Telemedicine in Neurosurgery: Lessons Learned from a Systematic Review of the Literature for the COVID-19 Era and Beyond

Benefits of Neurosurgical Teleconsults in the Management of Intracerebral Hemorrhage: Transfers and Transportation Cost Reduction

BACKGROUND

Our study explores the efficacy and economic benefits of neurosurgical teleconsultations in managing intracerebral hemorrhage (ICH), focusing on reducing unnecessary patient transfers and associated costs.

METHODS

We conducted a cost-savings analysis at our institution of a previously published pilot study involving a cohort of patients with ICH who were potential candidates for airlift to our tertiary care center but instead received neurosurgical consultation via teleconsultation to avoid the transfer. Data on patient demographics, distances, and costs were collected and analyzed to assess the economic impact of teleconsultations.

RESULTS

The cohort comprised 14 patients; we noted significant cost savings from avoiding interhospital transfers, ranging from $84,346.52 to $120,495.03 per patient. Teleconsultations facilitated immediate, collaborative decision-making between healthcare providers at community hospitals and a tertiary care center, reducing the need for expensive air transportation and unnecessary hospital transfers.

CONCLUSIONS

Neurosurgical teleconsultations offer a cost-effective alternative to traditional patient transfer methods for ICH management, providing substantial economic benefits while maintaining high physician and patient-family satisfaction levels. This study underscores the potential of our teleneurosurgery program to significantly reduce costs by reducing unnecessary financial burdens on patients' families and healthcare systems.

Telemedicine in Follow-up after Spine Surgery: Need of the Hour

Purpose  There is an acute shortage of neurosurgeons and spine surgeons especially in rural areas of low- and middle-income countries including India. Patients of spine surgery need to travel long distances for follow-up at tertiary care hospitals. This study was done to evaluate role and success rate of telemedicine in follow-up after spine surgery based on patients' diagnosis and demographic features and to identify barriers to successful telemedicine consultations. Materials and Methods  All patients undergoing spine surgeries including craniovertebral junction (CVJ) surgeries from January 2021 to June 2022 were included in the study. Success rate of telemedicine was calculated using a simple formula: Success rate of telemedicine = successful telemedicine consultations / total number of telemedicine consultation × 100. Success rate was evaluated with respect to demographic features and underlying disease-related factors. Results  Eighty-four patients formed the study group in which a total of 181 video teleconsultations were done. Overall success rate of telemedicine was 82.87%. Higher socioeconomic and educational statuses were related to higher success rates of tele-consultations ( p  < 0.05). Difficulty in assessing neurological condition using video call in follow-up cases of CVJ and issues related to Internet communication network leading to inability to video call and share image/videos were major causes of failures. Conclusion  Telemedicine may prove an effective option for following up patients undergoing spine surgeries except CVJ, which is likely to improve further with improvements in Internet connectivity.

Opportunities and Considerations for the Incorporation of Artificial Intelligence into Global Neurosurgery: A Generative Pretrained Transformer Chatbot-Based Approach

OBJECTIVE

Global neurosurgery is a public health focus in neurosurgery that seeks to ensure safe, timely, and affordable neurosurgical care to all individuals worldwide. Although investigators have begun to explore the promise of artificial intelligence (AI) for neurosurgery, its applicability to global neurosurgery has been largely hypothetical. We characterize opportunities and considerations for the incorporation of AI into global neurosurgery by synthesizing key themes yielded from a series of generative pretrained transformers (GPTs), discuss important limitations of GPTs and cautions when using AI in neurosurgery, and develop a framework for the equitable incorporation of AI into global neurosurgery.

METHODS

ChatGPT, Bing Chat/Copilot, You, Perplexity.ai, and Google Bard were queried with the prompt "How can AI be incorporated into global neurosurgery?" A layered ChatGPT-based thematic analysis was performed. The authors synthesized the results into opportunities and considerations for the incorporation of AI in global neurosurgery. A Pareto analysis was conducted to determine common themes.

RESULTS

Eight opportunities and 14 important considerations were synthesized. Six opportunities related to patient care, 1 to education, and another to public health planning. Four of the important considerations were deemed specific to global neurosurgery. The Pareto analysis included all 8 opportunities and 5 considerations.

CONCLUSIONS

AI may be incorporated into global neurosurgery in a variety of capacities requiring numerous considerations. The framework presented in this manuscript may facilitate the incorporation of AI into global neurosurgery initiatives while balancing contextual factors and the reality of limited resources.

How Informal Carers Support Video Consulting in Physiotherapy, Heart Failure, and Cancer: Qualitative Study Using Linguistic Ethnography

BACKGROUND

Informal carers play an important role in the everyday care of patients and the delivery of health care services. They aid patients in transportation to and from appointments, and they provide assistance during the appointments (eg, answering questions on the patient's behalf). Video consultations are often seen as a way of providing patients with easier access to care. However, few studies have considered how this affects the role of informal carers and how they are needed to make video consultations safe and feasible.

OBJECTIVE

This study aims to identify how informal carers, usually friends or family who provide unpaid assistance, support patients and clinicians during video consultations.

METHODS

We conducted an in-depth analysis of the communication in a sample of video consultations drawn from 7 clinical settings across 4 National Health Service Trusts in the United Kingdom. The data set consisted of 52 video consultation recordings (of patients with diabetes, gestational diabetes, cancer, heart failure, orthopedic problems, long-term pain, and neuromuscular rehabilitation) and interviews with all participants involved in these consultations. Using Linguistic Ethnography, which embeds detailed analysis of verbal and nonverbal communication in the context of the interaction, we examined the interactional, technological, and clinical work carers did to facilitate video consultations and help patients and clinicians overcome challenges of the remote and video-mediated context.

RESULTS

Most patients (40/52, 77%) participated in the video consultation without support from an informal carer. Only 23% (12/52) of the consultations involved an informal carer. In addition to facilitating the clinical interaction (eg, answering questions on behalf of the patient), we identified 3 types of work that informal carers did: facilitating the use of technology; addressing problems when the patient could not hear or understand the clinician; and assisting with physical examinations, acting as the eyes, ears, and hands of the clinician. Carers often stayed in the background, monitoring the consultation to identify situations where they might be needed. In doing so, copresent carers reassured patients and helped them conduct the activities that make up a consultation. However, carers did not necessarily help patients solve all the challenges of a video consultation (eg, aiming the camera while laying hands on the patient during an examination). We compared cases where an informal carer was copresent with cases where the patient was alone, which showed that carers provided an important safety net, particularly for patients who were frail and experienced mobility difficulties.

