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HILTON HEAD, SC—When neurologists see patients remotely, the focus should be on the patient, not on the technology behind the virtual visit, according to one researcher. 
“One of the big mistakes that is made with telehealth is focusing on the technology and not on the clinical care delivery,” said Kenneth Gaines, MD, Professor of Neurology at Vanderbilt University in Nashville. “It is the clinical care delivery that ought to drive the technology. Too often it happens in reverse…. That is a recipe for an ineffective program.”
Broadly speaking, telemedicine is medicine practiced at a distance. Ideally, it uses technology to facilitate a clinical care paradigm that improves efficiency, care coordination, and outcomes and lowers costs, Dr. Gaines said. The public increasingly expects this type of care to be available, he said.
“Why would telehealth be useful in neurology? In part because we deal with acute and chronic disease, which is what stroke is, for example, but also other diseases like epilepsy,” Dr. Gaines said at Vanderbilt’s 41st Annual Contemporary Clinical Neurology Symposium. In addition, neurologic diseases are complex, and generalists’ training in them may be limited. Telehealth could allow neurologists to assist general practitioners and provide neurologic care to areas with few neurologists.
Opportunity in Neurology
Systematic reviews in disease states like diabetes, hyperlipidemia, and hypertension have found that telemedicine may benefit patients. A 2015 Cochrane review of data from randomized controlled trials of interactive telemedicine found with moderate certainty that telemedicine decreased LDL and blood pressure, compared with usual care. It found with high certainty that among patients with diabetes, those who received telemedicine had lower glycated hemoglobin levels at nine months, compared with controls. Evidence to assess the effects of telemedicine in neurology, however, was inadequate.
Nevertheless, studies indicate telemedicine’s promise in neurology. Beck et al conducted the Connect.Parkinson trial, which included 195 patients with Parkinson’s disease who were randomized to usual care or usual care plus four virtual visits via video conferencing with a remote specialist. The researchers found that telemedicine was feasible and equivalent to usual care with regard to its effects on patients’ quality of life. The virtual house calls saved patients a median of 88 minutes and 38 miles per visit. Mammen et al analyzed survey data from patients with Parkinson’s disease and physicians and found that they generally were satisfied with the telemedicine approach, but technical problems affected individual experiences. Physicians’ greatest source of dissatisfaction was performing a detailed motor examination remotely.
Samii et al reported the experience of one Veterans Administration medical center that found it feasible to conduct follow-up visits with patients with Parkinson’s disease via telemedicine. Although the video quality initially was not sufficient to score the motor Unified Parkinson’s Disease Rating Scale, a videoconferencing unit upgrade allowed physicians to assess those measures, with the exception of elements that require physical contact, such as rigidity and retropulsion.
A study by Kane et al found that telemedicine assessments of patients with multiple sclerosis could reliably determine Expanded Disability Status Scale scores. Scores related to cerebellar and brainstem functions, however, were less consistent with the scores of a hands-on examiner than were scores related to optic, bowel, bladder, and cerebral functions.
In neurology, most studies of telemedicine have focused on stroke, perhaps because of the complex and time-sensitive nature of the disease and a maldistribution of health care providers, Dr. Gaines said.
The Telemedical Pilot Project for Integrative Stroke Care (TEMPiS) in Germany connected 12 community hospitals that had limited experience with stroke thrombolysis to two specialized stroke centers. In the first 22 months, patients treated at the community hospitals and at the stroke centers had equivalent rates of mortality and good functional outcomes that were similar to those in randomized trials, Schwab et al reported.
In the STRokE DOC trial, Meyer et al assessed whether telemedicine (ie, real-time, two-way audio and video communication and digital imaging interpretation) or telephone consultation was superior in acute stroke consultations. In all, 111 patients were randomized to telemedicine, and 111 were randomized to telephone consultation. Ninety-day functional outcomes and rates of intracerebral hemorrhage after treatment with thromblytics and mortality were equivalent between the groups. With telemedicine, neurologists were more likely to arrive at a correct treatment decision and less likely to violate trial protocols, Dr. Gaines said.
