined into a single diagnostic category. Fever and rash were the second and third most common diagnoses, respectively. In the telemedicine platform, each visit was assigned a single ICD-10 code to categorize the primary diagnosis.
Table 3.
Most Frequent Diagnoses
| DIAGNOSIS (30,000) | N | % OF TOTALa | % OF TOTAL EXCLUDING COVID-19 | % MALE | MEAN AGE |
|---|---|---|---|---|---|
| COVID-19/COVID-19 screening (see list below for ICD-10 codes) | 15,633 | 52.1 | — | 51 | 7.6 |
| Fever, unspecified [R50.9] | 2,157 | 7.2 | 15 | 51.9 | 4.3 |
| Rash and other nonspecific skin eruption [R21] | 1,003 | 3.3 | 7 | 52.9 | 4.2 |
| Acute upper respiratory infection, unspecified [J06.9] | 610 | 2.0 | 4.3 | 46.9 | 5.7 |
| Cough [R05] | 421 | 1.4 | 2.9 | 52 | 6.5 |
| Viral infection, unspecified [B34.9] | 395 | 1.3 | 2.8 | 54.7 | 5.9 |
| Acute pharyngitis, unspecified [J02.9] | 366 | 1.2 | 2.6 | 44 | 9.3 |
| Diarrhea, unspecified [R19.7] | 213 | 0.7 | 1.5 | 54.5 | 4.7 |
| Dysuria [R30.0] | 184 | 0.6 | 1.3 | 17.9 | 5.5 |
| Unspecified injury of head, initial encounter [S09.90XA] | 154 | 0.5 | 1.1 | 57.8 | 2.8 |
| Vomiting, unspecified [R11.10] | 150 | 0.5 | 1.0 | 54.7 | 4.7 |
aDenominator for percent is total number of telemedicine visits. Exactly one ICD-10 code reported per visit.
ICD, International Classification of Disease.
Note: COVID-19/COVID-19 Screening ICD-10 codes: Encounter for screening for other viral diseases [Z11.59]. Contact with and (suspected) exposure to other viral communicable diseases [Z20.828]. Contact with and (suspected) exposure to other communicable diseases [Z20.89]. Encounter for observation for suspected exposure to other biological agents ruled out [Z03.818]. Contact with and (suspected) exposure to unspecified communicable disease [Z20.9].
ANTIBIOTIC PRESCRIPTIONS
Antibiotic prescription rates showed a decreasing trend throughout the study period: 6.9% in May, 4.2% in June, 3.6% in July, and 3.3% in August. Overall, oral antibiotics were prescribed in 4.3% of telemedicine visits (1,282 visits). The most frequent diagnoses associated with antibiotic prescriptions were skin infections (35%), wounds (11.5%), impetigo (10.5%), and otitis media (8.7%).
REFERRAL FOR IMMEDIATE CARE
Following telemedicine consultations, 2,266 patients (9% of total telemedicine visits) were seen in-person at a PM Pediatrics urgent care location on the same day. The primary ICD-10 diagnosis codes associated with these in-person follow-up visits were COVID-19 related (1,088 visits), pharyngitis/tonsillitis (519 visits), and fever (391 visits). Table 4 details the top 10 diagnosis groups and most frequent ICD-10 codes for same-day in-person urgent care referrals. CPT codes were assigned to 28% of these in-person visits (656 codes). Approximately one-quarter of patients requiring same-day in-person care underwent procedures such as blood or urine testing (11.6%), radiography (5.9%), laceration repair (5.2%), splinting/immobilization (4.3%), abscess drainage (0.8%), or foreign body removal (0.6%).
Table 4.
