Resilience of Pediatric Telemedicine: Therapeutic Alliance and Practice-Level Experience During a Pandemic-Driven System Transformation

Abstract

Background:

The COVID-19 pandemic caused a sudden transition from in-person to virtual pediatric care, creating a natural experiment to evaluate patient experience with telemedicine under operational stress. As hybrid care models mature, understanding perceptions during this disruption can inform durable delivery strategies, particularly regarding the therapeutic alliance and practice-level experience.

Purpose:

To determine whether family experience with telemedicine was comparable to or differed from in-person care during the COVID-19 transition and to assess how delivery modality, pandemic phase, and patient characteristics were associated with experience outcomes.

Methods:

We conducted a retrospective, cross-sectional secondary analysis of 18,452 patient and family experience surveys linked to ambulatory pediatric encounters at a large academic medical center between January 1 and September 30, 2020. Encounters were categorized into pre-COVID, early COVID rapid deployment, and later COVID hybrid stabilization phases. Surveys reflected both in-person and synchronous video-based telemedicine visits; telemedicine accounted for approximately 30% of responses during the study period. Independent-samples t tests and multiple linear regression models evaluated associations among visit modality, experience metrics, and demographic characteristics. Primary outcomes were Overall Rating of Provider and Recommend Office.

Results:

During Early COVID, telemedicine visits demonstrated significantly higher provider ratings than in-person visits, indicating preservation of the therapeutic alliance during rapid system change, although the absolute difference was small. In the later COVID phase, telemedicine was associated with higher unadjusted office recommendation scores; however, this effect was not independently associated with delivery modality in adjusted models. Telemedicine remained an independent predictor of higher provider ratings.

Conclusions:

Telemedicine sustained clinician-level experience outcomes comparable to, and in some contexts higher than, in-person care across pandemic phases. Findings support institutionalizing hybrid pediatric care models, strengthening clinician virtual communication skills, and advancing digital equity efforts.

Keywords

telemedicine pediatrics patient satisfaction physician-patient relations COVID-19

Introduction

The integration of telemedicine into pediatric care, once used as a secondary modality largely to supplement rural access, underwent a forced and nearly universal acceleration during the COVID-19 pandemic. Although initially driven by distancing requirements, this period functioned as a natural experiment and a prolonged episode of crisis management for health systems worldwide. As clinical practice stabilizes into hybrid care models balancing virtual and in-person encounters, it is important to examine foundational data generated during that period. Understanding the resilience of patient experience during such a rapid transition may inform telemedicine policy and support high-quality pediatric care.

Existing literature across pediatric and adult specialties shows strong patient and provider satisfaction with telemedicine during the pandemic, largely because it preserved continuity of care.^1–21 Providers reported that virtual visits allowed efficient documentation while maintaining rapport when workflows were adapted to the medium.^{8–10,15,17,21} Families frequently viewed telemedicine as a functional access point when appointment delays and care disruptions were common.^11,16,19

Research also indicates that effective communication and minimal technical issues are central to positive telemedicine experiences.^13,18,22 Telemedicine has been viewed as a valuable modality for pediatric care, chronic disease management, preventive care, and general outpatient medicine.^{1,2,14,16,17,23,24} Families often favor a hybrid structure that mixes virtual and in-person care.^11,16,18,19 Convenience factors, such as reduced travel, fewer school interruptions, and the ability to include additional caregivers, may influence families’ choice of telemedicine.^1,11,17,22

Although the feasibility of virtual care is well established, relatively few studies have focused specifically on pediatric or family ambulatory settings during periods of acute operational stress.^12,14 Using the pandemic’s rapid-deployment phase as a stress test, we designed this study to examine the viability of telemedicine during a period of technical, logistical, and emotional strain for patients, families, and health providers.

We designed the present study under two guiding assumptions. First, the pediatric therapeutic alliance (defined by trust, communication quality, and perceived attentiveness) may be preserved even when encounters occur outside the traditional clinic environment. Second, reductions in logistical burden associated with virtual care may positively influence practice-level experience. The primary objectives of the study were: (1) to evaluate the resilience of family experience by comparing telemedicine and in-person scores during the early rapid-deployment (“Early COVID”) and subsequent stabilization (“Later COVID”) periods and (2) to assess the viability of hybrid care models by determining whether experience scores shifted across phases after controlling for demographics.

