Telemedicine and Neurological Practice in the COVID-19 Era
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.288994
Source of Support: None, Conflict of Interest: None
Keywords: Telehealth and COVID-19, telemedicine and neurosciences, teleneurology and COVID-19
SRS COV 2 is making us look at how neurological services are being delivered now, and how mode of delivery needs to radically change in the AC (After Corona) era. Telemedicine is an all-encompassing term, which includes the deployment of customized hardware and software, peripheral medical devices and a wide spectrum of telecommunication technologies. Using these, history can be taken, patients can be physically examined, investigations reviewed, and a provisional or final diagnosis made with the consultant and the patient physically separated. Distance has become meaningless. In fact, geography has become history! Synchronous real time telephone or video consults or asynchronous store and forward digital services can be used. The latter includes text messages, WhatsApp communication and email. Remote monitoring of patient data could include visualizing images, neuro physiological parameters and even surgical mentoring in the operation theatre.,,,,,,,,,
The COVID-19 outbreak has necessitated an immediate digital revolution. As recently as 2019 in a Price Waterhouse Cooper survey, 38% of chief executive officers of U.S. health care systems conceded that there was no digital component in their strategy. Telemedicine has existed for decades, but widespread implementation has not been forthcoming. The rapid use of Telemedicine has been an inadvertent fall out of COVID-19. Within a eight week time period, many institutions in the USA have adopted telemedicine due to dire necessity and relaxation of prior stringent regulations. Telehealth Coverage Policies in the time of COVID-19 have been modified. Interim rules have been issued.
A “telecommunications system” for telehealth services implies multimedia communications equipment. This includes, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician. A unique advantage of Telemedicine is that in the COVID-19 situation even quarantined doctors, whose numbers are steadily increasing worldwide, can continue to provide teleconsultations. Licensure requirements have been temporarily waived for Medicaid. Resources and telemedicine references have been created by professional societies like the American Academy of Neurology and American Association for Neuromuscular and Electrodiagnostic Medicine. Neurologists and neurosurgeons are quickly acquiring new tools and skills required to practice Remote Health Care. New clinical algorithms and robust telemedicine platforms and procedures will have to be developed for continued patient care.
The use of remote services has escalated from a slow rollout to a “need it now” priority. In the USA, the Centers for Medicare & Medicaid Services [CMS], state Medicaid, and state health agencies have now ensured that doctors are reimbursed for non–face-to-face services. In India, insurance companies are being requested to do likewise. The American Academy of Neurology also has a Telemedicine and Remote Care resources page (aan.com/telehealth) and a general resource center for all information related to COVID-19 (aan.com/COVID19. In the USA, a centralized licensing system has already been implemented. The recently notified Telemedicine Practice Guidelines of the Ministry of Health Govt. of India is causing an exponential increase in the use of Telemedicine in India. The author has personally given many webinars demystifying the Telemedicine Practice Guidelines. One of them was attended by 12,842 physicians and cardiologists. A webinar was also given to the members of the Neurological Society of India. During the last few weeks, the number of webinars in neurosciences originating from India itself has been increasing.
Many small medical practices and community hospitals need to quickly establish telehealth services to obtain neuro consults. Rising to the challenge, the American Telemedicine Association (ATA) is offering pro bono a Quick-Start Guide to Telehealth. Topics covered include: a) Technology, b) Clinical, c) Financial, d) Communication, e) Metrics after the COVID-19 Pandemic. Cardinale, while reviewing the current state of telemedicine in neurological healthcare, highlights evidence-based research and use cases for digital services. It has even been suggested that in-person visits should become an option! However, no telemedicine program can be created overnight. Existing telemedicine units can leverage them for response to Covid-19. Telemedicine can provide rapid access to subspecialists normally not available. Jefferson Health, Cleveland Clinic, and the University of Pittsburgh are examples of institutions providing virtual emergency neurologic care at other hospitals. The Mount Sinai system uses specialists at 8 hospitals to provide tele emergency consultations to 300 sites. Difficulties in implementing these programs are largely related to credentialing, staffing of specialists and payment. Attention to regulations, licensing, credentialing across hospitals, and program implementation take time. The author in 2016 reported on the operational challenges of setting up a multi-speciality telemedicine network in the Himalayas at a height of 14,000 feet in temperatures of -25C. In the last 5 years, 143 teleconsultations in Neurology and Neurosurgery have been given in these mountainous areas, including emergencies.
Teleneurology is a powerful and innovative way to provide neurology in deprived areas. Challenges in deploying teleneurology include cost, insufficient expertise to implement necessary technology, compliance and adherence with regulatory issues and fear of litigations. Tele neurology has demonstrated high patient satisfaction and even cost savings. Virtual neurological expertise can now be made available to rural areas reducing travel costs. In the USA billing is based on face-to-face video or phone interaction time with the patient.
