A Department Approach to Teleneurology

The Impact of COVID-19 on Neurology Practice

On March 13, 2020, the University of Pennsylvania Health System (UPHS), in response to growing numbers of coronavirus disease-19 (COVID-19) infections, discontinued in-person outpatient visits and elective procedures for the safety of patients and staff. Research was suspended, as was in-person medical student education. Limiting exposure of health care workers and conserving limited personal protective equipment (PPE) became of paramount importance. However, the measures required to achieve these goals resulted in a substantial reduction in our neurological services to patients in our community and throughout the system. The neurology department at the Perelman School of Medicine of the University of Pennsylvania (Penn Neurology) implemented a rapid agile pivot to telemedicine in neurology (teleneurology) to deliver neurological services in a safe and timely manner. Previous barriers to telemedicine such as limited reimbursement, licensing restrictions, and credentialing requirements were removed early on in the pandemic as insurers responded to the crisis by approving payment for all telemedicine activities at the same rates as in-person visits. State medical boards fast-tracked licensing or relaxed regulations allowing telemedicine visits by out-of-state providers. Less than 1 week later, Penn Neurology initiated a rapid deployment of teleneurology to replace in-person outpatient and inpatient visits. This process and its inherent challenges are described herein as a template for other departments and practices aiming to develop a teleneurology program.

The Need for Synchronous Video Teleneurology

In the setting of near-complete closure of our outpatient clinics, patients with both acute and chronic neurological problems were at risk of going without care for an unknown duration. Delay in evaluation, diagnosis, and treatment of many neurological conditions may result in higher morbidity and mortality. ^{1 –4} Inadequate follow-up of chronic neurological conditions carries an increased risk of emergency room visits, hospitalizations, falls and fractures, and infections, further threatening the health of patients. ^{5 –7} Emergency visits for transient ischemic attacks and minor strokes plummeted during the early stages of COVID-19 quarantine, as concern about infection placed patients at risk of permanent brain injury. ⁸ Acute and ongoing neurological care are vital for the health of our patients, but the limited access to in-person care imposed by the pandemic demanded alternative modes of care delivery.

The initial solution for our outpatient clinics was to perform telephone visits with patients known to our practice. However, the inability to perform a neurological examination impeded accurate diagnosis and appropriate management. Once a viable platform became available the practice converted to two-way real-time video and audio for outpatient and inpatient consults whenever possible. The neurological examination is critical to assessment of new and ongoing issues, and the provider–patient connection is compromised without visual cues. Unlike some other medical disciplines, neurologists can conduct a significant portion of the examination by video. For example, remote versions of movement disorders rating scales are validated and published ^{9 –11} and the National Institute of Health Stroke Scale is performed regularly through video in telestroke programs nationwide. Enhancing the examination with readily available household items has also been described. ¹² Synchronous audio/video teleneurology allows providers to perform key components of the neurological examination, unlike audio only visits, and was thus necessary for providing neurological care when in-person visits were deemed unsafe.

In addition to outpatient visits, rapid expansion of teleneurology for the inpatient setting was also needed to ensure the health and safety of our patients and providers. The benefits of telestroke are well established to improve acute stroke treatment at community hospitals with limited or no neurological expertise. ¹³ Telestroke services provided by the Penn stroke team were already active at multiple UPHS hospitals and this service was easily adapted to cover inpatient consults at all facilities. Similar to telestroke, the majority of teleneurology consults from inpatient floors were adequately assessed with real-time audio and video. Synchronous audio/video teleneurology consultations would allow critical components of the neurological examination to be performed while minimizing exposures and use of PPE.