Methods

STUDY DESIGN AND SETTING

We conducted a retrospective, single-center, cross-sectional secondary analysis of ambulatory pediatric encounters to evaluate patient and family experience during the rapid deployment of telemedicine prompted by the COVID-19 pandemic. The pandemic-driven transition was treated as a natural experiment, allowing comparison across care modalities. The study was conducted at a large academic pediatric medical center in the Pacific Northwest.

The institution schedules approximately 320,000 ambulatory visits annually across all sites of care. During calendar year 2020, approximately 66,000 visits were conducted via synchronous video-based telemedicine. Data for this analysis were extracted from ambulatory encounters occurring between January 1 and September 30, 2020, capturing the transition from predominantly in-person care to hybrid delivery models.

DATA SOURCE AND SURVEY INSTRUMENT

Patient and family experience data were derived from the Hospital Consumer Assessment of Healthcare Providers and Systems survey, a validated instrument developed by the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality.²⁵ Locally, this instrument is referred to as the Patient and Family Experience Survey.

The Patient and Family Experience Survey was administered by National Research Corporation (NRC) Health within 48 h of the clinical encounter via email or telephone, based on the family’s preferred communication method.²⁶ To reduce survey burden, families with multiple encounters received one survey attributed to their primary service line, and repeat surveys were limited to once every 180 days.

Survey data were extracted from NRC Health by institutional analytics staff. Encounter-level and demographic data were obtained from the electronic health record. All datasets were de-identified before analysis. Statistical analyses were conducted using Statistical Package for Social Sciences (SPSS), version 27.

STUDY POPULATION AND INCLUSION CRITERIA

The analytic sample included approximately 18,000 completed surveys, representing a 30% overall response rate from parents and guardians of pediatric patients who completed ambulatory visits during the study period. Surveys completed in English, Spanish, Russian, and Vietnamese were included, corresponding to validated translated versions of the Patient and Family Experience Survey instrument.

Ambulatory encounters included both in-person and telemedicine visits. For the Overall Rating of Provider measure, there were 18,452 total responses, of which 5,369 (29.1%) were associated with telemedicine encounters and 13,083 (70.9%) with in-person visits. For the “Would you recommend this provider’s office?” measure, there were 18,216 total responses, including 5,452 (29.9%) associated with telemedicine encounters and 12,764 (70.1%) associated with in-person visits. Overall, telemedicine encounters accounted for approximately 30% of patient and family experience survey responses during the study period.

ETHICAL CONSIDERATIONS

This study involved secondary analysis of deidentified data and did not include direct interaction with patients or families. Institutional review board oversight was not required.

OPERATIONALIZATION OF CONCEPTS

To evaluate the impact of rapid delivery transformation, encounters were categorized into three phases: pre-COVID baseline (January 1–March 15), representing traditional in-person care and used as the reference category in regression analysis, early COVID rapid deployment/stress test (March 16–July 31), representing the immediate postpandemic declaration period characterized by a forced, large-scale shift to telemedicine, and later COVID hybrid stabilization (August 1–September 30), representing a phase in which clinical operations began to stabilize into a hybrid model offering families a choice between virtual and in-person care.

Pre-COVID served as the baseline to understand scores before the disruption. Comparisons then evaluated telemedicine experience scores against in-person care across the Early COVID and Later COVID phases to determine whether virtual care was a resilient and viable option.

STUDY OUTCOME VARIABLES

This study utilized two primary metrics from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)-aligned Patient and Family Experience Survey to test assumptions regarding the pediatric therapeutic alliance and practice-level experience.

Overall Rating of Provider (Therapeutic Alliance Proxy): A 0–10 Likert scale, where 0 is the worst provider possible, and 10 is the best. This variable was used to test the modality resilience assumption by assessing whether the doctor-patient connection remains high when physical clinic amenities are removed. The Overall Rating of Provider item was selected as a proxy for therapeutic alliance because it reflects caregiver perceptions of communication, attentiveness, and trust—core elements of alliance that are not inherently dependent on the physical clinic environment.

