Consultation Requests and Satisfaction with a Telehealth Network for Epilepsy: Longitudinal Analysis of the Epilepsy Network Hessen Evaluation

Abstract

Background:

Telemedicine improves access to specialized medical expertise, as required for paroxysmal disorders. The Epilepsy Network Hessen Evaluation (ENHE) is a pilot cross-sectoral teleconsultation network connecting primary neurologists and pediatricians with epilepsy centers in Hessen, a federal German state.

Methods:

We prospectively and longitudinally evaluated telehealthcare in the ENHE. Participating physicians rated each consultation for satisfaction and impact on further management. The survey was administered at each consultation and 3 months later.

Results:

We analyzed 129 consultations involving 114 adult and pediatric patients. Their mean age was 34 years (standard deviation: 26, range: 0.1–91 years), 48% were female, and 34% were children and adolescents. The most common consultation requests were co-evaluation of an electroencephalogram (electroencephalogram [EEG]; 76%) and therapeutic (33%) and differential diagnosis (24%) concerns. Physicians transmitted one paraclinical examination on average (range: 1–4), predominantly EEG (85%), followed by magnetic resonance imaging (17%) and written records (9%). Response rates were 72% for the initial and 67% for the follow-up survey. Across respondents, 99% (n = 92) were satisfied with the ENHE. Overall, 80% of the consultations contributed to the diagnosis, and 90% were considered helpful for treatment, influencing it in 71% of cases. Seizure frequency had decreased more often (96%) than increased (4%) at 3 months. The initial diagnosis was confirmed in 78% of patients.

Discussion:

In this pilot teleconsultation network for paroxysmal disorders, diagnostic and therapeutic advice was perceived as helpful. Clinical outcomes were largely positive, suggesting tele-epileptology is viable for paroxysmal (seizure) disorders.

Introduction

Epilepsy is a chronic neurological disorder that is often difficult to diagnose and treat.¹ While epilepsy affects about 0.5–1% of the German population,² the proportion of patients with paroxysmal disorders is much higher. The lifetime prevalence of a single epileptic seizure is at least 10%, and epileptological expertise is required in many cases of etiologically ambiguous seizures and pharmacoresistant epilepsy. Individuals experience significantly impaired quality of life, employment disadvantages, and social stigma even after the first seizure, especially those with chronic epilepsy.^3
–5

Telemedicine has the potential to change and improve medical care. A major opportunity for telemedicine is the more efficient management of chronic disorders.^6
–8 Given the demographic changes occurring in many Western societies (including Germany), a discrepancy already exists between the need for chronic disease care and the availability of medical resources,⁹ such as at the state level.¹⁰ The length of hospital stay has steadily decreased in Germany.¹¹ During the COVID-19 pandemic, access to specialized health care was impeded for individuals with epilepsy.^12,13

Together, these problems particularly affect individuals with rare and complex epilepsies, which require expert and often resource-intensive medical knowledge,¹⁴ including assessments of neurophysiological examinations such as electroencephalogram (EEG), a cornerstone of epilepsy diagnosis.¹⁵ In addition, there are large gaps in general neuropediatric care and care for rare and complex epilepsy syndromes.¹⁶ Implementing a high-usability cross-sectoral teleconsultation service in epileptology can potentially improve and expand care for individuals with epilepsy by optimizing limited medical staff resources.¹⁷

The Epilepsy Network Hessen Evaluation (ENHE) is a pilot interprofessional (“doc-to-doc”) teleconsultation project in which physicians at private practices (both neurologists and pediatricians) and nonspecialized clinics can make telemedical inquiries for diagnostically or therapeutically difficult cases.^18,19 This network follows a hubs-and-spokes model; consultation requests from primary neurologists or pediatricians are sent to the epilepsy centers in Frankfurt am Main and Marburg (“hubs”) for consideration.

The ENHE is supplemented by a prospective scientific study that aims to examine the pilot project's quality and performance and gather evidence on opportunities and barriers to cross-sectoral specialized telemedical care. Despite advances such as “integrated care,” cross-sectoral fragmentation remains a structural issue in managing chronic disorders in the German health care system.

This prospective longitudinal questionnaire study aimed to examine the feasibility, quality, and provider-reported changes in medical outcomes of an epileptology teleconsultation network.

Methods

ENHE STRUCTURE

The ENHE is a pilot telemedical program using a hubs-and-spokes configuration. Its implementation was funded by the Hessian Ministry for Social Affairs and Integration (Hessisches Ministerium für Soziales und Integration [HMSI], Wiesbaden, Germany) and the Hessian Ministry of Science and Art (Hessisches Ministerium für Wissenschaft und Kunst [HMWK], Wiesbaden, Germany) to improve care for specific patient populations, particularly in rural regions in Hessen, a medium-sized state in Germany with 6.4 million inhabitants and a diverse population structure. Densely inhabited areas in southern Hessen contrast with more sparsely populated areas in northern and eastern Hessen. Specialist medical care is more difficult to access in the latter areas. This limited access especially affects less-mobile patient populations, such as those with epilepsy, who often have lower spatial mobility due to driving restrictions.

