Observations in a Virtual Telephone and WhatsApp Video-Enabled Neurology Clinic During Lockdown in Varanasi, India – A Preliminary Report
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.329546
Source of Support: None, Conflict of Interest: None
Keywords: COVID-19, lockdown, smartphone, teleneurology, WhatsApp
The COVID-19 pandemic has forced countries to proceed with lockdown as one of the important steps in facilitating social isolation and breaking the chain of viral transmission. Although the lockdown curtailed the infection rate in most countries including India, it also came up with a number of difficulties in day-to-day life. Health care of nonemergency non-COVID-19 patients was one of them. New as well as follow-up patients had difficulty in accessing the medical services. The hindrances were lack of public transport, restriction of travel by private transport, fear in patients as well as health care workers of contracting the COVID-19 infection, stopping of outpatient services, and admission of emergency cases only by medical centers. Indian population is one of the leading digital telecom users, with more than 1,198 million users. Hence, the government with the help of the policymakers initiated teleconsultation facilities for follow-up for nonserious new patients in various institutes including ours. The literal meaning of “telemedicine” is “to heal at distance.” It was used as a tool for health care delivery in addition to other activities such as medical education, health surveillance, disaster management, and public health promotions. Its potential role in disaster and health emergencies are well described. It has been used in India even before this pandemic as a medical education tool among multiple centers by sharing recent and updated information, case discussion, providing an opportunity for a second opinion, modifying the treatment decisions, acute stroke and neurotrauma management, and neurorehabilitation.,,,, The present study aimed to evaluate the efficacy and acceptability of teleconsultation as an option for in-person consultation in providing continued medical care for neurology patients during the national lockdown due to the COVID-19 pandemic.
Teleconsultation service was started on April 13, 2020, at S.S.H., I.M.S., BHU, Varanasi, India, in place of regular OPD schedule that was canceled due to the national lockdown because of the COVID-19 pandemic. The present study was conducted in the teleneurology OPD. Ethical clearance was obtained from the Institutional Ethics Committee (2020/EC/1996). Information regarding the availability of teleconsultation services was spread among the adjoining neighboring districts and states via newspaper, WhatsApp, and Twitter. Social media enabled the accessibility of teleconsultation services much easier for patients in remote areas. The consultants of different specialties and superspecialties were provided with a smartphone. A particular contact number was designated for each department. Each contact number with the name of the doctors was displayed in the print media on a daily basis. A consultant along with a senior resident, with less than 3 years of DM (Doctorate of Medicine) Neurology training, attended the tele-OPD at the designated teleconsultation facilities. In the teleneurology OPD, the consultants followed the same roster as that of the regular OPD to help the follow-up patients in contacting their treating physicians. The timing of the consultation was from 9 a.m. to 5 p.m. The consultations were accorded as per the guidelines of the Ministry of Health and Family Welfare. Information such as demographic details, types and duration of illness, provisional diagnosis, treatment details, any new or aggravation of the previous symptoms, prescribed treatment, satisfaction rate, and further follow-up were asked verbally to the patient/family members and the responses were noted in a prespecified format [Table 1] and later entered in an Excel worksheet. The clinical and treatment details were enquired from the family members for patients with cognitive decline, neurodegenerative disease, stroke, and neuroinfection. As the smartphone was enabled with 4G internet facility, it helped patients/family members to transfer their relevant documents such as previous prescriptions, investigations reports, neuroimages and its reports, as well as videos of the patients in certain cases. The revised treatment details were communicated to the patients via text message and WhatsApp. The telephonic and WhatsApp conversations were done in Hindi and English language only. A relative/family member knowing either of these two languages acted as a translator for patients knowing neither Hindi nor English. Patients with critical illnesses were advised to visit the emergency department that was operating 24 × 7 and were admitted to the neurology ward as per standard protocols, after testing negative for COVID-19.