CONCLUSIONS

Informal carers play a critical role in making video consultations safe and feasible, particularly for patients with limited technological experience or complex needs. Guidance and research on video consulting need to consider the availability and work done by informal carers and how they can be supported in providing patients access to digital health care services.

Evaluation of Nurse Navigator Support for Patients During Telehealth Neurosurgery Clinics

Telehealth clinics have been used in many specialities, including neurosurgery, to improve access for patients in rural communities. The introduction of nurse navigators involved with the patient before, during and after the clinic was evaluated. Clinics were held in a rural hospital with a nurse navigator present in the clinic with the patient, and the physician consulting remotely. A patient satisfaction survey and audit were conducted following ten telehealth clinics. Twenty-one new patients were able to be contacted out of 31 (68%) with an 11 question structured survey. Eighteen out of 21 (86%) stated they were satisfied with the quality of the clinic compared with an in-person clinic. Overall satisfaction scores of 7-10 were scored by 18/21 patients (86%) on a scale of 1-10. An estimated 10785 km of travel was saved for patients going to a rural hospital clinic rather than the neurosurgical centre. This study shows that the supportive role of nurse navigators throughout the patient telehealth clinic pathway merits further continuing evaluation.

Impact of COVID-19 pandemic on treatment and outcomes of cerebral arteriovenous malformations

BACKGROUND

There has been a recent decrease in interventional management of cerebral arteriovenous malformations (AVMs). The objective of our study was to evaluate the changing patterns in management of AVMs in the first year of the COVID-19 pandemic.

METHODS

The National Inpatient Sample (NIS) database was used. From 2016 to 2020, patients with an International Classification of Diseases, 10th revision (ICD-10) diagnosis code for a cerebral AVM were included. An intervention was defined as ICD-10 code for surgical, endovascular, or stereotactic radiosurgery treatment. Odds ratios (ORs) were calculated using a logistic regression model with covariates deemed to be clinically relevant.

RESULTS

63 610 patients with AVMs were identified between 2016 and 2020, 14 340 of which were ruptured. In 2020, patients had an OR of 0.69 for intervention of an unruptured AVM (P<0.0001) compared with 2016-19. The rate of intervention for unruptured AVMs decreased to 13.5% in 2020 from 17.6% in 2016-19 (P<0.0001). The rate of AVM rupture in 2020 increased to 23.9% from 22.2% in 2016-19 (P<0.0001). In 2020, patients with ruptured AVMs had an OR for inpatient mortality of 1.72 compared with 2016-19. Linear regression analysis from 2016 to 2020 showed an inverse relationship between intervention rate and rupture rate (slope -0.499, R2=0.88, P=0.019).

CONCLUSION

In 2020, the rate of intervention for unruptured cerebral AVMs decreased compared with past years, with an associated increase in the rate of rupture. Patients with ruptured AVMs also had a higher odds of mortality.

Challenges of Teleneurology in the Care of Complex Neurodegenerative Disorders: The Case of Parkinson's Disease with Possible Solutions

Teleneurology is a specialist field within the realm of telemedicine, which is dedicated to delivering neurological care and consultations through virtual encounters. Teleneurology has been successfully used in acute care (e.g., stroke) and outpatient evaluation for chronic neurological conditions such as epilepsy and headaches. However, for some neurologic entities like Parkinson's disease, in which an in-depth physical examination by palpating muscles and performing neurologic maneuvers is the mainstay of monitoring the effects of medication, the yield and feasibility of a virtual encounter are low. Therefore, in this prospective review, we discuss two promising teleneurology approaches and propose adjustments to enhance the value of virtual encounters by improving the validity of neurological examination: 'hybrid teleneurology', which involves revising the workflow of virtual encounters; and 'artificial intelligence (AI)-assisted teleneurology', namely the use of biosensors and wearables and data processing using AI.

Parenthood and neurosurgery in Europe, a white paper from the European association of neurosurgical societies' diversity in neurosurgery committee, part II - practice with children

Introduction

In the first part of this White Paper, the European Association of Neurosurgical Societies (EANS) Diversity in Neurosurgery Committee (DC) addressed the obstacles faced by neurosurgeons when planning to have a family and practice during pregnancy, attempting to enumerate potential, easily implementable solutions for departments to be more family-friendly and retain as well as foster talent of parent-neurosurgeons, regardless of their gender identity and/or sexual orientation. Attrition avoidance amongst parent-neurosurgeons is at the heart of these papers.

Research question

In this second part, we address the obstacles posed by practice with children and measures to mitigate attrition rates among parent-neurosurgeons. For the methodology employed to compose this White Paper, please refer to Supplementary Electronic Materials (SEM) 1.

Materials and methods

For composing these white papers, the European Association of Neurosurgical Societies (EANS)'s Diversity Committee (DC) recruited neurosurgeon volunteers from all member countries, including parents, aspiring parents, and individuals without any desire to have a family to create a diverse and representative working group (WG).

Results

In spite of the prevailing heterogeneity in policies across the continent, common difficulties can be identified for both mothers and fathers considering the utilization of parental leave.

Discussion and conclusion

Reconciliation of family and a neurosurgical career is challenging, especially for single parents. However, institutional support in form of childcare facilities and/or providers, guaranteed lactation breaks and rooms, flexible schedule models including telemedicine, and clear communication of policies can improve working conditions for parent-neurosurgeons, avoid their attrition, and foster family-friendly work environments.

Healthcare professional and manager perceptions on drivers, benefits, and challenges of telemedicine: results from a cross-sectional survey in the Italian NHS

BACKGROUND

The Covid-19 pandemic provided new challenges and opportunities for patients and healthcare providers while accelerating the trend of digital healthcare transformation. This study explores the perspectives of healthcare professionals and managers on (i) drivers to the implementation of telemedicine services and (ii) perceived benefits and challenges related to the use of telemedicine across the Italian National Health Service.

METHODS

An online cross-sectional survey was distributed to professionals working within 308 healthcare organisations in different Italian regions. Quantitative and qualitative data were collected through a self-administered questionnaire (June-September 2021). Responses were analysed using summary statistics and thematic analysis.