Recommend Office (Practice-Level Experience Proxy): A Likert scale assessing the likelihood of recommending the provider’s office. Because likelihood-to-recommend measures reflect broad institutional and operational aspects of care, including access, scheduling, wait times, reliability, and coordination, this item was interpreted as an indirect indicator of practice-level experience rather than as a direct measure of logistical convenience alone.^27,28 Findings for this outcome were therefore interpreted cautiously, particularly in adjusted analyses (see Table 1 ).

Table 1.

Definitions of Study Variables

VARIABLE	MEASUREMENT LEVEL	RANGE OR CODING	ROLE IN STUDY	SOURCE
Overall Rating of Provider	Ordinal	0–10, 10 = best	Outcome 1 (dependent variable), therapeutic-alliance proxy	HCAHPS-aligned Patient and Family Experience Survey
Recommend Office	Ordinal	0–10, 10 = best	Outcome 2 (dependent variable), practice-level experience proxy	HCAHPS-aligned Patient and Family Experience Survey
COVID phase	Nominal	Pre-COVID: Jan 1–Mar 15, 2020, Early COVID: Mar 16–Jul 31, 2020, Later COVID: Aug 1–Sep 30, 2020	Independent variable, Pre-COVID used as reference category	Encounter date linked to survey response
Care delivery modality	Nominal	0 = telemedicine, 1 = in-person	Independent variable	Encounter data linked to survey response
Race/Ethnicity	Nominal	White non-Hispanic, Hispanic, Black or African American, Asian, American Indian/Alaska Native, Native Hawaiian/Pacific Islander, two or more races, other, unknown/refused	Control variable, collapsed non-White indicator used in regression model	Electronic medical record linked to coded survey
Age	Continuous	Patient age in years	Control variable	Electronic medical record linked to coded survey
Administrative sex	Nominal	Male, female	Control variable	Electronic medical record linked to coded survey

HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems.

STATISTICAL ANALYSIS

Descriptive statistics and independent-samples t tests were used to compare mean experience scores between modalities within each phase. To isolate the effect of delivery modality on pediatric experience, two multiple linear regression models, one for each primary metric, were constructed using the backward elimination method. Independent variables in the multivariate analysis included delivery modality (telemedicine vs. in-person), study phase, and patient demographics (age, administrative sex, and ethnicity). A binary non-White variable was created to assess equity-related differences in experience outcomes. All analyses were conducted using SPSS, version 27.0, with a 95% level of statistical significance (p < 0.05) (see Fig. 1 ).

Fig. 1.

Diagrammatic representation of study design.

Results

A total of 18,452 surveys met the inclusion criteria for analysis. Table 2 provides the descriptive statistics of the study population organized by delivery modality across the three defined phases of the natural experiment (see Table 2 ).

Table 2.

Baseline Survey Data and Variables by Delivery Modality and Phase of Care during the COVID-19 Pandemic, 2020

