RESULTS
Between March 24, 2020 and June 30, 2020, our division completed 3,787 telemedicine visits, with 150 to 300+ visits being conducted per week from April through June (Figure 1). Beginning in June, in-person visits started being offered again on a case by case basis, and a hybrid model of in-person clinic visits and telemedicine video visits was adopted.
There were 788 patients seen for a pulmonary telemedicine visit from May 17,2020 through June 12, 2020.  A majority of these patients (67%) lived in Pennsylvania and nearly 30% lived in New Jersey. Over half of the patients were male. Nearly 60% of patients identified as being Caucasian and 25% as being African American. Nearly 90% of patients did not identify as being Hispanic or Latino. The median age of patients was 7 years (mean 7.79 years, standard deviation 5.8 years; 25-75% IQR 3-12 years).
Fifty-four (6.9%) patients responded to the survey about their experience with telemedicine. Six of these patients (11%) had prior experience with telemedicine in another division. The majority of patients were previously cared for at the institution’s main clinic site in Philadelphia (60%) and 40% were previously seen in suburban subspecialty care centers. Forty-one providers responded to the survey.  Over half of the providers who responded were physicians (Table 1). The most commonly seen diagnoses were patients with general pulmonary conditions, sleep-related breathing disorders, and asthma.
All of the providers who responded to the survey indicated they would be interested in continuing telemedicine in the future, and 46 patients (85%) indicated that they would be interested in telemedicine after the pandemic resolved (Figure 2). Both patients and providers were most interested in future telemedicine use for regular follow-up visits and to obtain an appointment sooner (Figure 3). Both patients and providers had a positive telemedicine experience, with 92% of patients rating their telemedicine experience as excellent or very good and 72% of providers rating their telemedicine experience as excellent or very good (Figure 4A). Benefits of telemedicine visits as perceived by patients and providers are further delineated in Figure 4B and 4C and had some areas of overlap. Additional comments provided by patients about the benefits of telemedicine visits were that the “patient does not have to miss a whole day of school” and it provided access to care for patients that live in another state by removing “a lot of the financial aspects of gas/food/hotel.”  Providers commented that telemedicine visits allowed them the ability “to see patients more frequently without them having to travel [to the appointment]”, provide care to patients during inclement weather, and improve efficiency and flow “due to a lack of barriers encountered during in person visits” (e.g. waiting for rooms to open up, waiting to be triaged).
Specific clinical program providers reported that telemedicine may be helpful for general pulmonary patients for more frequent follow-up, families with limited resources, those that live far away, patients that are clinically stable, instances of inclement weather preventing travel to appointments, and patients with frequent questions or phone calls. In the sleep medicine program, survey respondents supported the use of telemedicine for determining if a sleep study is needed, following up on sleep study results, non-invasive ventilatory support follow-up, and behavioral sleep concerns. Providers supported telemedicine visits for asthma follow-up care in those with historically normal lung function testing, in children too young to perform spirometry, or patients whose asthma is well controlled. Cystic fibrosis provider responses identified telemedicine as a useful method for completing quarterly follow-up visits alternating with in-person visits. The aerodigestive program respondents also supported the use of telemedicine for follow-up visits. The technology dependent center respondents reported that telemedicine may be useful for respiratory weaning, trouble-shooting ventilator challenges, and to check on equipment.
The majority of patients (76%) did not perceive significant technical difficulties during their telemedicine visits (Figure 5A). Providers cited technical difficulties sometimes with each aspect of telemedicine including audio, visual, patients not having access to the equipment, patients forgetting scheduled visits, and patients arriving late (Figure 5B). Providers and patients both expressed limitations in the physical examination and inability to obtain standard vital signs. Providers also felt lack of spirometry was a limitation. Both providers and patients indicated distractions at home or inability for a child to sit for video visit were limitations. Suggestions provided by patients to improve telemedicine included being able to use a laptop for the visit rather than a smart phone. Providers suggested having pre-visit check-in assistance to help patients work through technology challenges, using a larger screen for visits, and having improved physical examination capabilities.