Maintenance Notice

Due to necessary scheduled maintenance, the JMIR Publications website will be unavailable from Wednesday, July 01, 2020 at 8:00 PM to 10:00 PM EST. We apologize in advance for any inconvenience this may cause you.

Who will be affected?

Advertisement

Citing this Article

Right click to copy or hit: ctrl+c (cmd+c on mac)

Published on 25.06.20 in Vol 3, No 1 (2020): Jan-Jun

Preprints (earlier versions) of this paper are available at http://preprints.jmir.org/preprint/20049, first published Jun 16, 2020.

This paper is in the following e-collection/theme issue:

    Viewpoint

    Digital Approaches to Remote Pediatric Health Care Delivery During the COVID-19 Pandemic: Existing Evidence and a Call for Further Research

    1Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States

    2Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States

    3Department of Pediatrics, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States

    Corresponding Author:

    Sherif M Badawy, MD, MS, MBBCh

    Department of Pediatrics

    Northwestern University Feinberg School of Medicine

    225 E Chicago Avenue, Box #30

    Chicago, IL, 60654

    United States

    Phone: 1 312 227 4000 ext 74836

    Fax:1 312 227 9373

    Email: sbadawy@luriechildrens.org


    ABSTRACT

    The global spread of the coronavirus disease (COVID-19) outbreak poses a public health threat and has affected people worldwide in various unprecedented ways, both personally and professionally. There is no question that the current global COVID-19 crisis, now more than ever, is underscoring the importance of leveraging digital approaches to optimize pediatric health care delivery in the era of this pandemic. In this perspective piece, we highlight some of the available digital approaches that have been and can continue to be used to streamline remote pediatric patient care in the era of the COVID-19 pandemic, including but not limited to telemedicine. JMIR Pediatrics and Parenting is currently publishing a COVID-19 special theme issue in which investigators can share their interim and final research data related to digital approaches to remote pediatric health care delivery in different settings. The COVID-19 pandemic has rapidly transformed health care systems worldwide, with significant variations and innovations in adaptation. There has been rapid expansion of the leveraging and optimization of digital approaches to health care delivery, particularly integrated telemedicine and virtual health. Digital approaches have played and will play major roles as invaluable and reliable resources to overcome restrictions and challenges imposed during the COVID-19 pandemic and to increase access to effective, accessible, and consumer-friendly care for more patients and families. However, a number of challenges remain to be addressed, and further research is needed. Optimizing digital approaches to health care delivery and integrating them into the public health response will be an ongoing process during the current COVID-19 outbreak and during other possible future pandemics. Regulatory changes are essential to support the safe and wide adoption of these approaches. Involving all relevant stakeholders in addressing current and future challenges as well as logistical, technological, and financial barriers will be key for success. Future studies should consider evaluating the following research areas related to telemedicine and other digital approaches: cost-effectiveness and return on investment; impact on quality of care; balance in use and number of visits needed for the management of both acute illness and chronic health conditions; system readiness for further adoption in other settings, such as inpatient services, subspecialist consultations, and rural areas; ongoing user-centered evaluations, with feedback from patients, families, and health care providers; strategies to optimize health equity and address disparities in access to care related to race and ethnicity, socioeconomic status, immigration status, and rural communities; privacy and security concerns for protected health information with Health Insurance Portability and Accountability Act (HIPAA)–secured programs; confidentiality issues for some specific populations, especially adolescents and those in need of mental health services; early detection of exposure to violence and child neglect; and integration of training into undergraduate and graduate medical education and subspecialty fellowships. Addressing these research areas is essential to understanding the benefits, sustainability, safety, and optimization strategies of telemedicine and other digital approaches as key parts of modern health care delivery. These efforts will inform long-term adoption of these approaches with expanded dissemination and implementation efforts.

    JMIR Pediatr Parent 2020;3(1):e20049

    doi:10.2196/20049

    KEYWORDS



    The Burden of the COVID-19 Pandemic

    The global spread of COVID-19, the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has posed a public health threat and has affected people worldwide in various unprecedented ways, both personally and professionally. COVID-19 infection is asymptomatic in many cases; however, in more serious cases, it can lead to severe acute respiratory syndrome, which requires mechanical ventilation, circulatory support, and intensive care unit management. Overall, children have been much less affected than adults in terms of both prevalence and disease severity [1], although the long-term effects are as yet unknown and the evidence base is evolving. The World Health Organization declared COVID‐19 a pandemic on March 11, 2020 [2]. COVID-19 has been spreading rapidly worldwide among children and adults in 187 countries; according to the Johns Hopkins Coronavirus Resource Center, there have been 7,397,349 confirmed cases and 417,133 global deaths as of June 11, 2020 [3]. These numbers continue to increase every day, especially with the high reproductive number of SARS-CoV-2 [4]. Countries with the highest disease burden, particularly fatalities, include the United States, United Kingdom, Brazil, Italy, France, Spain, and Mexico [3].

    Several strategies have been implemented worldwide to limit the spread of COVID-19 infection, such as social (ie, physical) distancing and local or national stay-at-home mandates. These strategies, although necessary, have led not only to disruption of people’s normal routines or daily life in different ways but also to significant financial challenges to our society and economy across almost all sectors, including health care. Just a few of the many disruptions that are more relevant to pediatrics are lower availability of child care sources due to the closure of day care centers, preschool centers, and schools; homeschooling of children and adolescents; parents or caregivers who are working remotely, have been furloughed, or have temporarily or permanently lost their jobs; limited ability to decrease individual density in outpatient settings, such as pediatricians’ private offices and hospital clinics; postponement of elective surgeries, procedures, and imaging studies; avoidance of emergency rooms by children and families who may be in need of health care; and missed appointments for routine children’s vaccinations. All these challenges have resulted in increased levels of stress and uncertainty in the lives of our patients and their families.