RESULTS

Key factors driving the adoption of telemedicine have been grouped into (i) organisational drivers (reduce the virus spread-80%; enhance care quality and efficiency-61%), (ii) technological drivers (ease of use-82%; efficacy and reliability-64%; compliance with data governance regulations-64%) and (iii) regulatory drivers (regulations' semplification-84%). Nearly all respondents perceive telemedicine as useful in improving patient care (96%). The main benefits reported by respondents are shorter waiting lists, reduced Emergency Department attendance, decreased patient and clinician travel, and more frequent patient-doctor interactions. However, only 7% of respondents believe that telemedicine services are more effective than traditional care and 66% of the healthcare professionals believe that telemedicine can't completely substitute in-person visits due to challenges with physical examination and patient-doctor relationships. Other reported challenges include poor quality and interoperability of telemedicine platforms and scarce integration of telemedicine with traditional care services. Moreover, healthcare professionals believe that some groups of patients experience difficulties in accessing and using the technologies due to socio-cultural factors, technological and linguistic challenges and the absence of caregivers.

CONCLUSIONS

Respondents believe that telemedicine can be useful to complement and augment traditional care. However, many challenges still need to be overcome to fully consider telemedicine a standard of care. Strategies that could help address these challenges include additional regulations on data governance and reimbursements, evidence-based guidelines for the use of telemedicine, greater integration of tools and processes, patient-centred training for clinicians, patient-facing material to assist patients in navigating virtual sessions, different language options, and greater involvement of caregivers in the care process.

The Direction of Neurosurgery to Overcome the Living with COVID-19 Era : The Possibility of Telemedicine in Neurosurgery

OBJECTIVE

Due to the implementation of vaccinations and the development of therapeutic agents, the coronavirus disease 2019 (COVID-19) pandemic that started at the end of 2019 has entered a new phase. As a result, neurosurgeons should reconsider the way they treat their patients. As the COVID-19 situation prolongs, the change in neurosurgical emergency patients according to the number of confirmed cases is no longer clear. Outpatient treatment by telephone was permitted according to government policy. In addition, visits to caregivers in the intensive care unit were limited.

METHODS

The electronic medical records of patients who had been treated over the phone for a month (during April 2020, while the hospital was closing) were reviewed. Meanwhile, according to the limited visits to the intensive care unit, a video meeting was held with the caregivers. After the video meeting, satisfaction was evaluated using a questionnaire.

RESULTS

During April 2020, 1021 patients received non-face-to-face care over the telephone. Among the patients, no critical medical problem occurred due to non-face-to-face care. From July 2021 to December 2021, 321 patients were admitted to the neurosurgical intensive care unit and 107 patients (33.3%) including their caregivers agreed to video visits. Twice a week, advance notice was given that access would be made through a mobile device and the nurse explained to caregivers how to use the mobile device. The time for the video meeting was approximately 20 minutes per patient. Based on the questionnaire, 81 respondents (75.7%) answered that they agreed, and 26 respondents (24.3%) answered that they strongly agreed that was easy to communicate through video meetings. Fifty-two (48.6%) agreed and 55 (51.4%) strongly agreed that they were easy to understand the doctor's explanation. For overall satisfaction with this video meeting, three respondents (2.8%) gave 4/5 points and 95 respondents (88.8%) gave 5/5 points, and nine (8.4%) gave 3/5 points. Their reason was that there was not enough time.

CONCLUSION

In situations where patient visits are limited, video meetings through a mobile device can provide sufficient satisfaction to caregivers. Telemedicine will likely become common in the near future. Health care professionals should prepare and respond to these needs and changes. Therefore, establishing a system with institutional support is necessary.

Resource utilization in management of spontaneous intracerebral hemorrhage without systemic risk factors. Does early surgical decompression matter?

BACKGROUND

Even though different subtypes of spontaneous ICH are frequently linked to a poor prognosis, their causes, pathological features, and prognoses vary. Atypical intracerebral hemorrhage is the subtype of spontaneous ICH that usually occurs due to an underlying localized vascular lesion. It is unrelated to systemic vascular risk factors, mostly affects children and young adults and is associated with a relatively good outcome. This fact should be considered when planning the evaluation and treatment. Investigating the cause of this subtype is fundamental to providing optimal management. However, if resources do not allow completing the investigations, the cause will be more difficult to discover. Treatment decisions will be made under stress to save the patient's life, especially with rapidly deteriorating patients.

METHODS

We described three cases of spontaneous ICH without systemic risk factors where the bleeding source could not be determined before surgery due to a lack of resources, preventing preoperative vascular investigation. Knowing that the atypical ICH has a distinct identity, regarding etiology and prognosis, encouraged the surgeons to resort to early surgical decompression as an alternative plan. We reviewed the literature searching for supporting evidence.

RESULTS

The results of treatment of the presented cases were satisfactory. The lack of reported similar cases was brought to light by a literature analysis that sought to provide backing for the proposed management strategy. In the end, we supplied two graphic organizers to help readers remember the different types and treatment of hemorrhagic stroke.

CONCLUSION

There isn't enough evidence to show that there are other ways to treat atypical intracerebral haemorrhage when resources are limited. The presented cases highlight the importance of decisionmaking in resource-constrained situations when patient outcomes can be improved.

Outcomes of Telestroke Inter-Hospital Transfers Among Intervention and Non-Intervention Patients

Background

Telestroke is an established telemedicine method of delivering emergency stroke care. However, not all neurological patients utilizing telestroke service require emergency interventions or transfer to a comprehensive stroke center. To develop an understanding of the appropriateness of inter-hospital neurological transfers utilizing the telemedicine, our study aimed to assess the differences in outcomes of inter-hospital transfers utilizing the service in relation to the need for neurological interventions.

Methods

The pragmatic, retrospective analysis included 181 consecutive patients, who were emergently transferred from telestroke-affiliated regional medical centers between October 3, 2021, and May 3, 2022. In this exploratory study investigating the outcomes of telestroke-referred patients, patients receiving interventions were compared to those that did not following transfer to our tertiary center. Neurological interventions included mechanical thrombectomy (MT) and/or tissue plasminogen activator (tPA), craniectomy, electroencephalography (EEG), or external ventricular drain (EVD). Transfer mortality rate, discharge functional status defined by modified Rankin scale (mRS), neurological status defined by National Institutes of Health Stroke Scale (NIHSS), 30-day unpreventable readmission rate, 90-day clinical major adverse cardiovascular events (MACE), and 90-day mRS, and NIHSS were studied. We used χ2 or Fisher exact tests to evaluate the association between the intervention and categorical or dichotomous variables. Continuous or ordinal measures were compared using Wilcoxon rank-sum tests. All tests of statistical significance were considered to be significant at P < 0.05.

