Abstract
Introduction
Teleneurology has its beginnings in acute stroke care, where clinical models have validated the benefits of telemedicine for treating stroke urgently. Beyond acute stroke care, the field of teleneurology is quickly advancing and expanding to improve patient care for a wide variety of neurological disorders. Specialty teleconsultations are increasing for various neurological conditions such as Parkinson's disease, multiple sclerosis, and epilepsy where expertise, timing, and accessibility are critical.
Lee H. Schwamm, M.D., Vice Chairman, Department of Neurology, and Director of Acute Stroke Services at Massachusetts General Hospital and Director of the Partners Telestroke Center in Boston, MA, comments that the principles of acute stroke care are translated to other areas of teleneurology.
“In acute stroke care you need to bring high levels of experience and clinical judgment to a healthcare setting in a very short period of time and work within a model that encourages a financially stable solution,” Schwamm said. “Expertise on demand and immediacy fuels the desire for telemedicine in all areas of neurology and the type of evaluation being requested is often formulaic and validated so that you can do this reliably.”
Advances are rapidly occurring for outpatient treatment of people with neurological disorders, easing the challenges that patients with disabilities face, which provides patient-centered care and helps with adherence to treatment. Technology is also being brought to settings where more sophisticated interventions are provided.
New Frontiers
Two key factors driving the use of teleneurology consultations are a lack of access to specialists and the challenges that patients with neurological disabilities face when traveling to outpatient settings. For these reasons, teleconsultations are increasing for a variety of neurological conditions including Parkinson's disease, according to Lawrence R. Wechsler, M.D., Professor and Chair, Department of Neurology and Vice President for Telemedicine at the University of Pittsburgh Medical Center (UPMC).
Parkinson's disease is a movement disorder affecting approximately 1 million people in the United States, according to the National Parkinson Foundation, and is a slowly progressive condition that leads to abnormal movements such as tremors, imbalance, and lack of coordination. Eventually a person may have difficulty with walking and activities of daily living. Teleneurology consultants via videoconferencing may be used in Parkinson's disease to assess tremors, balance, gait, and symptom relief.
“In teleconsultation here at UPMC, we hold a remote clinic for patients with Parkinson's disease,” Wechsler said. “There is a neurologist at a hospital about 50 miles from Pittsburgh who has a large practice and sees a large number of Parkinson's patients. When these patients need to see an expert in movement disorders they normally have to travel to Pittsburgh once a month, but now these patients are seen via videoconferencing just as if they were scheduled for an appointment. The expert sees the patient, talks with them, and the nurse helps facilitate the examination. Holding this clinic remotely saves the patients about an hour and a half in each direction.”
Schwamm comments that if home telemedicine was a financial reality and incentives in the system were a reality, an expert might see a Parkinson's patient briefly once a week to monitor their status. “In a fee-for-service model we waste a lot of fuel, patients' time, secretarial time, transport time, and elevator use,” Schwamm said. “It takes a lot to bring a person to the hospital. But there are small pilot studies looking at evaluation of patients with movement disorders, which validate the fact that you can make accurate diagnoses and standard assessments and that video evaluation is highly effective for these assessments.”
Schwamm states that, ideally, through telemedicine, a physician could see a Parkinson's patient at various intervals after their medication dose to assess response, something that is difficult to do in a conventional outpatient setting. And he states there is tremendous advantage to seeing how people function in their homes. “If the reimbursement model were there you might see six patients an hour doing 10-minute visits to assess these types of issues,” Schwamm said.
Epilepsy is another condition for which teleconsultations are increasingly common for diagnosis, monitoring, and assessment. Epilepsy affects nearly 3 million people in the United States, according to the Epilepsy Foundation, with an estimated annual cost of $15.5 billion in direct and indirect costs. Epilepsy causes seizures, which typically last seconds to minutes and affect a person's physical and mental capabilities.
Schwamm comments that for people with chronic stable epilepsy, outpatient evaluations can be performed via videoconferencing where patient and clinician talk about symptoms and complications. “Many of these evaluations can be done over videoconferencing and of course, some might still have to schedule an outpatient visit at their healthcare facility,” Schwamm said. “The transactional nature of medicine is that we get paid face-to-face, but if you were equally compensated for telemedicine this would be greatly attractive to patients and doctors.”