CHARACTERISTIC	IN-PERSON: PRE-COVID	IN-PERSON: EARLY COVID	IN-PERSON: LATER COVID	TELEMEDICINE: PRE-COVID	TELEMEDICINE: EARLY COVID	TELEMEDICINE: LATER COVID
Age, y, mean (SD)	10.07 (6.69)	10.12 (7.02)	9.85 (6.41)	13.95 (4.10)	10.56 (6.63)	10.77 (7.36)
Administrative sex, n (%)
Male	2,132 (51.8)	1,680 (49.8)	3,466 (51.2)	5 (27.8)	1,659 (49.5)	1,392 (51.0)
Female	1,985 (48.2)	1,693 (50.2)	3,308 (48.8)	13 (72.2)	1,693 (50.5)	1,336 (48.9)
Self-reported race/Ethnicity, n (%)
Two or more races	208 (5.0)	172 (5.1)	383 (5.7)	1 (5.6)	182 (5.4)	149 (5.5)
American Indian/Alaska Native	93 (2.3)	70 (2.1)	115 (1.7)	N/A	64 (1.9)	53 (1.9)
Asian	323 (7.8)	259 (7.7)	594 (8.8)	N/A	256 (7.6)	203 (7.4)
Black or African American	211 (5.1)	173 (5.1)	383 (5.7)	N/A	122 (3.6)	125 (4.6)
Hispanic	886 (21.5)	686 (20.3)	1,499 (22.1)	4 (22.2)	693 (20.7)	549 (20.1)
Native Hawaiian/Pacific Islander	26 (0.6)	23 (0.7)	47 (0.7)	N/A	24 (0.7)	13 (0.5)
Non-Hispanic White	1,982 (48.1)	1,705 (50.5)	3,145 (46.4)	10 (55.6)	1,764 (52.6)	1,428 (52.3)
Other	169 (4.1)	139 (4.1)	251 (3.7)	1 (5.6)	115 (3.4)	104 (3.8)
Unknown/Refused	221 (5.4)	147 (4.4)	359 (5.3)	2 (11.1)	132 (3.9)	108 (4.0)
Survey responses, mean (SD)
Overall Rating of Provider (0–10)	9.27 (1.51)	9.36 (1.36)	9.28 (1.49)	9.38 (0.96)	9.48 (1.21)	9.44 (1.27)
Recommend Office (0–10)	9.36 (1.59)	9.44 (1.41)	9.34 (1.65)	9.64 (0.49)	9.47 (1.34)	9.41 (1.49)

Values are presented as mean (SD) or n (%). N/A indicates no reported responses in the uploaded table for that subgroup/cell. COVID-19 phase labels and capitalization were standardized.

In comparing the two primary experience proxies between the early COVID rapid-deployment/stress-test phase and the later COVID hybrid-stabilization phase, telemedicine demonstrated scores that were comparable to traditional in-person encounters, with a statistically higher provider-rating score during early COVID and higher but nonsignificant unadjusted Recommend Office scores during Later COVID.

THERAPEUTIC ALLIANCE: OVERALL RATING OF PROVIDER

During the initial early COVID stress test, the mean score for the in-person group was statistically lower (9.36 ± 1.339) than the telemedicine group (9.48 ± 1.224), providing early evidence of modality resilience [t(5929) = −3.442, p = 0.001]. Although statistically significant, the absolute difference of 0.12 points represents approximately 1.2% of the 10-point scale range and should be interpreted as a small effect.

In the later COVID stabilization phase, the mean of the telemedicine group (9.44 ± 1.279) was numerically higher than the in-person group (9.28 ± 1.494), however, this observed difference did not reach statistical significance [t = −0.179, p = 0.858]. Accordingly, the finding should not be interpreted as a statistically supported trend but rather as evidence that perceived provider quality was comparable across modalities as hybrid workflows matured.

PRACTICE-LEVEL EXPERIENCE: RECOMMEND OFFICE

During the later COVID stabilization phase, unadjusted Recommend Office scores for telemedicine responses (9.40 ± 1.505) were numerically higher than those for in-person encounters (9.34 ± 1.648), but the difference was not statistically significant in the corrected comparison [t = −1.60, p = 0.110]. This finding should be interpreted as a practice-level signal rather than as evidence that delivery modality alone drove recommendation scores (see Table 3 ).

Table 3.

Comparison of Mean Experience Scores for Telemedicine versus In-Person Encounters During Early and Later COVID-19 Phases

PHASE	OUTCOME	MODALITY	N	MEAN	SD	SE MEAN	T	P
Early COVID	Overall Rating of Provider	In-person	3,017	9.36	1.339	0.024	−3.442	0.001
Early COVID	Overall Rating of Provider	Telemedicine	2,914	9.48	1.224	0.023
Early COVID	Recommend Office	In-person	2,942	9.44	1.394	0.026	−0.84	0.401
Early COVID	Recommend Office	Telemedicine	2,958	9.47	1.350	0.025
Later COVID	Overall Rating of Provider	In-person	6,097	9.28	1.494	0.019	−0.179	0.858
Later COVID	Overall Rating of Provider	Telemedicine	2,337	9.44	1.279	0.026
Later COVID	Recommend Office	In-person	5,957	9.34	1.648	0.021	−1.60	0.110
Later COVID	Recommend Office	Telemedicine	2,375	9.40	1.505	0.031

MULTIVARIATE ANALYSIS

After controlling for patient age and ethnicity, telemedicine maintained a positive and statistically significant association with the Overall Rating of Provider, the proxy for therapeutic alliance. Scores in telemedicine encounters were higher by 0.139 points (p < 0.001), supporting the interpretation that perceived provider quality was preserved across the digital transition.

