Providers' Perceptions of Neurology Care Delivered Through Telemedicine Technology

Abstract

Background:

The COVID-19 pandemic and subsequent acceleration of telemedicine usage allowed many neurologists to trial telemedicine for neurological care. The purpose of this study is to explore neurology providers' experiences with delivering telemedicine care during the COVID-19 pandemic.

Methods:

Semistructured video interviews were conducted with 27 neurology providers who practice at a single, urban academic center. Interviews were transcribed and analyzed for content and themes.

Results:

Five major themes were identified: virtual examination subspecialty differences, tips and tricks for the virtual examination, improved infrastructure needs, future technologies that could support the virtual examination, and preferences for the postpandemic telemedicine protocol. Subspecialists who described their visits as more focused on behavioral examination and obtaining patient history reported fewer limitations with delivering neurological care through telemedicine platforms.

Conclusions:

The implementation of a telemedicine system should reflect the needs of each neurology subspecialty. Funding is needed to improve logistical infrastructure for health providers' telemedicine visits, such as technical and administrative assistance, as well as creation and testing of technologies to support physical examination in the virtual environment.

Introduction

Telemedicine in the field of neurology has been associated with lower health care costs and quality patient care.^1

–5 Beginning in 2019, the coronavirus (COVID-19) pandemic drastically transformed the manner in which neurology care is delivered in the United States (U.S.), with a 533% increase in telemedicine-delivered outpatient neurology care in the 3 weeks after March 15, 2020.⁶ For the purposes of this article, telemedicine will be defined as health care delivered to a patient in a different geographical location using synchronous audio–video interactions.^7
–9

Understanding neurology providers' experiences and perceptions of delivering telemedicine care can inform clinical and policy decision-making. The COVID-19 pandemic and subsequent acceleration of telemedicine use by neurology providers offered an ideal opportunity to evaluate providers' experiences with telemedicine.^6,10 During the pandemic, the majority of neurology providers (73%) viewed their overall experience of telemedicine visits as the same (rather than worse or better) as in-person visits.¹¹

However, some neurology providers experienced a sense of loss from telemedicine due to the lack of physical examination and fears related to missing nonverbal cues.⁷ Of the few studies that explored neurology provider perceptions of telemedicine during the COVID-19 pandemic, research gaps include missing perspectives by subspecialty differentiation and a lack of focus on video-based telemedicine, but rather audio-based telephone telemedicine.^6,11,12

Additionally, the studies that explored neurology provider perceptions of telemedicine during the COVID-19 pandemic were largely performed at a single neurology center or department.^6,11,12 Studying provider perspectives at additional neurology centers can solidify results and increase the generalizability of findings.¹²

Thus, the purpose of this study is to explore neurology providers' experiences with delivering telemedicine care during the COVID-19 pandemic.

Methods

Semistructured interviews were conducted with a convenience sample of neurology providers from a single, urban academic center. An interview guide was developed with a multidisciplinary team to elucidate the experience of neurology telemedicine across subspecialties. Interview guide items included scheduling, connectivity, environmental barriers, rapport building, obtaining patient history, patient teaching, ensuring patient privacy, conducting the neuro examination, involving family in the visit, making a neurological diagnosis, and administrative issues related to conducting telemedicine visits.

The Johns Hopkins Medicine Institutional Review Board acknowledged this study as exempt human subjects research (IRB00254594).

PARTICIPANTS

Providers were eligible for individual interviews if they were neurology providers in the Johns Hopkins Health System. A researcher (B.F.D.) with no affiliation with the providers invited them through e-mail to participate.

INTERVIEWS

All individual interviews were conducted between February and March of 2021 through the videoconferencing platform Zoom™ and lasted ∼30 min. Following oral consent, all interviews were video and audio recorded as well as transcribed using Zoom's live transcription feature. The interviewer (B.F.D.) used a semistructured interview guide and probes to elicit the responses.