    Digital Approaches to Pediatric Health Care Delivery

    There is no question that the current global COVID-19 crisis, now more than ever, is underscoring the importance of leveraging digital approaches to optimize pediatric health care delivery in the era of this pandemic. Given the restrictions and limitations of in-person or face-to-face visits, many patients, families, and clinicians, including pediatricians, are increasingly realizing the potential of these tools. Additionally, access to personal technology is increasingly ubiquitous [5-7]. Moreover, there is growing evidence to support the feasibility, acceptability, and efficacy of digital behavioral interventions in pediatric populations [8-16], although economic evaluations are lacking [17]. However, concerns remain related to inequity of access to the internet, especially broadband connections; therefore, promotion of digital and telehealth equity is urgently needed. In this perspective piece, we highlight some of the available digital approaches that have been and can continue to be used to streamline remote pediatric patient care in the era of the COVID-19 pandemic, including and beyond telemedicine alone. JMIR Pediatrics and Parenting is currently publishing a COVID-19 special theme issue for investigators to share their interim and final research data related to digital approaches to remote pediatric health care delivery in different settings, such as telemedicine or telehealth, web-based interventions, mobile apps, wearable devices, and other novel digital strategies [Multimedia Appendix 1] [18].

    Telemedicine

    Telemedicine has been the main approach to deliver pediatric health care during the COVID-19 pandemic when it is accessible, available, and appropriate to address the present problem. Only 8% of Americans had used telemedicine at one point in 2019 [19]; however, this number has significantly increased during the recent pandemic. A number of barriers to wide adoption were reported earlier, such as discomfort of patients, parents, and providers using telemedicine technology, lower reimbursement rates, and preference for in-person visits. The only exception has been people in remote or rural areas with limited access to care, especially from specialists and subspecialists [20,21]. Due to the lack of an effective vaccine or therapy for COVID-19 as well as social distancing and stay-at-home lockdown orders, exploring alternatives for in-person visits is inevitable. On March 17, 2020, the US government issued a key temporary waiver for several rules related to Health Insurance Portability and Accountability Act (HIPAA) regulations around telemedicine for both audio and video communications [22,23]. This waiver is a recognition of the value and the urgent need to use telemedicine as well as the existing high-quality evidence supporting its utility. Additionally, insurers in the United States have expanded their coverage and reimbursement of various types of home (ie, direct to consumer) telemedicine visits [22]. Telemedicine has clear benefits and unique potential for scalability for general pediatricians as well as pediatric specialists in academic, community, and private sectors as well as in urban and rural settings [24-40]. However, clinics and institutions should pay careful attention to establishing plans to provide required technical support for these services and to integrate them with their workflows. This workflow process involves not only providers but also administrative support staff, nurses, social workers, case managers, other team members, patients, and patients’ families. Telemedicine is being used more frequently in pediatric care, and a number of studies have examined its quality of care. In a home-based telehealth videoconferencing group of adolescent transplant recipients living a median of 57 miles from a transplant center, medication adherence generally improved, although technological difficulties limited participation [41]. A telemedicine approach is appropriate for several indications, ranging from prevention of long-term or chronic health conditions by promoting well-being to management of acute illness and provision of mental health services.

    Psychosocial Support

    Technology itself can be used for therapeutic benefit; in children and adolescents, this application has mostly been directed toward improving mental health and decreasing substance use. A recent systematic review and meta-analysis that included 29 different programs found a medium effect size for internet-based cognitive behavioral therapy (iCBT) for depression and anxiety in children and adolescents compared to waitlist control groups [42]. At least 10 evidence-based iCBT programs are available for adolescent anxiety [43]. Importantly, these programs showed moderate to high use, especially with adjunct support from coaches, teachers, or therapists, to demonstrate credibility and to help users complete their target behavior [43]. Interestingly, even without support, when evidence-based iCBT is open-access and self-directed, engagement is lower than in controlled trials; however, many adolescents still achieved significant reductions in anxiety levels [44]. iCBT is also being adapted for more populations, such as adolescents with intellectual disability and anxiety [45]; youth insomnia [46]; sickle cell disease [47]; and chronic pain [48], including functional abdominal pain or dyspepsia [49]. The latter, in particular, was found to result in cost savings and lower health care utilization [50].

    A systematic review examining the use of remotely delivered psychological therapies for chronic pain conditions in children and adolescents included 10 eligible studies [51]. These studies involved patients with headache, juvenile idiopathic arthritis, sickle cell disease, irritable bowel syndrome, and mixed pain syndromes [51]. Reduced headache severity was the only positive finding [51]. An innovative motivational intervention for young people with schizophrenia involving a virtual community of peers with schizophrenia and motivational coaches enhanced social motivation and decreased depressive symptoms [52]. Further, some interventions have been tailored with the goal of delivery at more pertinent moments; these are called just-in-time adaptive interventions (JITAIs). For example, a mobile health intervention for homeless adolescent mothers involves a wearable wristband that measures electrodermal activity as a marker of stress and times the notification of stress signals to prompt the adolescent to use emotion regulation support [53]. It also important to note that evaluating minimal clinically important, relevant, and meaningful differences or effects as a result of these psychosocial interventions, rather than only focusing on effect sizes, is a key consideration when evaluating their effectiveness [54]. Despite the overall promising outcomes related to digital psychosocial interventions, broad and public dissemination and implementation of these interventions is still limited, and more research is needed in this area.

