Implementing Virtual Care in Neurology - Challenges and Pitfalls

Telestroke Training: Considerations for Expansion of Vascular Neurology Program Requirements

Telemedicine for stroke (Telestroke) has been a key component to efficient, widespread acute stroke care for many years. The expansion of reimbursement through the Furthering Access to Stroke Telemedicine Act and rapid deployment of telemedicine resources during the COVID-19 public health emergency have further expanded remote care, with practitioners of varying educational backgrounds, and experience providing acute stroke care via telemedicine (Telestroke). Some Telestroke practitioners have not had fellowship-level vascular neurology training and many are without training specific to virtual modalities. While many vascular neurology fellowship programs incorporate Telestroke training into the curriculum, components of this curriculum are not consistent, extent of involvement is variable, and not all fellows receive hands-on training in remote care. Furthermore, the extent of training and evaluation of Telestroke in American Board of Psychiatry and Neurology training requirements and Accreditation Council for Graduate Medical Education assessments for vascular neurology fellowship are not standardized. We suggest that Telestroke be formally incorporated into vascular neurology fellowship curricula and provide considerations for key components of this training and metrics for evaluation.

Virtual neurology survey: Factors influencing virtual care use among Ontario neurologists

Background and objectives

Current virtual care guidance lacks specialty-specific considerations. Neurological care is unique due to its reliance on physical examination and complex patient population. Our aim was to determine which factors impact virtual care suitability in neurology, virtual care adoption patterns, and satisfaction with virtual care among neurologists.

Methods

Surveys were sent to Ontario neurologists through a shared email from September to November 2021. The survey consisted of four parts: demographics, virtual care adoption patterns, factors influencing virtual care use, and physician satisfaction with virtual care.

Results

Sixty-six of 380 (17.4%) neurologists completed the survey. The pandemic resulted in a substantial increase in virtual care use, from 1.6% of all ambulatory visits in 2019 to 70.6% in 2020. Video teleconferencing was considered more appropriate across a broader range of presentations than phone visits, with both methods more suited to follow-ups. Neurologists were largely satisfied with virtual care except for the virtual neurological examination. The neurological presentations identified as least amenable to virtual consultation were movement disorders, limb weakness, gait/balance changes, and vision changes. Four presentations were felt to be most amenable to virtual care: sleep disorders, seizure, headache, and dizziness/syncope. Factors that were felt to reduce virtual care suitability included discussion of sensitive topics and acute presentations.

Conclusion

Neurologists were satisfied with virtual care as a means of providing outpatient care, though the specific reason for referral influenced perceived appropriateness. These results can inform the basis of the development of consensus guidelines for virtual care provision in neurology.

From fragmentation to functionality: Enhancing coherence of digital health integration in health systems

Digital health programs continue to be implemented within Canadian health systems at a steady pace. The effectiveness of digital health initiatives has been rigorously analyzed, with both benefits and drawbacks extensively commented on. While the discussion about digital health continues, both positive and negative perspectives of it are approaching saturation in their themes. Accepting that digital health is here to stay post-pandemic, the focus should shift to strategies and supports needed to avoid the fragmentation of care through digital health implementation. This short article poses three questions which policy-makers and decision-makers should explore as part of a level-setting exercise with involved stakeholders at the outset of a digital health program's consideration. An implementation team should design the digital health program to have equity as its foundational focus, conduct value-based evaluations, and position the program in a learning health system framework to guard against the fragmentation of care.

GPT-4 Performance for Neurologic Localization

Background and Objectives

In health care, large language models such as Generative Pretrained Transformers (GPTs), trained on extensive text datasets, have potential applications in reducing health care disparities across regions and populations. Previous software developed for lesion localization has been limited in scope. This study aims to evaluate the capability of GPT-4 for lesion localization based on clinical presentation.

Methods

GPT-4 was prompted using history and neurologic physical examination (H&P) from published cases of acute stroke followed by questions for clinical reasoning with answering for "single or multiple lesions," "side," and "brain region" using Zero-Shot Chain-of-Thought and Text Classification prompting. GPT-4 output on 3 separate trials for each of 46 cases was compared with imaging-based localization.