Within the ENHE, all consultations are initiated by a primary neurologist or pediatrician (“spoke”) and answered with delay by the epilepsy center (“hub”). Consultations are based on the written history, physical examination, and relevant further medical data. If necessary, personal information exchange is possible using a videoconference service. A consultation is completed upon receipt of the written medical statement from the primary doctor. The ENHE features a digital management system for consultations through which they can be initiated and their status can be monitored (Panvision GmbH, Essen, Germany). Scientific questionnaires for this evaluation are also administered through this platform. Consultations were free of charge for all participants in the ENHE, and the HMSI and HMWK covered the infrastructure costs during the pilot phase of the ENHE project.

If a consultation is made, the “hub” is informed through the digital platform and e-mail to a preconfigured e-mail account. Patient information, pre-existing written history reports, imaging data, and EEG data are transmitted separately through a secured telemedicine network within a pre-existing teleradiology network (JiveX; VISUS Health IT GmbH, Bochum, Germany). Written reports (as PDFs in the digital imaging and communications in medicine [DICOM]-container format) and imaging data (in the native DICOM format) can be viewed online in the teleradiology platform using a local radiology workstation.

EEG data are transmitted in the DICOM-container format and locally transferred to a secured server in the hospital environment of the “hub,” where it is reviewed using a multiformat-compatible EEG viewer in the original EEG format (encevis Epilepsy; AIT Austrian Institute of Technology GmbH, Vienna, Austria). Then, consultation statements are transferred to the primary physician in a digital PDF format. For technical details, see also the article by Mues et al.¹⁸

STUDY SETTING, POPULATION, AND DESIGN

This analysis is based on data collected prospectively and longitudinally as part of the scientific evaluation of the ENHE, including all participating primary neurologists and pediatricians who consulted the epilepsy centers in Frankfurt am Main and Marburg. These epilepsy centers provide specialized inpatient and outpatient care for individuals with epilepsy (including rare and complex epilepsies and developmental and epileptic encephalopathies) and other paroxysmal disorders. The questionnaire was administered in German in consecutive consultations between May 2020 and September 2022.

Neurologists and pediatricians throughout Hessen were contacted by the project team in Frankfurt in 2018 and asked to participate in the ENHE; reasons for declining participation were studied previously.¹⁹ All participating physicians agreed to participate in the study before enrolment. Seven private practices and four hospital departments participated as “spokes” (Fig. 1). All participating physicians received a questionnaire upon completion of each consultation. The questionnaires were made available for digital completion through the electronic consultation platform. In a personal work list, each participant could check the status of their consultations and complete the questionnaires directly.

Fig. 1.

Map summarizing ENHE participants' locations. All participant locations of the ENHE are marked on a map of the German federal state of Hessen (left side). Within the map, red markers indicate epilepsy centers (“hubs”), and blue markers indicate primary neurologists (“spokes”). A map of Germany and the location of Hessen within it are inserted in the upper right corner. Please note that some cities have more than one organization. The full annotated and interactive map is available at https://umap.openstreetmap.de/de/map/enhe_46834 The map data are copyrighted by the OpenStreetMap contributors and are available at https://www.openstreetmap.org The map was created with umap (https://umap.openstreetmap.de/de). ENHE, Epilepsy Network Hessen Evaluation.

The questionnaires contained questions about the reason for consultation, their satisfaction with it, and whether it influenced their diagnostic or therapeutic decision. A follow-up questionnaire was automatically sent after 3 months to capture a follow-up and health care provider-reported clinical outcome. Completing the questionnaires was voluntary and independent of the medical consultation in the individual case. Noncompletion did not result in any disadvantage for further telemedical consultations in the network.

Since validated telehealth surveys were lacking for our application,²⁰ we used an individually constructed questionnaire that included 13 Likert-type, multiple-choice, and open-ended items. The 3-month follow-up questionnaire included two additional follow-up-related items, containing 15 items in total.

This study was approved by the Institutional Review Boards of the Goethe-University Frankfurt (reference: 171/18) and the Hessen State Medical Board (reference: MC 69/2019). It was registered with the German Clinical Trials Register (DRKS) and assigned the accession number DRKS00014858 and Universal Trial Number U1111-1215-2748 (registered: April 29, 2021; www.drks.de/DRKS00014858).

QUESTIONNAIRE ITEMS

We recorded patient age, gender, and number of teleconsultations per patient (more than one teleconsultation per patient was possible if deemed necessary by the requesting physician). We also recorded the date and time of each teleconsultation request and respective response. We differentiated teleconsultation requests for differential diagnostic issues, therapeutic co-assessment, co-evaluation of an EEG, sociomedical issues, and other (open) consultation requests. We also evaluated each consultation's number and type of data transferred (written history/physical examination, EEG, magnetic resonance imaging [MRI], and/or computed tomography [CT]).