The Neglected First Year
Dr. Gaines helped create a comprehensive stroke care model at Ochsner Medical Center in New Orleans that incorporated telemedicine. The program targeted acute stroke treatment as well as what Dr. Gaines calls the neglected first year after hospitalization for stroke. “In the chronic phase of stroke, these folks have significant disability. It is a significant stressor for their families and their caregivers, and unfortunately we have relatively poor risk factor control and inadequate medication compliance in this segment,” he said. Patients have high death rates due to recurrent stroke, complications of stroke, and other cardiovascular diseases.
The medical center provided telemedicine consultations to 22 affiliated hospitals. In addition, a Stroke Mobile team that consisted of a nurse and a health educator visited patients’ homes monthly for one year to address stroke risks and complications. Stroke Mobile staff used HIPAA-compliant video communication to facilitate telemedicine consultations with a vascular neurologist or advanced practice clinician during the home visits.
This model decreased length of hospital stay by one day, decreased cost per case by 9%, and lowered readmission and stroke recurrence by about 17% each. Furthermore, between 85% and 90% of patients achieved control of risk factors such as blood pressure, diabetes, and cholesterol. “Projects like this can offer us a much better, more comprehensive approach,” said Dr. Gaines.
Performing Neurologic Exams Remotely
Researchers have found that the NIH Stroke Scale can be administered as reliably in a telehealth setting as in person, Dr. Gaines said. Shafqat et al found that four NIH Stroke Scale items had excellent agreement (ie, orientation, motor arm, motor leg, and neglect), and six items had good agreement (ie, language, dysarthria, sensation, visual fields, facial palsy, and gaze), whereas two items (ie, commands and ataxia) had poor agreement, when they compared remote and in-person assessments.
Certain examination elements require the assistance of a nurse or emergency department doctor who is with the patient, and a neurologist’s confidence in his or her ability to perform a neurologic examination via telehealth may depend on how much he or she is “willing to ask people to do,” Dr. Gaines said. “I will ask somebody to shine a light into the eyes so I can look at the pupils. I will have a person who is helping me in the ER setting do a Babinski sign and watch for the response. I have diagnosed a hereditary neuropathy with liability to pressure palsies via teleneurology.”
Emergency department doctors and nurses often know how to perform elements of neurologic examinations, even if they do not routinely use them. “We spend time training nurses at our sites to help us,” he said.
In addition, neurologists can assess gait, which typically is not tested in emergency rooms but can provide valuable information. A patient’s gait might help a neurologist identify cerebellar infarcts that otherwise would have been attributed to dizziness, for example.
Telemedicine presents “opportunities … to impact stroke care and hopefully other areas of neurology as well. It is not nearly as daunting as you might think to do these consults virtually,” Dr. Gaines said. “It is a great opportunity for us to put systems of care in place to deal with some of the inequities and problems with delivery that we have.”
—Jake Remaly
Suggested Reading
Beck CA, Beran DB, Biglan KM, et al. National randomized controlled trial of virtual house calls for Parkinson disease. Neurology. 2017;89(11):1152-1161.
Flodgren G, Rachas A, Farmer AJ, et al. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2015;(9):CD002098.
Kane RL, Bever CT, Ehrmantraut M, et al. Teleneurology in patients with multiple sclerosis: EDSS ratings derived remotely and from hands-on examination. J Telemed Telecare. 2008;14(4):190-194.
Mammen JR, Elson MJ, Java JJ, et al. Patient and physician perceptions of virtual visits for Parkinson’s disease: a qualitative study. Telemed J E Health. 2018;24(4):255-267.
Meyer BC, Raman R, Hemmen T, et al. Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded, prospective study. Lancet Neurol. 2008;7(9):787-795.
Samii A, Ryan-Dykes P, Tsukuda RA, et al. Telemedicine for delivery of health care in Parkinson’s disease. J Telemed Telecare. 2006;12(1):16-18.
Schwab S, Vatankhah B, Kukla C, et al. Long-term outcome after thrombolysis in telemedical stroke care. Neurology. 2007;69(9):898-903.
Shafqat S, Kvedar JC, Guanci MM, et al. Role for telemedicine in acute stroke. Feasibility and reliability of remote administration of the NIH stroke scale. Stroke. 1999;30(10):2141-2145.