Most Frequent Diagnosis Groups and International Classification of Disease-10s for Same-Day In-Person Urgent Care Visits
| DIAGNOSIS GROUP AND MOST FREQUENT DIAGNOSES | ICD-10 CODE | VISIT COUNT |
|---|---|---|
| Factors influencing health status and contact with health services | — | 1,137 |
| Contact with and (suspected) exposure to other viral communicable diseases | Z20.828 | 790 |
| Encounter for screening for other viral diseases | Z11.59 | 298 |
| Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified | — | 872 |
| Fever, unspecified fever cause | R50.9 | 279 |
| Dysuria | R30.0 | 168 |
| Diseases of the respiratory system | — | 724 |
| Sore throat | J02.9 | 372 |
| Viral upper respiratory tract infection | J06.9 | 58 |
| Injury, poisoning, and certain other consequences of external causes | — | 458 |
| Facial laceration, initial encounter | S01.81XA | 22 |
| Chin laceration, initial encounter | S01.81XA | 18 |
| Diseases of the ear and mastoid process | — | 227 |
| Acute swimmer’s ear of left side | H60.332 | 14 |
| Acute suppurative otitis media of left ear without spontaneous rupture of tympanic membrane, recurrence not specified | H66.002 | 14 |
| Infectious and parasitic diseases | — | 215 |
| Viral syndrome | B34.9 | 76 |
| Viral illness | B34.9 | 42 |
| Diseases of the skin and subcutaneous tissue | — | 121 |
| Abscess | L02.91 | 14 |
| Eczema, unspecified type | L30.9 | 5 |
| Diseases of the genitourinary system | — | 108 |
| Acute vaginitis | N76.0 | 25 |
| Urinary tract infection | N39.0 | 12 |
| Diseases of the digestive system | — | 67 |
| Gastroenteritis | K52.9 | 15 |
| Constipation, unspecified constipation type | K59.00 | 13 |
| External causes of morbidity and mortality | — | 54 |
| Bitten or stung by nonvenomous insect and other nonvenomous arthropods, initial encounter | W57.XXXA | 15 |
| Insect bite, unspecified site, initial encounter | W57.XXXA | 9 |
Emergency department (ED) referral was necessary in 219 visits (0.7%). ED referrals were more frequent during evening hours, with nearly 40% occurring between 8 PM and midnight (Table 5), likely due to the closing hours of both telemedicine and in-person urgent care facilities. The demographic profile of patients referred to the ED was similar to the overall study population in terms of sex, state, and insurance distribution.
Table 5.
Visits and Emergency Department Referrals by Hour of Day
| HOUR OF DAY | VISITS | NO. OF VISITS RESULTING IN ED REFERRAL (%) |
|---|---|---|
| 8–12 | 6,675 | 32 (14.6) |
| 12–16 | 10,331 | 40 (18.3) |
| 16–20 | 9,037 | 61 (27.9) |
| 20–24 | 3,957 | 86 (39.3) |
| Total | 30,000 | 219 (100) |
ED, emergency department.
Patients referred to the ED were younger (mean age 5.1 ± 5.1 years) compared to the general telemedicine population (7.6 ± 5.4 years, p < 0.001). Fever was the most common diagnosis leading to ED referral (39 visits) (Table 6). Other frequent reasons for ED referral included respiratory distress, vomiting, and urticaria, predominantly in children under 3 years of age. The top five chief complaints resulting in ED referral were fever, vomiting, lower abdominal pain, head injury, and viral infections.
Table 6.
Most Frequent Diagnoses of Emergency Department Referrals
| DIAGNOSIS | VISITS | PERCENT VISITS (MALE), % | AGE (AVERAGE) |
|---|---|---|---|
| Fever, unspecified [R50.9] | 39 | 48.7 | 4.3 |
| Vomiting, unspecified [R11.10] | 10 | 50 | 1.7 |
| Lower abdominal pain, unspecified [R10.30] | 9 | 55.6 | 8.7 |
| Unspecified injury of head, initial encounter [S09.90XA] | 7 | 28.6 | 2 |
| Viral infection, unspecified [B34.9] | 7 | 42.9 | 4.6 |
| Diarrhea, unspecified [R19.7] | 6 | 50 | 8.7 |
| Unspecified abdominal pain [R10.9] | 6 | 100 | 7.2 |
| Laceration without foreign body of lip, initial encounter [S01.511A] | 5 | 80 | 5.6 |
| Acute respiratory distress [R06.03] | 3 | 33.3 | 0.3 |
| Allergic urticaria [L50.0] | 3 | 33.3 | 2 |
COVID-19 TESTING
Beyond in-person urgent care follow-up, telemedicine also facilitated referrals for COVID-19 testing at urgent care locations without a second in-person clinical examination. After telemedicine screenings, 14,659 patients were referred for COVID-19 PCR testing, 2,740 for antibody testing, and 290 for antigen testing. 175 patients were referred for both PCR and antibody tests.