Results

Among the 181 transferred patients, 114 (63%) received neuro-intervention and 67 (37%) did not. The death rate during the index admission was not statistically significant between the intervention and non-intervention groups (P = 0.196). The discharge NIHSS and mRS were worse in the intervention compared to the non-intervention (P < 0.05 each, respectively). The 90-day mortality and cardiovascular event rates were similar between intervention and non-intervention groups (P > 0.05 each, respectively). The 30-day readmission rates were also similar between the two groups (14% intervention vs. 13.4% non-intervention, P = 0.910). The 90-day mRS were not significantly different between intervention and non-intervention groups (median 3 (IQR: 1 - 6) vs. 2 (IQR: 0 - 6), P = 0.109). However, 90-day NIHSS was worse in the intervention compared to non-intervention group (median 2 (IQR: 0 - 11) vs. 0 (IQR: 0 - 3), P = 0.004).

Conclusions

Telestroke is a valuable resource that expedites emergent neurological care via referral to a stroke center. However, not all transferred patients benefit from the transfer process. Future multicenter studies are warranted to study the effects or appropriateness of telestroke networks, and to better understand the patient characteristics, resources allocation, and transferring institutions to improve telestroke care.

Evaluating patient and neurosurgeon perspectives on virtualisation of neurosurgery clinics in the COVID-19 era: a prospective mirror survey study

BACKGROUND

The COVID-19 pandemic has compelled a global shift in healthcare service delivery towards virtualisation, including in Neurosurgery. Our study aims to elucidate the patient and neurosurgeon perceptions of virtual neurosurgery consultations (VNCs) and formulate a guidance algorithm based on our experience.

METHODS

Between June 2020 and December 2020, we prospectively surveyed patients and neurosurgeons following their VNCs using a 10-item survey (four qualitative and six five-point Likert scale questions). Non-parametric hypothesis testing and grounded coding with inter-coder agreement was used to analyse quantitative and qualitative data, respectively.

RESULTS

106 patients and 10 neurosurgeons completed the survey. Wilcoxon rank-sum test revealed a statistically significant difference between the neurosurgeon and patient responses (p < 0.001). Patients perceived VNCs benefits to be enhanced efficiency (n = 142) and communication (28); and VNCs drawbacks as safety (46), technological (32), and administration (15) issues. Neurosurgeons perceived VNCs benefits to be enhanced efficiency (13), reduced COVID-19 exposure (2); and VNCs drawbacks as examination practicality (14), technological (6), and concerns for patients (6). Neurosurgeons perceived the relative indications for VNCs as postoperative follow-up clinics, and scan result discussions; and relative contraindications as neuro-oncology, new patients, and patients with worsening neurological symptoms.

CONCLUSIONS

Our mirror-survey study provides preliminary evidence that VNCs render increased efficiency, communication, and safety in the current COVID-19 era. Going forward, we believe that further improvements in technology and administration are necessary, greater neurosurgeon appreciation of the patient-perceived benefits of VNCs is required, and neurosurgeons are to exercise clinical discernment on when to use VNCs.Key PointsWhat are the perceptions of patient and consultant neurosurgeons towards virtual neurosurgery consultations (VNCs)?Patient-perceived benefits of VNCs: enhanced efficiency/communication; VNC drawbacks: safety, technological, and administration issues. Neurosurgeon-perceived VNCs benefits of VNCs: enhanced efficiency, reduced COVID-19 exposure; VNC drawbacks: examination practicality, technological, and concerns for patients.Post-operative reviews and scan result discussions are perceived relative indications for VNCs; whereas new patient consultations, neuro-oncology and patients with new-onset neurological deficits are perceived relative contraindications for VNCs.Improvement in technology and administration is necessary; greater neurosurgeon appreciation of patient-perceived VNCs benefits is required, and neurosurgeons are to exercise clinical discernment on when to use VNCs.

Process improvement using telemedicine consultation to prevent unnecessary interfacility transfers for low-severity blunt head trauma

OBJECTIVE

Mild traumatic brain injuries (MTBI) associated with intracranial haemorrhage are commonly transferred to tertiary care centres. Recent studies have shown that transfers for low-severity traumatic brain injuries may be unnecessary. Trauma systems can be overwhelmed by low acuity patients justifying standardisation of MTBI transfers. We sought to evaluate the impact of telemedicine services on mitigating unnecessary transfers for those presenting with low-severity blunt head trauma after sustaining a ground level fall (GLF).

METHOD

A process improvement plan was developed by a task force of transfer centre (TC) administrators, emergency department physicians (EDP), trauma surgeons and neurosurgeons (NS) to facilitate the requesting EDP and the NS on-call to converse directly to mitigate unnecessary transfers. Consecutive retrospective chart review was performed on neurosurgical transfer requests between 1 January 2021 and 31 January 2022. A comparison of transfers preintervention and postintervention (1 January 2021 to 12 September 2021)/(13 September 2021 to 31 January 2022) was performed.

RESULTS

The TC received 1091 neurological-based transfer requests during the study period (preintervention group: 406 neurosurgical requests; postintervention group: 353 neurosurgical requests). After consultation with the NS on-call, the number of MTBI patients remaining at their respective ED's with no neurological degradation more than doubled from 15 in the preintervention group to 37 in the postintervention group.

CONCLUSION

TC-mediated telemedicine conversations between the NS and the referring EDP can prevent unnecessary transfers for stable MTBI patients sustaining a GLF if needed. Outlying EDPs should be educated on this process to increase efficacy.

Acceptability and feasibility of telehealth outpatient video-link consultations: A national cross-sectional survey of surgeons prior to the COVID-19 pandemic

OBJECTIVE

This study explored use and perceived barriers to the use of post-operative video-link telehealth among a sample of Australian surgeons shortly before the COVID-19 pandemic.

METHODS

During 2019-2020, a survey was mailed to RACS or RANZCOG Fellows.

DESIGN

Cross-sectional survey.

SETTING AND PARTICIPANTS

A total of 907 surgeons practising in Australia completed the survey.

MAIN OUTCOME MEASURES

The study-specific survey assessed telehealth use in the last 3 months and the perceived barriers and enablers to the use of post-operative teleconsultations, across the domains: quality of care; convenience and efficiency; legal/regulatory issues; financial issues and technological issues.

RESULTS

Twenty-five percent of eligible surgeons returned the survey, with n = 763 pre-pandemic responses included in analyses. Approximately one-quarter (26%) of surgeons had used telehealth post-operatively with patients in the last 3 months. The most frequently endorsed barriers to use related to quality of care: 'I cannot undertake a patient examination' and 'I cannot provide the same level of care as during an in-person consultation'; and convenience and efficiency: 'Teleconsultations are more difficult to arrange'. Surgeons who had recently used telehealth were less likely to endorse most barriers. Younger age, awareness of Medicare telehealth reimbursement and working in neurosurgery, urology, paediatric surgery and plastic and reconstructive surgery (compared to general surgery) were associated with recent telehealth use by surgeons.