HILTON HEAD, SC—When neurologists see patients remotely, the focus should be on the patient, not on the technology behind the virtual visit, according to one researcher.
“One of the big mistakes that is made with telehealth is focusing on the technology and not on the clinical care delivery,” said Kenneth Gaines, MD, Professor of Neurology at Vanderbilt University in Nashville. “It is the clinical care delivery that ought to drive the technology. Too often it happens in reverse…. That is a recipe for an ineffective program.”
Broadly speaking, telemedicine is medicine practiced at a distance. Ideally, it uses technology to facilitate a clinical care paradigm that improves efficiency, care coordination, and outcomes and lowers costs, Dr. Gaines said. The public increasingly expects this type of care to be available, he said.
“Why would telehealth be useful in neurology? In part because we deal with acute and chronic disease, which is what stroke is, for example, but also other diseases like epilepsy,” Dr. Gaines said at Vanderbilt’s 41st Annual Contemporary Clinical Neurology Symposium. In addition, neurologic diseases are complex, and generalists’ training in them may be limited. Telehealth could allow neurologists to assist general practitioners and provide neurologic care to areas with few neurologists.
Opportunity in Neurology
Systematic reviews in disease states like diabetes, hyperlipidemia, and hypertension have found that telemedicine may benefit patients. A 2015 Cochrane review of data from randomized controlled trials of interactive telemedicine found with moderate certainty that telemedicine decreased LDL and blood pressure, compared with usual care. It found with high certainty that among patients with diabetes, those who received telemedicine had lower glycated hemoglobin levels at nine months, compared with controls. Evidence to assess the effects of telemedicine in neurology, however, was inadequate.
Nevertheless, studies indicate telemedicine’s promise in neurology. Beck et al conducted the Connect.Parkinson trial, which included 195 patients with Parkinson’s disease who were randomized to usual care or usual care plus four virtual visits via video conferencing with a remote specialist. The researchers found that telemedicine was feasible and equivalent to usual care with regard to its effects on patients’ quality of life. The virtual house calls saved patients a median of 88 minutes and 38 miles per visit. Mammen et al analyzed survey data from patients with Parkinson’s disease and physicians and found that they generally were satisfied with the telemedicine approach, but technical problems affected individual experiences. Physicians’ greatest source of dissatisfaction was performing a detailed motor examination remotely.
Samii et al reported the experience of one Veterans Administration medical center that found it feasible to conduct follow-up visits with patients with Parkinson’s disease via telemedicine. Although the video quality initially was not sufficient to score the motor Unified Parkinson’s Disease Rating Scale, a videoconferencing unit upgrade allowed physicians to assess those measures, with the exception of elements that require physical contact, such as rigidity and retropulsion.
A study by Kane et al found that telemedicine assessments of patients with multiple sclerosis could reliably determine Expanded Disability Status Scale scores. Scores related to cerebellar and brainstem functions, however, were less consistent with the scores of a hands-on examiner than were scores related to optic, bowel, bladder, and cerebral functions.
In neurology, most studies of telemedicine have focused on stroke, perhaps because of the complex and time-sensitive nature of the disease and a maldistribution of health care providers, Dr. Gaines said.
The Telemedical Pilot Project for Integrative Stroke Care (TEMPiS) in Germany connected 12 community hospitals that had limited experience with stroke thrombolysis to two specialized stroke centers. In the first 22 months, patients treated at the community hospitals and at the stroke centers had equivalent rates of mortality and good functional outcomes that were similar to those in randomized trials, Schwab et al reported.
In the STRokE DOC trial, Meyer et al assessed whether telemedicine (ie, real-time, two-way audio and video communication and digital imaging interpretation) or telephone consultation was superior in acute stroke consultations. In all, 111 patients were randomized to telemedicine, and 111 were randomized to telephone consultation. Ninety-day functional outcomes and rates of intracerebral hemorrhage after treatment with thromblytics and mortality were equivalent between the groups. With telemedicine, neurologists were more likely to arrive at a correct treatment decision and less likely to violate trial protocols, Dr. Gaines said.
