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

Service process factors affecting patients' and clinicians' experiences on rapid teleconsultation implementation in out-patient neurology services during COVID-19 pandemic: a scoping review

Background

The adoption of teleconsultation for outpatient neurology services was limited until the onset of the COVID-19 pandemic which forced many outpatient neurology services to rapidly switch to virtual models. However, it remains unclear how this change has impacted patients’ and clinicians’ perceptions of service quality. The purpose of this scoping review is to identify process factors that influence patients’ and clinicians’ experiences of outpatient teleconsultation services during COVID-19.

Methods

Arksey and O’Malley scoping review framework was used to search PubMed, Scopus, CINAHL, and PsycInfo for original peer-reviewed research studies that examined the experiences of synchronous teleconsultation between a clinician and patient in a home-setting since the World Health Organization announced the COVID-19 global pandemic. The service quality model SERVQUAL was used to conduct a deductive thematic analysis to identify the key factors that impacted the patients’ and clinicians’ perception of teleconsultation services.

Results

A total of nineteen studies published between January 1, 2020, and April 17, 2021, were identified. The most common service process factors affecting the patients’ and clinicians’ experiences of teleconsultation were technical issues, addressing logistical needs, communication, ability to perform clinical activities, appropriate triage, and administrative support.

Conclusions

Our findings identified six key service process factors affecting the patients’ and clinicians’ teleconsultation experiences in outpatient neurology services. The need for improvement of triage process and standardizing administrative virtual care pathway are identified as important steps to improve patients and clinicians’ teleconsultation experiences compared to pre-COVID era. More research is needed to assess outpatient neurology teleconsultation service quality from patients’ and clinicians’ perspectives.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07908-4.

Parkinson's patients situation during the SARS CoV-2 pandemic and their interest in telemedicine A cross-sectional study

Background

During the SARS CoV-2 pandemic, telemedicine experienced an enormous boom. Also, for Parkinson’s patients there are upcoming alternatives to regular care.

Objective

The aim of the present study was to interview Parkinson’s patients under the impression of the first lockdown in Germany about their health care situation, but especially about the use of and attitudes towards videotherapy and -consultation.

Methods

Northern German members of the German Parkinson Association were mailed a 16-item questionnaire including demographic questions on a one-time basis. The voluntary participants answered regarding their health care situation during the first German SARS CoV-2 lockdown, as well as attitudes towards videotherapy/-consultations.

Results

The 332 (of 974 questionnaires) responding evaluated their care situation predominantly (58.7%) unchanged during lockdown. There was hardly any previous experience in the areas of videotherapy and -consultations (15.4% and 3%, respectively), but at the same time mostly imaginability of implementation (54.2% and 56%, respectively) and the belief that they could motivate themselves to do so (51.8%). A total of 69% welcomed technical support for the implementation of videotherapy.

Conclusion

In principle, there seems to be both, a need and an interest in telematics in healthcare such as videotherapy and video consultations, even if further barriers such as technical implementation need to be addressed. An expansion of telemedical services and infrastructure seems desirable not only in the pandemic situation, but also in the long term against the backdrop of demographic change, especially in an area like Schleswig-Holstein. Further studies are needed.

Patient and Clinician Perspectives of New and Return Ambulatory Teleneurology Visits

BACKGROUND AND OBJECTIVES

To evaluate the adoption and perceived utility of video visits for new and return patient encounters in ambulatory neurology subspecialties.

METHODS

Video visits were launched in an academic, multi-subspecialty, ambulatory neurology clinic in March 2020. Adoption of video visits for new and return patient visits was assessed using clinician-level scheduling data from March 22 to May 16, 2020. Perceived utility of video visits was explored via a clinician survey and semistructured interviews with clinicians and patients/caregivers. Findings were compared across 5 subspecialties and 2 visit types (new vs return).