CONCLUSIONS

Some surgeons' perceived barriers to telehealth pre-COVID may be overcome by COVID-19-related telehealth uptake and familiarisation. However, many barriers will need to be addressed to ensure that telehealth adoption is sustained beyond the pandemic.

Interactive Neurosurgery Lecture Series: A Global Education Platform of Tele-Teaching During the Coronavirus Disease 2019 Pandemic and Beyond

OBJECTIVE

To explore the worldwide impact of a virtual neurosurgery-neuroscience lecture series on optimizing neurosurgical education with tele-teaching.

METHODS

A retrospective analysis was performed from our Zoom database to collect data from October 15, 2020, to December 14, 2020, and from September 27, 2021, to December 13, 2021. A comparative analysis of participants in the 2 different time frames was performed to investigate the impact of tele-teaching on neurosurgical education worldwide. To evaluate participant satisfaction, the yearly continuing medical education reports of 2020-2021 were analyzed. Data related to the distribution of lectures by subspecialties were also described.

RESULTS

Among the 11 lectures of the first period, 257 participants from 17 countries in 4 different continents were recorded, with a mean of 64 (standard deviation = 9.30) participants for each meeting; 342 attendees participated from 19 countries in 5 continents over the 11 lectures of the second part, with an average of 82.8 (standard deviation = 14.04) attendees; a statistically significant increase in participation between the 2 periods was identified (P < 0.001) A total of 19 (2020) and 21 (2021) participants submitted the continuing medical education yearly survey. More than 86.4% of overall responses considered the lectures "excellent." The main topics reported during lectures in 2020-2021 were related to brain tumors (33.7%) and education (22.1%).

CONCLUSIONS

The COVID-19 pandemic has increased the need to introduce new educational approaches for teaching novel ways to optimize patient care. Our multidisciplinary Web-based virtual lecture series could represent an innovative tele-teaching platform in neurosurgical training.

The use of telemedicine in pre-surgical evaluation: a retrospective cohort study of a neurosurgical oncology practice

PURPOSE

To determine if there was a discrepancy between telemedicine versus in-person New Patient Visits (NPVs) regarding the conversion rate to operative and radiosurgery cases at a tertiary surgical neuro-oncology practice.

METHODS

A retrospective analysis was performed of patients who had an outpatient encounter with a neurosurgeon from the Tumor Division at our institution's Department of Neurosurgery between February 1, 2021 and April 30, 2021. NPVs during this period were registered as either telemedicine or in-person appointments. The primary endpoint of the study was to compare the rate at which telemedicine NPVs and in-person NPVs underwent surgery or radiosurgery, reported as the surgical conversion rate.

RESULTS

A total of 206 patients were included in this study. Of them, 119 (57.8%) were seen using telemedicine and 87 (42.2%) were seen in clinic via an in-person visit. A total of 70 (34%) of all patients underwent surgery or radiosurgery. Of the 119 patients seen via telemedicine, 40 (33.6%) underwent surgery or radiosurgery; during the same period, 87 NPVs were conducted in person and 30 (34.5%, p = 1.0) received an intervention. Further stratification revealed no differences between the two groups across measured criteria including diagnosis, number of pre-operative visits, elapsed time from appointment to surgery, follow-up visits, and distance from home address to neurosurgical clinic.

CONCLUSION

Telemedicine NPVs did not differ significantly from in-person NPVs when evaluating the likelihood of a new patient committing to surgical treatment. This study provides quantifiable evidence that telemedicine is an effective means of meeting new patients and planning complex neurosurgical interventions.

Telemedicine in practice: Patient selection and strategies adopted in spinal care during the COVID-19 era and beyond

Background:

The SARS-CoV-2 (COVID-19) pandemic has had a substantial effect on health-care systems around the world. To deal with this challenge, we developed a prospectus design and test a teleconsultation procedure suitable for both diagnostic and therapeutic needs of outpatients in our Spine and Spinal Cord Surgery Units.

Methods:

(1) The first 15 patients received in-person and telemedicine visits: Our pilot began with screening protocol that involved 15 patients who received an in-person assessment and a telemedicine consult. The 15 patients who were selected were already known to our unit after having had at least one previous in-person visit. Further, they had to be neurologically intact or have a stable neurological examination. The secondary teleconsultation took place as a synchronous face-to-face communication between the doctor and the patient through a video interface (Lifesize Video Conferencing, Austin, Texas). If the patient demonstrated worsening of symptoms or of their condition, they were rescheduled for an immediate/timely in-person revisit with a spinal physician. (2) Fifty patients were offered telemedicine visits alone: 35 accepted: Next, from 2020 to 2021, we provided a questionnaire to 50 patients, we deemed eligible for teleconsultations: 35 agreed to the teleconsultations, while 15 refused (i.e., selecting direct in-person assessments).

Results:

We found a comparable quality for the clinical consultations/assessments provided in-person versus through telemedicine. Further, the additional 35 patients who were positively impressed with the quality of the medical care provided utilizing the telemedicine/remote visits alone.

Conclusion:

When pandemic conditions worsen, telemedicine appears to be a viable and important tool/ alternative for spinal surgeons to screen potential patients for treatment/surgery. This preliminary study suggests that a remote examination may be effective, particularly in patients who have previously undergone prior in-person evaluations.

Challenges of Telemedicine during the COVID-19 pandemic: a systematic review

BACKGROUND

The COVID-19 pandemic has prompted the decrease of in-person visits to reduce the risk of virus transmission. Telemedicine is an efficient communication tool employed between healthcare providers and patients that prevents the risk of exposure to infected persons. However, telemedicine use is not infallible; its users reported multiple issues that complicated the expansion of this technology. So, this systematic review aimed to explore the barriers and challenges of telemedicine use during the pandemic and to propose solutions for improving future use.

METHODS

A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement. PubMed, Scopus, Web of Science, Academic Search Complete, CINAHL, Embase, and Science Direct were used to look for articles addressing barriers and challenges, in addition to articles proposing solutions. Studies were screened by title and abstract, followed by a full-text review. Risk of bias assessment was done using Critical Appraisal Skills Program for qualitative studies, Newcastle-Ottawa Scale for cross-sectional studies, and A MeaSurement Tool to Assess Systematic Reviews for systematic reviews. After the extraction of data, a narrative synthesis and analysis of the outcomes were performed.