    Supporting Preventive Behaviors

    One specific population that is amenable to digital health interventions is adolescents, who are avid users of technology. Adolescence is a life period in which the majority of individuals are relatively healthy. It is also a time to establish healthy behaviors and prevent the development of future chronic illnesses. A review of less intensive SMS text messaging interventions for prevention, treatment, and knowledge outcomes for sexually transmitted infections (STIs) has shown equivocal results [55]. Additionally, other digital media interventions only showed effects on STI knowledge [56] as well as condom attitudes and self-efficacy [57]. Further, electronic STI testing was also found to be feasible and acceptable to young people and to increase uptake of testing [58]. Multiple technology interventions have been developed to address other behaviors in adolescents, such as alcohol use, smoking, and drug use. A meta-analysis of SMS text messaging interventions to reduce young adult binge drinking did not show effectiveness [59], while brief interventions and mobile applications showed some improvement in knowledge [60,61]. Intervening earlier in adolescence may provide a greater window of opportunity to enact effective, long-lasting behavior changes.

    Medication Adherence and Self-Management

    Digital interventions targeting adherence and disease management provide opportunities to enhance communication between patients and their health care teams. Multiple technologies have been used to support disease monitoring and self-management outside clinical settings and outside the purview of parents. In two recent systematic reviews, adherence-promoting interventions have been shown to be efficacious among children and adolescents with or without chronic medical conditions. However, most of the studies were low to moderate in quality; most were pilot studies, only a few were randomized controlled trials, and all had variable follow-up periods [8,10]. Monitoring patients’ moods using technology may have several benefits. It can improve self-awareness of emotions and behaviors, decrease the amount of time to seek mental health help due to symptom awareness, and enhance clinicians’ understanding of their patients’ symptoms and functioning [62]. Several interventions use SMS text message–based support, such as for HIV medication adherence [63,64]; however, these interventions are not always effective [65]. Further, remote monitoring of asthma through an electronic health intervention led to similar asthma control to a usual care group, with fewer in-person visits [66]. Self-management interventions for type 1 diabetes may be more effective with clinician support [67] or when they involve videogames [68]. Further, to address childhood obesity, self-monitoring is often a key treatment component in behavioral interventions for weight loss. However, for these mobile interventions, a small but significant effect size has been reported [69]. Moreover, other novel digital interventions are being developed and tested in various health care fields, such as interactive power toothbrushes to improve plaque removal [70] and eye-gaze control technology for cerebral palsy [71].

    Peer Support

    Digital approaches to optimize peer support are another interesting area of research that could improve pediatric health and well-being and also provide career and educational support. For example, for youth with physical disabilities, various formats of electronic mentoring from near peers were found to be helpful in making career decisions, coping with daily life, and advancing social skills; these benefits were a result of garnering support from other young people who understood their health challenges [72,73]. Social media has been used for healthy nutrition interventions [74], most notably for increasing desirable food consumption (fruits and vegetables) [75]; however, the effectiveness of these interventions remains unclear, and there are concerns related to social undesirability of posting health-related weight goals publicly as opposed to in private online groups [76].


    A Call for Further Research

    Although the field of digital intervention continues to grow at a fast pace, several unanswered questions and knowledge gaps remain and should be explored further [77-81]. In particular, telemedicine and other digital approaches for pediatric health care delivery across different settings (eg, academic and community) are expected to continue, especially after their wide adoption during the COVID-19 pandemic. Patients, families, and providers are more comfortable with these approaches [82,83], and several financial barriers related to system adoption and reimbursement concerns have been resolved. Furthermore, in 2008, the American Academy of Pediatrics (AAP) established a Section on Telehealth Care (SOTC) [84]. In 2019, the AAP-SOTC launched a telemedicine initiative: SPROUT (Supporting Pediatric Research on Outcomes and Utilization of Telehealth) [85]. SPROUT is a Collaborative Telehealth Research Network funded by the National Institutes of Health (NIH) [85]. These efforts and the current widespread use of telemedicine in pediatrics reflect the importance and the need for further research to leverage and optimize remote and digital pediatric health care delivery.

    Future studies should consider evaluating the following research areas related to telemedicine and other digital approaches: cost-effectiveness return on investment; impact on quality of care; balance of the use and number of visits needed for the management of both acute illness and chronic health conditions; system readiness for further adoption in other settings, such as inpatient services, subspecialist consultations, and rural areas; ongoing user-centered evaluations with feedback from patients, families, and health care providers; strategies to optimize health equity and address disparities in access to care related to race and ethnicity, socioeconomic status, immigration status, and for rural communities; privacy and security concerns for protected health information with HIPAA-secured programs; confidentiality issues for some specific populations, especially adolescents and people in need of mental health services; early detection of violence exposure and child neglect; and finally, integration of training into undergraduate and graduate medical education and subspecialty fellowships. Addressing these research areas is essential to understanding the benefits, sustainability, safety, and optimization strategies of telemedicine and other digital approaches as key parts of modern health care delivery. These efforts will inform long-term adoption of these approaches with expanded dissemination and implementation efforts.