Govindarajan et al. stress that comprehensive training in clinical bedside neurology is necessary to safely practice teleneurology. The American Academy of Neurology Telemedicine Work Group has developed a model curriculum including evaluation tools. Neurology residents normally receive little to no formal training in telemedicine. Afshari et al. showed that a formal didactic and clinic-based teleneurology curriculum was useful. Statistically significant improvement in knowledge and perspectives, about the promise and limitations of teleneurology practice was demonstrated. Telemedicine requires close interaction between doctor and patient, body language communication strategies, appropriate documentation and time management. Some consultants may be more comfortable with direct physical interaction. Laws, regulations, payment policies and workflow are needed to establish a telemedicine unit. Staff needs to support scheduling. IT needs to integrate electronic medical records with telehealth applications Doctors and patients need to connect with each another seamlessly using the telehealth platform. Billing, prior authorizations, managerial supervision and e prescribing modalities need to be addressed. Student and resident education needs to be reconfigured. Stakeholders in the eco system particularly doctors, administrators, hospitals, and networks need to benefit by developing economically viable telehealth models.
Illustrations of specialised teleneurology units
Telemedicine use is expanding across a wide variety of neurologic disorders.Tele stroke: Maximum work and publications is in the area of tele stroke.,,, Legal and regulatory barriers impeding Telestroke adoption or delivery are being identified. It has been established that Telestroke is providing an effective solution for small and under resourced hospitals. With the onset of COVID-19, telestroke services are being further expanded to reduce or avoid physical visits. Lack of stroke specialists, has resulted in many European rural areas remaining underserved. There is increasing use of evidence-based therapy enabling coverage of large areas of low population density. Telemedicine in stroke care has shown to be safe. Quality improvement is being ensured by standardising stroke treatment throughout a telestroke network. Intensive training and obtaining feedback and follow up is critical. Outcomes after intravenous tissue plasminogen activator treatment via telemedicine are similar to those achieved with in-person evaluations. Amyotrophic Lateral Sclerosis (ALS). Remote multidisciplinary care of ALS patients has been reported as feasible and acceptable to patients and doctors. A trained telemedicine nurse makes a house visit and performs and records a multidisciplinary assessment of the patient. Consultants review assessments and advise through videoconferencing.Movement Disorders – Remote clinical evaluation has been shown to be feasible in hyperkinetic movement disorders. Cognitive testing, genetic counselling and other counselling-based therapeutic interventions have also been used.Polyneuropathy Tele-polyneuropathy clinics are operational. In this pilot, Wilson et al. demonstrated that guideline concordant poly neuropathy care can be remotely provided with high levels of satisfaction.Tele rehabilitation using virtual reality has been used to reduce healthcare costs and encourage continuity of care. Effectiveness of tele rehabilitation for the treatment of cognitive disorders following stroke have been documented.Head Injuries. The author has personally given teleconsultations for more than 2000 patients in the last 20 years. More than 90% were follow-up or post-operative. Telemedicine has been successfully deployed in the initial management of acute minor head trauma. Patients with head injury have been managed in non-neurosurgical centres in Johor state using tele consults from neurosurgeons.General Neurology - From India, Gowda et al. demonstrated successful implementation of outpatient-based collaborative teleneurology consultation in Karnataka in 189 patients, having various clinical conditions. The Tele-Medicine Centre at National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore has started providing teleneurology services from 2010 to all district hospitals of Karnataka in collaboration with Department of Health and Family Welfare, Government of Karnataka through Karnataka State Wide Area Network (KSWAN).eNeuro Intensive Care: Electronic Intensive Care Unit (e-ICU) monitoring programs, which allow nurses and physicians to remotely monitor the status of 60 to 100 patients in ICUs in multiple hospitals also involve neuro intensivists. eICU services for neurological patients have been available in India from 2016 onwards. From Aug 2018 to Feb 2020, the Apollo eACCESS TeleICU has done 53 inpatient acute neurology and neurosurgery consultations out of a total 409 teleconsultations for acute issues in patients in various ICU's distributed all over India. From 2016-2019 of the 3070 ICU patients seen 10.9% had a diagnosis of stroke.
Teleneurology services during COVID-19 lockdown
Patients with neurological diseases and those immunocompromised are at higher risk of complications when infected by the Corona virus. To reduce risks due to physical contact, Telemedicine is particularly relevant. Many electronic medical record systems have virtual encounter functions. They have traditionally been underutilized. The Medical University of South Carolina employs virtual rounding. Medical record pre-rounding is completed remotely by all team members. A rich medical education experience for trainees is maintained through virtual “table rounds” and academic discussions using teleconferencing platforms. Only one team member will be “in-house” to move the workstation on wheels and to perform neurological exams.