The questionnaire assessed satisfaction with the consultation, usability, time to respond, and the provided response on a five-point Likert scale. Primary physicians were also asked to rate whether the recommendations made in the consultation were helpful in the further diagnosis of the patient, whether they influenced diagnostic and/or treatment decisions, and whether they were ultimately followed on a five-point Likert scale.

At the 3-month follow-up, we asked whether the individual was still in the primary doctor's care and followed up on user satisfaction, agreement with the consultation, helpfulness in constructing a diagnostic workup, and ultimate influence on diagnosis and/or treatment. We also assessed changes in seizure frequency and whether the initial diagnosis from the consultation remained valid.

STATISTICAL ANALYSIS

We used descriptive and nonparametric statistics to evaluate demographic, clinical, technical, satisfaction, and outcome aspects included in the questionnaires. Within-group distributions of nominal variables were compared using Cochran's Q test with Benjamini–Hochberg-corrected pairwise post hoc tests. Within-group distributions of ordinal variables were compared using the Friedman test with Benjamini–Hochberg-corrected pairwise or homogeneous subset post hoc tests. Between-group interval and ordinal data were compared using the Mann–Whitney U test, and between-group nominal data were compared using the chi-square or Fisher's exact test, as appropriate, based on expected cell frequencies. Multiple between-group analyses were also corrected for using the Benjamini–Hochberg method. A two-tailed p-value of <0.05 was considered statistically significant. All analyses were performed with the SPSS (version 29; IBM Corp., Armonk, NY) or R (version 4.2.2; R Core Team, Vienna, Austria) statistical software.

Results

DEMOGRAPHIC DATA

Teleconsultations involved 114 patients treated for paroxysmal (seizure) disorders. The mean age of patients at first consultation was 33.7 years (standard deviation [SD]: 25.7, range: 1 day to 91 years). Among all patients, 34% (n = 39) were <18 years of age, 48% (n = 55) were female, and three were recorded as “other” gender. Among adults, the mean age was 47.7 years (SD: 20.1, range: 18–91 years), and 53% (n = 40) were female. Among children, the mean age was 6.7 years (SD: 5.6, range: 1 day to 17 years), and 38.5% (n = 15) were female; the “other” gender was only recorded for children.

CONSULTATION CHARACTERISTICS

We evaluated 129 teleconsultations, of which 41 (31.8%) were for pediatric patients. Of the 114 patients, most (n = 103, 90.4%) had 1 consultation, 9 (7.9%) had 2 consultations, and 2 (1.7%) had 4 consultations. At the first consultation, the most common request was for EEG co-evaluation in 98 cases (76%), followed by therapeutic co-assessment (n = 43, 33.3%) and help with differential diagnosis (n = 31, 24%); sociomedical requests were rare (n = 2, 1.6%; all p < 0.001). Notably, each consultation could include more than one type of request.

EEG data were transferred more frequently than any other type of data (all p < 0.001; Table 1), consistent with the reported reasons for the requests. Reasons for requests in cases with repeated consultations were generally similar to those in cases with only one consultation. Most consultations were requested in the early afternoon. Responses began in the early working hours and continued into the late evening, reflecting staffing levels. The median consultation latency was 1 day (interquartile range: 3.5 days).

Table 1.

General Consultation Characteristics in the Epilepsy Network Hessen Evaluation

	N (%)	p
Request for
EEG co-evaluation	98 (76)	Ref.
Therapeutic co-assessment	43 (33.3)	<0.001^a
Aid in differential diagnosis	31 (24)	<0.001^a
Sociomedical issue	2 (1.6)	<0.001^a
Other issues	5 (3.9)	<0.001^a
Request for (in those with >1 teleconsultation)
EEG co-evaluation	19 (73.1)	0.798^b
Therapeutic co-assessment	11 (42.3)	0.352^b
Aid in differential diagnosis	3 (11.5)	0.125^b
Sociomedical issue	1 (3.8)	0.364^b
Other issues	1 (3.8)	0.999^b
Transferred data
EEG	109 (84.5)	Ref.
MRI	22 (17.1)	<0.001^a
CT	3 (2.3)	<0.001^a
Previously written records	12 (9.3)	<0.001^a
Other data	1 (0.8)	<0.001^a
Separate data types (median, range)	1, 1–4
Time data
Time of consultation request (median, range), hours:minutes	13:38 (00:38–23:19)
Time of consultation response (median, range), hours:minutes	14:59 (08:52–21:07)
Median consultation latency, median (IQR, range), days	1 (3.5, 0.05–70.8)

Compared to the reference category (Cochran's Q test).

Compared to cases with only one consultation (Fisher's exact test).

CT, computed tomography; EEG, electroencephalogram; IQR, interquartile range; MRI, magnetic resonance imaging; Ref., reference category.

QUESTIONNAIRE DATA

The response rate was 72.1% (n = 93) for the initial questionnaire (completed after the first consultation) and 66.7% (n = 86) for the 3-month follow-up questionnaire.