However, the direct association between modality and recommend office was not significant in the multivariate analysis (B = 0.043, p = 0.107), indicating that broader institutional and operational factors beyond modality itself influenced office recommendations during the stabilization phase.

Regarding phases of the transition, encounters during the early COVID stress test were associated with significantly higher scores compared with the pre-COVID baseline, increasing by 0.081 points (p = 0.002) for recommend office and 0.073 points (p = 0.002) for overall rating of provider. Among control variables used to evaluate equity-related differences, responses from non-White families regarding recommend office were lower by 0.048 points (p = 0.043). This finding may indicate a small but statistically significant gap in practice-level experience during rapid system transformation. Age demonstrated a positive association with Overall Rating of Provider (B = 0.004, p = 0.034) ( Table 4 ).

Table 4.

Multivariable Linear Regression Results for Primary Experience Outcomes

PREDICTOR	RECOMMEND OFFICE: B	RECOMMEND OFFICE: SE	RECOMMEND OFFICE: P	OVERALL RATING OF PROVIDER: B	OVERALL RATING OF PROVIDER: SE	OVERALL RATING OF PROVIDER: P
COVID phase: Early COVID	0.081	0.026	0.002	0.073	0.024	0.002
COVID phase reference category	Pre-COVID			Pre-COVID
Care delivery modality: Telemedicine	0.043	0.027	0.107	0.139	0.025	<0.001
Modality reference category	In-person			In-person
Age	0.003	0.002	0.092	0.004	0.002	0.034
Non-White race/ethnicity	−0.048	0.024	0.043	−0.034	0.022	0.115
Constant	9.343	0.028	<0.001	9.258	0.026	<0.001

B, unstandardized regression coefficient; SE, standard error.

Discussion

The COVID-19 pandemic triggered a sudden transition from in-person to virtual pediatric care, creating a natural experiment for patient experience comparisons. As hybrid models stabilize, understanding how pediatric families perceived telemedicine during this disruption, especially the resilience of the therapeutic alliance and the factors shaping practice-level experience, can help inform delivery strategy.^22,29

During the early COVID rapid-deployment phase, the mean Overall Rating of Provider was statistically higher for telemedicine than for in-person care (9.48 vs. 9.36). However, the absolute difference was small. There is no universally established minimum clinically important difference for HCAHPS or pediatric Patient and Family Experience Survey scores; therefore, this difference is best interpreted as evidence that provider ratings were maintained across modalities rather than as evidence of clinically meaningful modality superiority.

As operations normalized in the stabilization phase, the provider-rating difference was no longer statistically significant. This supports a cautious interpretation: telemedicine appeared capable of preserving clinician-level experience, but the data do not support overstating modality superiority once hybrid workflows mature.

By contrast, unadjusted Recommend Office scores were numerically higher for telemedicine during stabilization but were not statistically significant in the corrected comparison. Because this measure captures practice-level performance beyond the clinician encounter, including access, scheduling, wait times, reliability, and coordination, the finding remains consistent with evidence that mature telehealth operations can improve aspects of care delivery.^27,28,30 However, the nonsignificant adjusted effect on Recommend Office indicates that delivery modality alone did not independently drive recommendation scores.