We analyzed the initial 90 days data of the TNCO OPD. The total number of patients who attended the TNCO was 1,567. The average patient attendance including new and follow-up cases was 35 per day. Out of these, 77% telephonic calls were from the Varanasi district, and the rest from the adjoining districts and states such as Bihar, Jharkhand, Madhya Pradesh, West Bengal, and Assam, and from countries such as Nepal. A total of 502 (32%) were new patients who either contacted us first or were referred by or unable to contact their previous treating consultants of other institutes or hospitals. The average duration of consultation was around 8 to 10 minutes for follow-up patients, whereas for the new patients, it was around 15 minutes.
Out of the 1,567 patients, 72% were males. The median (interquartile range) age of the patients was 42 (18–58) years. About 60% of the patients were from rural areas. Five hundred and two (32%) patients were new, whereas 1,065 (68%) were follow-up cases. Out of the 1,065 follow-up patients, 361 (23%) were follow-up cases with new symptoms. The most common mode of communication used was telephonic conversation using WhatsApp (84%) followed by telephonic conversation only (12%). Very few patients (2%) took consultation via text message due to the nonavailability of smartphones. Two hundred and eleven (13%) patients with critical illnesses were advised to visit the emergency department and to get admission in the neurology ward after testing negative for COVID-19. Around 87% of patients were advised to review in person later considering the nonseriousness of the illness [Table 2]. The patients seeking teleconsultation most commonly had epilepsy (19%) followed by low backache and stroke (18% each), headache (13%), and neck pain (12%) [Table 3]. All psychogenic nonepileptic seizure (PNES; n = 6) cases were diagnosed via WhatsApp videos of the ictal event sent by the relatives revealing the characteristics features of PNES. The diagnosis of PNES was based on a definite set of criteria. All had normal electroencephalographic recordings. Such patients were also advised to take the consultation of the psychiatry department. WhatsApp videos were also helpful in confirming the diagnosis of a few epilepsy (n = 11) and Parkinson's disease (n = 7) cases. A total of 1,002 (64%) patients sent their investigations, of which 890 (89%) were on WhatsApp and 112 (11%) patients communicated it verbally on telephonic conversation. Among the 224 shared radiological images, 60 images were related to stroke, 45 to low backache cases, 35 to epilepsy cases, 32 to headache patients, 30 to cervical pain cases, 14 to meningitis patients, six to intracranial space-occupying lesion (ICSOL) cases, and two to multiple sclerosis patients [Table 2], [Figure 1]. A total of 770 (49%) patients were advised to continue the same treatment after evaluation, whereas the treatment was modified in 347 (22%) cases. About 90% (n = 1,411) felt satisfied with the treatment advice via teleconsultation. The reasons mentioned were saving of travel time, saving of travel expenditure, avoidance of long queues and discomfort at the outpatient clinic. However, the remaining 10% (n = 156) patients were of the opinion to visit the consultant in person because they found it difficult to communicate the symptoms and treatment details telephonically.
Telecommunication has been a boon for chronic and disabled neurological patients by providing neurological expertise in a cost-effective manner. In the past, telemedicine had been used effectively in different nations in managing neurological patients of various categories such as acute stroke, movement disorders, headache, dementia, multiple sclerosis, and epilepsy.,,,,,,,, In developing countries like India, the telemedicine facilities with a proper infrastructure were limited to few centers only. However, it remained constantly a medium of case discussion, clinicopathological meetings, webinars, lectures, workshops, and teleconsultation OPDs at these centers.
The S.S.H., I.M.S., B.H.U. also started the tele-OPD like other health care centers in a well-planned manner to meet the needs of the non-COVID-19 patients. We used smartphones with WhatsApp as the medium of communication because patients belonging to remote areas with poor resources might not have access to other advanced and technically demanding applications such as Skype, Zoom, or Webex.
In the TNCO OPD, the patient attendance per day was much lower (n = 35) as compared with our routine general neurology consultation OPD (n = 170). Out of all the 1,567 patients, 77% were from the Varanasi district only. The reasons for the low attendance and the majority of consultations being from the native district may be poor socioeconomic status and the lack of knowledge of such consultations in remote districts and adjacent states because of the display of information in the local print media.