Satisfaction

Overall satisfaction with the consultation service was high, with 98.9% of consultations resulting in a fully or mostly satisfactory response. The aggregated median response for overall satisfaction, consultation content, response latency, and ease of use was complete satisfaction (1 on the 5-point Likert scale). Each item was also rated highly, with an item-wise median of 1 for all items (Table 2). However, when comparing the specific aspects of user satisfaction, primary physicians rated satisfaction with consultation content (p = 0.024) and time to response (p = 0.032) higher than ease of use.

Table 2.

Overall Questionnaire Results

OVERALL RESPONSE	MEAN AGREEMENT (MEDIAN, RANGE), 1 = STRONGLY AGREE, 5 = STRONGLY DISAGREE	“I AGREE” BY CATEGORY	p
Q1–Q4: Satisfaction
Q1: “I am [overall] satisfied with the advice I received in this case.”	1.1 (1, 1–3)	Fully: 93.5% Mostly: 5.4% Neutral: 1.1%	Ref.
Q2: “I am satisfied with the ease of requesting a consultation.”	1.8 (1, 1–5)	Fully: 69.9% Mostly: 6.5% Neutral: 5.4% Mostly disagree: 11.8% Disagree: 6.5%	<0.001^a
Q3: “I am satisfied with consultation response latency.”	1.2 (1, 1–5)	Fully: 88.2% Mostly: 8.6% Neutral: 1.1% Mostly disagree: 1.1% Disagree: 1.1%	Ref.
Q4: “I am satisfied with the recommendation given in the consultation.”	1.1 (1, 1–3)	Fully: 90.3% Mostly: 8.6% Neutral: 1.1%	Ref.
Q5–Q9: Helpfulness/influence on management
Q5: “The recommendations helped me plan further management for the patient.”	1.3 (1, 1–3)	Fully: 73.9% Mostly: 20.5% Neutral: 5.7%	Ref.
Q6: “The consultation helped me in making a diagnosis.”	1.6 (1, 1–3)	Fully: 65.1% Mostly: 15.1% Neutral: 19.8%	0.236
Q7: “The recommendations have influenced my diagnostic decision.”	1.6 (1, 1–3)	Fully: 63.2% Mostly: 9.2% Neutral: 27.6%	0.035
Q8: “The recommendations helped me in the treatment of the patient.”	1.4 (1, 1–3)	Fully: 68.1% Mostly: 22% Neutral: 9.9%	0.411
Q9: “The recommendations have influenced my treatment decision.”	1.7 (1, 1–3)	Fully: 60.9% Mostly: 9.8% Neutral: 29.3%	0.030
Q10–Q11: Adoption of recommendations
Q10: “I followed the diagnostic assessment in the consultation.”	Completely: 96% Partially: 3% Did not follow:1%
Q11: “I have adopted the therapy recommendation in the consultation.”	Completely: 95%Partially: 4%Did not adopt: 1%

Compared to other category variables (Friedman test, homogeneous subset post hoc analysis), thus, more than one reference category is possible.

Helpfulness/influence on management

Primary physicians rated all aspects of helpfulness highly, with a median response of complete agreement across aggregated items (1 on the five-point Likert scale) and for each item (Table 2). When comparing individual items, it was apparent that perceived helpfulness in planning further management, making a diagnosis, and treatment did not differ significantly. Similarly, the perceived influence on diagnosis and treatment did not differ significantly. However, the perceived helpfulness in planning further treatment was rated more highly than actual therapeutic (p = 0.030) and diagnostic (p = 0.035) influence.

Adoption of recommendations

Even considering that perceived influence on decision making was not rated as highly as strategic helpfulness, adoption of both diagnostic and therapeutic recommendations was high, with 99% of primary neurologists stating that they fully (96% and 95%, respectively) or partially (3% and 4%, respectively) followed the given diagnostic and/or therapeutic recommendations (Table 2).

Three-month follow-up

At 3 months, 51.2% (n = 44) of the initially followed-up patients were still being treated by their primary neurologist. Satisfaction with overall advice and specific recommendations remained high, with 97.7% of respondents agreeing fully or partially. Over time, neither overall system satisfaction (mean rank = both 1.50, p = 0.999) nor specific consultation satisfaction (1.48 vs. 1.50, p = 0.439) changed significantly.

The same was true for perceived helpfulness in planning further management (both 1.50, p = 0.999), diagnosis (both 1.50, p = 0.999), and treatment (1.49 vs. 1.51, p = 0.819). The perceived impact of the consultation on diagnosis (1.48 vs. 1.52, p = 0.467) and treatment (1.49 vs. 1.51, p = 0.827) did not change significantly at 3 months. Where this was part of the consultation (n = 24), seizure frequency decreased in 95.8% (n = 23) of patients treated according to the consultation and increased in only 4.2% (n = 1). In 77.9% of consultations, the diagnosis suggested in the consultation had since been confirmed by the primary physician.

COMPARISON BETWEEN CONSULTATIONS ACCORDING TO CARE LEVEL

Significant differences emerged when comparing consultations requested by physicians in private practices with those in hospitals. Hospital-based neurologists or pediatricians more frequently requested therapeutic co-assessment than those in private practice (p = 0.045). However, their requests in other categories did not differ significantly (Table 3). While the frequency of EEG data transmission was comparable across both health care settings, MRI data transfers were significantly more common among hospital-based physicians. Notably, only hospital-based physicians transmitted CT images. The median data types transferred per consultation were also significantly greater among hospital-based physicians.

