Will teleneurology hit the big time?

Implementing Virtual Care in Neurology - Challenges and Pitfalls

Virtual care is here to stay. The explosive expansion of telehealth caused by the SARS-CoV-2 pandemic is more than a necessary measure of protection. The key drivers of this transition in healthcare delivery to a virtual setting are changes in patient behavior and expectations and societal attitudes, and prevailing technologies that are impossible to ignore. The younger population - Generation Z - is increasingly connected and mobile-first. We are heading to a world where we expect to see healthcare in general and neurology, in particular, delivered virtually. The medical community should prepare for this overhaul; proper implementation of virtual care from the ground up is the need of the hour. In an era of virtualization, it is up to the medical community to ensure a well-informed patient population, overcome cultural differences and build digital infrastructure with enhanced access and equity in care delivery, especially for the aging neurological patient population, which is not technologically savvy. Virtual care is a continuum of care that needs deeper integration at systematic levels. The design principles of a patient's journey need to be incorporated while simultaneously placing physician satisfaction with a better user experience at the center of implementation. In this paper, we discuss common challenges and pitfalls of virtual care implementation in neurology - logistical, technical, medicolegal, and those faced in incorporating health and medical education into virtual care - intending to provide solutions and strategies.

Addressing cost and time barriers in chronic disease management through telemedicine: an exploratory research in select low- and middle-income countries

BACKGROUND

Despite evidence supporting telehealth provision in developed countries, there is limited evidence regarding its economic benefits for patients living in areas where access and cost present major barriers to health care, particularly in low- and middle-income countries (LMICs). This study explores the economic benefits of telemedicine for patients, in terms of cost and times savings, and its potential role in improving chronic disease outcomes.

METHODS

This retrospective cross-sectional study compared telemedicine services with hypothetical in-person consultations, with a focus on patient travel time and travel cost savings. A database containing teleconsultation visits (N = 25,182) conducted at health facilities in remote regions of Afghanistan, Pakistan, Tajikistan, and the Kyrgyz Republic, was analyzed. A two-sample homoscedastic t test was used to determine differences between the two groups. A one-way sensitivity analysis was also conducted, presuming in-person teleconsultations at 90%, 75%, and 50%.

RESULTS

The study extracted data from 25,182 teleconsultation visits (12,814 males; 12,368 females). The cumulative patient savings through the program amounted to USD 9,175,132, and 1,876,146 h, or 213.1 years. A significant difference was seen between the two groups in terms of mean time savings (p-value <0.05), and a nearly significant difference was observed in terms of mean cost savings (p-value = 0.05).

CONCLUSIONS

This study suggests that considerable economic benefits imparted to patients in low-resource settings of LMICs via accessing telemedicine. Telemedicine has great potential to improve chronic disease outcomes in low-resource areas by reducing socioeconomic barriers related to cost and access, and increasing uptake of services, thereby enabling early intervention and long-term management.

Multidisciplinary Approach and Outcomes of Tele-neurology: A Review

In rural and underserved areas, there are restrictions in healthcare due to the lack of availability of neurologists; patients have to travel long distances to receive the required care. Considering the fact that neurological conditions have large mortality and disability rates, there is a need for innovative services like tele-neurology. It is an important tool in improving the health and quality of life by using different ways of communication between neurologists and patients, or neurologists and other providers. We examine the current types of facilities available in tele-neurology, as well as outcomes, barriers, limitations, legal litigations, and the multidisciplinary nature based on prior studies. We have also suggested recommendations for the future of tele-neurology including effective-accessibility and inexpensive-utilization in developing countries. There are various tele-health programs created by The Veterans Health Administration including a clinical video tele-health (CVT) system. This system allows direct patient care of veterans by neurologists. The University of South Carolina implemented a web-based tele-stroke program in which acute ischemic stroke patients were treated in the Emergency Department (ED) of rural hospitals by neurologists, after consulting with rural ED physicians. With growing technology and popularity of tele-neurology, there are now international collaborative efforts in tele-medicine that are looking to be adapted to tele-neurology. Thus, tele-neurology can provide quality neurological care with patient satisfaction, as well as time and cost savings. The tele-stroke group established by TRUST-tPA trial (Therapeutic Trial Evaluating Efficacy of Telemedicine (TELESTROKE) of Patients With Acute Stroke) has 10 community hospital-emergency rooms that were connected to a stroke center. It was found that tele-stroke is appropriate in places where there is no way for a patient to access a stroke unit within a 4.5-hour time window. Like other tele-neurology subtypes, tele-epilepsy and pediatric tele-neurology also offer more follow-up care to people of remote areas which have limited access. There are other subtypes like mental health, chronic neurological care, and hospitalist which are very effective in improving outcome and quality of life of people living in remote areas. Tele-neurology has effectively reduced travel costs and times; there is high patient satisfaction and reduced disparity for general and specialized neurological care. But there are certain limitations like large equipment costs, certain bandwidth requirement, and trained staff to use the equipment. Transmission of patient information using public internet raises the concern of legality. There should be sufficient encryption to satisfy the Health Insurance Portability and Accountability Act (HIPAA) requirements to ensure patient confidentiality and safety of personal data. The adaptation of tele-neurology is a powerful and innovative way to enhance healthcare in areas with a shortage of specialists. Implementation of this tool is limited due to cost burden, lack of expertise to implement necessary technology, legal litigations, and suitable financial and professional incentives for the users. This review focuses on the trajectory of utilization and the issues to be addressed in order to provide the full benefits of tele-neurology to undeserved communities in the future.