Results

GPT-4 successfully processed raw text from H&P to generate accurate neuroanatomical localization and detailed clinical reasoning. Performance metrics across trial-based analysis for specificity, sensitivity, precision, and F1-score were 0.87, 0.74, 0.75, and 0.74, respectively, for side; 0.94, 0.85, 0.84, and 0.85, respectively, for brain region. Class labels within the brain region were similarly high for all regions except the cerebellum and were also similar when considering all 3 trials to examine metrics by case. Errors were due to extrinsic causes-inadequate information in the published cases, and intrinsic causes-failures of logic or inadequate knowledge base.

Discussion

This study reveals capabilities of GPT-4 in the localization of acute stroke lesions, showing a potential future role as a clinical tool in neurology.

Participants' perspectives of "NeuroSask: Active and Connect"-a virtual chronic disease management program for individuals with a neurological condition

Introduction

Neurological conditions account from more than half of Canadians requiring chronic care. Both physical activity and the development of a self-management skillset are critical components supporting individuals with chronic health conditions. "NeuroSask: Active and Connected" is a virtual chronic disease management program offering twice weekly neuro-physiotherapist directed "active" exercise sessions, followed by weekly knowledge-exchange "connect" sessions with invited guest experts. NeuroSask was launched April 2020 in response to the restricted services and supports for people with neurological conditions. The program aimed to provide seated physical activity, social interaction, and access to expertise in neurological conditions and neurorehabilitation. A program evaluation of NeuroSask was conducted to gain participants' perspectives.

Methods

All participants registered for the NeuroSask program were invited to complete optional online surveys (SurveyMonkey) circulated by email at 3 occasions post-program launch: 10 weeks, 1 year, and 2 years. Participants could complete any one or all of the surveys, at their discretion. The number of potential respondents changed dependent on the total number of participants registered for NeuroSask at the time the survey was circulated. Questions were co-designed by multi-stakeholder team members. Descriptive statistics were used for closed-ended questions and a reflexive thematic analysis was completed with coding conducted in NVivo 12 Plus for open-ended text.

Results

Response rates (participants/registrants) were as follows: 10-week survey 260/793, one year survey 326/1224, and 2-year survey 434/1989. 90% of participants reported being in either the age categories of 40-59 years or above 60 years. 75% of both survey respondents and program registrants were female. 70% of both survey respondents and program registrants reported a diagnosis of multiple sclerosis and 30% reported other neurological conditions. Survey respondents were from all ten Canadian provinces, with 45% reporting living outside of large cities. Respondents reported preferring online vs. in person format for this type of programming. Three main themes, and eight corresponding subthemes were identified highlighting the perceived impact and key components of the NeuroSask program: Theme 1 "together in a positive and encouraging environment" (subthemes 1a: connection, 1b: empowerment); Theme 2 "access to enthusiastic qualified leaders from home" (subthemes 2a: leader characteristics, 2b: accessibility, 2c: program logistics); Theme 3 "being able to enjoy everyday life" (subthemes 3a: symptom benefits and beyond, 3b: carry-over, 3c: keep going, please do not cancel).

Conclusion

NeuroSask is an example of an accessible and meaningful virtual approach to providing ongoing support for some individuals with neurological conditions. It was perceived as beneficial for fostering community and connection in a positive environment with perceived benefits extending beyond symptom management to participant reported improvements in function, daily life, and disease experience.

Telehealth and Technology: New Directions in Cancer Care

ABSTRACT

Telehealth is a broad concept that refers to any delivery of health care in real time using technologies to connect people or information that are not in the same physical location. Until fairly recently, telehealth was more aspiration than reality. This situation changed radically due in part to the COVID-19 pandemic, which led to a near-overnight inability for patients to be seen for routine management of chronic health conditions, including those with cancer. The purpose of this brief narrative review is to outline some areas where emerging and future technology may allow for innovations with specific implications for people with a current or past diagnosis of cancer, including underserved and/or historically excluded populations. Specific topics of telehealth are broadly covered in other areas of the special issue.

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.