RESULTS

Video visits were adopted rapidly; all clinicians (n = 65) integrated video visits into their workflow within the first 6 weeks, and 92% of visits were conducted via video, although this varied by subspecialty. Utility of video visits was higher for return than new patient visits, as indicated by surveyed (n = 48) and interviewed clinicians (n = 30), aligning with adoption patterns. Compared with in-person visits, clinicians believed that it was easier to achieve a similar physical examination, patient-clinician rapport, and perceived quality of care over video for return rather than new patient visits. Of the 25 patients/caregivers interviewed, most were satisfied with the care provided via video, regardless of visit type, with the main limitation being the physical examination.

DISCUSSION

Teleneurology was robustly adopted for both new and return ambulatory neurology patients during the COVID-19 pandemic. Return patient visits were preferred over new patient visits, but both were feasible. These results provide a foundation for developing targeted guidelines for sustaining teleneurology in ambulatory care.

Telemedicine and current clinical practice trends in the COVID-19 pandemic

Telemedicine is the medical practice of caring for and treating patients remotely. With the spread of the coronavirus disease-2019 (COVID-19) pandemic, telemedicine has become increasingly prevalent. Although telemedicine was already in practice before the 2020 pandemic, the internet, smartphones, computers, and video-conferencing tools have made telemedicine easily accessible and available to almost everyone. However, there are also new challenges that health care providers may not be prepared for, including treating and diagnosing patients without physical contact. Physician adoption also depends upon reimbursement and education to improve the telemedicine visits. We review current trends involving telemedicine, how pandemics such as COVID-19 affect the remote treatment of patients, and key concepts important to healthcare providers who practice telemedicine.

The application of telehealth to remote and rural Australians with chronic neurological conditions

BACKGROUND

Patients with chronic disease in rural and remote regions endure limited access to specialised medicine. Telehealth has addressed this issue with demonstrable benefits such as a reduction in costs to patients.

AIMS

To explore the patient satisfaction of telehealth in Australia.

METHODS

Patients from all around Australia, including Queensland, Victoria, Tasmania, South Australia, Australian Capital Territory and even Western Australia were referred to a Sydney-based neurologist. After their initial face to face consultation, review consultations were performed by telehealth. All had chronic diseases (trigeminal neuralgia, facial pain or Parkinson disease) and received a standardised questionnaire comprising of demographics, satisfaction of technical aspects and quality of the consultation. The questionnaires were administered by the Practice Manager to remove observer bias.

RESULTS

Twenty-nine patient questionnaires were completed by 13 patients who had follow-up telehealth consultations. One hundred per cent of patients reported satisfaction with the overall telehealth experience and would use it again. All were satisfied with the specialist and the privacy. The majority were satisfied with the voice quality (86%), visual quality (79%), ease of connectivity (93%) and length of the consultation (97%). In total, they saved nearly $17 000 in travel costs and on average, each patient avoided 937 km and saved $550.

CONCLUSION

Telehealth has proven to have multiple advantages, including improved access to healthcare, decreased costs, reduced inconvenience and improved management of chronic and complex conditions. The positive results advocate the use of telehealth for follow up of rural and remote patients with chronic disease.

E-Health & Innovation to Overcome Barriers in Neuromuscular Diseases. Report from the 1st eNMD Congress: Nice, France, March 22-23, 2019

By definition, neuromuscular diseases are rare and fluctuating in terms of symptoms; patients are often lately diagnosed, do not have enough information to understand their condition and be proactive in their management. Usually, insufficient resources or services are available, leading to patients' social burden. From a medical perspective, the rarity of such diseases leads to the unfamiliarity of the medical staff and caregiver and an absence of consensus in disease assessment, treatment, and management. Innovations have to be developed in response to patients' and physicians' unmet needs.It is vital to improve several aspects of patients' quality of life with a better comprehension of their disease, simplify their management and follow-up, help their caregiver, and reduce the social and economic burden for living with a rare debilitating disease. Database construction regrouping patients' data and symptoms according to specific country registration on data privacy will be critical in establishing a clear consensus on neuromuscular disease treatment.Clinicians also need technological innovations to help them recognize neuromuscular diseases, find the best therapeutic approach based on medical consensus, and tools to follow patients' states regularly. Diagnosis also has to be improved by implementing automated systems to analyze a considerable amount of data, representing a significant step forward to accelerate the diagnosis and the patients' follow up. Further, the development of new tools able to precisely measure specific outcomes reliably is of the matter of importance in clinical trials to assess the efficacy of a newly developed compound.In this context, creation of an expert community is essential to communicate and share ideas. To this end, 97 clinicians, healthcare professionals, researchers, and representatives of private companies from 9 different countries met to discuss the new perspective and challenges to develop and implement innovative tools in the field of neuromuscular diseases.