    Conclusions

    The aforementioned interventions only offer a glimpse into the future of technology for pediatric health; now, a pathway to their wider utilization has been established due to greatly increased need. The COVID-19 pandemic has rapidly transformed health care systems worldwide, with significant variations and innovations in adaptation. There has been rapid expansion of the leveraging and optimization of digital approaches to health care delivery, particularly integrated telemedicine and virtual health. The fight against the COVID-19 pandemic is ongoing and will continue to be a top priority for national and international health organizations as well as health care systems worldwide. Digital approaches including but not limited to telemedicine, such as those described in this viewpoint, have played and will play major roles as invaluable and reliable resources to overcome restrictions and challenges imposed during the COVID-19 pandemic and to increase access to effective, accessible, and consumer-friendly care to more patients and families. Increasing numbers of providers, nurses, administrative staff, and institutions are building experience and comfort using these digital approaches, which have undoubtedly changed the way we practice medicine. However, a number of challenges remain when optimizing and integrating digital approaches for health care delivery into the public health response to the current COVID-19 outbreak and other possible future pandemics. Regulatory changes are essential to support the safe and wide adoption of these approaches. Involving all relevant stakeholders in addressing ongoing and future challenges as well as logistical, technological, and financial barriers will be key for success. This includes support for research funding to develop a sound evidence base for the efficacy of pediatric digital interventions as well as to understand their reach to heterogeneous pediatric patient populations to limit exacerbation of health care disparities. Digital approaches to health care delivery, particularly telemedicine, are ideal strategies to optimize general pediatric and subspecialty care for all children and adolescents regardless of their location.

    Acknowledgments

    This project was supported by NIH, grant number 1K23MH111922-01A1 (PI: Radovic), and the National Institute of Mental Health (NIMH), grant number K23HL150232 (PI: Badawy), from the National Heart, Lung, and Blood Institute. AR receives support from The Center for Enhancing Triage and Utilization for Depression and Emergent Suicidality (ETUDES) In Pediatric Primary Care, P50MH115838-03 (PI: Brent), which is an Advanced Laboratories for Accelerating the Reach and Impact of Treatments for Youth and Adults with Mental Illness (ALACRITY) Research Center from NIMH. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH.

    Conflicts of Interest

    None declared.

    Multimedia Appendix 1

    JMIR Pediatrics and Parenting (JPP) COVID-19 Call for Papers.