Table 3.

Consultation Characteristics and Questionnaire Results by Health Care Setting

ITEM	PRACTICE, N (%)	HOSPITAL, N (%)	p
Request for
EEG co-evaluation	47 (77.0)	51 (75.0)	0.999
Therapeutic co-assessment	13 (21.3)	30 (44.1)	0.045
Aid in differential diagnosis	12 (19.7)	19 (27.9)	0.999
Sociomedical issue	1 (1.6)	1 (1.5)	0.999
Other issues	3 (4.9)	2 (2.9)	0.999
Transferred data
EEG	51 (83.6)	58 (85.3)	0.812
MRI	4 (6.6)	18 (26.5)	0.004
CT	0	3 (4.4)	n.a.
Previously written records	8 (13.1)	4 (5.9)	0.226
Other data	1 (1.6)	0	n.a.
Separate data types, median (range)	1 (1.2, 1–2)	1 (1.5, 1–4)	0.032
Time data
Median consultation latency, median (IQR, range), days	1 (0.6, 0.05–70.8)	2 (1, 0.06–54.8)	0.033

OVERALL RESPONSE	PRACTICE AVERAGE AGREEMENT (MEDIAN, RANGE), 1 = STRONGLY AGREE, 5 = STRONGLY DISAGREE	HOSPITAL AVERAGE AGREEMENT (MEDIAN, RANGE), 1 = STRONGLY AGREE, 5 = STRONGLY DISAGREE	p
Q1: “I am [overall] satisfied with the advice I received in this case.”	1.1 (1, 1–3)	1.1 (1, 1–2)	0.999
Q2: “I am satisfied with the ease of requesting a consultation.”	1.3 (1, 1–5)	2.3 (2, 1–5)	<0.001
Q3: “I am satisfied with consultation response latency.”	1.0 (1, 1–2)	1.3 (1, 1–5)	0.042
Q4: “I am satisfied with the recommendation given in the consultation.”	1.0 (1, 1–2)	1.2 (1, 1–3)	0.039
Q5: “The recommendations helped me plan further management for the patient.”	1.1 (1, 1–3)	1.6 (1, 1–3)	<0.001
Q6: “The consultation helped me in making a diagnosis.”	1.4 (1, 1–3)	1.8 (2, 1–3)	0.008
Q7: “The recommendations have influenced my diagnostic decision.”	1.3 (1, 1–3)	2.1 (2, 1–3)	<0.001
Q8: “The recommendations helped me in the treatment of the patient.”	1.1 (1, 1–3)	1.8 (2, 1–3)	<0.001
Q9: “The recommendations have influenced my treatment decision.”	1.3 (1, 1–3)	2.0 (2, 1–3)	<0.001

n.a., not applicable.

Overall satisfaction did not differ significantly between the two health care settings. Nevertheless, private practice physicians expressed greater satisfaction regarding response latency (p = 0.042) and specific consultation advice (p = 0.039) than hospital-based physicians. However, private practice physicians rated the ease of system use significantly lower (p < 0.001).

Several significant differences emerged between the health care settings when considering the perceived helpfulness of advice and the influence on further patient management. Helpfulness was rated more highly by private practice physicians across all variables, with a higher average agreement for helpfulness in making a diagnosis (1.4 vs. 1.8, p = 0.008), further management (1.1 vs. 1.6, p < 0.001), and treating the patient (1.1 vs. 1.8, p < 0.001). Hospital-based physicians also considered the consultation less influential for their diagnosis (2.1 vs. 1.3 for practice based, p < 0.001) and further management (2.0 vs. 1.3, p < 0.001).

COMPARISON BETWEEN CONSULTATIONS FOR PEDIATRIC AND ADULT PATIENTS

Regarding overall consultation characteristics, request types differed between pediatric and adult consultations only for EEG co-evaluation, which was more commonly requested in pediatric than in adult consultations (p = 0.014). The generally rare requests for sociomedical advice (n = 2) were made only for adults. Transferred data types were similar between adult and pediatric patients. However, CT images and previous written reports were only transferred in consultation requests for adults. There was a trend toward faster responses in consultations for adult patients, but this difference was not statistically significant (p = 0.056).

Discussion

The ENHE represents an innovative interprofessional telemedical approach to improving patient care in epilepsy, especially for patients in rural and underserved areas. Several key findings emerged from this study. First, overall satisfaction with the system was high. The ENHE played a significant role in diagnosis and treatment, and provider-reported outcomes at 3 months were favorable. Second, EEG co-examination was the primary consultation request, identifying a health care gap well suited to telemedical solutions.²¹ Third, significant differences in patient characteristics and perceived helpfulness emerged between health care settings, with physicians in private practice rating the system generally higher than those in hospitals. In the literature, little is generally known about the efficacy of interprofessional (“doc-to-doc”) telemedicine networks for epilepsy since most studies reported “patient-to-doc” services, often in the context of the COVID-19 pandemic.^22,23 Therefore, our results expand the knowledge regarding interprofessional systems.