Each interview covered the same general topics, although the participant was free to structure the conversation within each topic. New topics brought up by participants were discussed as they arose, and field notes were taken.

ANALYSIS

M.A.S. and B.F.D. viewed the video recordings and interview transcripts side by side, checking the transcriptions for accuracy and making appropriate corrections. Following the viewing of each video interview, they summarized providers' thoughts on each question and performed reflective journaling.¹³ They selected quotations from each interview that best represented each provider's opinion of telemedicine. Next, they performed deductive content analysis using methods discussed by Halcomb and Davidson.¹³ Care was taken to ensure that codes accurately captured the participants' meaning.

B.F.D. performed a content analysis to elicit common themes, and M.A.S. reviewed the content analysis and performed validation. To ensure credibility, they met weekly to discuss interview methods and appraise any bias. They kept field notes to provide an audit trail for themes and indicators. They determined that saturation had been reached when no new codes emerged.¹⁴ During the final stage, quotations that represented the themes were selected (Table 1).¹³

Table 1.

Representative Quotations

INITIALS, SPECIALTY	REPRESENTATIVE QUOTATION
Theme 1: Virtual examination subspecialty differences
Participant 17, neuromuscular	“In good conscience I can't see a new patient [via telemed] because most of the questions that I'm asking involve some degree of hands-on evaluation. And so I feel really queasy when I've been asked to see a patient with a neuromuscular condition online.”
Participant 14, neuromuscular	“…that's part of how I triage people for follow up so if there's something they're saying ‘I'm deteriorating. This is changing’ I say okay we're going to need you to come into the clinic. And if you're saying ‘Everything is stable. I need refills' and we talk to you about labs or whatever. Let's do that as televisit.”
Participant 16, neuromuscular	“…my physical exam is, is everything to me. And if I can't do reflexes, and I can't get an accurate strength measurement, and I can't do my quantitative sensory testing on patients, I can't give them a diagnosis.” “For me something like as I mentioned reflexes can be the difference between diagnosing somebody with… a little bit of weakness…and thinking they have a disease like ALS or Lou Gehrig's disease.”
Participant 6, cerebrovascular	“It's just not, it's just not the same and it will never be…because of the like physical cues that you're missing that you would get in person from the patient.”
Participant 5, cerebrovascular	“But to be honest, in stroke neurology, I think that when I feel that a patient needs a good exam, I put him in as a as an in-person visit. For most patients, we don't need to do a very precise exam for stroke, because, we know the deficit the patient has you know the patient says they're worse you know we can, we can kind of gauge the situation and decide whether or not they need imaging at the hospital.”
Participant 1, cerebrovascular	“In a telemedicine visit it feels like you have more time…I find myself, taking more history and obtaining more information, assuming that the everything is perfect like there's no connection issues, and no sound issues.”
Participant 10, sleep	“There is nothing about the neurological exam that will be that helpful… My practice is really about history….”
Participant 9, sleep	“[Telemedicine] might even be more advantageous because we get to see the patient home environment. Sometimes they call from their bedroom and so that gives me more information about their sleep environment…so I think it's actually, in many ways, telemedicine is actually preferred.”
Participant 20, neuroimmunology	“You can pick up obvious things like you know if there's an obvious drift you can pick that up if there's some coordination difficulty, obviously speech you know I'm movement abnormalities - facial. I mean, you can't really test reflexes, you can get a sense of things, but you know you can't get like a complete physical exam. And there's just there's no way around that.”
Theme 2: Tips and tricks for the virtual examination
Participant 26, neuro-oncology	“And then for the strength evaluation in the lower extremities I have them stand up, stand on one leg and squat. And if a person can squat on one leg they're able to lift their own body weight…”
Participant 11, pediatric epilepsy	“I make them do some fun things…run to the stairs run back, stand on one foot walk backwards. I'll you know, let's say I see you have a dog, go chase your dog for a minute.”
Theme 3: Improved infrastructure needs