    PDF File (Adobe PDF File), 95 KB

    References

    1. Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, et al. Epidemiology of COVID-19 Among Children in China. Pediatrics 2020 Jun;145(6). [CrossRef] [Medline]
    2. World Health Organization. Coronavirus (COVID-19) outbreak   URL: https://www.who.int/westernpacific/emergencies/covid-19 [accessed 2020-05-06]
    3. Johns Hopkins Coronavirus Resource Center. COVID-19 Dashboard   URL: https://coronavirus.jhu.edu/map.html [accessed 2020-05-06]
    4. Liu Y, Gayle AA, Wilder-Smith A, Rocklöv J. The reproductive number of COVID-19 is higher compared to SARS coronavirus. J Travel Med 2020 Mar 13;27(2) [FREE Full text] [CrossRef] [Medline]
    5. Andersen M, Jiang J. Pew Research Center. 2018 May 31. Teens, Social Media & Technology 2018   URL: https://www.pewresearch.org/internet/2018/05/31/teens-social-media-technology-2018/ [accessed 2020-01-17]
    6. Pew Research Center. 2019 Jun 12. Mobile Fact Sheet   URL: https://www.pewresearch.org/internet/fact-sheet/mobile/ [accessed 2020-01-17]
    7. Badawy SM, Thompson AA, Liem RI. Technology Access and Smartphone App Preferences for Medication Adherence in Adolescents and Young Adults With Sickle Cell Disease. Pediatr Blood Cancer 2016 May;63(5):848-852. [CrossRef] [Medline]
    8. Badawy SM, Barrera L, Sinno MG, Kaviany S, O'Dwyer LC, Kuhns LM. Text Messaging and Mobile Phone Apps as Interventions to Improve Adherence in Adolescents With Chronic Health Conditions: A Systematic Review. JMIR Mhealth Uhealth 2017 May 15;5(5):e66 [FREE Full text] [CrossRef] [Medline]
    9. Badawy SM, Cronin RM, Hankins J, Crosby L, DeBaun M, Thompson AA, et al. Patient-Centered eHealth Interventions for Children, Adolescents, and Adults With Sickle Cell Disease: Systematic Review. J Med Internet Res 2018 Jul 19;20(7):e10940 [FREE Full text] [CrossRef] [Medline]
    10. Badawy SM, Kuhns LM. Texting and Mobile Phone App Interventions for Improving Adherence to Preventive Behavior in Adolescents: A Systematic Review. JMIR Mhealth Uhealth 2017 Apr 19;5(4):e50 [FREE Full text] [CrossRef] [Medline]
    11. Badawy SM, Thompson AA, Kuhns LM. Medication Adherence and Technology-Based Interventions for Adolescents With Chronic Health Conditions: A Few Key Considerations. JMIR Mhealth Uhealth 2017 Dec 22;5(12):e202 [FREE Full text] [CrossRef] [Medline]
    12. Radovic A, Badawy SM. Technology Use for Adolescent Health and Wellness. Pediatrics 2020 May;145(Suppl 2):S186-S194. [CrossRef] [Medline]
    13. Ramsey WA, Heidelberg RE, Gilbert AM, Heneghan MB, Badawy SM, Alberts NM. eHealth and mHealth interventions in pediatric cancer: A systematic review of interventions across the cancer continuum. Psychooncology 2020 Jan;29(1):17-37. [CrossRef] [Medline]
    14. Majeed-Ariss R, Baildam E, Campbell M, Chieng A, Fallon D, Hall A, et al. Apps and Adolescents: A Systematic Review of Adolescents' Use of Mobile Phone and Tablet Apps That Support Personal Management of Their Chronic or Long-Term Physical Conditions. J Med Internet Res 2015 Dec 23;17(12):e287 [FREE Full text] [CrossRef] [Medline]
    15. Fedele DA, Cushing CC, Fritz A, Amaro CM, Ortega A. Mobile Health Interventions for Improving Health Outcomes in Youth: A Meta-analysis. JAMA Pediatr 2017 May 01;171(5):461-469 [FREE Full text] [CrossRef] [Medline]
    16. Marcolino MS, Oliveira JAQ, D'Agostino M, Ribeiro AL, Alkmim MBM, Novillo-Ortiz D. The Impact of mHealth Interventions: Systematic Review of Systematic Reviews. JMIR Mhealth Uhealth 2018 Jan 17;6(1):e23 [FREE Full text] [CrossRef] [Medline]
    17. Badawy SM, Kuhns LM. Economic Evaluation of Text-Messaging and Smartphone-Based Interventions to Improve Medication Adherence in Adolescents with Chronic Health Conditions: A Systematic Review. JMIR Mhealth Uhealth 2016 Oct 25;4(4):e121 [FREE Full text] [CrossRef] [Medline]
    18. Badawy S, Radovic A. JMIR Pediatrics and Parenting. Call for Papers: "Theme Issue 2020: Digital Approaches for Pediatric Healthcare Delivery during the Coronavirus (Covid-19) Pandemic" in the JMIR Pediatrics and Parenting (JPP) Special Theme Issue/E-Collection   URL: https://pediatrics.jmir.org/announcement/view/204 [accessed 2020-05-06]
    19. American Well. 2019. Telehealth Index: 2019 Consumer Survey   URL: https:/​/static.​americanwell.com/​app/​uploads/​2019/​07/​American-Well-Telehealth-Index-2019-Consumer-Survey-eBook2.​pdf [accessed 2020-05-07]
    20. Dorsey ER, Topol EJ. State of Telehealth. N Engl J Med 2016 Jul 14;375(2):154-161. [CrossRef] [Medline]
    21. Turner A, Ricketts T, Leslie LK. Comparison of Number and Geographic Distribution of Pediatric Subspecialists and Patient Proximity to Specialized Care in the US Between 2003 and 2019. JAMA Pediatr 2020 May 18. [CrossRef] [Medline]
    22. CMS. Centers for Medicare & Medicaid Services. 2020 Mar 17. Medicare Telemedicine Health Care Provider Fact Sheet   URL: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet [accessed 2020-05-06]
    23. US Department of Health & Human Services. Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency   URL: https:/​/www.​hhs.gov/​hipaa/​for-professionals/​special-topics/​emergency-preparedness/​notification-enforcement-discretion-telehealth/​index.​html [accessed 2020-05-06]
    24. Ardura M, Hartley D, Dandoy C, Lehmann L, Jaglowski S, Auletta JJ, Transplant-Associated Learning Network Team (TALNT). Addressing the Impact of the Coronavirus Disease 2019 (COVID-19) Pandemic on Hematopoietic Cell Transplantation: Learning Networks as a Means for Sharing Best Practices. Biol Blood Marrow Transplant 2020 Apr 24 [FREE Full text] [CrossRef] [Medline]