The Neglected First Year
Dr. Gaines helped create a comprehensive stroke care model at Ochsner Medical Center in New Orleans that incorporated telemedicine. The program targeted acute stroke treatment as well as what Dr. Gaines calls the neglected first year after hospitalization for stroke. “In the chronic phase of stroke, these folks have significant disability. It is a significant stressor for their families and their caregivers, and unfortunately we have relatively poor risk factor control and inadequate medication compliance in this segment,” he said. Patients have high death rates due to recurrent stroke, complications of stroke, and other cardiovascular diseases.
The medical center provided telemedicine consultations to 22 affiliated hospitals. In addition, a Stroke Mobile team that consisted of a nurse and a health educator visited patients’ homes monthly for one year to address stroke risks and complications. Stroke Mobile staff used HIPAA-compliant video communication to facilitate telemedicine consultations with a vascular neurologist or advanced practice clinician during the home visits.
This model decreased length of hospital stay by one day, decreased cost per case by 9%, and lowered readmission and stroke recurrence by about 17% each. Furthermore, between 85% and 90% of patients achieved control of risk factors such as blood pressure, diabetes, and cholesterol. “Projects like this can offer us a much better, more comprehensive approach,” said Dr. Gaines.
Performing Neurologic Exams Remotely
Researchers have found that the NIH Stroke Scale can be administered as reliably in a telehealth setting as in person, Dr. Gaines said. Shafqat et al found that four NIH Stroke Scale items had excellent agreement (ie, orientation, motor arm, motor leg, and neglect), and six items had good agreement (ie, language, dysarthria, sensation, visual fields, facial palsy, and gaze), whereas two items (ie, commands and ataxia) had poor agreement, when they compared remote and in-person assessments.
Certain examination elements require the assistance of a nurse or emergency department doctor who is with the patient, and a neurologist’s confidence in his or her ability to perform a neurologic examination via telehealth may depend on how much he or she is “willing to ask people to do,” Dr. Gaines said. “I will ask somebody to shine a light into the eyes so I can look at the pupils. I will have a person who is helping me in the ER setting do a Babinski sign and watch for the response. I have diagnosed a hereditary neuropathy with liability to pressure palsies via teleneurology.”
Emergency department doctors and nurses often know how to perform elements of neurologic examinations, even if they do not routinely use them. “We spend time training nurses at our sites to help us,” he said.
In addition, neurologists can assess gait, which typically is not tested in emergency rooms but can provide valuable information. A patient’s gait might help a neurologist identify cerebellar infarcts that otherwise would have been attributed to dizziness, for example.
Telemedicine presents “opportunities … to impact stroke care and hopefully other areas of neurology as well. It is not nearly as daunting as you might think to do these consults virtually,” Dr. Gaines said. “It is a great opportunity for us to put systems of care in place to deal with some of the inequities and problems with delivery that we have.”
—Jake Remaly
Suggested Reading
Beck CA, Beran DB, Biglan KM, et al. National randomized controlled trial of virtual house calls for Parkinson disease. Neurology. 2017;89(11):1152-1161.
Flodgren G, Rachas A, Farmer AJ, et al. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2015;(9):CD002098.
Kane RL, Bever CT, Ehrmantraut M, et al. Teleneurology in patients with multiple sclerosis: EDSS ratings derived remotely and from hands-on examination. J Telemed Telecare. 2008;14(4):190-194.
Mammen JR, Elson MJ, Java JJ, et al. Patient and physician perceptions of virtual visits for Parkinson’s disease: a qualitative study. Telemed J E Health. 2018;24(4):255-267.
Meyer BC, Raman R, Hemmen T, et al. Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded, prospective study. Lancet Neurol. 2008;7(9):787-795.
Samii A, Ryan-Dykes P, Tsukuda RA, et al. Telemedicine for delivery of health care in Parkinson’s disease. J Telemed Telecare. 2006;12(1):16-18.
Schwab S, Vatankhah B, Kukla C, et al. Long-term outcome after thrombolysis in telemedical stroke care. Neurology. 2007;69(9):898-903.
Shafqat S, Kvedar JC, Guanci MM, et al. Role for telemedicine in acute stroke. Feasibility and reliability of remote administration of the NIH stroke scale. Stroke. 1999;30(10):2141-2145.
