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

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.