Telemedicine and neurosciences

The Utility of Remote Video Technology in Continuing Neurosurgical Care in the COVID-19 Era: Reflections from the Past Year

Objective

In 2020, the coronavirus disease 2019 (COVID-19) pandemic exposed existing stressors in the neurosurgical care infrastructure in the United States. We aimed to detail innovative technologic solutions inspired by the pandemic-related restrictions that augmented neurosurgical education and care delivery.

Methods

Several digital health and audiovisual innovations were implemented, including use of remote video technology to facilitate inpatient consultations and outpatient ambulatory virtual visits, optimize regional hospital neurosurgical coverage, expand interdisciplinary patient management conferences (i.e., tumor board), and further enhance the neurosurgical resident education program. Enterprise patient experience data were queried to evaluate patient satisfaction following the switch to virtual visits.

Results

Between January 2020 and April 2021, use of virtual visits more than doubled in the Department of Neurosurgery. A survey of 10,772 patients following ambulatory visits showed that virtual visits were equal if not better in providing satisfactory patient care than in-person visits. After switching our interdisciplinary spine tumor board to a virtual meeting, we increased surgeon participation and attendance by 49.29%. Integration of remote audiovisual technology in resident didactics and clinical training improved our ability to provide comprehensive and personalized educational experiences our trainees.

Conclusions

Digital health technology has improved neurosurgical care and comprehensive training at our institution. Investment in the technologic infrastructure required for these remote audiovisual services during the COVID-19 pandemic will facilitate the expansion of neurosurgical care provision for patients across the United States in the future. Governing bodies within organized neurosurgery should advocate for the continued financial and licensing support of these service on a national fiscal and policy level.

Video teleconsultation services for persons with epilepsy during COVID-19 pandemic: An exploratory study from public tertiary care hospital in Southern India on feasibility, satisfaction, and effectiveness

PURPOSE

During the COVID-19 pandemic, there is a large unmet need for follow-up services, particularly for chronic diseases such as epilepsy. Alternative methods to reach these people have become necessary. We assessed the feasibility, satisfaction, and effectiveness of video teleconsultation using mobile phones for managing persons with epilepsy (PWEs) on follow-up at a tertiary care center in the southern part of India.

PATIENTS AND METHODS

We included PWEs aged 18 years and over who have been evaluated in person within the past six months, with details available in electronic health records (EHRs), and advised regular follow-up after getting telephonic consent. We excluded those requiring emergency care and those seeking teleconsultation for new symptoms. Participants were sent a message in English and in the local language about the possibility of a video teleconsultation. If willing, they were informed about the date, time, and technical requirements such as smartphones, browsing facilities, etc. Feasibility and effectiveness were assessed. Satisfaction/acceptability was assessed using Telemedicine Satisfaction Questionnaire.

RESULTS

From June 2020 to October 2020, we selected 336 PWEs after screening 1100 records, and we tried video teleconsultation in 141 (41.8%) PWEs. We achieved successful video connections in 95 (28.2%) and audio consultations in 46 (13.6%). The median duration for calling the participants, making successful connections, and consultation was 8 (5-14) min. The majority required two (47.4%) or three (32.6%) attempts. Sixty-five PWEs (68.4%) used caretaker's mobile phones. We gave prescriptions to all, and 18 received new drugs. Out of 95 PWEs, 90% either 'agreed' or 'strongly agreed' on 12 out of 14 telemedicine satisfaction questions.

CONCLUSION

Although we need to make video teleconsultation more feasible, our synchronous mobile video teleconsultation model is an effective and acceptable method to follow up PWEs. This real-time model has the advantage that it does not require any mobile application to be downloaded and installed. Further studies are needed to evaluate methods to improve the reach of these services particularly to vulnerable groups of the population.

A Collaborative Tele-Neurology Outpatient Consulation Service in Karnataka: Seven Years of Experience From a Tele-Medicine Center

Background

Neurology services in rural and semi-urban part of India are very limited, due to poor infrastructure, resources, and manpower. Tele-neurology consultations at a non-urban setup can be considered as an alternative and innovative approach and have been quite successful in developed countries. Therefore, an initiative to bridge this health gap through Tele-Medicine has been taken by the Government of India.

Aim

To study the sociodemographic and clinical profiles of patients who have received collaborative Tele-Neurology consultations from the Tele-Medicine Centre, National Institute of Mental Health and Neurosciences, Bengaluru.

Methodology

We reviewed case files of such patients between December 2010 and March 2017. A total 189 collaborative tele-neurology outpatient consultations were provided through the Tele-Medicine Centre, located at a tertiary hospital-based research centre in southern India.

Results

The mean age of the patients was 39.6 (±19) years and 65.6% were aged between 19 to 60 years; 50.8% were male. The most common diagnosis was a seizure disorder in 17.5%, followed by cerebrovascular accident/stroke in 14.8%. Interestingly, 87.3% were found to benefit from tele-neurology consultations using interventions such as a change of medications in 30.1%, referral to a specialist for review in 15.8%, and further evaluation of illness and inpatient care for 7.93%.