System-Level Support

Implementation of teleneurology on a department-wide basis would not have been possible without the support of a centralized system-wide telemedicine team. Early in the pandemic, UPHS created a telemedicine command center to rapidly expand telemedicine capabilities and support both providers and patients. From early March through May 2020, telemedicine encounters grew from about 50 per day to >7,000 virtual visits daily throughout the health system. In March, April, and May, >360,000 telemedicine visits, including both phone and video visits, were performed. The health system initially utilized a legacy platform then converted to a uniform cloud-based platform to provide sufficient capacity. Many other innovations were subsequently instituted at UPHS to facilitate the widespread adoption of telemedicine. The command center was available to troubleshoot problems and provide instruction. Tip sheets were made available on a variety of telemedicine-related topics and posted on a connected health website. Frequent communications from the command center and weekly town hall meetings delivered updates on many aspects of telemedicine, including technology changes, billing, legal issues, licensing, and best practices. Information was distributed from department champions to divisions and individual providers to keep everyone up to date on the rapidly changing environment.

Telemedicine activities required frequent workflow and technology adjustments on the part of the providers. Centers for Medicare and Medicaid Services (CMS) and other insurers changed billing and reimbursement requirements several times during the pandemic and there was insufficient time to fully integrate a robust telemedicine platform with the electronic medical record (EMR). The connected health center created workarounds to optimize efficiencies wherever possible. This effort included creation of Smart Phrases with standard language to document critical elements such as telephone versus video, time of encounter, and acknowledgement of the limitations of telemedicine. Smart Phrases were updated centrally as the legal and coding environment changed. A cloud-based telemedicine platform was adopted allowing sufficient expansion across many providers and thousands of simultaneous encounters. Security and convenience issues were addressed from the telemedicine executive team either directly or after consultation with the vendor. A virtual switchboard was created by the UPHS connected health team that imported data from the EMR to facilitate connection to the virtual rooms, allow more streamlined communication with patients through text and e-mail, and establish a more efficient workflow. The responsiveness to the concerns and needs of the clinical providers greatly enhanced satisfaction and acceptance of telemedicine and was instrumental to its success. Table 1 summarizes these key components of system-level support.

Provider Education

Strategies for successful provider education are summarized in Table 2. As telemedicine activities within the UPHS and department of neurology evolved, education in the form of provider videos, tip sheets, and live meetings were made available. To disseminate this information throughout the department, leaders in each division were appointed to train others within their divisions, develop more consolidated and department-specific educational materials for presentation at faculty meetings, and pilot software changes ahead of departmental roll-out. Division champions were chosen based on their technology skills or prior telemedicine experience, but also based on communication skills and rapport with team members. Although some providers expressed concerns regarding the limitations of telemedicine, they all soon adapted and became users of the platform. As a result, the department was able to rapidly return to pre-COVID-19 clinical visit numbers (Fig. 1) and became one of the fastest adopters of telemedicine in our institution.

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Fig. 1.

(A) Number of teleneurology versus in-person visits from March through June 2020. Teleneurology visits include telephone and synchronous video visits. (B) Proportion of synchronous video versus telephone teleneurology visits from March through June 2020.

Webside Manner

Providers must demonstrate professionalism when performing teleneurology to gain patient trust and facilitate care. Interacting with patients during video encounters requires different considerations than in-person visits. The experience within our department during the pandemic resulted in guidance regarding webside manner that was transmitted to providers in the department. These tips are listed in Table 3 and included (1) sit in a well-lit, quiet, organized, and private space with work-appropriate attire; (2) be cognizant of good posture and avoid fidgeting with props or pens; (3) look into the camera as opposed to the screen when directly speaking with patients; (4) introduce yourself and ask for two identifiers from the patient; and (5) learn the names of anyone else joining the patient in the virtual visit. As teleneurology may be new to most patients (and providers), it is helpful to acknowledge the newness of it all. Many providers find it efficient to use one device for video and another for documentation and viewing images. Providers were encouraged to be patient with temporary blips in technology. Good webside manner puts patients at ease, regardless of the outpatient or inpatient teleneurology setting. Additional information on webside manner is available on the American Academy of Neurology website.