Discussion
The COVID-19 pandemic necessitated rapid adaptation within pediatric urgent care, leading to the swift implementation of telemedicine platforms. Within the first year of launching its telemedicine service, PM Pediatrics managed over 100,000 virtual visits. This study focused on the initial four-month period of widespread platform availability, analyzing 30,000 pediatric telemedicine encounters. A significant portion of these visits (6,214) were evaluated by pediatric emergency physicians, with the remainder managed by experienced pediatric urgent care providers.
Findings from Schinasi et al. suggest comparable diagnostic accuracy between virtual and in-person ED intake,[8] supporting the effectiveness of our telemedicine model in delivering accurate pediatric urgent care remotely. In over 90% of cases, telemedicine provided complete care, with only 9.2% requiring same-day urgent care and a minimal 0.7% needing ED referral. ED referrals were more common in younger children and during later evening hours, coinciding with the closure of telemedicine and in-person facilities. The platform demonstrated efficiency with short wait times (most patients seen within 15 minutes) and rapid chart completion (median 16.3 minutes), enabling timely care delivery and access to electronic medical records.
A limitation of this study regarding in-person urgent care referrals is the tracking of only those patients who presented to PM Pediatrics locations. It is possible that some patients sought in-person care elsewhere, potentially underestimating the true need for in-person follow-up. Patient satisfaction surveys, though limited by a low response rate (3%), could offer further insights into the adequacy of same-day in-person care within our institution.
The study’s low antibiotic prescription rate of 4.3% is noteworthy, indicating responsible antibiotic stewardship even within a telemedicine setting where in-person examinations were limited. This rate is significantly lower than a 2019 study of pediatric telemedicine by Ray et al., which reported a 52% antibiotic prescription rate.[18] In our study, antibiotic prescriptions were primarily for skin infections, conditions readily assessable via video examination, contrasting with conditions like otitis media that require in-person assessment.
The observed decrease in antibiotic prescribing rates over the study period, from May to August, may correlate with the easing of pandemic-related restrictions and increased availability of in-person healthcare options. Conditions potentially requiring antibiotics might have been increasingly directed to in-person care for thorough physical examinations, contributing to the reduced telemedicine antibiotic prescribing.
A key strength of our telemedicine platform lies in its exclusive use of pediatric-trained providers who also practice in our in-person urgent care centers, adhering to established pediatric care standards. This pediatric-specific expertise likely contributes to the low antibiotic prescribing rate and underscores the importance of specialized pediatric providers in delivering high-quality telemedicine care to children.
Telemedicine holds significant potential to enhance access to quality care for underserved populations, including low-income and rural communities. However, this study’s patient population largely mirrored the demographics of our pre-pandemic in-office patient base. While digital outreach efforts were made to promote the telemedicine service, the patient population remained skewed towards higher-income groups and those geographically proximate to our physical locations. Limited mass marketing capacity and the relatively short study period likely restricted broader community awareness and uptake of telemedicine services.
Furthermore, access to telemedicine requires digital literacy and resources, potentially creating barriers for families lacking reliable internet access or the necessary devices. The low representation of non-English speaking patients in our telemedicine visits, despite multilingual in-office services, also suggests potential access disparities.
Another limitation is the study’s context within a unique and evolving phase of the COVID-19 pandemic. The findings may not fully reflect typical telemedicine utilization patterns outside of pandemic-related healthcare disruptions. During the study period, many pediatric practices were closed or had limited capacity for sick visits. Notably, over half of the telemedicine visits were COVID-19 related, highlighting the platform’s crucial role in providing access to testing and addressing pandemic-related concerns when other resources were scarce.
Conclusions
Telemedicine, when delivered by pediatric-trained providers, can effectively provide comprehensive medical care for children while maintaining responsible antibiotic prescribing practices. Telemedicine proved to be a transformative tool for pediatric urgent care during the COVID-19 pandemic, demonstrating the robustness of audiovisual examinations for a wide range of pediatric complaints. The rapid provision of care to 30,000 children within four months underscores telemedicine’s essential public health function during periods of healthcare crisis and its potential for ongoing integration into pediatric healthcare delivery. As families continue to embrace telemedicine, defining best practices in pediatric telehealth will be crucial for ensuring high-quality, accessible care in the future.
Acknowledgment
The authors gratefully acknowledge Dr. James M. Chamberlain for his valuable review and feedback on this manuscript.
Disclosure Statement
The authors declare no competing financial interests.
Funding Information
This research received no specific funding.
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