A study evaluating the role of telemedicine in the follow-up of epilepsy patients randomly assigned 41 out-of-town epilepsy patients being seen at an epilepsy clinic in Western Canada to conventional care or telemedicine, and found that 90% of patients indicated a need for companion travel to a conventional treatment. Results of the study showed that 83% preferred that their next visit be a telemedicine visit; patient costs were significantly lower in the telemedicine group compared to the conventional group; and approximately 90% of patients in both groups were satisfied with the quality of care. The authors conclude that telemedicine can help in the follow-up of epilepsy patients, reduce patient costs, and improve patient satisfaction. 1
Additional advances in the treatment of Parkinson's disease and epilepsy are rapidly increasing in telemedicine with capabilities for remote programming of deep brain stimulators in Parkinson's patients, and in epilepsy, telemedicine is used for emergent treatment of status epilepticus where a teleneurologist videoconferences with clinicians at a remote center and EEG data is transmitted for rapid diagnosis and treatment guidance.
Multiple sclerosis (MS) is a chronic central nervous system disease that generally appears between the ages of 20 and 50 years old, and currently affects approximately 400,000 people in the United States, according to the National MS Society. People with MS may have a fairly benign course or experience various levels of progressive disability that can significantly affect their ability to communicate, walk, and carry out activities of daily living. The needs of MS patients can be complex and challenging, and innovative advances in telemedicine may support both patients' and clinicians' needs.
Joseph Finkelstein, M.D., Ph.D., Director of the Chronic Disease Informatics Program at the Johns Hopkins University and Associate Director of Informatics at the MS Center of Excellence at the Baltimore Veterans Administration Medical Center, has been involved in the development and evolution of patient-centered technologies and computer-guided care since 1995.
Finkelstein and his colleagues developed a Home Automated Telemanagement (HAT) system that implements a modular approach to supporting the needs of patients and clinicians. Specifically, the HAT system, an academic test bed, allows clinicians to evaluate the impact of telemedicine interventions in patients with a variety of chronic health conditions.
“The goal is to facilitate patient-centered care, support providers in following evidence-based treatment guidelines, and support patients in following individualized treatment plans,” Finkelstein said.
One pilot study conducted by Finkelstein and his colleagues evaluated one component of the HAT system that supports a home-based exercise program prescribed by physical therapists (PT) for MS patients. 2 The study evaluated whether the HAT system could help providers prescribe individualized exercise treatment plans and whether patients could carry out their prescribed treatments at home and improve overall functional capacity such as the ability to ambulate and perform other tasks.
In this study, the PT prescribes the exercise regimen using a Web-based interface provided by the HAT system, and MS patients use their computer at home, which communicates through a modem and connects with the central HAT server. Patients are guided step-by-step through their exercise program via automated textual, video, and audio prompts. Patients' self-report information after each exercise session, which is sent to the HAT's central server. If the system detects patients are not following an exercise or an exercise is too easy or the patient has a side effect such as pain, then data are generated, which the PT reviews. The PT can then adjust the regimen, which will immediately change on the patient's unit.
Results of the study showed patients were very satisfied with the service and expressed interest in future use, and patients experienced significant improvements in the 25-Foot Walk, Six-Minute Walk Test, and Berg Balance scale.
“MS can be a chronic, debilitating condition which requires life-long treatment, and rehabilitation is a very important feature in MS care, which is frequently challenged by barriers including access, cost, and program adherence,” Finkelstein said. “This small pilot study showed overall promise in our ability to positively affect functional outcomes through the HAT system.”
Finkelstein has received funding to develop a more comprehensive system to improve overall MS care management, which will include patient education, medication monitoring, monitoring of mood disorders such as anxiety and depression, rehabilitation, and other aspects of care.
Finkelstein states that such interactive content may be provided through laptops, cellphones, PDAs, iPods, and so forth, and stresses that it is important to provide a variety of channels for user-friendly access. Challenges of specific populations must be kept in mind, as patients with MS, for instance, may have blurred vision, which may necessitate a larger screen.
Still other areas of telemedicine are emerging in neurology, including advances in sleep studies, stroke rehabilitation, and the use of teleneurology for medical education.
Challenges
While teleneurology is advancing quickly, there are still challenges to be overcome. Some of the current challenges include the need for high-quality broadband connectivity in remote areas, adequate reimbursement for teleneurology services, easier licensing and credentialing processes for clinicians, and fair accessibility and provision of technology for patients.
