Telemedicine in pediatrics: Lessons learned, best practices, and the changing policy landscape

Telehealth is defined as the provision of health care services via remote technologies rather than through in-person encounters.¹ As an umbrella term, telehealth encompasses synchronous video visits, audio-only encounters, and asynchronous communication through secure messaging platforms and integrated patient portals. In the United States, adoption of telemedicine was gradual prior to 2020; however, the COVID-19 pandemic precipitated an unprecedented expansion.² Pediatric practices and health systems adopted telehealth almost overnight to maintain continuity of care while minimizing the risk of SARS-CoV-2 transmission. In September 2021, the American Academy of Pediatrics (AAP) released its policy statement “Improving Access to and Quality of Pediatric Health Care”, calling for equitable telehealth access, payment reform, and integration of telehealth within the pediatric medical home.¹ The AAP’s Section on Telehealth Care and related guidance documents, including Pediatric Telehealth Best Practices, were subsequently developed to support sustainable and high-quality implementation nationwide.³ As patient and family demand persists beyond the pandemic, optimal use of telehealth now requires careful attention to quality, confidentiality, equity, and evolving policy frameworks.

Telehealth utilization in medicine

Post-pandemic data demonstrate that telehealth utilization remains substantially higher than pre-2020 levels.⁴ Pediatricians frequently use video visits for follow-up of chronic conditions such as attention-deficit/hyperactivity disorder (ADHD), asthma, anxiety, and depression, as well as for selected acute complaints. Behavioral health integration has emerged as one of telehealth’s most impactful applications, with virtual therapy and counseling improving engagement, comfort, and continuity of care for children and adolescents.^5,6 Multiple studies have demonstrated improved access for families in rural and underserved areas, while urban families benefit from reduced travel time, fewer missed workdays, and increased scheduling flexibility.^7,8

Telehealth has a unique potential to mitigate the impact of social determinants of health by addressing barriers related to transportation, geography, and caregiver work constraints. Virtual care has expanded access to pediatric subspecialty services in rural and low-income urban communities and supports care coordination for children with complex needs.^9-13 Programs leveraging telehealth for asthma management and school-based mental health services have demonstrated reductions in emergency utilization and improved screening access for at-risk youth.

The Changing landscape of telehealth: Coding, coverage, and policy shifts

Pandemic-era emergency waivers were given for coverage of audio-only visits, cross-state licensure flexibility, and payment parity for telehealth services to continue care for patients in the face of adversity.^14,15 According to Fall 2025 updates from the Center for Connected Health Policy (CCHP), many states reimburse multiple telehealth modalities under Medicaid—including live video, audio-only, store-and-forward, and remote patient monitoring (RPM).^16-18 Forty states plus Washington, D.C., cover all 4 key telehealth types, though limitations may apply. Several states have expanded telehealth under Medicaid to include behavioral and developmental services that are highly relevant to pediatrics:^16,18 For example, New Mexico increased coverage of evidence-based therapies (DBT, EMDR, FFT, TF-CBT) via telehealth, including services that support pediatric behavioral health. Arkansas clarified that autism and Applied Behavior Analysis (ABA) services can be delivered via telehealth in specific circumstances under Medicaid manuals, supporting care continuity for children with autism. While most states have eliminated stringent geographic restrictions, a few states maintain limited constraints, such as Hawaii and Maryland, still have legacy geographic restrictions in administrative codes that can affect eligibility for some telehealth services, although these may be outdated or in conflict with broader telehealth expansion goals. Telehealth policy in the United States remains largely state-driven. However, half a decade from the pandemic, we are seeing many waivers sunset, and pediatricians are now facing a rapidly changing reimbursement landscape. Medicaid programs differ in covered modalities, eligible providers, and reimbursable services. State-specific manuals and telehealth policy trackers are essential tools for pediatric practices navigating reimbursement and compliance. Ongoing updates from the AAP and federal agencies emphasize the need for pediatric-specific telehealth coding guidance, including appropriate use of evaluation and management (E/M) codes, modifiers, and place-of-service designations.^14,15 Continued advocacy is necessary to ensure that reimbursement structures align with clinical realities and equity goals. Table 1 consolidates practical resources for pediatricians navigating this changing landscape.