Participant 15, neuromuscular	“…I gotta get to my briefcase and get my computer out and log on to Hopkins. And then, so all of a sudden I'm like, oh no, I'm not going to be ready, give me five minutes. And when you only have a half hour for a patient visit, and we're having to flip between in person and this, I mean your head is spinning.”
Participant 16, neuro-oncology	“I am not efficient with a fusion clinic [in-person and tele-visit]. I separate to make all in person in a day. Because of logistics. I have to leave 1 room…get de-masked, de-shielded. Find a new room that is HIPPA compliant. Make sure it's a secured space. So that is not my space. I will not have my notes prepared. There is a lot of time pressure.”
Participant 2, cerebrovascular	“Some patients may not be on WiFi… they're using cellular data so the video quality can be interrupted or just paused or I… will take time away from the visit to have to ask them to move to another location in their house maybe or to try holding their phone still or something like that.”
Participant 26, neuro-oncology	“I think what is definitely missing is you know like the YouTube videos or the something for patients to have the education for what the [telehealth] experience will be like, what to expect, how they're going to log in that they might have connection difficulties”
Participant 27, cerebrovascular	“I think we have to figure out a way to have better support for the patient and the physician…You know a way of pushing a ‘panic button’ if we need some outside help during an intervention with connectivity.”
Participant 25, movement disorders	“The most important thing would be to figure out ways to get patients who are unable to access telemedicine the access that they need that we could see more patients in more remote areas, or patients who could not have the technological capability, whether it's a cell phone with a camera, for example, or the internet speed, to be able to do a tele visit.”
Theme 4: Future technologies that could support the virtual examination
Participant 24, movement disorder	“So if there was something that was integrated into the [video visit] platform where … I could display a heads up prompt on top of my picture where there's some little thing that's moving around, and their eye movements are following it and then their cameras tracking their eye movements and quantifying the speed and the accuracy.”
Participant 25, movement disorder	“At the end of the day I think that leveraging of various mobile technologies, apps on your phone, virtual reality, and maybe even like predictive models like machine learning and artificial intelligence to help guide diagnosis in situations where you're not able to fully do it… I think the future is endless.”
Participant 22, movement disorder	“One is an accelerometer gyroscope combined technology, which is again present on your phone…attach your phone on your arm and see how much your arm is tremoring or the finger taps on your phone, see how fast or slow…or put your phone on your thigh, see how fast you can toe tap” “I'm focusing on the phone a lot because everybody has a phone…Attach your phone to your body and see if you walk a certain distance, how fast you can walk and how much. What's your cadence like are you swaying from side to side.”
Theme 5: Preferences for the postpandemic telemedicine protocol
Participant 7, cerebrovascular	“If Hopkins wants to sustain telemedicine, which I think is great, I think there are a lot of people who can't travel. And that is a prime population that we should target. But if they're going to do that, we need support staff to make it work. We need tech people who can pick up the phone and deal with the issue right then in there, not me and the patient trying to figure out how we can fix it.”
Participant 8, cerebrovascular	“There's no reason I can't see a patient in Oklahoma virtually. I know I can't, because of the rules, but that should all go away…this is political and states want to keep revenue in their own states and that's all we have all the state licensure but it's all stupid.”
Participant 16, neuromuscular	“I specifically have a number of patients who are limited in their ability for transportation…It's been wonderful actually being able to see them so easily right and to just literally go inside their home for these follow up visits and see them and see how they're doing, and without them having to take a big expensive, you know, getting transportation or an ambulance or whatever to come see me in clinic.”

Results

A total of 27 neurology providers agreed to participate in this study. The majority of providers were under 50 years old (62%), male (67%), and cerebrovascular or neuromuscular subspecialists (59%) (Table 2). We identified five major themes: (1) virtual examination subspecialty differences, (2) tips and tricks for the virtual examination, (3) improved infrastructure needs, (4) future technologies that could support the virtual examination, and (5) preferences for the postpandemic telemedicine protocol.