Management of children with glucose-6-phosphate dehydrogenase deficiency presenting with acute haemolytic crisis during the SARs-COV-2 pandemic

Background and Objectives

Shortage of blood during the severe acute respiratory syndrome‐COV‐2 (SARs‐COV‐2) pandemic impacted transfusion practice. The primary aim of the study is to assess management of acute haemolytic crisis (AHC) in glucose‐6‐phosphate dehydrogenase(G6PD)‐ deficient children during SARs‐COV‐2 pandemic, and then to assess blood donation situation and the role of telemedicine in management.

Methods

Assessment of G6PD‐deficient children attending the Emergency Department (ER) with AHC from 1 March 2020 for 5 months in comparison to same period in the previous 2 years, in three paediatric haematology centres. AHC cases presenting with infection were tested for SARs‐COV‐2 using RT‐PCR. Children with Hb (50–65 g/L) and who were not transfused, were followed up using telemedicine with Hb re‐checked in 24 h.

Results

A 45% drop in ER visits due to G6PD deficiency‐related AHC during SARs‐COV‐2 pandemic in comparison to the previous 2 years was observed. 10% of patients presented with fever and all tested negative for COVID‐19 by RT‐PCR. 33% of patients had Hb < 50 g/L and were all transfused. 50% had Hb between 50 and 65 g/L, half of them (n = 49) did not receive transfusion and only two patients (4%) required transfusion upon follow up. A restrictive transfusion strategy was adopted and one of the reasons was a 39% drop in blood donation in participating centres.

Conclusion

Fewer G6PD‐deficient children with AHC visited the ER during SARs‐COV‐2 and most tolerated lower Hb levels. Telemedicine was an efficient tool to support their families. A restrictive transfusion strategy was clear in this study.

Telemedicine Can Support Measurable and High-Quality Epilepsy Care During the COVID-19 Pandemic

Routine outpatient epilepsy care has shifted from in-person to telemedicine visits in response to safety concerns posed by the coronavirus disease 2019 (COVID-19) pandemic. But whether telemedicine can support and maintain standardized documentation of high-quality epilepsy care remains unknown. In response, the authors conducted a quality improvement study at a level 4 epilepsy center between January 20, 2019, and May 31, 2020. Weekly average completion proportion of standardized documentation used by a team of neurologists for adult patients for the diagnosis of epilepsy, seizure classification, and frequency were analyzed. By December 15, 2019, a 94% average weekly completion proportion of standardized epilepsy care documentation was achieved that was maintained through May 31, 2020. Moreover, during the period of predominately telemedicine encounters in response to the pandemic, the completion proportion was 90%. This study indicates that high completion of standardized documentation of seizure-related information can be sustained during telemedicine appointments for routine outpatient epilepsy care at a level 4 epilepsy center.

Efficiency and satisfaction with telephone consultation of follow-up patients in neuro-urology: Experience of the COVID-19 pandemic

Aim

The COVID‐19 pandemic led to limit patients’ visits to the neuro‐urology department. Telemedicine was seen as a pragmatic solution to provide follow‐up care. This study aimed to assess the efficiency and satisfaction of a telephone consultation in neuro‐urology.

Methods

During the pandemic, the scheduled medical visits were converted into telephone consultation. For each teleconsultation, the physician assessed the efficiency and the patient‐rated global satisfaction of the teleconsultation. The physician and the patient assessed whether this teleconsultation replaced a physical visit.