Inpatient and Emergency Department Teleneurology Implementation

In March, to provide inpatient consultations services to all UPHS hospitals, the neurology department distributed iPads mounted on wheeled carts to the six hospital campuses in the UPHS network within a week. Local providers and nursing staff were trained to operate the devices and assist in the neurological examination. By April, the UPHS robotics team had developed carts with cameras that had greater capabilities, including pan-tilt-zoom cameras and battery backup. All neurology inpatient consults were performed by telemedicine unless either the requesting provider or the neurologist determined that an in-person visit was necessary. When an in-person visit was performed, one individual (usually the attending) would go into the room to perform the examination and the remainder of the team watched remotely through secure live video, whether from a conference room, from an office, or from home. This accomplished staffing of our inpatient services with a smaller team and limited exposure of health care providers. Equally importantly, it preserved much needed PPE and prevented further reduction of the workforce due to infections among providers. Family meetings and ancillary services evaluations could also be conducted using the teleneurology carts. The immediate collaboration between neurology, the emergency department, and the inpatient units and the successful adaptation of teleneurology into their workflow demonstrated to other departments why teleneurology was needed to save critical resources and prevent mass exposure for both patients and the hospital workforce.

Outpatient Implementation and Office Workflow Changes

The conversion to telemedicine posed an enormous administrative challenge for the department. Table 4 lists several administrative tasks that are unique to a telemedicine program. Patients had to be contacted before their visit and instructed on the change of format as well as instructed on downloading and using the videoconferencing app. This process required a strong interface between the faculty, staff, administrative, and operations team. Although not directly on the “front lines” of the COVID-19 crisis staff members dedicated many hours to accomplish this mission. Administrative assistants contacted patients by phone to convert their visits to teleneurology and confirm that they would perform the visit from their home address; they then followed up with messages through the switchboard containing instructions for preparing their devices. A link to a consent form was also sent to new patients, including consent to telemedicine. Research staff and EEG/EMG technicians were recruited to perform technology checks ahead of the telemedicine visit to ensure patients had received switchboard messaging, ensure adequate video and audio quality and were able to successfully connect for the visit. Patients unable to demonstrate adequate technology for a telemedicine visit during the tech check were converted to telephone, and the provider notified in the switchboard saving time and effort. After instituting these workflow changes, telemedicine visits increased dramatically and the majority of interactions were considered successful by patients and providers.

Patient Selection

There were several considerations when determining appropriate patients for telemedicine. A thorough history and video examination, including mental status, cranial nerves, gross and fine motor function, coordination, and gait, are sufficient for at least initial management of most neurological diagnoses. In some cases, however, the examination by telemedicine may not be considered sufficient for an adequate assessment. Neuro-ophthalmology and neuromuscular physicians most commonly requested in-person visits rather than telemedicine due to the limitations of their focused examination. Although these visits were performed virtually during the first few weeks of the pandemic, either through phone or video depending on patient capability, patients requiring these subspecialties were prioritized once in-person visits were resumed on a limited basis. Other subspecialty providers, such as cognitive, epilepsy, multiple sclerosis, and movement disorders were more comfortable with a teleneurology examination. Another selection factor was the exposure risk of an in-person visit. Patients with pre-existing conditions, advanced age, or immunosuppression were preferentially seen by telemedicine when possible and acceptable to the patient. In some cases, patients preferred to be seen by telemedicine because of a desire to avoid hospital settings, difficulty with transportation, or mobility issues. The technological capabilities of the patient and his or her caregivers also had to be considered. The lack of internet connectivity, smartphones or computers, or the inability to understand the software requirements for telemedicine changed the approach to telephone or required in-person visits when an examination was necessary for optimal care. Despite these challenges, we have been impressed by the numbers of successful visits conducted even with our older populations with neurodegenerative disease.

Patient Education

Many patients had not experienced virtual visits before the COVID-19 pandemic, and some approached them more casually than others. Patients have been at work, in grocery stores, and in dim and noisy environs during their video visit, compromising privacy and effective communication. The neurological examination requires coaching, camera adjustments, and environmental preparation to assess effectively. Early on it became obvious that setting expectations and guidance for patients before virtual outpatient visits would be a good investment. Table 5 suggests tips to give patients before the visit; many tips are applicable to the success of any telemedicine visit, not just teleneurology.