RESULTS

Among 1194 papers identified, only 27 studies were included. Barriers and challenges were assembled under 7 categories: technical aspects, privacy, data confidentiality and reimbursement, physical examination and diagnostics, special populations, training of healthcare providers and patients, doctor-patient relationship, and acceptability. Poor internet connection and lack of universal access to technology were among the technical barriers. Concerns about patient privacy and reimbursement hindered the use of telemedicine too. Physical examination and certain procedures were impossible to perform via telemedicine. Training both healthcare providers and patients was deficient. The doctor-patient relationship was troubled by telemedicine, and both healthcare providers and patients were reluctant to use telemedicine.

CONCLUSION

Widespread use of telemedicine is still hampered by various barriers and challenges. Healthcare providers should work with various stakeholders to implement the proposed solutions. More research and policy changes are essential to optimize telemedicine utilization.

Telemedicine and the right to health: A neurosurgical perspective

Neurosurgical task force is limited and unevenly distributed. Telemedicine has become increasingly popular, and could help neurosurgical centers meet patient right to care. This scoping review aims to evaluate the impact and feasibility of telemedicine on the right to neurosurgical care, using the AAAQ toolbox. The AAAQ toolbox consists of Availability, Accessibility, Acceptability and Quality. Neurosurgical availability is limited by the number of neurosurgeons, but by using task shifting and -sharing via telemedicine, the number of patients receiving neurosurgical care could increase without increasing the number of neurosurgeons. Telemedicine can improve geographic accessibility to neurosurgical care, but may also introduce technological literacy barriers. Acceptability of telemedicine is a double-edged sword; while a useful service, telemedicine also creates ethical concerns regarding privacy and confidentiality. Regulations and adaptations for vulnerable patient groups are key considerations for deploying telemedicine. Finally, there is emerging evidence that the quality of remote neurosurgical diagnostics and care can keep high standards. Overall, telemedicine has the potential of taking neurosurgery one step closer to meeting patient right to health, globally.

Family-acquired photographs for the evaluation of pediatric head shape via telemedicine: an analysis of photograph quality

OBJECTIVE

Telemedicine can be an effective tool for the evaluation of the pediatric patient with a cranial deformity, but it increases the reliance of neurosurgical providers on data provided by patients and families. Family-acquired photographs, in particular, can be used to augment the evaluation of pediatric head shape abnormalities via telemedicine, but photographs of sufficient quality are necessary. Here, the authors systematically reviewed the quality and utility of family-acquired photographs for patients referred to their pediatric neurosurgery clinic for telemedicine-based head shape evaluations.

METHODS

All telemedicine encounters that were completed for head shape abnormalities at the authors’ institution between May 2020 and December 2021 were retrospectively reviewed. Instructions were sent to families prior to each visit with examples of ideal photographs. Three orthogonal views of the patient’s head—frontal, lateral, and vertex—were requested. Data were collected regarding demographics, diagnosis, follow-up, and photograph quality. Quality variables included orthogonality of each requested view, appropriate distance, appropriate lighting, presence of distracting elements, and whether hair obscured the head shape.

RESULTS

Overall, 565 patients had 892 visits during the study period. A total of 1846 photograph requests were made, and 3335 photographs were received for 829 visits. Of 2676 requested orthogonal views, 1875 (70%) were received. Of these, 1826 (97%) had adequate lighting, 1801 (96%) had appropriate distance, and 1826 (97%) had no distracting features. Hair did not obscure the head shape on the vertex view in 557 visits with orthogonal vertex views (82%). In-person follow-up was requested for further medical evaluation in 40 visits (5%).

CONCLUSIONS

The family-acquired photographs in this series demonstrated high rates of adequate lighting and distance, without distracting features. Lack of orthogonality and obscuration of the head shape by hair, however, were more common issues. Family education prior to the visit may improve the quality of family-acquired photographs but requires an investment of time by medical staff. Efforts to further improve photographic quality will facilitate efforts to perform craniometric evaluations through telemedicine visits.

The Legal and Socioeconomic Considerations in Spine Telemedicine

Telemedicine has become indispensable in today's health care because of the recent ongoing COVID-19 crisis. Although it has been beneficial in coping with the pandemic, there is still much uncertainty as to whether it will have a permanent role in treating spine patients. Some of the ongoing legal challenges include patient confidentiality, liability coverage for treating healthcare workers, and financial reimbursements by insurance companies. One of the impediments of telemedicine is its lack of a standard legal framework. Telehealth is currently regulated through a state-based system with each state having its own policy regarding this practice. In addition, each of the components of a virtual visit represent a potential area for legal concerns. Nonetheless, telemedicine has the ability to provide convenient and effective health care to patients. However, the spine surgeon, as well as other physicians, must consider the legal issues along with some socioeconomic factors identified herein. Moreover, without parity and uniformity, the incentive to offer telehealth services decreases. There may be a need for modifications in the law, insurance policies, and medical malpractice coverage to strengthen their support to telemedicine usage. As spine surgeons become more familiarized with the telemedicine framework, its role in patient care will likely expand.

Parental Satisfaction from Telemedicine in the Follow-up of Children Operated for Craniosynostosis during COVID-19 Pandemic

OBJECTIVE

The current study aimed to evaluate the satisfaction level of parents from telemedicine use in the long-term follow-up of children operated for craniosynostosis during the COVID-19 pandemic.

DESIGN

A cross-sectional 9-question survey analysis using Qualtrics survey software.

SETTING

An institutional study carried out at a national, tertiary level academic center in the Slovak Republic.

PATIENTS

All patients operated for non-syndromic and syndromic craniosynostosis in our department, who participated in the virtual postoperative follow-up consultations from March 23, 2020, through July 2, 2021, were included in our series. They were enrolled 498 patients, with the parents of 256 children being responding to the survey.

INTERVENTIONS

The survey remained open until July 16, 2021, two weeks after the last virtual consultations. It was delivered to the parents by e-mail to generate closed 5-point Likert scale responses.

RESULTS

Overall, 72.3% of parents were satisfied with the telemedicine program, and 67.2% found it convenient. Collectively, 89.1% reported that the received instructions were helpful to them. However, only 18.7% of them answered that they would prefer telemedicine consultations in the future.

CONCLUSION

The results of this study showed a high satisfaction from the parents during the virtual follow-up of children operated for craniosynostosis. However, despite their positive experience with telemedicine, the vast majority of parents stated that they would prefer in-person visits in the future.

The impact of telephone consultations due to COVID-19 on paediatric neurosurgical health services

PURPOSE

The aim of the study was to evaluate the role of telephone consultations due to the pandemic in the management of paediatric neurosurgical patients and, furthermore, to examine the proportion of patients who eventually needed a face-to-face appointment and assess the underline reasons for that.