Our multivariable models showed that telemedicine remained independently and positively associated with Overall Rating of Provider (+0.139) after adjustment, while the adjusted effect on Recommend Office was not significant. Taken together, these findings suggest that the therapeutic alliance may be resilient to modality change, whereas practice-level recommendations depend on a broader operational infrastructure, including front-end communication, technical support, navigation, care coordination, and visit reliability.^27,28

Temporally, early COVID encounters had higher scores than the pre-COVID baseline for both Recommend Office (+0.081) and Overall Rating of Provider (+0.073). This pattern may reflect the distinctive context of early pandemic care, during which families may have valued continuity and access under crisis conditions. However, because this study was observational, these phase effects should not be interpreted as causal.

We also observed a small but statistically significant equity-related gap: non-White families reported lower Recommend Office scores (B = −0.048, p = 0.043). This finding is important because home-based telemedicine can amplify inequities if broadband access, device availability, language support, or digital readiness are insufficient.^22,31,32 Federal analyses similarly show persistent differences in telehealth modality and access, underscoring the need for equity-focused implementation strategies.^22,29

These findings support pre-emptive equity strategies, including digital-readiness screening, language-concordant support, reliable interpreter integration, device or connectivity support when needed, and monitoring of experience outcomes by race, ethnicity, language, and modality. Pediatric guidance also emphasizes embedding telehealth within the medical home and tracking quality and access as part of implementation.^2,23

The positive association between child age and provider ratings may reflect developmental differences in comfort with video-based interaction, although the study design does not allow causal interpretation. Future pediatric telemedicine workflows should account for developmental stage, caregiver role, privacy needs, and visit type when determining which encounters are best suited to virtual care.^24,33

OPERATIONAL AND CLINICAL CONSIDERATIONS FOR FUTURE IMPLEMENTATIONS

From a health-system perspective, these findings suggest that telemedicine can preserve clinician-level experience when supported by reliable workflows and clinician communication practices adapted to the virtual environment. Operational considerations include standardized previsit outreach, minimized virtual queue times, clear next-step communication, contingency plans for technical disruptions, and integration of language services for families who need them.^2,27,28,30

Access equity should remain central to telemedicine design. Programs should anticipate differences in device access, connectivity, language preference, and digital readiness and should monitor whether families experience virtual care differently across demographic groups.^22,31,32

LIMITATIONS

First, as an observational study, residual confounding is possible, including visit reason, acuity, prior relationship with the clinician, and family expectations. Second, modality selection may be endogenous, families choosing telemedicine could differ systematically in expectations, digital readiness, or care needs. Third, survey-mode effects, including email, SMS, and telephone administration, may interact with modality.²⁶ Fourth, the pandemic environment introduced time-varying factors, including policy changes, staffing constraints, community prevalence, and shifting family expectations, that could influence both satisfaction and modality availability.^12,22,29 Finally, although our analysis identified a significant gap for non-White families, we may underestimate disparities tied to language, broadband, or device access because video versus audio data and detailed digital-access variables were not uniformly available.^22,31,32

FUTURE DIRECTIONS

Future work should focus on identifying which components of the pediatric therapeutic alliance, such as caregiver-clinician trust, adolescent privacy, communication clarity, and teach-back, are most sensitive to modality. Additional studies should evaluate equity interventions, including device or connectivity support, embedded interpreter workflows, and digital-readiness screening, using patient and family experience outcomes and utilization metrics as key endpoints.^{22,24,31–33} Continued tracking of hybrid care models is needed to determine whether telemedicine-associated experience benefits persist as visit types, staffing models, and scheduling templates mature.^27,28,30

Authors’ Contributions

J.R.: Study design, data collection, data preparation, statistical analysis, drafting of portions of the article and D.Z.: Study design, statistical analysis design and validation, drafting of portions of the article.

Footnotes

Acknowledgments

The authors thank the data science professionals at Seattle Children’s Hospital who facilitated data extraction and sharing and worked with the authors to make sure that the provided variables were appropriate for the study.

Ethics Considerations

The Institutional Review Board at Seattle Children’s waived the requirement for approval because the study used deidentified data and involved no patient interactions.

Data Availability

The data used for this study are subject to institutional restrictions. Data may be made available upon reasonable request and with appropriate institutional permission.

Disclosure Statement

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The article has not been submitted, published, or presented in any other journal or conference.

Funding Information

The authors received no financial support for the research, authorship, and/or publication of this article.

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