These tips can be incorporated into the virtual visit invitation that gets e-mailed or texted to the patient at the time of appointment scheduling. A video provides visual and audio illustration that can resonate with a wide audience and facilitate compliance and understanding. A link to the video can also be disseminated within a reminder message about the virtual visit. The video should be short, narrated in layman's terms spoken slowly and clearly, and supplemented with subtitles for patients with hearing difficulties. Comparison screens are helpful to illustrate common pitfalls. Light background music and animations (which are handy during quarantine video production) keep the video interesting and the viewer engaged, which affords a greater chance of impact. We were able to enlist a dedicated and talented medical student who translated the tips into a video as part of her Technology in Medicine elective. When we forwarded our teleneurology patient tips video to our telemedicine command center, it was embraced as a leading example for other departments to share with their patients. The link to the video is provided here: https://www.youtube.com/watch?v=2uSh2RdoTMs

Provider and Patient Satisfaction

The large volume of telemedicine encounters during the pandemic provided a unique opportunity to collect important information about the utility of telemedicine in a variety of neurological specialties. Much is known about patient satisfaction with telemedicine and teleneurology, ^14,15 and many patients reacted favorably to “seeing” us during this frightening and isolating time. However, fewer provider surveys have been performed and published. A novel questionnaire was developed regarding provider perceptions about the history, examination, quality of the physician–patient relationship, personal connection, technical adequacy, and overall impression of the visit. Providers were given a link and a quick response code to access the questionnaire from a web browser, smartphone, or tablet device. The survey applied to each individual encounter and were completed either directly after the visit or shortly thereafter. Weekly reminders were sent to all providers to complete the questionnaire. As of July 10, 1,645 surveys had been submitted by 56 of 160 (35%) providers invited to participate. Sufficient encounter-specific data were collected to permit future research by linking survey EMR. Results of the data should contribute to quality improvement initiatives improving the delivery of teleneurology across the health system and allowing our health system to define the value of teleneurology to insurers.

The movement disorders division took the opportunity of this high volume of telemedicine visits to collect survey data from 150 patients through telephone. In addition to satisfaction questions, patients were asked open-ended questions about advantages and challenges of the visit, whether they would like to use telemedicine in the future, and the ability to communicate sufficiently through video. The patient survey can be linked back to the provider survey results to compare impressions from the same visit. Understanding the needs and preferences of our patients will be critical to the success of our teleneurology program going forward.

Teleneurology After COVID-19

Our providers hope to continue telemedicine beyond the pandemic, both to relieve the burden on our patients who have difficulty travelling to the UPHS and to widen our geographical impact in providing care. We learned that rapid implementation is feasible although it demands extraordinary agility. However, the reimbursement waivers and relaxation of licensing will expire with the emergency declarations or shortly thereafter. The future direction of teleneurology will likely depend upon whether these policy changes continue beyond the expiration. Given the success of telemedicine and the favorable responses from both patients and providers there will be pressure from many professional and patient organizations to support the future of telemedicine. Based on the experience during this COVID-19 crisis, many neurologists in our department see an important role for teleneurology in their future practice. Perhaps as many as half of return patients could be seen by telemedicine saving time and travel expense and opening additional in-person office time for new and complex patients. The neurological examination by telemedicine has limitations, but methods for enhancing the examination such as measuring gradations in strength and observing functional abilities are emerging to expand the landscape of neurological problems adequately addressed by a video visit. The ability to incorporate family members regardless of location to obtain additional history and discuss assessments and plans represents an advance that improves patient care and saves valuable time for all involved.

Not all patients are able to perform a telemedicine visit. The digital divide prevents those without adequate connectivity or understanding of technology to take advantage of the opportunities provided by telemedicine. Education of patients in advance of their appointments has been critical to the success of our program but is very labor and time intensive, and thus may require different strategies to be practical in the long term. These disparities should be aided by the efforts of governmental and private agencies to expand broadband coverage to rural areas and increase penetration of smartphone and computer technology. Improvements in software features making connection with providers easier hopefully will also extend the benefits of telemedicine to a broader range of neurological patients. It is incumbent upon us as providers to demand narrowing of the digital divide at local, state, and federal governmental levels to allow telemedicine access to populations at risk, especially those where racial and socioeconomic disparities in health care threaten health and well-being.