PATIENT DEMOGRAPHICS AND HEALTH CARE GAPS

The wide age range of patients for whom consultations were requested, from neonates to older adults, underscores the broad applicability of this telemedicine approach. There was an unexpectedly high number of consultations for pediatric patients, with many requests for EEG co-evaluation in neonates and infants. There is a significant shortage of neuropediatric care and neurophysiological expertise for pediatric patients in Germany.²¹ We demonstrated that telemedicine is a well-accepted method to bridge this gap successfully. A further interesting finding of this study is the difference in consultations requested by neurologists in private practices and those in hospitals. Hospital-based neurologists appeared to have a more complex patient cohort based on the higher frequency of therapeutic co-assessment requests and the greater median data types transferred per consultation, which might have influenced their overall satisfaction and perceived helpfulness of consultations.

SATISFACTION WITH THE ENHE SYSTEM

Regardless of the health care setting, primary physicians demonstrated a strong commitment to and satisfaction with the ENHE telehealth system, underscored by their strong response rates and consistently positive feedback from the initial and 3-month evaluations. Notably, high satisfaction levels with telehealth applications, particularly from the patient's perspective, are commonly reported in the literature.^24,25 Such almost ubiquitous positive findings have led to some caution about the utility of satisfaction as a singular metric in telehealth studies.²⁶ The voluntary nature of ENHE participation may have attracted physicians with a predisposition toward digital technology and an above-average understanding of telemedicine, which may have unwittingly led to an overestimation of provider satisfaction.

However, it is recognized that assessing provider satisfaction provides a more nuanced understanding of telehealth's strengths and areas for improvement than patient surveys.²⁷ Consistent with this, our detailed analysis showed evident differences in provider satisfaction across specific dimensions. For example, while the ENHE was designed with usability in mind, our findings indicate that usability metrics still lagged behind other satisfaction parameters, such as response latency or consultation content, underscoring the need to continue improving the system's usability. Notably, the use of standardized technical components means that the system could be used in other parts of Germany and equally in other developed countries. It could even be adapted for low- and middle-income countries under certain technical prerequisites.²⁸

Comparative analyses between health care settings revealed additional differences. While satisfaction with the ENHE was widespread, private practice physicians were significantly more satisfied with the content of consultations than hospital-based physicians, but less satisfied with the system's usability. This disparity suggests that private practice neurologists, perhaps due to the inherent limitations of a smaller practice, perceive greater value in telemedicine consultations, but require easier-to-use teleconsultation systems. Resource and time constraints are often more pronounced in private practice than hospital departments, which can share the workload or even assign individual physicians to manage teleconsultations. This difference is relevant since perceived workload predicts unwillingness to continually use telemedicine.²⁹

UTILITY OF ENHE CONSULTATIONS

The consultations provided through the ENHE played a significant role in shaping the diagnosis and treatment strategies of primary neurologists and pediatricians, demonstrated by the high agreement with usefulness and consultation influence across our cohort. In addition, most primary physicians in every care setting adopted the recommendations provided through the consultations. Again, differentiating between the health care settings allowed us to gain further insights. Neurologists in private practice rated both helpfulness and influence higher than those in hospitals. This difference may reflect less specialized experience with seizure disorders among private practice neurologists, but could also reflect the greater medical complexity of cases seen in hospitals. Notably, regardless of the health care setting, almost all respondents reported following the advice given in the first teleconsultation after 3 months. In addition, most patients (95.8%) had a provider-reported reduction in seizure frequency at 3 months.

While an important limitation of this study was the lack of a comparison cohort of conventionally treated patients, our results suggest that the telemedicine consultation at least contributed to positive outcomes for the patients who received it. Furthermore, in 77.9% of consultations, the diagnosis suggested in the initial consultation could be confirmed by the primary neurologist or pediatrician by the 3-month follow-up, demonstrating the usefulness of telemedicine evaluation even for epilepsy, a disorder only intermittently clinically apparent. This observation could imply that the reported significant advantages of specialized care by an epilepsy center³⁰ can at least partially be preserved when expertise is provided through a telemedicine program. The median latency for consultations was only 1 day, suggesting that the system efficiently provides timely feedback, which is critical in managing conditions such as epilepsy, where timely intervention can significantly impact patient outcomes.

Conclusions

Our results demonstrate that a telemedical interprofessional consultation system improved access to specialized medical expertise and was associated with very satisfactory provider-reported medical outcomes. In summary, the ENHE pilot program showcases the potential of telemedical consultations in improving patient care in neurology, especially in regions where specialized care is less accessible. Such programs can be instrumental in bridging the gap between primary neurologists and specialized centers, ensuring that patients receive consistent and high-quality care, regardless of their geographic location. Further research might examine patient perspectives and assess the economic implications of such telemedical networks.