Results

About 358 neurologic patients were included in the study. The mean efficiency of the telephone consultation was 9.3/10 (±1.5). The mean global satisfaction was 9.0/10 (±1.3). The majority of the patients (52.4%) would prefer a physical consultation. 90.2% might convert some clinic visits to teleconsultations in the future. No agreement was found between the patient and the physician when they were asked if the teleconsultation replaced the physical consultation initially scheduled (weight kappa = 0.02; 95% confidence interval = [−0.06 to 0.11]). Cognitive impairment, difficulty to obtain relevant information, and lack of physical examination were unfavorable to the efficiency of the teleconsultation. Cognitive impairment, embarrassing nature of the teleconsultation, and preference for a physical consultation were unfavorable to satisfaction of the patient.

Conclusion

Telemedicine in neuro‐urology was associated with a high satisfaction of the patients and was described as efficient by the physicians. Despite this, the majority of the patients reported a preference for physical consultation. The COVID‐19 pandemic might be an opportunity to refine our practices in neuro‐urology and to develop telemedicine.

Teleneurology clinics for polyneuropathy: a pilot study

Introduction

Polyneuropathy (PN) is a common condition with significant morbidity. We developed tele-polyneuropathy (tele-PN) clinics to improve access to neurology and increase guideline-concordant PN care. This article describes the mixed-methods evaluation of pilot tele-PN clinics at three community sites within the Greater Los Angeles VA Healthcare System.

Methods

For the first 25 patients (48 scheduled visits), we recorded the duration of the tele-PN visit and exam; the performance on three guideline-concordant care indicators (PN screening labs, opiate reduction, physical therapy for falls); and patient-satisfaction scores. We elicited comments about the tele-PN clinic from patients and the clinical team. We combined descriptive statistics with qualitative themes to determine the feasibility and acceptability of the tele-PN clinics.

Results

The average tele-PN encounter and exam times were 28.5 and 9.1 min, respectively. PN screening lab completion increased from 80 to 100%. Opiate freedom improved from 68 to 88%. Physical therapy for patients with recent falls increased from 58 to 100%. The tele-PN clinic was preferred for follow-up over in-person clinics in 86% of cases. Convenience was paramount to the clinic’s success, saving an average of 231 min per patient in round-trip travel. The medical team’s caring and collaborative spirit received high praise. While the clinic’s efficiency was equal or superior to in-person care, the limited treatment options for PN and the small clinical exam space are areas for improvement.

Conclusion

In this pilot, we were able to efficiently see and examine patients remotely, promote guideline-concordant PN care, and provide a high-satisfaction encounter.

Hospital Utilization Among Rural Children Served by Pediatric Neurology Telemedicine Clinics

Importance

Telemedicine is increasingly used to provide outpatient pediatric neurology consultations in underserved communities. Although telemedicine clinics have been shown to improve access, little is known about how they alter patients' utilization of hospital services.

Objective

To evaluate the association between access to telemedicine clinics and hospital utilization among underserved children with neurologic conditions.

Design, Setting, and Participants

This retrospective cross-sectional study included 4169 patients who received outpatient care from pediatric neurologists affiliated with an academic children's hospital in California between January 1, 2009, and July 31, 2017, either in person or using telemedicine.

Exposures

Consultation modality (telemedicine or in person) in the outpatient neurology clinics.

Main Outcomes and Measures

Demographic and clinical variables were abstracted from the hospital's electronic medical records. The association between the modality of outpatient neurology care and patients' utilization of the emergency department and hospitalizations was evaluated. Both all-cause and neurologic condition-related hospital utilization were analyzed using multivariable negative binomial regression in overall and matched samples.