METHODS

This retrospective study included all the paediatric neurosurgical patients who had a telephone appointment during a 3-month lockdown period. Overall, 319 patients (186 males and 133 females) aged 8.36 ± 4.88 (mean ± SD) had a consultation via telephone. Two hundred fifty-one (78.7%) patients had a follow-up assessment and 68 (21.3%) were new appointments.

RESULTS

Patients were divided between two main groups. Group A included 263 patients (82.4%) whose consultation was adequate via telephone, and Group B included 56 patients (17.6%) who required a complementary face-to-face appointment. Patients who were more likely to require a supplementary appointment were patients with either dysraphism or ventriculomegaly and benign enlarged subarachnoid spaces (BESS) (43.3% and 36.4%, respectively). Interestingly, most children with hydrocephalus who underwent a cerebrospinal fluid (CSF) diversion procedure and children with Chiari I malformation were appropriately assessed via telephone (85.1% and 83.3%, respectively). Finally, children aged < 2 years (55.2%) were better managed with face-to-face appointments. No difference was noticed regarding follow-up and new appointments.

CONCLUSION

Although telemedicine was not unknown to neurosurgical services, the actual application of telephone or video consultations remained quite limited. It was COVID-19 pandemic who reinforced the use of telemedicine, and taking into consideration its promising results, we can safely assume that it can be incorporated into neurosurgical health care even once the pandemic crisis has resolved.

The Role of Telemedicine in Surgical Specialties During the COVID-19 Pandemic: A Scoping Review

BACKGROUND

The objective of this study was to evaluate the current body of evidence on the use of telemedicine in surgical subspecialties during the COVID-19 pandemic.

METHODS

This was a scoping review conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). MEDLINE via Ovid, PubMed, and EMBASE were systematically searched for any reports discussing telemedicine use in surgery and surgical specialties during the first period (February 2020-August 8, 2020) and second 6-month period (August 9-March 4, 2021) of the COVID-19 pandemic.

RESULTS

Of 466 articles screened through full text, 277 articles were included for possible qualitative and/or quantitative data synthesis. The majority of publications in the first 6 months were in orthopedic surgery, followed by general surgery and neurosurgery, whereas in the second 6 months of COVID-19 pandemic, urology and neurosurgery were the most productive, followed by transplant and plastic surgery. Most publications in the first 6 months were opinion papers (80%), which decreased to 33% in the second 6 months. The role of telemedicine in different aspects of surgical care and surgical education was summarized stratifying by specialty.

CONCLUSION

Telemedicine has increased access to care of surgical patients during the COVID-19 pandemic, but whether this practice will continue post-pandemic remains unknown.

Construction and Application of an Intelligent Response System for COVID-19 Voice Consultation in China: A Retrospective Study

Background: The outbreak of novel coronavirus disease 2019 (COVID-19) has led to tremendous individuals visit medical institutions for healthcare services. Public gatherings and close contact in clinics and emergency departments may increase the exposure and cross-infection of COVID-19.

Objectives: The purpose of this study was to develop and deploy an intelligent response system for COVID-19 voice consultation, to provide suggestions of response measures based on actual information of users, and screen COVID-19 suspected cases.

Methods: Based on the requirements analysis of business, user, and function, the physical architecture, system architecture, and core algorithms are designed and implemented. The system operation process is designed according to guidance documents of the National Health Commission and the actual experience of prevention, diagnosis and treatment of COVID-19. Both qualitative (system construction) and quantitative (system application) data from the real-world healthcare service of the system were retrospectively collected and analyzed.

Results: The system realizes the functions, such as remote deployment and operations, fast operation procedure adjustment, and multi-dimensional statistical report capability. The performance of the machine-learning model used to develop the system is better than others, with the lowest Character Error Rate (CER) 8.13%. As of September 24, 2020, the system has received 12,264 times incoming calls and provided a total of 11,788 COVID-19-related consultation services for the public. Approximately 85.2% of the users are from Henan Province and followed by Beijing (2.5%). Of all the incoming calls, China Mobile contributes the largest proportion (66%), while China Unicom and China Telecom are accounted for 23% and 11%. For the time that users access the system, there is a peak period in the morning (08:00–10:00) and afternoon (14:00–16:00), respectively.

Conclusions: The intelligent response system has achieved appreciable practical implementation effects. Our findings reveal that the provision of inquiry services through an intelligent voice consultation system may play a role in optimizing the allocation of healthcare resources, improving the efficiency of medical services, saving medical expenses, and protecting vulnerable groups.

High-quality neurosurgeon communication and visualization during telemedicine encounters improves patient satisfaction

INTRODUCTION

While recent studies have focused on confirming satisfaction with telemedicine during the coronavirus disease 2019 (COVID-19) era, we leveraged a novel survey instrument to identify associations between patient experience and telemedicine-specific factors such as device selection, audio/visual resolution, and connection stability.

METHODS

Telemedicine visit data were gathered from our institution between June 22, 2020 and February 14, 2021. Each patient indicated their overall visit score, likelihood-to-recommend (LTR) score, and device used for the encounter. Remaining questions were randomly distributed to patients to ensure equal distribution across respondents.

RESULTS

Over 34 weeks, there were 901 unique neurosurgical telemedicine visits linked to a post-visit survey at our institution. The LTR top box score percentage showed no significant change across 34 weeks (p = 0.218). After adjusting across available covariates, patients who experienced wait times exceeding 20 min were significantly less likely to report high overall scores (aOR: 0.12; 95% CI: 0.03-0.41; p = 0.001). Patients who indicated they were less able to understand the provider (aOR: 0.22; 95% CI: 0.07-0.66; p = 0.007), or who indicated the provider was not able to properly see them (aOR: 0.11; 95% CI: 0.03-0.43; p = 0.002) were associated with substantially lower overall scores. Visits with interrupted connectivity or those forced to move to a regular phone call were not important predictors of overall score.

CONCLUSIONS

In the largest description of patient satisfaction with telemedicine in the neurosurgical setting during the COVID-19 era, we identified timely and high-quality physician-patient visualization and communication as among the most important predictors of patient satisfaction in virtual settings.

Safety and Quality in Syndromic Neurosurgery

The developing field of syndromic neurosurgery has significant challenges and opportunities in quality and safety. Quality care must be safe, effective, patient-centered, timely, efficient, and equitable; the Donabedian model focused on system structures, processes, and outcomes is a helpful framework to guide improvement in these areas. Ultimately, a successful syndromic neurosurgery program will bring together an interested multidisciplinary team of experts who will grow care through open communication and steady improvement efforts.