Best practices for pediatric telehealth

High-quality pediatric telehealth going forward will require standardized, intentional implementation:^12,13

• Complementary Care Model – Telehealth should augment, not replace, in-person visits and remain integrated within the patient’s medical home.
• Continuity and Coordination – Clear communication between virtual and in-person providers is essential to maintain longitudinal care.
• Confidentiality Protections – Private time for adolescents, clear explanations of confidentiality limits, and secure platforms are critical.
• Assessment and Escalation Protocols – Standardized criteria for escalation to in-person care (e.g., respiratory distress, high fever, suicidal ideation) should be embedded into workflows.
• Comprehensive Documentation – Documentation should include visit modality, participants, consent, privacy safeguards, and technical limitations.
• Workflow Optimization – Designation of telehealth champions, staff training, and continuous quality improvement support sustainability and patient satisfaction.

Future challenges: AI integration and ethical considerations

Within telehealth, AI-driven decision-support systems have been shown to aid triage, identify red flags, and assist in differential diagnosis. The AAP’s Artificial Intelligence in Pediatric Health Care statement recognizes the growing role of AI in optimizing care and safety. ¹⁹ In practice today, clinicians are using AI-enabled stethoscopes for detecting murmurs. Another example of AI-assisted telehealth documentation through natural language processing (NLP) has been shown to extract unstructured data, perform classification and analysis to transform patient care by indicating health risks and progress of patients to better manage care. For example, a patient with asthma can be classified into the correct category and stratified for risk and likelihood of exacerbation given the current regimen, thereby reducing provider documentation burden to allow more focus on direct patient care. Future integration of remote patient monitoring (RPM) devices into AI algorithms could generate real-time alerts, improving outcomes for chronic disease management.

As AI tools make decisions on data they are trained on, limitations can occur depending on whether pediatric validation occurred in these data sets. Systems used without oversight have the potential to exacerbate existing disparities if trained on non-representative datasets. Privacy and data security must be rigorously protected, particularly when handling pediatric behavioral or genetic information. Transparency regarding how AI tools process and interpret data, potential biases, and model limitations must be established.¹⁹ Investing in and developing safeguards against algorithmic bias to ensure equitable, transparent, and accountable AI use becomes our moral and ethical responsibility.¹⁹

Conclusion

Telehealth in pediatrics has evolved from a pandemic necessity into a foundational component of modern pediatric care. When aligned with quality improvement, technological innovation, and equity-centered policy, telehealth can sustainably expand access and improve outcomes for children and families. Ongoing AAP policy updates and coding guidance continue to play a central role in supporting pediatricians nationwide. Collaboration among pediatric organizations, payers, and policymakers is essential to align policy with equity-centered care delivery. Investments in broadband infrastructure, device access, and workforce training are critical. With clinicians remaining as the central decision-makers, using AI as a supplement rather than a replacement for judgment is essential for its long-term sustainability.

References

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15. American Academy of Pediatrics. Coding for telehealth services. AAP Telehealth Resources. Updated 2024.
16. Center for Connected Health Policy. State Telehealth Laws and Reimbursement Policies Report, Fall 2025. CCHP; October 27, 2025. Updated summary of state telehealth laws and Medicaid telehealth reimbursement policies. Accessed January 2026.
17. Centers for Medicare & Medicaid Services. Medicaid & CHIP Telehealth Toolkit. Medicaid.gov; February 2024. Comprehensive guidance on telehealth policy, coverage, and implementation across state Medicaid and CHIP programs. Accessed January 2026.
18. U.S. Department of Health and Human Services, Office for the Advancement of Telehealth. State Medicaid Telehealth Coverage. Telehealth.HHS.gov; updated data on Medicaid telehealth reimbursement and policy. Accessed January 2026. https://telehealth.hhs.gov/providers/billing-and-reimbursement/state-medicaid-telehealth-coverage
19. American Academy of Pediatrics. Artificial intelligence in pediatric health care. Pediatrics. 2024. https://www.aap.org/en/practice-management/health-information-technology/artificial-intelligence-in-pediatric-health-care/?srsltid=AfmBOoqPPcFh2XaMIFbX0SwqTJ3cL79hwdR44CXVROlaPFcRhsv3Vxek