Footnotes

Authors' Contributions

Conceptualization: J.P.Z., F.R., S.S.-B., S.K., and A.S.; data curation: J.P.Z., F.R., S.S.-B., S.K., M.F., A.N., and A.S.; formal analysis: J.P.Z., F.R., S.S.-B., C.R., S.K., M.F., A.N., C.M., and A.S.; funding acquisition: J.P.Z., F.R., M.F., A.N., and A.S.; investigation: J.P.Z., F.R., S.S.-B., C.R., S.K., C.E., P.S., J.M., E.B., M.T., O.S., S.S., A.D., K.-H.H., E.S., K.S.-G,, M.F., A.N., C.M., and A.S.; methodology: J.P.Z., F.R., S.S.-B., C.R., S.K., A.N., and A.S.; project administration: J.P.Z., F.R., S.S.-B., S.K., M.F., A.N., C.M., and A.S.; resources: J.P.Z., F.R., S.S.-B., C.R., S.K., C.E., P.S., J.M., E.B., M.T., O.S., S.S., A.D., K.-H.H., E.S., K.S.-G., M.F., A.N., C.M., and A.S.; supervision: F.R., S.S.-B., S.K., and A.S.; validation: J.P.Z. and A.S.; visualization: J.P.Z. and A.S.; writing—original draft, review, and editing: J.P.Z., F.R., S.S.-B., C.R., S.K., C.E., P.S., J.M., E.B., M.T., O.S., S.S.-B., A.D., K.-H.H., E.S., K.S.-G., M.F., A.N., C.M., and A.S.

Disclosure Statement

All authors participated in the ENHE. J.P.Z., F.R., S.S.-B., S.K., A.N., C.M., and A.S. participated as members of epilepsy centers and were part of the administrative team that conceptualized and established the network. J.P.Z. reports personal fees from GW Pharmaceuticals outside the submitted work. F.R. reports personal fees from Angelini Pharma/Arvelle Therapeutics, Eisai, GW Pharmaceuticals/Jazz Pharma, and UCB Pharma, and grants from the Detlev-Wrobel-Fonds for Epilepsy Research, the Deutsche Forschungsgemeinschaft (DFG), the Federal Ministry of Education and Research (BMBF), the LOEWE Programme of the State of Hesse, and the European Union outside the submitted work. S.S.-B. reports personal fees from Eisai, Desitin Pharma, GW Pharmaceuticals, Zogenix, UCB Pharma, and Marinus Pharma outside the submitted work. C.M. reports speaker's honoraria from Eisai and UCB and travel support from GW Pharmaceuticals outside the submitted work.

A.S. reports personal fees and grants from Angelini Pharma, Biocodex, Desitin Arzneimittel, Eisai, GW Pharmaceuticals, Marinus Pharma, Precisis, Takeda, UCB Pharma, UNEEG Medical, and Zogenix outside the submitted work. All other authors report no further conflicts of interest.

Funding Information

The ENHE was funded by the Hessian Ministry for Social Affairs and Integration (HMSI) and the Hessian Ministry of Science and Art (HMWK), including funding for technical infrastructure and medical and administrative personnel.

References

Oto

The misdiagnosis of epilepsy: Appraising risks and managing uncertainty. Seizure, 2017; 44:143–146; doi: 10.1016/j.seizure.2016.11.029

Beghi

, Giussani

, Nichols

, et al. Global, regional, and national burden of epilepsy, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol, 2019; 18(4):357–375; doi: 10.1016/S1474-4422(18)30454-X

Willems

, Hochbaum

, Zöllner

, et al. Trends in resource utilization and cost of illness in patients with active epilepsy in Germany from 2003 to 2020. Epilepsia, 2022; 63(6):1591–1602; doi: 10.1111/epi.17229

Strzelczyk

, Aledo-Serrano

, Coppola

, et al. The impact of epilepsy on quality of life: Findings from a European survey. Epilepsy Behav, 2023; 142:109179; doi: 10.1016/j.yebeh.2023.109179

Jacoby

Stigma, epilepsy, and quality of life. Epilepsy Behav, 2002; 3(6):10–20; doi: 10.1016/S1525-5050(02)00545-0

Whitehead

, Seaton

. The effectiveness of self-management mobile phone and tablet apps in long-term condition management: A systematic review. J Med Internet Res, 2016; 18(5):e97; doi: 10.2196/jmir.4883

Zöllner

, Noda

, McCoy

, et al. Use of health-related apps and telehealth in adults with epilepsy in Germany: A multicenter cohort study. Telemed J E Health, 2023; 29(4):540–550; doi: 10.1089/tmj.2022.0238

Semprino

, Fasulo

, Fortini

, et al. Telemedicine, drug-resistant epilepsy, and ketogenic dietary therapies: A patient survey of a pediatric remote-care program during the COVID-19 pandemic. Epilepsy Behav, 2020; 112:107493; doi: 10.1016/j.yebeh.2020.107493

Samia

, Sahu

, Ali

, et al. Telemedicine for Individuals with epilepsy: Recommendations from the International League Against Epilepsy Telemedicine Task Force. Seizure, 2023; 106:85–91; doi: 10.1016/j.seizure.2023.02.005

10.

