Challenges

Although beneficial for allowing adolescents to continue accessing necessary care during a time when traditional methods of access were limited, increased use of telehealth has both exacerbated as well as added new domains to long-existing concerns with delivering SHS to adolescents.

Service Delivery

Two of the biggest concerns with providing adolescent SHS have always been privacy and confidentiality.  Although telehealth helps to mitigate privacy concerns by allowing patients to access an appointment anywhere, providers cannot always ensure there is a quiet and private space available.  Attending virtual SHS appointments at home presents challenges to young people who may live in a household with other family members where privacy is limited or nonexistent.  They may be especially reluctant to speak candidly or at all with a provider about their sexual health if they don’t feel accepted or supported by others in the household and cannot find a private space to attend the appointment.

Certain concerns around confidentiality have also continued with telehealth use, particularly around billing and insurance procedures. These procedures may involve sending documents like an Explanation of Benefits or bill to the adolescents home, alerting parents or guardians that they sought SHS. Even without specifics of services received, these documents can prompt questions about which services were sought and why, which can be troubling for an adolescent living in a home where they don’t feel supported by others.

Other challenges for the use of telehealth include implementation barriers related to a provider’s comfort with clinical decision-making in the absence of a complete physical exam or laboratory data. Providers report feeling uncomfortable asking patients to provide on-camera views of their body as part of their SHS physical examination because of limitations in patient privacy and provider-perceived impropriety. Some providers also feel uncomfortable making diagnoses or other clinical decisions without an in-person physical exam.

Technology, Equity, and Access

Equity concerns are also prevalent for adolescents seeking telehealth SHS. The Children’s Hospital of Philadelphia (CHOP) Division of Adolescent Medicine studied the outcomes of rapidly modifying their telehealth services and found disparities in usage and access. The majority of telehealth patients were white female minors with private insurance. Patients coded as non-white in the electronic health record had lower visit completion rates than white patients.

Patients with limited socioeconomic means face additional barriers to accessing care, including limited access to adequate internet service or proper, working electronic devices such as smartphones, tablets, or computers.  These barriers around equity and limited socioeconomic means lead to decreased access to necessary care for those adolescents who may need SHS the most.

Billing and Payment

With increased usage of telehealth services, a relatively new challenge that has come up is cost and coverage of these services.  This can be another barrier for adolescents seeking SHS but may not have the means to pay for these services, or do not want documentation sent to their home for confidentiality reasons as discussed earlier.  Those with private insurance may be required to pay a co-pay, or even a portion of the service, while others who are uninsured may get stuck with the entire bill. While policies were put in place before and during the COVID-19 national emergency to both mitigate and in some cases eliminate costs of related to telehealth services to make care more accessible, uninsured adolescents may still be left to pay retail prices for some prescriptions, including birth control or some treatment medications.

Solutions

The increased use of telehealth to provide SHS to adolescents requires unique solutions to the challenges presented. As we have seen throughout the pandemic, these challenges are constantly evolving, so solutions must be sustainable and adaptable, particularly with the adolescent population.

Service Delivery, Privacy, and Confidentiality

Providers can address privacy concerns by taking measures both before and during the appointment to ensure privacy for the adolescent. These can include:

• Ensuring the adolescent has a comfortable, private, quiet space to meet when scheduling the appointment and choosing an ideal time for these conditions
• Asking if anyone else is in the room at the start of the visit
• Limiting disclosure to those nearby by encouraging the use of headphones, asking yes or no questions, and leveraging the video platform chat function to allow adolescents to type responses, and
• Rescheduling if the patient is not sure they will have privacy for the entire appointment.
• Panning the provider’s camera so the adolescent can see that there is no one else in the room with them, and ensuring that no one enters the space for the duration of the appointment.

Similarly, confidentiality should be considered and ensured before and throughout the appointment, much like a provider would want to ensure confidentiality in an in-person exam room setting. Explaining the confidentiality policy at the beginning of the visit is good practice. It allows the adolescent to express any questions or concerns to be more comfortable sharing information during the visit.  Alternative methods of billing and payment should also be explored in order to prevent insurance documents from being mailed to the adolescent’s home.

Secure electronic health record patient portals add another layer of confidentiality, provided they limit access to the adolescent. They allow adolescents to communicate privately with providers and enable services, such as viewing test results, without requiring the adolescent to disclose their information to anyone else. Adolescents may be more encouraged to seek SHS and communicate with their provider knowing they can do it through a secure portal, and can do so without needing to schedule an appointment or attend an in-office visit.

Some states allow minors to access and manage their own electronic health records without the involvement of parents or guardians.  In states or jurisdictions where parents are not restricted from accessing their child’s patient portal, care should be taken to ensure confidential information is not posted there.  A referral can also be made to another community-based clinic where more confidential practices are used.