    25. Brough HA, Kalayci O, Sediva A, Untersmayr E, Munblit D, Rodriguez Del Rio P, et al. Managing childhood allergies and immunodeficiencies during respiratory virus epidemics - The 2020 COVID-19 pandemic: A statement from the EAACI-section on pediatrics. Pediatr Allergy Immunol 2020 Apr 22 [FREE Full text] [CrossRef] [Medline]
    26. Cini C, Bortot G, Sforza S, Mantovani A, Landi L, Esposito C, et al. Paediatric urology practice during COVID-19 pandemic. J Pediatr Urol 2020 Apr 25 [FREE Full text] [CrossRef] [Medline]
    27. Espinoza J, Crown K, Kulkarni O. A Guide to Chatbots for COVID-19 Screening at Pediatric Health Care Facilities. JMIR Public Health Surveill 2020 Apr 30;6(2):e18808 [FREE Full text] [CrossRef] [Medline]
    28. Finkelstein JB, Nelson CP, Estrada CR. "Ramping up telemedicine in pediatric urology - Tips for using a new modality". J Pediatr Urol 2020 Apr 17. [CrossRef] [Medline]
    29. Frieden IJ, Püttgen KB, Drolet BA, Garzon MC, Chamlin SL, Pope E, Hemangioma Investigator Group. Management of infantile hemangiomas during the COVID pandemic. Pediatr Dermatol 2020 Apr 16 [FREE Full text] [CrossRef] [Medline]
    30. Garg SK, Rodbard D, Hirsch IB, Forlenza GP. Managing New-Onset Type 1 Diabetes During the COVID-19 Pandemic: Challenges and Opportunities. Diabetes Technol Ther 2020 Jun;22(6):431-439. [CrossRef] [Medline]
    31. Mann DM, Chen J, Chunara R, Testa PA, Nov O. COVID-19 transforms health care through telemedicine: evidence from the field. J Am Med Inform Assoc 2020 Apr 23 [FREE Full text] [CrossRef] [Medline]
    32. Ohannessian R, Duong TA, Odone A. Global Telemedicine Implementation and Integration Within Health Systems to Fight the COVID-19 Pandemic: A Call to Action. JMIR Public Health Surveill 2020 Apr 02;6(2):e18810 [FREE Full text] [CrossRef] [Medline]
    33. Patel PD, Cobb J, Wright D, Turer R, Jordan T, Humphrey A, et al. Rapid Development of Telehealth Capabilities within Pediatric Patient Portal Infrastructure for COVID-19 Care: Barriers, Solutions, Results. J Am Med Inform Assoc 2020 Apr 17 [FREE Full text] [CrossRef] [Medline]
    34. Ray KN, Kahn JM. Connected Subspecialty Care: Applying Telehealth Strategies to Specific Referral Barriers. Acad Pediatr 2020;20(1):16-22. [CrossRef] [Medline]
    35. Sawalha AH, Manzi S. Coronavirus Disease-2019: Implication for the care and management of patients with systemic lupus erythematosus. Eur J Rheumatol 2020 Apr 08. [CrossRef] [Medline]
    36. Szperka CL, Ailani J, Barmherzig R, Klein BC, Minen MT, Halker Singh RB, et al. Migraine Care in the Era of COVID-19: Clinical Pearls and Plea to Insurers. Headache 2020 May;60(5):833-842 [FREE Full text] [CrossRef] [Medline]
    37. Veerapandiyan A, Wagner KR, Apkon S, McDonald CM, Mathews KD, Parsons JA, et al. The care of patients with Duchenne, Becker, and other muscular dystrophies in the COVID-19 pandemic. Muscle Nerve 2020 Apr 24. [CrossRef] [Medline]
    38. Woo Baidal JA, Chang J, Hulse E, Turetsky R, Parkinson K, Rausch JC. Zooming Toward a Telehealth Solution for Vulnerable Children with Obesity During Coronavirus Disease 2019. Obesity (Silver Spring) 2020 Apr 30 [FREE Full text] [CrossRef] [Medline]
    39. Wosik J, Fudim M, Cameron B, Gellad ZF, Cho A, Phinney D, et al. Telehealth transformation: COVID-19 and the rise of virtual care. J Am Med Inform Assoc 2020 Jun 01;27(6):957-962 [FREE Full text] [CrossRef] [Medline]
    40. Ray KN, Mehrotra A, Yabes JG, Kahn JM. Telemedicine and Outpatient Subspecialty Visits Among Pediatric Medicaid Beneficiaries. Acad Pediatr 2020 Apr 08 [FREE Full text] [CrossRef] [Medline]
    41. Kelly SL, Steinberg EA, Suplee A, Upshaw NC, Campbell KR, Thomas JF, et al. Implementing a Home-Based Telehealth Group Adherence Intervention with Adolescent Transplant Recipients. Telemed J E Health 2019 Nov;25(11):1040-1048. [CrossRef] [Medline]
    42. Grist R, Croker A, Denne M, Stallard P. Technology Delivered Interventions for Depression and Anxiety in Children and Adolescents: A Systematic Review and Meta-analysis. Clin Child Fam Psychol Rev 2019 Jun;22(2):147-171 [FREE Full text] [CrossRef] [Medline]
    43. Radomski AD, Wozney L, McGrath P, Huguet A, Hartling L, Dyson MP, et al. Design and Delivery Features That May Improve the Use of Internet-Based Cognitive Behavioral Therapy for Children and Adolescents With Anxiety: A Realist Literature Synthesis With a Persuasive Systems Design Perspective. J Med Internet Res 2019 Feb 05;21(2):e11128 [FREE Full text] [CrossRef] [Medline]
    44. March S, Spence SH, Donovan CL, Kenardy JA. Large-Scale Dissemination of Internet-Based Cognitive Behavioral Therapy for Youth Anxiety: Feasibility and Acceptability Study. J Med Internet Res 2018 Jul 04;20(7):e234 [FREE Full text] [CrossRef] [Medline]
    45. Hronis A, Roberts R, Roberts L, Kneebone I. Fearless Me! : A feasibility case series of cognitive behavioral therapy for adolescents with intellectual disability. J Clin Psychol 2019 Jun;75(6):919-932. [CrossRef] [Medline]
    46. Werner-Seidler A, Johnston L, Christensen H. Digitally-delivered cognitive-behavioural therapy for youth insomnia: A systematic review. Internet Interv 2018 Mar;11:71-78 [FREE Full text] [CrossRef] [Medline]