“One of the most important issues is access to high-quality reliable bandwidth,” Schwamm said. “Given the rapid pace of adoption of technology in medicine, disparities in access to technology and bandwidth will soon translate into disparities to access in healthcare. If you are poor and don't have access to a computer, you won't have access to online consultations, personal health coaches, medication information, or virtual support groups. Patients today are invested in their health and they are connecting to others and participatory in their healthcare and they need access to and skills to utilize the technology.”
The federal government has made a push toward making high bandwidth available throughout the country so that all communities have access to that connectivity, and improving the availability of low-cost devices that can access that bandwidth, according to Schwamm. “This is where mobile devices will win out in the end, and people will use their Smartphone, etc. for communication, and I believe texting will be an important component in telemedicine.”
Reimbursement and credentialing are other important issues. “Reimbursement is a huge issue,” Wechsler said. “We know that telemedicine can be very helpful for patients, but in many cases teleneurology is not reimbursed. And there are issues with licensing and credentialing. If you cross the state border, you have to have a license in that state. And things become even more difficult with International consultations. It would be helpful to streamline this to have a national credentialing process for telemedicine specialists.”
Next Steps
From a technology point of view, next steps include advancements in and accessibility to high-quality resolution and the ability to use mobile devices and translate interactive content onto an iPhone or iPad, for example, to provide greater immediacy and accessibility to communication and education.
“We are light years ahead from where we were 5 years ago, but 5 years from now we will be in a whole new place,” Wechsler said. “This will open up new possibilities and capabilities to treat neurological patients remotely. The ability to immediately view studies such as EEGs or PET scans or other digital imaging that we normally use in our diagnostic bag is not always immediately available, so we need to be able to connect with all of the tools we use in neurology.”
Wechsler comments that UPMC is engaged in developing an overreaching system-wide plan for telemedicine throughout every aspect of UPMC. “It is critical for a system like ours to concentrate on how to integrate all of our telemedicine applications throughout the various departments such as radiology and dermatology,” Wechsler said. “Right now each department has their own system and tends not to interact, but we should have a central platform where you build an interface and plug into it and it has all of the components such as storage, videoconferencing, and documentation, and it is standardized and intersects with the electronic medical records program. Eventually, telemedicine will not be seen as separate but rather just one of the ways that we practice medicine.”
In addition to easy access, high resolution of transmitted data and images is critical for teleneurology. “There is a revolution going on that's being driven by people's appetite for watching high-definition movies on the Internet, and this is driving research and development in video compression technology which can benefit telemedicine,” Schwamm said.
Key resolution features needed in teleneurology include temporal resolution—the refresh rate has to be fast when evaluating a tremor, for instance. And spatial resolution is important because fine detail is needed to be able to examine a pupil, for instance, and see it react in real time.
“There are companies that are moving up the value chain to create more expensive and higher quality devices, but the floor is also rising,” Schwamm said. “Pretty soon the bulk of videoconferencing is going to shift to software-based videoconferencing that you load onto your computer 2 days before an appointment which will be valid for the one exchange and then erases itself and the patient's privacy is protected and all the user will require is a computer and a webcam. Skype and Google Chat are getting very good and soon they will be good enough for these types of interactions. And companies such as Vidyo are building these interfaces and exciting new software products. Also we will see a rise in for-profit telemedicine companies offering software based videoconferencing algorithms and a rise in doc in the box for-profit telemedicine companies. There is a lot of unchartered territory, and we have to be cautious about how we protect the public, but there is tremendous opportunity.”
And finally, major health organizations are getting on board and helping advance telemedicine efforts within their field including the American Academy of Neurology (AAN).
Jack Tsao, M.D., D.Phil., a Commander in the U.S. Navy Medical Corps., serves as the Director for the Traumatic Brain Injury Programs, U.S. Navy Bureau of Medicine and Surgery, Washington DC; Associate Professor of Neurology at the Uniformed Services University of the Health Sciences, Bethesda, Maryland; and is the Chair of AAN's Telemedicine Work Group (TWG).
Tsao comments that the TWG group is working on a state-of-the-art teleneurology white paper for the AAN, which will summarize the validated use of telemedicine in acute stroke care and describe benefits and lessons learned in that arena that may serve as a model for the continued expansion of telemedicine into other areas of neurology.
“Telemedicine is one form of practice which is now gaining favor within the field, and there is great potential for expanding and changing the practice of neurology to benefit our patients using technology that is now available,” Tsao said.
The paper will also describe some of the challenges facing teleneurologists such as credentialing and licensing issues. Wechsler, Vice Chair of the TWG, adds that the paper will provide recommendations to the AAN board about how to promote and enhance telemedicine within the field of neurology.