Table 2.

Participant Characteristics, n = 27

CHARACTERISTICS	n (%)
Age, years
30–39	8 (31)
40–49	8 (31)
50–59	5 (19)
60–69	3 (12)
70–79	2 (8)
Gender
Male	18 (67)
Female	9 (33)
Specialty
Cerebrovascular	9 (33)
Neuromuscular	7 (26)
Movement disorders	4 (15)
Neuroimmunology	2 (7)
Sleep	2 (7)
Epilepsy	2 (7)
Neuro-oncology	1 (4)

Note: one neurology provider did not offer their age range.

VIRTUAL EXAMINATION SUBSPECIALTY DIFFERENCES

Across subspecialties, providers agreed that they could confidently assess the following examination components in the virtual environment: cognition and language evaluation, cranial nerve examination, gross strength visualization for asymmetry with pronator drift, fine finger movements, and gait.

Conversely, the providers consistently identified the following components of the examination that were difficult or impossible to assess in the virtual environment: reflexes, sensation, muscle tone, subtle changes in strength, and fundoscopy. However, major differences in providers' opinions of virtual examination across subspecialties were evident and are described below.

Neuromuscular providers expressed the most dissatisfaction with conducting a neurological examination in the virtual environment. They emphasized that it is critical for a new patient appointment to be in person, but suggested that some follow-up appointments could be appropriate for virtual visits. They explained that a large number of patients have limited mobility, such as inability to stand unassisted, and that virtual visits are not adequate to detect downward trends in such patients. However, they were able to diagnose a small subset of disorders, such as myasthenia gravis, through telemedicine because symptoms were visible on the video screen (e.g., eye weakness, facial droop).

Movement disorder providers were most concerned about internet bandwidth that was insufficient to assess the speed and accuracy of movement, especially for disorders such as bradykinesia. Many movement disorder specialists also expressed dissatisfaction regarding camera angles that could not offer sufficient visual information for the gait examination. Patient safety was also a concern and some described asking care partners to provide support to the patient during the gait examination or for other motor examination elements.

Cerebrovascular providers had the most varying opinions of telemedicine within a subspecialty. One cerebrovascular provider reported that they could obtain 90–95% of the patient information needed through telemedicine. Other cerebrovascular providers stated that they could not perform an appropriate neurological examination virtually due to critical missing physical cues. Two cerebrovascular providers who were hesitant about virtual neurological examinations pointed out that their training occurred exclusively in the in-person setting, leading to their discomfort when assessing a patient in the virtual environment.

Neurological providers for the subspecialties of sleep and epilepsy described few neurological examination limitations because of their emphasis on history-taking during visits. They reported that some elements of the virtual visit are better than in the in-person environment. For example, out-of-town family members can attend the telemedicine visits, offering additional history or note-taking for the patient. In addition, patients can display their medicine bottles during the video visit.

Additionally, providers noted gaining insight into the patient's day-to-day living situation and habits by viewing their environmental surroundings through the video platform. Last, some patients felt more at ease during the neurological examination in the comfort of their own home.

TIPS AND TRICKS FOR THE VIRTUAL EXAMINATION

For many of these examination components mentioned, providers relayed suggestions or tips and tricks that enable them to obtain the needed evaluation in the virtual environment. As a common example, four providers described how they instructed the patient or the patient's care partner to utilize household items to test sensation, such as a cold spoon, one prong of a fork, a toothpick, a feather, or a tissue. Providers relayed that these sensory tests in the virtual environment offer mixed success.

They described using the screen sharing feature to have the patient describe a picture to test language, to deliver a digital questionnaire, or for the provider to deliver teaching. They also suggested utilizing a care partner to manipulate the camera to assess gross body movements in the upper or lower extremities, such as gait.