    47. Palermo TM, Dudeney J, Santanelli JP, Carletti A, Zempsky WT. Feasibility and Acceptability of Internet-delivered Cognitive Behavioral Therapy for Chronic Pain in Adolescents With Sickle Cell Disease and Their Parents. J Pediatr Hematol Oncol 2018 Mar;40(2):122-127 [FREE Full text] [CrossRef] [Medline]
    48. Tang W, Zhang L, Ai Y, Li Z. Efficacy of Internet-delivered cognitive-behavioral therapy for the management of chronic pain in children and adolescents: A systematic review and meta-analysis. Medicine (Baltimore) 2018 Sep;97(36):e12061 [FREE Full text] [CrossRef] [Medline]
    49. Bonnert M, Olén O, Lalouni M, Hedman-Lagerlöf E, Särnholm J, Serlachius E, et al. Internet-Delivered Exposure-Based Cognitive-Behavioral Therapy for Adolescents With Functional Abdominal Pain or Functional Dyspepsia: A Feasibility Study. Behav Ther 2019 Jan;50(1):177-188 [FREE Full text] [CrossRef] [Medline]
    50. Lalouni M, Ljótsson B, Bonnert M, Ssegonja R, Benninga M, Bjureberg J, et al. Clinical and Cost Effectiveness of Online Cognitive Behavioral Therapy in Children With Functional Abdominal Pain Disorders. Clin Gastroenterol Hepatol 2019 Oct;17(11):2236-2244.e11. [CrossRef] [Medline]
    51. Fisher E, Law E, Dudeney J, Eccleston C, Palermo TM. Psychological therapies (remotely delivered) for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev 2019 Apr 02;4:CD011118 [FREE Full text] [CrossRef] [Medline]
    52. Schlosser DA, Campellone TR, Truong B, Etter K, Vergani S, Komaiko K, et al. Efficacy of PRIME, a Mobile App Intervention Designed to Improve Motivation in Young People With Schizophrenia. Schizophr Bull 2018 Aug 20;44(5):1010-1020 [FREE Full text] [CrossRef] [Medline]
    53. Leonard NR, Casarjian B, Fletcher RR, Praia C, Sherpa D, Kelemen A, et al. Theoretically-Based Emotion Regulation Strategies Using a Mobile App and Wearable Sensor Among Homeless Adolescent Mothers: Acceptability and Feasibility Study. JMIR Pediatr Parent 2018;1(1):e1 [FREE Full text] [CrossRef] [Medline]
    54. Cuijpers P, Turner EH, Koole SL, van Dijke A, Smit F. What is the threshold for a clinically relevant effect? The case of major depressive disorders. Depress Anxiety 2014 May;31(5):374-378. [CrossRef] [Medline]
    55. Taylor D, Lunny C, Lolić P, Warje O, Geldman J, Wong T, et al. Effectiveness of text messaging interventions on prevention, detection, treatment, and knowledge outcomes for sexually transmitted infections (STIs)/HIV: a systematic review and meta-analysis. Syst Rev 2019 Jan 08;8(1):12 [FREE Full text] [CrossRef] [Medline]
    56. Wadham E, Green C, Debattista J, Somerset S, Sav A. New digital media interventions for sexual health promotion among young people: a systematic review. Sex Health 2019 Apr;16(2):101-123. [CrossRef] [Medline]
    57. Widman L, Golin CE, Kamke K, Burnette JL, Prinstein MJ. Sexual Assertiveness Skills and Sexual Decision-Making in Adolescent Girls: Randomized Controlled Trial of an Online Program. Am J Public Health 2018 Jan;108(1):96-102. [CrossRef] [Medline]
    58. Wilson E, Free C, Morris TP, Syred J, Ahamed I, Menon-Johansson AS, et al. Internet-accessed sexually transmitted infection (e-STI) testing and results service: A randomised, single-blind, controlled trial. PLoS Med 2017 Dec;14(12):e1002479 [FREE Full text] [CrossRef] [Medline]
    59. Bastola MM, Locatis C, Maisiak R, Fontelo P. The Effectiveness of Mobile Phone-Based Text Messaging to Intervene with Problem Drinking in Youth and Younger Adult Population: A Meta-Analysis. Telemed J E Health 2020 Mar;26(3):270-277. [CrossRef] [Medline]
    60. Ganz T, Braun M, Laging M, Schermelleh-Engel K, Michalak J, Heidenreich T. Effects of a stand-alone web-based electronic screening and brief intervention targeting alcohol use in university students of legal drinking age: A randomized controlled trial. Addict Behav 2018 Feb;77:81-88. [CrossRef] [Medline]
    61. Hides L, Quinn C, Cockshaw W, Stoyanov S, Zelenko O, Johnson D, et al. Efficacy and outcomes of a mobile app targeting alcohol use in young people. Addict Behav 2018 Feb;77:89-95. [CrossRef] [Medline]
    62. Dubad M, Winsper C, Meyer C, Livanou M, Marwaha S. A systematic review of the psychometric properties, usability and clinical impacts of mobile mood-monitoring applications in young people. Psychol Med 2018 Jan;48(2):208-228. [CrossRef] [Medline]
    63. Liu AY, Vittinghoff E, von Felten P, Rivet Amico K, Anderson PL, Lester R, et al. Randomized Controlled Trial of a Mobile Health Intervention to Promote Retention and Adherence to Preexposure Prophylaxis Among Young People at Risk for Human Immunodeficiency Virus: The EPIC Study. Clin Infect Dis 2019 May 30;68(12):2010-2017 [FREE Full text] [CrossRef] [Medline]
    64. Navarra AD, Gwadz MV, Whittemore R, Bakken SR, Cleland CM, Burleson W, et al. Health Technology-Enabled Interventions for Adherence Support and Retention in Care Among US HIV-Infected Adolescents and Young Adults: An Integrative Review. AIDS Behav 2017 Nov;21(11):3154-3171 [FREE Full text] [CrossRef] [Medline]
    65. Linnemayr S, Huang H, Luoto J, Kambugu A, Thirumurthy H, Haberer JE, et al. Text Messaging for Improving Antiretroviral Therapy Adherence: No Effects After 1 Year in a Randomized Controlled Trial Among Adolescents and Young Adults. Am J Public Health 2017 Dec;107(12):1944-1950. [CrossRef] [Medline]
    66. van den Wijngaart LS, Roukema J, Boehmer ALM, Brouwer ML, Hugen CAC, Niers LEM, et al. A virtual asthma clinic for children: fewer routine outpatient visits, same asthma control. Eur Respir J 2017 Oct;50(4) [FREE Full text] [CrossRef] [Medline]
