Introduction
With each passing day during the COVID-19 pandemic, we are learning more about the disease and its impact on our patients and their attitude towards healthcare. We are also learning to quickly adapt to new changes that are affecting our practice in the field of pediatrics. When the United States declared a national emergency during the COVID-19 pandemic in March 2020, medical care drastically shifted to telehealth medicine. Implemented by the Centers for Medicare & Medicaid Services (CMS), such telehealth services that were already in place pre-pandemic were further broadened to provide ease of access and coverage to patients due to the newly issued shelter-in-place orders. These new provisions rapidly gained popularity among patients of all ages. A recent study showed a substantial decrease in in-person visits by 80 % and a surge in telemedicine usage for adult urgent and non-urgent care. The authors found that during a 6-week period, telemedicine usage increased by as much as 683 % for urgent care. [1] The pediatric population was especially impacted by seeing a significant drop in immunizations for measles vaccine-containing administration, as reported by the Centers for Disease Control and Prevention (CDC).[2]

In addition, some studies have also shown disproportionate telehealth utilization depending on factors such as patient age, socioeconomic status, and geography [3].

Community pediatric healthcare is challenging and involves interaction with patients from varied socioeconomic and language and ethnic backgrounds. During the COVID-19 pandemic delivering outpatient pediatric care has presented itself with challenges that were unseen and unplanned. We present our observations from a community pediatric clinic in a geographic location considered to be an epicenter of the COVID-19 pandemic. Our pediatric practice has especially been affected by "stay-at-home orders". Our perspective reflects our experience of how the parent outlook has changed towards outpatient clinic visits, telemedicine, and vaccination during the time period of March 10, 2020, to May 31, 2020, during the COVID-19 pandemic.

We saw patterns of multiple visit cancellations by the patients, hesitance in appointment scheduling for non-urgent issues. We saw that an increasing number of patients preferred telehealth visits for non-urgent clinical symptoms. The reasons cited towards a preference for telehealth visits were to avoid crowded waiting rooms to avoid exposure to COVID-19, the convenience of being at home, obtaining reassurance from the healthcare team. However, one parent of a patient younger than 1 month expressed that they preferred an in- person visit more as she thought that the healthcare team is better able to identify “if something is wrong with my baby”.

Based on the above observations, we suggest that the option of video visits should be provided to the patients wherever possible. Video camera/telephone can be utilized as per patient preference. The ability to interact without the fear of contracting and better perception of facial expressions with the absence of personal protective equipment seems to help provide better physician-patient interaction and trust- building. Due to limited opportunity to conduct a full physical exam over the video/ telephone visit, patients should still be encouraged to visit the healthcare facility for urgent medical concerns. In addition, patients should also be educated to monitor vitals such as height, weight, head circumference, respiratory rate, and heart rate to optimize patient care during a telehealth visit.

During this period, we also observed that some parents wanted to defer vaccinations or refuse vaccinations altogether. In such cases, reminders were sent to families either through telephone calls or letters reminding them about the importance of vaccinations and the option of scheduling a telehealth visit. Patients who had missed their appointments were rescheduled once the “shelter at home” orders were lifted. Priority was given to patients less than 2 years of age who had delayed vaccination and patients who had urgent medical issues. Education to the family for the continued need for vaccination is critical and was reinforced at every patient encounter. Our observations reflect important changes in the delivery of outpatient pediatric care those other practices facing the pandemic should anticipate and prepare for. Our observations also emphasize the changing outlook of patients and providers towards digital healthcare delivery platforms.