Telemedicine for endovascular neurosurgery consultation during the COVID-19 era: patient satisfaction survey

Background

The coronavirus disease 2019 pandemic necessitated the use of telemedicine for most medical specialties, including neurosurgery, although before the pandemic, neurosurgeons infrequently used telemedicine for outpatient visits. We conducted a patient-centric evaluation of telemedicine in our endovascular neurosurgery practice, covering a 4-month period early in the pandemic.

Methods

Survey e-mails after telemedicine visits were sent to all patients who underwent an outpatient telemedicine visit between March 11, 2020, and June 22, 2020, at an endovascular neurosurgery clinic affiliated with a tertiary care center.

Results

Of 140 patients, 65 (46%) completed the e-mail survey. Of the 65 respondents, 35 (54%) agreed or strongly agreed with the statement that even before their telemedicine experience, they thought telemedicine would be a convenient way to receive a neurological consultation. After their telemedicine visit, 47 (72%) agreed or strongly agreed with this statement, and 28 (43%) agreed or strongly agreed that they would prefer telemedicine for future visits. Of the 65 respondents, 61 (94%) rated their telemedicine visit as average or better: 34 (52%) rated it excellent, 12 (18%) rated it above average, and 15 (23%) rated it average. When patients compared their telemedicine visit with a prior in-person clinic visit, only 10 of 44 patients (23%) thought the telemedicine visit was more complicated than an in-person visit, and 21 of 44 (48%) said they would prefer telemedicine for future visits.

Conclusions

Our patients expressed satisfaction with their telemedicine visits, and telemedicine will likely play an important role in future outpatient endovascular neurosurgery consultations.

Telehealth in surgery: an umbrella review

BACKGROUND

Telehealth use has increased worldwide during the COVID-19 pandemic. However, hands-on requirements of surgical care may have resulted in slower implementation. This umbrella review (review of systematic reviews) evaluated the perceptions, safety and implementation of telehealth services in surgery, and telehealth usage in Australia between 2020 and 2021.

METHODS

PubMed was searched from 2015 to 2021 for systematic reviews evaluating real-time telehealth modalities in surgery. Outcomes of interest were patient and provider satisfaction, safety, and barriers and facilitators associated with its use. Study quality was appraised using the AMSTAR 2 tool. A working group of surgeons provided insights into the clinical relevance to telehealth in surgical practice of the evidence collated.

RESULTS

From 2025 identified studies, 17 were included, which were of low to moderate risk of bias. Patient and provider satisfaction with telehealth was high. Time savings, decreased healthcare resource use and lower costs were reported as key advantages of the service. Inability to perform comprehensive examinations was noted as the primary barrier. In Australia, peak telehealth usage coincided with the introduction of temporary telehealth services and increased lockdown measures.

CONCLUSIONS

Patients and providers are broadly satisfied with telehealth and its benefits. Barriers may be overcome via multidisciplinary collaboration. Telehealth may benefit surgical care long-term if implemented correctly both during and after the COVID-19 pandemic.

Clinical effectiveness of and family experience with telephone consultation in a regional pediatric neurosurgery center in the United Kingdom

OBJECTIVE

Pediatric neurosurgery outpatient consultation is conducted face-to-face (FTF) conventionally. Reasons for not using telemedicine include the perceived difficulty with obtaining a reliable history and an inability to perform a physical examination. However, FTF consultation can cause distress and inconvenience to the child and family. In 2018, the authors' department piloted a clinical nurse specialist-led telephone consultation (TC) for follow-up appointments. This was extended to the routine neurosurgery clinics in 2020. In this study, the authors evaluate 1) the effectiveness of TC, 2) families' experience with TC compared with traditional FTF appointments, and 3) the factors associated with their preferences.

METHODS

In this prospective study using a survey methodology, TCs carried out by 2 consultant neurosurgeons and 1 nurse specialist over 8 weeks were evaluated. Based on clinical background, each patient was assigned to a TC or FTF appointment. Clinical and surgical details and home postal code were recorded. At the end of each TC, the clinician recorded whether the child required an FTF appointment within 3 months. In addition, patients/families answered 1) how the current TC compared with FTF consultation, and 2) their preference of TC or FTF for the next consultation.

RESULTS

A total of 114 TCs were included. No child required an FTF appointment within 3 months. Overall, compared with an FTF appointment, the TC was the "same/better/much better" for 101 families (89%), and "worse/much worse" for 13 (11%). Two-thirds of families preferred the next appointment to be a TC. Families attending a TC for new appointments preferred the next appointment to be FTF compared with those attending a follow-up TC (6/8 [75%] vs 31/106 [29%], p = 0.006). A high rating of the current TC was associated with a preference for a TC as the next appointment (p < 0.0001). Families preferring TC over FTF lived farther from the hospital (mean 38 vs 27 km) (p = 0.029).

CONCLUSIONS

From the clinicians' perspective, TC is adequate in appropriately selected patients as either the primary mode of consultation or as a triage system. From a service users' perspective, the majority of families felt that the appointment was the same/better than traditional FTF appointments. The findings suggested that 1) new patients should be offered FTF appointments; 2) follow-up TCs should be offered to families when possible; and 3) clinicians should develop their skills in conducting TCs. The authors' results have led to a modification of our algorithm in delivering traditional outpatient service and telemedicine with telephone.

United States Medicolegal Progress and Innovation in Telemedicine in the Age of COVID-19: A Primer for Neurosurgeons

Telemedicine has received increased attention in recent years as a potential solution to expand clinical capability and patient access to care in many fields, including neurosurgery. Although patient and physician attitudes are rapidly shifting toward greater telemedicine use in light of the COVID-19 pandemic, there remains uncertainty about telemedicine's regulatory future. Despite growing evidence of telemedicine's utility, there remain a number of significant medicolegal barriers to its mass adoption and wider implementation. Herein, we examine recent progress in state and federal regulations in the United States governing telemedicine's implementation in quality of care, finance and billing, privacy and confidentiality, risk and liability, and geography and interstate licensure, with special attention to how these concern teleneurosurgical practice. We also review contemporary topics germane to the future of teleneurosurgery, including the continued expansion of reciprocity in interstate licensure, expanded coverage for homecare services for chronic conditions, expansion of Center for Medicare and Medicaid Services reimbursements, and protections of store-and-forward technologies. Additionally, we discuss recent successes in teleneurosurgery, stroke care, and rehabilitation as models for teleneurosurgical best practices. As telemedicine technology continues to mature and its expanse grows, neurosurgeons' familiarity with its benefits, limitations, and controversies will best allow for its successful adoption in our field to maximize patient care and outcomes.