    67. Deacon AJ, Edirippulige S. Using mobile technology to motivate adolescents with type 1 diabetes mellitus: A systematic review of recent literature. J Telemed Telecare 2015 Dec;21(8):431-438. [CrossRef] [Medline]
    68. Theng Y, Lee JWY, Patinadan PV, Foo SSB. The Use of Videogames, Gamification, and Virtual Environments in the Self-Management of Diabetes: A Systematic Review of Evidence. Games Health J 2015 Oct;4(5):352-361. [CrossRef] [Medline]
    69. Darling KE, Sato AF. Systematic Review and Meta-Analysis Examining the Effectiveness of Mobile Health Technologies in Using Self-Monitoring for Pediatric Weight Management. Child Obes 2017 Oct;13(5):347-355. [CrossRef] [Medline]
    70. Erbe C, Klees V, Braunbeck F, Ferrari-Peron P, Ccahuana-Vasquez RA, Timm H, et al. Comparative assessment of plaque removal and motivation between a manual toothbrush and an interactive power toothbrush in adolescents with fixed orthodontic appliances: A single-center, examiner-blind randomized controlled trial. Am J Orthod Dentofacial Orthop 2019 Apr;155(4):462-472 [FREE Full text] [CrossRef] [Medline]
    71. Karlsson P, Allsop A, Dee-Price B, Wallen M. Eye-gaze control technology for children, adolescents and adults with cerebral palsy with significant physical disability: Findings from a systematic review. Dev Neurorehabil 2018 Nov;21(8):497-505. [CrossRef] [Medline]
    72. Lindsay S, Cagliostro E, Leck J, Stinson J. A 12-Week Electronic Mentoring Employment Preparation Intervention for Youth With Physical Disabilities: Pilot Feasibility Randomized Controlled Trial. JMIR Pediatr Parent 2019 Mar 29;2(1):e12088 [FREE Full text] [CrossRef] [Medline]
    73. Lindsay S, Kolne K, Cagliostro E. Electronic Mentoring Programs and Interventions for Children and Youth With Disabilities: Systematic Review. JMIR Pediatr Parent 2018 Oct 24;1(2):e11679 [FREE Full text] [CrossRef] [Medline]
    74. Chau MM, Burgermaster M, Mamykina L. The use of social media in nutrition interventions for adolescents and young adults-A systematic review. Int J Med Inform 2018 Dec;120:77-91 [FREE Full text] [CrossRef] [Medline]
    75. Hsu MSH, Rouf A, Allman-Farinelli M. Effectiveness and Behavioral Mechanisms of Social Media Interventions for Positive Nutrition Behaviors in Adolescents: A Systematic Review. J Adolesc Health 2018 Nov;63(5):531-545. [CrossRef] [Medline]
    76. Klassen KM, Douglass CH, Brennan L, Truby H, Lim MSC. Social media use for nutrition outcomes in young adults: a mixed-methods systematic review. Int J Behav Nutr Phys Act 2018 Jul 24;15(1):70 [FREE Full text] [CrossRef] [Medline]
    77. Burke BL, Hall RW, Section on Telehealth Care. Telemedicine: Pediatric Applications. Pediatrics 2015 Jul;136(1):e293-e308 [FREE Full text] [CrossRef] [Medline]
    78. Committee on Pediatric Workforce, Marcin JP, Rimsza ME, Moskowitz WB. The Use of Telemedicine to Address Access and Physician Workforce Shortages. Pediatrics 2015 Jul;136(1):202-209 [FREE Full text] [CrossRef] [Medline]
    79. Olson CA, McSwain SD, Curfman AL, Chuo J. The Current Pediatric Telehealth Landscape. Pediatrics 2018 Mar;141(3) [FREE Full text] [CrossRef] [Medline]
    80. Tomines A. Pediatric Telehealth: Approaches by Specialty and Implications for General Pediatric Care. Adv Pediatr 2019 Aug;66:55-85. [CrossRef] [Medline]
    81. Utidjian L, Abramson E. Pediatric Telehealth: Opportunities and Challenges. Pediatr Clin North Am 2016 Apr;63(2):367-378. [CrossRef] [Medline]
    82. Haddad RN, Sakr C, Khabbaz L, Azouri H, Eid B. Telephone Consultation and Prescription in Pediatrics: Contributing Factors and Impact on Clinical Outcomes. Front Pediatr 2019;7:515 [FREE Full text] [CrossRef] [Medline]
    83. López Seguí F, Batlle Boada A, García García JJ, López Ulldemolins A, Achotegui Del Arco A, Adroher Mas C, et al. Families' Degree of Satisfaction With Pediatric Telehomecare: Interventional Prospective Pilot Study in Catalonia. JMIR Pediatr Parent 2020 Mar 26;3(1):e17517 [FREE Full text] [CrossRef] [Medline]
    84. American Academy of Pediatrics. Section on Telehealth Care (SOTC)   URL: https://services.aap.org/en/community/aap-sections/telehealth-care/ [accessed 2020-06-11]
    85. American Academy of Pediatrics. Supporting Pediatric Research on Outcomes and Utilization of Telehealth (SPROUT)   URL: https://services.aap.org/en/community/aap-sections/telehealth-care/sprout/ [accessed 2020-06-11]


    Abbreviations

    AAP: American Academy of Pediatrics
    COVID-19: coronavirus disease
    HIPAA: Health Insurance Portability and Accountability Act
    iCBT: internet-based cognitive behavioral therapy
    JITAI: just-in-time adaptive intervention
    NIH: National Institutes of Health
    SARS-CoV-2: severe acute respiratory syndrome coronavirus 2
    SOTC: Section on Telehealth Care
    SPROUT: Supporting Pediatric Research on Outcomes and Utilization of Telehealth
    STI: sexually transmitted infection


    Edited by G Eysenbach; submitted 10.05.20; peer-reviewed by E Fisher, K Binger, W Hansen; comments to author 04.06.20; revised version received 11.06.20; accepted 14.06.20; published 25.06.20

    ©Sherif M Badawy, Ana Radovic. Originally published in JMIR Pediatrics and Parenting (http://pediatrics.jmir.org), 25.06.2020.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Pediatrics and Parenting, is properly cited. The complete bibliographic information, a link to the original publication on http://pediatrics.jmir.org, as well as this copyright and license information must be included.