Conclusion

This study has demonstrated the successful implementation of outpatient-based collaborative tele neurology consultation in Karnataka.

The beliefs of Senegal's physicians toward the use of telemedicine

INTRODUCTION

Telemedicine is seen as a potential solution to improve access to specialist services in underserved areas, but using telemedicine depends on physicians' beliefs regarding its use. Applying the theory of planned behaviour, there are three kinds of beliefs of relevance: behavioural, normative and control beliefs. This study aimed to determine the behavioural, normative and control beliefs of Senegal's physicians regarding the use of telemedicine.

METHODS

A qualitative descriptive study involving individual interviews with physicians was conducted between January and June 2014. It included 32 physicians working in public hospitals and 37 physicians working in district health centres. Interviews were taped, transcribed and their content coded thematically using the NVivo 10 software.

RESULTS

The most significant positive behavioural belief was that telemedicine makes experts' opinions accessible despite distance; the most important negative behavioural belief was that telemedicine can lead to medical errors. The positive normative belief mentioned most was that patients approve the use of telemedicine, but the negative normative belief mentioned most was that the patients would not approve it. The prevailing positive control belief was that physicians will use telemedicine if it is easy to use and the most cited negative control belief was that physicians will not use telemedicine if they have insufficient time.

CONCLUSION

The results of this study provide a better understanding of the beliefs of Senegal's physicians regarding telemedicine, which can help in designing interventions to promote its use. Such interventions may help improve access to healthcare in rural areas.

A study on collaborative telepsychiatric consultations to outpatients of district hospitals of Karnataka, India

INTRODUCTION

The Indian National Mental Health Survey (NMHS) of 2015-2016 has estimated 13.7% lifetime and 10.6% point prevalence for mental illnesses. It has identified that the treatment gap for mental illnesses ranges between 70% and 92%. Tele-Psychiatric consultations could be an alternative and innovative approach to bridge this gap in low resource settings.

AIMS

To study the sociodemographic and clinical profiles of patients who have received collaborative Tele-Psychiatric consultations across district hospitals in Karnataka, India.

METHODOLOGY

We performed a retrospective review of case files of patients who have received collaborative Tele-Psychiatric consultations from January 2013 to June 2017 through video-conferencing. A total of 139 consultations were provided to patients in the state of Karnataka.

RESULTS

The mean age of the sample is 31 (±15.5) years. 61.8% were male and 79.8% were aged more than 18 years. In total, 25.9% of them had schizophrenia and other psychotic disorders, 14.4% had mental retardation, 13.7% had a mood disorder and 14.4% had a substance use disorder. 67.6% of patients had been advised pharmacotherapy, 7.9% had been advised rehabilitation along with pharmacotherapy and 24.4% were advised further evaluation of illness and inpatient care at a higher centre.

CONCLUSION

Collaborative tele-psychiatric consultations to district hospitals from an academic tertiary care hospital can be feasible and are likely to benefit patients from rural areas. There is a need for more studies to elucidate their acceptability by patients, caregivers and professionals.

Teleneurocritical care and telestroke

Telestroke and teleneurologic intensive care units (teleneuro-ICUs) optimize the diagnosis and treatment of neurologic emergencies. Establishment of a telestroke or teleneuro-ICU program relies on investment in experienced stroke and neurocritical care personnel as well as advanced telecommunications technologies. Telemanagement of neurologic emergencies can be standardized to improve outcomes, but it is essential to have a relationship with a tertiary care facility that can use endovascular, neurosurgical, and neurocritical care advanced therapies after stabilization. The next stage in telestroke/teleneuro-ICU management involves the use of mobile stroke units to shorten the time to treatment in neurocritically ill patients.

Telemedicine for genetic and neurologic evaluation in the neonatal intensive care unit

OBJECTIVE

Evaluate whether telemedicine can be used to perform dysmorphology and neurologic examinations in the neonatal intensive care unit (NICU) by determining the examination accuracy, limitations and optimized procedures.

STUDY DESIGN

Prospective evaluation of NICU patients referred for subspecialty consultation for dysmorphic features (n=10) or encephalopathy (n=10). A physician at bedside (bedside clinician) performed an in-person examination that was viewed in real time by a remote physician (remote consultant). Standardized examinations were recorded and compared. Subsequently, a qualitative approach established technique adjustments and optimization procedures necessary to improve visualization.

RESULT

Telemedicine examinations identified 81 of 87 (93%) dysmorphology examination abnormalities and 37 of 39 (92%) neurologic examination abnormalities. Optimization of remote consultant visualization required an active bedside clinician assisting in camera and patient adjustments.

CONCLUSION

Telemedicine can be used to perform accurately many components of the dysmorphology or neurologic examinations in NICU patients, but physicians must be mindful of specific limitations.