The commonest types of illness seen in the TNCO OPD were epilepsy, stroke, low backache, and headache. Epilepsy patients comprised 19% of total patients. The different subgroups were generalized tonic–clonic seizure, focal seizures, and focal with bilateral tonic–clonic seizures. A total of 42 (14%) patients had a recurrence of seizures. They were advised to get admitted in the nearest health care facility for treatment. History of drug default, unhealthy lifestyle, and ignorance of the precipitating factors were important causes of breakthrough seizures. In a study including 465 patients of epilepsy, author observed that telecommunication was more cost-effective, had a higher satisfaction rate, and a lesser loss to follow-up without any significant difference in breakthrough seizure events than face-to-face clinical management. Similarly, Rasmusson and Hartshorn also reported nonsignificant differences between telemedicine and in-person clinic regarding the occurrence of seizure episodes, number of emergency visits, and medication compliance.
Stroke patients (both ischemic and hemorrhagic) also took the benefits of telecommunication. Acute stroke cases were advised for urgent neuroimaging. Those who had their magnetic resonance imaging (MRI)/computed tomography (CT) images were asked to send the pictures on WhatsApp. Acute stroke (ischemic/hemorrhagic) patients were admitted after ruling out for COVID-19. The patients belonging to distant places were advised admission to a nearby hospital. The follow-up cases (72%) contacted us for poststroke complications such as spasticity, poststroke pain, depression, complex regional pain syndrome, review of the investigations, as well as ongoing medications related to etiology and associated comorbidities. Studies have shown that the treatment rates with intravenous (IV) tissue plasminogen activator (tPA) increased significantly with the application of telestroke at the peripheral level, and the outcomes were similar to patients who were treated in-person.,,, Telestroke avoids the unnecessary transportation delays leading to earlier administration of IV tPA and a greater probability of good outcomes. However, at our center, none of the ischemic cases were thrombolyzed because all came after a window period.
The patients with symptoms suggestive of peripheral neuropathy (6%) were enquired in detail. Details of the onset, duration, progression, positive and negative symptoms, symmetry, associated comorbidities, and drug intake history were noted, and the patients were advised to take relevant investigations. Those having the images of electrodiagnostic studies were analyzed, whereas patients without these were advised to get an appointment from the neurophysiology lab. The advised investigations were reviewed on the next TNCO visit. After a final diagnosis, appropriate treatment was started.
Out of the 1,567 patients, 209 (13%) had headaches encompassing different spectrums such as episodic migraine, chronic migraine (CM), and tension-type headache (TTH). A substantial proportion of the patients were diagnosed with episodic migraine (n = 50) and TTH (n = 14) during the tele-OPD. The stress, anxiety, and fear due to the COVID-19 pandemic may be the possible reasons. In a randomized trial of telemedicine efficacy and safety for nonacute headaches, Müller et al. also reported that telemedicine consultation was as efficient and safe as a traditional consultation by showing nonsignificant differences in disability assessment using headache questionnaires between the two groups.
A total of 14 multiple sclerosis (MS) patients used the teleconsultation services, and two were diagnosed based on the available clinical history, examination findings, and laboratory investigations. Robb et al. also mentioned telemedicine facility as a cost-effective and time-saving one in 36 MS patients. About 97% of patients were of the opinion to recommend telemedicine visits to others, and 94% found it easy to communicate with their respective physicians.
We encountered dementia patients, who were only 3% of the total cases. The new cases were evaluated in various domains such as memory, language, attention, executive function, and visuospatial ability. The routine blood investigations and cranial imaging were reviewed on smartphones. In a study of 188 patients with dementia, 98 were followed up via telemedicine services, and the rest attended the dementia clinic in person. Changes in the mean annualized Mini-Mental State Examination score were not significantly different between the two groups indicating that telemedicine can be a useful alternative to in-person visits for the management of dementia patients in remote areas.