Sun in an editorial from China points out that since the COVID-19 pandemic most pre and postoperative neurosurgical visits were conducted virtually. According to “Neurosurgery News,” a national continuing education platform for neurosurgeons, 40 national online outpatient question-and-answer sessions and 39 cloud seminars had been hosted in just 4 weeks. 5G technology was used in a few. Virtual visits and online seminars attracted more than 280,000 patients and 1000 neurosurgical professionals. Reports from Jordan revealed that patients with chronic neurologic diseases were able to reach consultants and residents by telephone. Texting and chatting through WhatsApp was also used. Physical visits to the Emergency Department was only if Telemedicine could not be deployed. Patients with multiple sclerosis and myasthenia gravis on immunomodulatory medications, those on warfarin and antiepileptics were advised telephonically. Consultants were available remotely to answer questions from patients or from in-hospital staff, and to help with reading EEGs. WhatsApp was used to send material for residents to read. E-learning apps like Zoom and Microsoft Teams were used by consultants to participate in lectures and meetings. Private pharmacies in Jordan responded to online and phone ordering and a home delivery system, approved by the government. However, a regular Telemedicine system was not available.
As patients with suspected COVID-19 could present with acute stroke, a telestroke unit was initially established at Utah USA, to enable remote evaluation. Training and access to technology platforms was provided. The telestroke unit was subsequently expanded to include virtual evaluation of seizures, multiple sclerosis and other conditions. The authors point out that institutions with telemedicine capabilities have started virtual “rounding” with no patient contact. Rounding “styles” will continue to evolve. Solutions will be different for different hospital systems depending on neurologic disease complexity and levels of COVID-19 prevalence. Remote evaluation could well be the new normal during the pandemic with additional long-distance support. American Academy of Neurology has developed guidelines for clinicians and practices for implementing telemedicine services during the Public Health Emergency. Potential HIPAA penalties are being waived for good faith use of telemedicine. FaceTime and Skype can now be used though a HIPAA compliant platform is recommended to avoid complications after the emergency has ended.,
Many Multiple Sclerosis centres are utilising telemedicine to avoid non-essential hospital visits during the COVID-19 pandemic. High patient acceptability has been found. Remote monitoring of infection risk, in people with multiple sclerosis, especially those on immunosuppressant drugs, during COVID-19 pandemic is essential. A digital triage tool, easily setup using Google Forms, was sent to patients to quickly identify people with high risk of COVID-19 infection. Reducing physical visits to MS centres reduced risk of infection spreading. A low-cost, in-home, telemedicine-enabled assessment of disability in multiple sclerosis specially designed for the lockdown period has been used. The American Academy of Neurology has made available a “Telemedicine and Remote Care Implementation Guide”, that discusses most common forms of non–face-to-face care and coding elements necessary to provide these services. 30 patients with amyotrophic lateral sclerosis were called for a teleconsult in Italy, when the COVID-19 infection was at its peak. For many, the video consult broke the isolation. Kondziolka, in a recent communication, points out that with the COVID-19 pandemic, most conferences of organized neurosurgical associations and societies worldwide have been cancelled or postponed. International and national flights have been banned temporarily in most countries. Self-isolation and social distancing has become the norm. This translates into a reduction in operative experience and formal in-person resident training.
After doing virtual visits for several weeks, a neurologist is said to have remarked, “Isn't this the way it always ought to be?” This comment eloquently summarizes the possible future direction of neurological practice. The AC (After Corona) era will never be the same again. The impact of telemedicine is unlikely to recede. Telemedicine capabilities are likely to be embedded within normal operations, scalable, interoperable and built on a strong, reliable infrastructure, so that it is useful even after the acute COVID-19 crisis resolves. The global pandemic will have a lasting effect. As medical and surgical neurological specialists belonging to the cream of the cream of society, it is imperative that we embrace and adopt cost effective, need based, appropriate technology to extend our now limited reach. As a senior citizen trained in the BC (Before Computers – not Before Corona) era, I believe that technology is only an enabler to achieve an end and not an end in itself. It is still possible to deliver TLC (tender, loving care) virtually and empathize with the patient on a screen (small or big). We need to move with the times. To paraphrase Charles Darwin, “It is not the strongest of the species that survives, not the most intelligent, but the one most adaptable to change”. The writing is on the wall.
The author is thankful to Ms. Lakshmi for secretarial assistance.
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Conflicts of interest
There are no conflicts of interest.