Results

The telemedicine cohort comprised 378 patients (211 [55.8%] male), and the in-person cohort comprised 3791 patients (2090 [55.1%] male). The mean (SD) age at the first encounter was 7.4 (5.4) years for the telemedicine cohort and 7.8 (5.1) years for the in-person cohort. The telemedicine cohort was more likely than the in-person cohort to have nonprivate insurance (public insurance, self-pay, or uninsured), lower education, and lower household income. The rates of all-cause and neurologic hospital encounters were lower among children who received pediatric neurology consultations over telemedicine compared with children who received care in the in-person clinics (5.7 [95% CI, 3.5-8.0] vs 20.1 [95% CI, 18.1-22.1] per 100 patient-years and 3.7 [95% CI, 2.0-5.3] vs 8.9 [95% CI, 7.8-10.0] per 100 patient-years, respectively; P < .001). Even after adjusting for demographic and clinical factors, the telemedicine cohort had a lower risk of hospital encounters (emergency department visits and admissions) with an adjusted incidence rate ratio of 0.57 (95% CI, 0.38-0.88) for all-cause encounters and an adjusted incidence rate ratio of 0.60 (95% CI, 0.36-0.99) for neurologic encounters. After matching on travel time to the neurology clinic, the adjusted incidence rate ratio was 0.19 (95% CI, 0.04-0.83) for all-cause admissions and 0.14 (95% CI, 0.02-0.82) for neurologic admissions.

Conclusions and Relevance

Pediatric neurology care through real-time, audiovisual telemedicine consultations was associated with lower hospital utilization compared with in-person consultations, suggesting that high-cost hospital encounters can be prevented by improving subspecialty access.

Interprofessional Care for Neuromuscular Disease

PURPOSE OF REVIEW

This review aims to delineate interprofessional care models for neuromuscular disease. Evidence regarding both the benefits and barriers to interprofessional neuromuscular care in both inpatient and outpatient settings is presented. Finally, opportunities to improve both access to and quality of care provided by interprofessional team clinics will be discussed.

RECENT FINDINGS

Although the term "multidisciplinary" is often misapplied to denote any interprofessional team-based care setting, there are important differences in team structure and dynamics in each of the three most common models: multidisciplinary, interdisciplinary, and transdisciplinary care. Evidence favors the more integrated interdisciplinary and transdisciplinary models for better patient outcomes and decreased staff burnout. Coordinated interprofessional care results in improved health outcomes, resource utilization, and patient satisfaction for persons with adult and pediatric neuromuscular disease. Distance remains the greatest barrier to specialized team-based care for this population; telehealth technologies may make interprofessional care more accessible to these persons. Despite limited evidence for the broader population of persons with neuromuscular disease, consensus guidelines increasingly support this model of care delivery. Further work may help determine effectiveness for other populations of persons with neuromuscular disease and best practices within these team-based models of care.

Appointment completion in pediatric neurology telemedicine clinics serving underserved patients

Background

To determine whether telemedicine improves access to outpatient neurology care for underserved patients, we compared appointment completion between urban, in-person clinics and telemedicine clinics held in rural and underserved communities where neurology consultations are provided remotely.

Methods

In this retrospective study, we identified patients scheduled for outpatient care from UCDH pediatric neurologists between January 1, 2009, and July 31, 2017, in person and by telemedicine. Demographic and clinical variables were abstracted from electronic medical records. We evaluated the association between consultation modality and visit completion in overall and matched samples using hierarchical multivariable logistic regression.

Results

We analyzed 13,311 in-person appointments by 3,831 patients and 1,158 telemedicine appointments by 381 patients. The average travel time to the site of care was 45.8 ± 52.1 minutes for the in-person cohort and 22.3 ± 22.7 minutes for the telemedicine cohort. Telemedicine sites were located at an average travel time of 217.1 ± 114.8 minutes from UCDH. Telemedicine patients were more likely to have nonprivate insurance, lower education, and lower household income. They had different diagnoses and fewer complex chronic conditions. Telemedicine visits were more likely to be completed than either "cancelled" or missed ("no show") compared with in-person visits (OR 1.57, 95% CI: 1.34-1.83; OR 1.66, 95% CI: 1.31-2.10 matched on travel time to the site of care; OR 2.22, 95% CI: 1.66-2.98 matched on travel time to UCDH).