Although some providers became frustrated when patients attended virtual appointments in public, one provider, who relayed a story of a patient attending a virtual appointment in a grocery store, capitalized on this environment by assessing coordination as the patient reached for items. Although most providers agree that subtle changes in strength cannot be assessed in the telemedicine environment, the providers can assess antigravity strength and symmetry.

IMPROVED INFRASTRUCTURE NEEDS

The providers conveyed that many of the negatives of telemedicine for the delivery of neurology care could be addressed through improved infrastructure and resources. First, patients need to be prepared for the visit, for example, with an e-mail outlining what to expect during the telemedicine visit, how to decrease environmental distractions, and videos that demonstrate how to connect to the video portal.

Second, neurologists need a designated space to conduct telemedicine appointments; clinics and hospitals should consider provider televisit-capable computers and reserved rooms. Ideally, providers could utilize the computer for both in-person and virtual visits, and a sign on the reserved room could indicate when virtual visits are in progress. These measures would decrease transition time such as logging on to a separate computer or commuting to a new location.

Third, providers also expressed a need for staff to support the technological needs of patients. Providers' frustration with telemedicine varied by whether the provider had staff members (i.e., medical office coordinator or nurse) who ensured that the patient logged in and could troubleshoot any difficulties before the provider joining. Providers also reported the need for consistent information technology assistance such as designated information technology staff that the providers could utilize to help patients navigate connectivity issues when they occur.

FUTURE TECHNOLOGIES THAT COULD SUPPORT THE VIRTUAL EXAMINATION

Providers indicated that technological innovation has the potential to drastically improve telemedicine. For instance, providers suggested that wearable devices be used to provide quantifiable information during and between visits, such as step counts, heart rate, balance, or electrocardiogram output. Providers pointed out that a large proportion of patients have access to a smartphone, which could feasibly be used to collect such wearable information.

Another technology-based innovation to support neurology-based telemedicine is a dynamometer-like device to measure subtle changes in strength. Providers also suggested technology to facilitate and assess visual fields through screen prompts and camera tracking of eye movements. Providers reported that many of these technologies have already been created, but emphasized a need for their application in the telemedicine setting for neurology care delivery in the home.

Other technologies mentioned that could help with the neurological examination include a self-administered cognition assessment, software to measure information about limb movement, or a device that delivers a stimulus (e.g., electric poles or vibration) to test sensation. Some providers suggested that patients be sent a “black bag” for virtual visits, filled with items that would assist in the virtual neurological examination, such as a device to measure forced vital capacity.

Many expressed that there were limitless possibilities of utilizing technology to improve the telemedicine neurological examination.

PREFERENCES FOR THE POSTPANDEMIC TELEMEDICINE PROTOCOL

At the end of the interview, neurology providers were asked to explain their ideal protocol for telemedicine. Almost every provider suggested that they would like to deliver care using a hybrid model, combining in-person visits with virtual visits, with dedicated days for each. Many providers suggested that they would typically use the in-person format for new patient visits and the virtual format for follow-up appointments or discussing laboratory or imaging results. Other providers relayed that they would provide yearly in-person appointments, with all other appointments using the telemedicine format.

Neurologists perceived that the option of telemedicine provided high value for many patients and their families. They highlighted the importance of telemedicine for improving access for neurology patients with mobility limitations and for those who live remotely or out of state. Visits were shorter, with no driving time, no parking fees, no navigating the hallways of a large facility, and minimal waiting time.

There were numerous benefits for the care partner, including the ability for geographically remote family members to join neurology appointments and less missed work. Inclusion of family and the decreased patient burden on visit days were viewed by providers as important reasons to make telemedicine a part of ongoing clinical practice.

Providers also emphasized the need for improved digital access for low-income populations, such as public locations that could provide internet access and at the same time offer a private environment for a telemedicine appointment. Last, many expressed frustrating experiences of conducting a visit, only to discover that their patient was from a particular state in which they could not provide care and subsequently they were required to end the visit. Providers emphasized the need for advocacy for initiating or extending cross-state licensure.