Telemedicine Interest for Routine Follow-Up Care Among Neurology Patients in Arkansas

BACKGROUND

Teleneurology in Arkansas has been used primarily for management of acute stroke with a state-funded hub-and-spoke model allowing physicians at rural hospitals to access vascular neurologists in time to facilitate tissue plasminogen activator administration. Routine neurologic care has been provided only in small pilot studies. We wished to determine patient interest in participating in teleneurology for routine follow-up visits as well as demographic and medical factors associated with interest.

MATERIALS AND METHODS

New and established patients of the Neurology Outpatient Clinic at the University of Arkansas for Medical Sciences (UAMS) were surveyed between March 2011 and December 2012 to assess their interest in participating in teleneurology as well as potential factors associated with their interest.

RESULTS

Of 1,441 respondents, 52.4% were interested in telemedicine. Of those interested versus uninterested in telemedicine, respectively, 68.9% versus 36.32% traveled more than 1 h to the clinic, 64.7% versus 35.3% had difficulty secondary to neurological conditions, 22.6% versus 6.8% had missed medical appointments due to travel problems, and 43.1% versus 9.4% had travel-imposed financial hardship.

CONCLUSIONS

Telemedicine interest for routine follow-up visits was strong among patients at the UAMS Neurology Outpatient Clinic. Factors positively associated with interest included long travel distances, travel expenses, and transportation difficulties. These results suggest that implementing a telemedicine program for follow-up visits would be acceptable to neurology patients for routine ongoing care.

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.

The use of retinal photography in nonophthalmic settings and its potential for neurology

BACKGROUND

Ocular fundus examination is an important element of the neurological examination. However, direct ophthalmoscopy is difficult to perform without pupillary dilation and requires extensive practice to accurately recognize optic nerve and retinal abnormalities. Recent studies have suggested that digital retinal photography can replace direct ophthalmoscopy in many settings.

REVIEW SUMMARY

Ocular fundus imaging is routinely used to document and monitor disease progression in ophthalmology. Advances in optical technology have made it easier to obtain high-quality retinal imaging, even without pupillary dilation. Retinal photography has a high sensitivity, specificity, and interexamination/intraexamination agreement compared with in-person ophthalmologist examination, suggesting that photographs can be used in lieu of ophthalmoscopy in many clinical situations. Nonmydriatic retinal photography has recently gained relevance as a helpful tool for diagnosing neuro-ophthalmologic disorders in the emergency department. In addition, several population-based studies have used retinal imaging to relate ophthalmic abnormalities to the risk of hypertension, renal dysfunction, cardiovascular mortality, subclinical and clinical stroke, and cognitive impairment. The possibility of telemedical consultation offered by digital retinal photography has already increased access to timely and accurate subspecialty care, particularly for underserved areas.

CONCLUSIONS

Retinal photography (even without pupillary dilation) has become increasingly available to medical fields outside of ophthalmology, allowing for faster and more accurate diagnosis of various ocular, neurological, and systemic disorders. The potential for telemedicine may provide the additional benefits of improving access to appropriate urgent consultation in both clinical and research settings.