Conclusions

The use of telemedicine for outpatient pediatric neurology visits has high odds of completion and can serve as an equal adjunct to in-person clinic visits.

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.

Connected health and multiple sclerosis

There is as yet no consensual definition of "connected health". In general, the term refers to the growing use of technology and, in particular, mobile technology in medicine. Over the past 10 years, there have been an increasing number of published reports on the wide-ranging and heterogeneous fields involving the application of technology in medicine, ranging from telemedicine to tools to improve patients' evaluation and monitoring by physicians, as well as a multitude of patient-centered applications. They also represent promising tools in the field of clinical research. This report is a review of the importance of using this technology in the management of multiple sclerosis patients.

Telehealth applications for outpatients with neuromuscular or musculoskeletal disorders

Telehealth describes the provision of medical services remotely through technology, and may enhance patient access to specialty care services. Although teleneurology has expanded widely since the introduction of telestroke in 1999, telehealth services for outpatients with neuromuscular or musculoskeletal disorders are less widespread. In this narrative review, we will describe the current technology, applications, outcomes, and limitations of this dynamically growing field. Evidence for telehealth applications related to neuromuscular diseases, palliative care, specialized multidisciplinary services, and musculoskeletal care are reviewed. With growing demand for specialized services and finite resources, telehealth provides a promising avenue to promote access to high-quality care, decrease the cost and burden of travel for patients, and with the expansion of software to personal computing and mobile devices, offer flexible, low-overhead practice opportunities for clinicians. Providers embarking on careers in telehealth should be aware of current legal restrictions impacting care to minimize risk and avoid liability. Muscle Nerve 58: 475-485, 2018.

A spatial analysis of amyotrophic lateral sclerosis (ALS) cases in the United States and their proximity to multidisciplinary ALS clinics, 2013

Background

Amyotrophic lateral sclerosis (ALS) is a fatal motor neuron disease that typically results in death within 2–5 years of initial symptom onset. Multidisciplinary ALS clinics (MDCs) have been established to provide specialty care to people living with the disease.

Objective

To estimate the proximity of ALS prevalence cases to the nearest MDC in the US to help evaluate one aspect of access to care.

Methods

Using 2013 prevalence data from the National ALS Registry, cases were geocoded by city using geographic information system (GIS) software, along with the locations of all MDCs in operation during 2013. Case-to-MDC proximity was calculated and analyzed by sex, race, and age group.

Results

During 2013, there were 72 MDCs in operation in 30 different states. A total of 15,633 ALS cases were geocoded and were distributed throughout all 50 states. Of these, 62.6% were male, 77.9% were white, and 76.2% were 50–79 years old. For overall case-to-MDC proximity, nearly half (44.9%) of all geocoded cases in the US lived >50 miles from an MDC, including approximately a quarter who lived >100 miles from an MDC. There was a statistically significant difference between distance to MDC by race and age group.

Conclusions

The high percentage of those living more than 50 miles from the nearest specialized clinic underscores one of the many challenges of ALS. Having better access to care, whether at MDCs or through other modalities, is likely key to increasing survivability and obtaining appropriate end-of-life treatment and support for people with ALS.

Remote care of a patient with stroke in rural Trinidad: use of telemedicine to optimise global neurological care

We report a patient driven home care system that successfully assisted 24/7 with the management of a 68-year-old woman after a stroke-a global illness. The patient's caregiver and physician used computer devices, smartphones and internet access for information exchange. Patient, caregiver, family and physician satisfaction, coupled with outcome and cost were indictors of quality of care. The novelty of this basic model of teleneurology is characterised by implementing a patient/caregiver driven system designed to improve access to cost-efficient neurological care, which has potential for use in primary, secondary and tertiary levels of healthcare in rural and underserved regions of the world. We suggest involvement of healthcare stakeholders in teleneurology to address this global problem of limited access to neurological care. This model can facilitate the management of neurological diseases, impact on outcome, reduce frequency of consultations and hospitalisations, facilitate teaching of healthcare workers and promote research.