Discussion

In this study, we explored the experiences of neurology providers who were new to the delivery of care using a telemedicine platform. Following semistructured interviews with 27 neurology providers, 5 themes emerged: (1) virtual examination subspecialty differences, (2) tips and tricks for the virtual examination, (3) improved infrastructure needs, (4) future technologies that could support the virtual examination, and (5) preferences for the postpandemic telemedicine protocol. These themes indicate a pathway toward improving telemedicine systems during this time of expansion.

Similar to our findings, previous research suggested that neurology providers are most concerned about limitations in virtual neurological assessments during telemedicine visits, especially assessments of muscle tone, reflexes, and sensation,^12,15,16 as well as loss of nonverbal patient cues.^12,17 Regardless, many of the providers interviewed in this study expressed that the virtual physical examination is sufficient for certain situations such as stable patients and follow-up visits.

Our study differs from several prior studies in that providers offered potential solutions for limitations in the virtual neurological examination, approaches to standardize the virtual neurological examination in the virtual environment, and ideas for potential innovations, many of which could harness the power of emerging technologies. Funding will be needed to test adaptations and technologies discussed in this study and create new technologies to support telemedicine. Such innovations could drastically improve the virtual neurological examination and thus neurological-based telemedicine.

A modifiable concern expressed by providers was the need for improved system infrastructure. Providers reported that the telemedicine experience would be enhanced through technical and administrative assistance to support the patient in navigating the telemedicine system. Although research indicates that neurology care delivered through telemedicine is cost saving for patients,^16,18 more research is needed to highlight the cost-effectiveness of telemedicine integration into health systems. While major start-up expenditures might be incurred (equipment and training),^18,19 researchers should consider if telemedicine might provide long-term financial savings for health facilities.^3,16,18,20

Some subspecialties perceive a greater potential for telemedicine-delivered neurology expertise, including sleep, epilepsy, and cerebrovascular neurology. This study also indicates that telemedicine might enhance neurological care beyond face-to-face visits since it allows for more family-centered care through the inclusion of distant care partners and improved access for patients with mobility limitations. This is critical in the field of neurology as patients often require significant support from their care partners and families.

Improved access for patients with disabilities and improved family involvement are important considerations for policy makers when deliberating upon the extension of COVID-19 pandemic telemedicine reimbursement policies in the postpandemic environment.^10,21
–23

LIMITATIONS AND STRENGTHS

This study has several limitations. The neurology providers who agreed to participate may have had more positive or negative viewpoints of telemedicine than those providers who declined to be interviewed on this topic. Representation could have been enhanced by the addition of headache subspecialists. Additionally, the resources at a large academic center may be different from that experienced by other neurologists, limiting the transferability of our findings.

Despite these limitations, this article adds an important element to the literature, including a path forward for telemedicine use by neurology specialists. The methodological approach, including content analysis validation and verification with selection of representative quotes, provided rigor for this qualitative study.

Additionally, the inclusion of providers with diverse subspecialties offers information about differences in perceptions of telemedicine among providers with varying patient populations.

Conclusions

This exploration of neurology providers' perceptions of telemedicine provided important insight regarding how telemedicine was leveraged during the pandemic. We found that most providers could perform a majority of the neurological examination tasks through telemedicine, but that the virtual platform was perceived to be most limiting for neuromuscular neurologists. The providers met these challenges with resilience, adapting examination maneuvers for the virtual environment and generating ideas for potential innovations.

For neurology-based telemedicine to be sustained and scaled, there are significant infrastructure and policy challenges to be considered. Moving forward, provider perceptions are critical to inform clinical practice and policy.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

B.F.D.'s time on this article was supported by the Robert Wood Johnson Future of Nursing Scholars Program.

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