Future neurohospitalist: teleneurohospitalist

Despite the growing demand for emergency neurological evaluations and neurohospitalists, the supply of neurologists remains relatively fixed over time.  Telemedicine is a unique tool that has the ability to put a medical specialist like a neurologist in 2 places in a relatively short period of time, expanding expertise in many rural and in some underserved urban facilities that would ordinarily be devoid of such expertise. Teleneurology is a branch of telemedicine that consults and practices through remote neurological evaluation. Telestroke is defined as remote stroke evaluation. The demand for timely neurological evaluation, especially acute stroke evaluation and treatment with intravenous recombinant tissue plasminogen activator (IV rtPA), continues to fuel the growth of neurohospitalists, telestroke, and teleneurology services.  Remote, rural, or underserved urban emergency departments and hospitals which are unable to successfully recruit a neurologist or neurohospitalist to provide this service are uniquely suited to a teleneurology option.  The number of private practices and academic centers providing telestroke services has grown significantly in the past decade with continued growth expected.  We describe the benefits and drawbacks of teleneurology/telestroke, as well as other practical aspects for the teleneurohospitalist.

Teleneurology applications: Report of the Telemedicine Work Group of the American Academy of Neurology

OBJECTIVE

To review current literature on neurology telemedicine and to discuss its application to patient care, neurology practice, military medicine, and current federal policy.

METHODS

Review of practice models and published literature on primary studies of the efficacy of neurology telemedicine.

RESULTS

Teleneurology is of greatest benefit to populations with restricted access to general and subspecialty neurologic care in rural areas, those with limited mobility, and those deployed by the military. Through the use of real-time audio-visual interaction, imaging, and store-and-forward systems, a greater proportion of neurologists are able to meet the demand for specialty care in underserved communities, decrease the response time for acute stroke assessment, and expand the collaboration between primary care physicians, neurologists, and other disciplines. The American Stroke Association has developed a defined policy on teleneurology, and the American Academy of Neurology and federal health care policy are beginning to follow suit.

CONCLUSIONS

Teleneurology is an effective tool for the rapid evaluation of patients in remote locations requiring neurologic care. These underserved locations include geographically isolated rural areas as well as urban cores with insufficient available neurology specialists. With this technology, neurologists will be better able to meet the burgeoning demand for access to neurologic care in an era of declining availability. An increase in physician awareness and support at the federal and state level is necessary to facilitate expansion of telemedicine into further areas of neurology.

Telemedicine in India: the Apollo story

The challenges faced and the methods implemented by the Apollo Hospitals Group in introducing telemedicine in the Indian setting are discussed in this article. Using Information and Communication Technology (ICT) to make available secondary and tertiary medical expertise to suburban and rural India was thought of as early as 1997. In March 2000, the world's first Very Small Aperture Terminal (VSAT)-enabled village hospital was commissioned. Today, with 115 centers including 9 overseas, the Apollo Telemedicine Networking Foundation (ATNF) is the oldest and largest multispecialty telemedicine network. More than 57,000 teleconsultations in various disciplines, ranging from sexual medicine to neurosurgery, have been provided. Patients have been evaluated from distances ranging from 120 to 4,500 miles. A majority (85%) of these teleconsults were reviews. The successful proof of concept validation studies, carried out from 2000 to 2001 by Apollo, were instrumental in the Indian Space Research Organization (ISRO) including telemedicine as a major thrust area. The pioneering role played by Apollo is also discussed in using VSAT-enabled Hospitals on Wheels. The paper reviews the significant role played by ATNF in the growth and development of telemedicine in South Asia. Academic activities are also highlighted. The pioneering efforts in the field of m-health, home telecare, the Pan African e-Network Project, starting the first formal educational course in telehealth and various other e-initiatives are elaborated.

Stroke telemedicine

Stroke telemedicine is a consultative modality that facilitates care of patients with acute stroke at underserviced hospitals by specialists at stroke centers. The design and implementation of a hub-and-spoke telestroke network are complex. This review describes the technology that makes stroke telemedicine possible, the members that should be included in a telestroke team, the hub-and-spoke characteristics of a telestroke network, and the format of a typical consultation. Common obstacles to the practice of telestroke medicine are explored, such as medicolegal, economic, and market issues. An example of a state-based telestroke network is thoroughly described, and established international telestroke networks are presented and compared. The opportunities for future advances in telestroke practice, research, and education are considered.

Stroke telemedicine

Stroke telemedicine is a consultative modality that facilitates care of patients with acute stroke at underserviced hospitals by specialists at stroke centers. The design and implementation of a hub-and-spoke telestroke network are complex. This review describes the technology that makes stroke telemedicine possible, the members that should be included in a telestroke team, the hub-and-spoke characteristics of a telestroke network, and the format of a typical consultation. Common obstacles to the practice of telestroke medicine are explored, such as medicolegal, economic, and market issues. An example of a state-based telestroke network is thoroughly described, and established international telestroke networks are presented and compared. The opportunities for future advances in telestroke practice, research, and education are considered.