HILTON HEAD, SC—When neurologists see patients remotely, the focus should be on the patient, not on the technology behind the virtual visit, according to one researcher.
“One of the big mistakes that is made with telehealth is focusing on the technology and not on the clinical care delivery,” said Kenneth Gaines, MD, Professor of Neurology at Vanderbilt University in Nashville. “It is the clinical care delivery that ought to drive the technology. Too often it happens in reverse…. That is a recipe for an ineffective program.”
Broadly speaking, telemedicine is medicine practiced at a distance. Ideally, it uses technology to facilitate a clinical care paradigm that improves efficiency, care coordination, and outcomes and lowers costs, Dr. Gaines said. The public increasingly expects this type of care to be available, he said.
“Why would telehealth be useful in neurology? In part because we deal with acute and chronic disease, which is what stroke is, for example, but also other diseases like epilepsy,” Dr. Gaines said at Vanderbilt’s 41st Annual Contemporary Clinical Neurology Symposium. In addition, neurologic diseases are complex, and generalists’ training in them may be limited. Telehealth could allow neurologists to assist general practitioners and provide neurologic care to areas with few neurologists.
Opportunity in Neurology
Systematic reviews in disease states like diabetes, hyperlipidemia, and hypertension have found that telemedicine may benefit patients. A 2015 Cochrane review of data from randomized controlled trials of interactive telemedicine found with moderate certainty that telemedicine decreased LDL and blood pressure, compared with usual care. It found with high certainty that among patients with diabetes, those who received telemedicine had lower glycated hemoglobin levels at nine months, compared with controls. Evidence to assess the effects of telemedicine in neurology, however, was inadequate.
Nevertheless, studies indicate telemedicine’s promise in neurology. Beck et al conducted the Connect.Parkinson trial, which included 195 patients with Parkinson’s disease who were randomized to usual care or usual care plus four virtual visits via video conferencing with a remote specialist. The researchers found that telemedicine was feasible and equivalent to usual care with regard to its effects on patients’ quality of life. The virtual house calls saved patients a median of 88 minutes and 38 miles per visit. Mammen et al analyzed survey data from patients with Parkinson’s disease and physicians and found that they generally were satisfied with the telemedicine approach, but technical problems affected individual experiences. Physicians’ greatest source of dissatisfaction was performing a detailed motor examination remotely.
Samii et al reported the experience of one Veterans Administration medical center that found it feasible to conduct follow-up visits with patients with Parkinson’s disease via telemedicine. Although the video quality initially was not sufficient to score the motor Unified Parkinson’s Disease Rating Scale, a videoconferencing unit upgrade allowed physicians to assess those measures, with the exception of elements that require physical contact, such as rigidity and retropulsion.
A study by Kane et al found that telemedicine assessments of patients with multiple sclerosis could reliably determine Expanded Disability Status Scale scores. Scores related to cerebellar and brainstem functions, however, were less consistent with the scores of a hands-on examiner than were scores related to optic, bowel, bladder, and cerebral functions.
In neurology, most studies of telemedicine have focused on stroke, perhaps because of the complex and time-sensitive nature of the disease and a maldistribution of health care providers, Dr. Gaines said.
The Telemedical Pilot Project for Integrative Stroke Care (TEMPiS) in Germany connected 12 community hospitals that had limited experience with stroke thrombolysis to two specialized stroke centers. In the first 22 months, patients treated at the community hospitals and at the stroke centers had equivalent rates of mortality and good functional outcomes that were similar to those in randomized trials, Schwab et al reported.
In the STRokE DOC trial, Meyer et al assessed whether telemedicine (ie, real-time, two-way audio and video communication and digital imaging interpretation) or telephone consultation was superior in acute stroke consultations. In all, 111 patients were randomized to telemedicine, and 111 were randomized to telephone consultation. Ninety-day functional outcomes and rates of intracerebral hemorrhage after treatment with thromblytics and mortality were equivalent between the groups. With telemedicine, neurologists were more likely to arrive at a correct treatment decision and less likely to violate trial protocols, Dr. Gaines said.