The merits of telecommunication are many. The safety of health care workers, patients, and their family members is the biggest advantage during the COVID-19 pandemic. Telecommunication reduced unnecessary in-person encounters and chances of COVID-19 spread. To advise for the lifestyle modifications such as regular exercise, adequate sleep, and healthy dietary habit in a prescribed format was much easier via the smartphones in our study. Telecommunication is also cost-effective in terms of saving a lot on travel expenditure, daily wages, travel time, and work absenteeism. Among the various categories, patients with chronic neurological disorders such as movement disorders, MS, epilepsy, dementia, and headache can get the maximum benefit as they visit many times for treatment revision and with minor symptoms. A study reported on the effective telestroke consultation using tablets and smartphones with adequate results. Considering these advantages, other applications such as Skype, Zoom, and Webex can also be used in the future as a means of telecommunication, provided the users are well acquainted with such programs.
Various applications such as the use of smartphone tools, programs that improve medication adherence, electronic diaries for seizures/migraine, body-worn sensors to monitor falls in Parkinson's disease, “smart home” installation with activities of daily living assistance, and robotic technologies to enhance remote physical exams are under investigation for their use in selected circumstances.,,
Although we tried to give the best possible advice after viewing the diagnostic images on the smartphone, poor visibility of the snapshots of the radiological images in the majority of patients was one of the major limitations in TNCO. The images were taken by the patients/family members against a natural background and were contributory to some extent in confirming the diagnosis in cases of intracerebral hemorrhage, large infarcts, ICSOL, and herniated disc. With these images, to diagnose cases of lacunar stroke, meningitis, malformations of the brain, neurodegenerative diseases, and MS with certainty was impossible. However, the radiologist's written reports sent via smartphones solved the issue to a great extent. Similar to other studies, the inability to perform some aspects of neurological examination as well as the neurophysiological tests was also a demerit. Furthermore, patients belonging to poor socioeconomic classes with unaffordability for smartphones might have been also benefitted less. There is also variability in patients' ability to operate their mobile phones despite adequate training. This can interfere with the evaluation by a clinician in a timely manner. Patients with cognitive dysfunction and visual or hearing impairments who do not have suitable caretakers may not get effective consultation advice. The queries of the patients and relatives that would have been easily answered face to face were also quite time-consuming while typing as simple text message or WhatsApp text message. The other factors in our effective telecommunication setup were poor internet connectivity at some remote places, lack of a proper electronic medical record system, requirement of a telepresenter, and dearth of proper telemedicine infrastructure at the peripheral level, which are indeed part and parcel of more effective telecommunication. Similar to other studies, a significant disparity was also observed between the neurologist's need and availability of neurological care in the rural areas., In-person consultation usually does not have these physical, social, language, and economic barriers.
However, once the lockdown gets over, the world will never be the same again. The impact of the telemedicine services will continue, as this is the need of the hour. It is cost-effective, need-based, and uses technology that is accessible by all. It can also be used as a medical education platform for resident teaching via webinars and continuing medical education apart from virtual medical expertise for patient care, which will be the same as an in-person consultation. Patient listening to the clinical history with a sharp clinical acumen will be the key in the further evolution of the role of teleconsultation services.
Hence, parallel tele-OPD with routine OPD is a good option in the future. It will particularly help in the management of follow-up patients visiting without any new complaints, and treatment can be modified after assessment of the disability. In addition, assigning specialty clinics on a particular day will make the follow-up much more streamlined.
Although teleneurology cannot replace in-person communication, it seems as effective as the latter in different neurological conditions. In the present situation of the national lockdown due to the COVID-19 pandemic, it has a pivotal role in preventing the patients as well as health care workers from unnecessary exposure and reducing the cost of health care. The COVID-19 pandemic has provided us an opportunity to build a good infrastructure of telecommunication at both the central and peripheral levels, which will save time and unnecessary expenditure of the patients as well as reduce the case burden in the higher centers.
We acknowledge all our patients for giving their consent and participating in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
[Table 1], [Table 2], [Table 3]