Kohlhase

, Rosenow

, Golbach

, et al. State-specific differences in healthcare of epilepsy patients in Germany. Clin Epileptol, 2023; doi: 10.1007/s10309-023-00610-3

11.

Willems

, Strzelczyk

, Rosenow

, et al. Impact of DRG billing on length of hospital stay for patients with epilepsy. Clin Epileptol, 2023; 36(3):217–223; doi: 10.1007/s10309-023-00583-3

12.

Körbel

, Rosenow

, Maltseva

, et al. Impact of COVID-19 pandemic on physical and mental health status and care of adults with epilepsy in Germany. Neurol Res Pract, 2022; 4(1):44; doi: 10.1186/s42466-022-00209-5

13.

Mann

, Maltseva

, Von Podewils

, et al. Supply problems of antiseizure medication are common among epilepsy patients in Germany. Epilepsy Behav, 2023; 138:108988; doi: 10.1016/j.yebeh.2022.108988

14.

Lavin

, Gray

, Brodie

. Telemedicine and epilepsy care. Neurol Clin, 2022; 40(4):717–727; doi: 10.1016/j.ncl.2022.03.004

15.

Lemke

, Kluger

, Krämer

Hans Berger and 100 years electroencephalogram Insights into his life and his research on the “electrencephalogram.”. Clin Epileptol, 2024; doi: 10.1007/s10309-024-00664-x

16.

Gali

, Joshi

, Hueneke

, et al. Barriers, access and management of paediatric epilepsy with telehealth. J Telemed Telecare, 2022; 28(3):213–223; doi: 10.1177/1357633X20969531

17.

Graessner

, Storf

, Schaefer

. Healthcare networks for people with rare diseases: Integrating data and expertise. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz, 2022; 65(11):1164–1169; doi: 10.1007/s00103-022-03592-1

18.

Mues

, Hamer

, Von Podewils

, et al. Telemedicine in epilepsy care: Doc-to-doc applications: Part II: Current projects in Germany. Z für Epileptol, 2021; 34(3):299–305; doi: 10.1007/s10309-021-00426-z

19.

Zöllner

, Noda

, McCoy

, et al. Attitudes and barriers towards telemedicine in epilepsy care: A survey among neurological practices. Z für Epileptol, 2021; 34(3):318–323; doi: 10.1007/s10309-021-00417-0

20.

Langbecker

, Caffery

, Gillespie

, et al. Using survey methods in telehealth research: A practical guide. J Telemed Telecare, 2017; 23(9):770–779; doi: 10.1177/1357633X17721814

21.

Rosenow

, Audebert

, Hamer

, et al. Tele-EEG: Current applications, challenges, and technical solutions. Klin Neurophysiol, 2018; 49(4):208–215; doi: 10.1055/a-0627-8047

22.

Willems

, Balcik

, Noda

, et al. SARS-CoV-2-related rapid reorganization of an epilepsy outpatient clinic from personal appointments to telemedicine services: A German single-center experience. Epilepsy Behav, 2020; 112:107483; doi: 10.1016/j.yebeh.2020.107483

23.

Feldmeier

, Löffler

, Altiner

, et al. Audiovisual teleconsultation for patients with epilepsy in primary care in rural Germany: A pilot study on feasibility and acceptance. Pilot Feasibility Stud, 2022; 8(1):213; doi: 10.1186/s40814-022-01171-4

24.

Mounessa

, Chapman

, Braunberger

, et al. A systematic review of satisfaction with teledermatology. J Telemed Telecare, 2018; 24(4):263–270; doi: 10.1177/1357633X17696587

25.

Johansson

, Wild

. Telemedicine in acute stroke management: Systematic review. Int J Technol Assess Health Care, 2010; 26(2):149–155; doi: 10.1017/S0266462310000139

26.

Williams

, May

, Esmail

. Limitations of patient satisfaction studies in telehealthcare: A systematic review of the literature. Telemed J E Health, 2001; 7(4):293–316; doi: 10.1089/15305620152814700

27.

Whitten

, Love

. Patient and provider satisfaction with the use of telemedicine: Overview and rationale for cautious enthusiasm. J Postgrad Med, 2005; 51(4):294–300.

28.

Bassa

, Hahner

, Braun

, et al. Telemedicine and international projects: From Asia to Africa: Chances for the future?. Nervenarzt, 2024; 95:236–241; doi: 10.1007/s00115-023-01605-1

29.

Kubota

, Kuroda

, Horinouchi

, et al. Barriers to telemedicine among physicians in epilepsy care during the COVID-19 pandemic: A national-level cross-sectional survey in Japan. Epilepsy Behav, 2022; 126:108487; doi: 10.1016/j.yebeh.2021.108487

30.

Lowerison

, Josephson

, Jetté

, et al. Association of levels of specialized care with risk of premature mortality in patients with epilepsy. JAMA Neurol, 2019; 76(11):1352; doi: 10.1001/jamaneurol.2019.2268