The Neglected First Year
Dr. Gaines helped create a comprehensive stroke care model at Ochsner Medical Center in New Orleans that incorporated telemedicine. The program targeted acute stroke treatment as well as what Dr. Gaines calls the neglected first year after hospitalization for stroke. “In the chronic phase of stroke, these folks have significant disability. It is a significant stressor for their families and their caregivers, and unfortunately we have relatively poor risk factor control and inadequate medication compliance in this segment,” he said. Patients have high death rates due to recurrent stroke, complications of stroke, and other cardiovascular diseases.
The medical center provided telemedicine consultations to 22 affiliated hospitals. In addition, a Stroke Mobile team that consisted of a nurse and a health educator visited patients’ homes monthly for one year to address stroke risks and complications. Stroke Mobile staff used HIPAA-compliant video communication to facilitate telemedicine consultations with a vascular neurologist or advanced practice clinician during the home visits.
This model decreased length of hospital stay by one day, decreased cost per case by 9%, and lowered readmission and stroke recurrence by about 17% each. Furthermore, between 85% and 90% of patients achieved control of risk factors such as blood pressure, diabetes, and cholesterol. “Projects like this can offer us a much better, more comprehensive approach,” said Dr. Gaines.
Performing Neurologic Exams Remotely
Researchers have found that the NIH Stroke Scale can be administered as reliably in a telehealth setting as in person, Dr. Gaines said. Shafqat et al found that four NIH Stroke Scale items had excellent agreement (ie, orientation, motor arm, motor leg, and neglect), and six items had good agreement (ie, language, dysarthria, sensation, visual fields, facial palsy, and gaze), whereas two items (ie, commands and ataxia) had poor agreement, when they compared remote and in-person assessments.
Certain examination elements require the assistance of a nurse or emergency department doctor who is with the patient, and a neurologist’s confidence in his or her ability to perform a neurologic examination via telehealth may depend on how much he or she is “willing to ask people to do,” Dr. Gaines said. “I will ask somebody to shine a light into the eyes so I can look at the pupils. I will have a person who is helping me in the ER setting do a Babinski sign and watch for the response. I have diagnosed a hereditary neuropathy with liability to pressure palsies via teleneurology.”
Emergency department doctors and nurses often know how to perform elements of neurologic examinations, even if they do not routinely use them. “We spend time training nurses at our sites to help us,” he said.
In addition, neurologists can assess gait, which typically is not tested in emergency rooms but can provide valuable information. A patient’s gait might help a neurologist identify cerebellar infarcts that otherwise would have been attributed to dizziness, for example.
Telemedicine presents “opportunities … to impact stroke care and hopefully other areas of neurology as well. It is not nearly as daunting as you might think to do these consults virtually,” Dr. Gaines said. “It is a great opportunity for us to put systems of care in place to deal with some of the inequities and problems with delivery that we have.”
—Jake Remaly
Suggested Reading
Beck CA, Beran DB, Biglan KM, et al. National randomized controlled trial of virtual house calls for Parkinson disease. Neurology. 2017;89(11):1152-1161.
Flodgren G, Rachas A, Farmer AJ, et al. Interactive telemedicine: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2015;(9):CD002098.
Kane RL, Bever CT, Ehrmantraut M, et al. Teleneurology in patients with multiple sclerosis: EDSS ratings derived remotely and from hands-on examination. J Telemed Telecare. 2008;14(4):190-194.
Mammen JR, Elson MJ, Java JJ, et al. Patient and physician perceptions of virtual visits for Parkinson’s disease: a qualitative study. Telemed J E Health. 2018;24(4):255-267.
Meyer BC, Raman R, Hemmen T, et al. Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded, prospective study. Lancet Neurol. 2008;7(9):787-795.
Samii A, Ryan-Dykes P, Tsukuda RA, et al. Telemedicine for delivery of health care in Parkinson’s disease. J Telemed Telecare. 2006;12(1):16-18.
Schwab S, Vatankhah B, Kukla C, et al. Long-term outcome after thrombolysis in telemedical stroke care. Neurology. 2007;69(9):898-903.
Shafqat S, Kvedar JC, Guanci MM, et al. Role for telemedicine in acute stroke. Feasibility and reliability of remote administration of the NIH stroke scale. Stroke. 1999;30(10):2141-2145.