Will Teleneurology Change How Doctors Provide Care?

RIVIERA BEACH, FL—Teleneurology is a disruptive approach that could change the way neurologists think about providing care, according to a lecture given at the 42nd Annual Meeting of the Southern Clinical Neurological Society. Teleneurology could make specialized care available for everyone at any time or place, but the approach “needs greater acceptance by providers, patients, and payers,” said David J. Houghton, MD, MPH, Chief of the Division of Movement and Memory Disorders at Ochsner Health System in New Orleans.

Teleneurology may be defined as the provision of neurologic care from a distance using various technologies. One factor that could indicate a need for teleneurology is the unavailability of neurologic care in certain, especially rural, areas. Half of American hospitals have fewer than 100 beds and do not routinely have neurology services available because of low demand. Teleneurology could meet the urgent need to provide specialty expertise, such as epileptology, throughout a given geographic area, said Dr. Houghton. Also, teleneurology can contribute to a patient-centered model of care by allowing individuals to avoid inconvenient or expensive travel.

Major applications of teleneurology include emergency services (eg, for stroke or status epilepticus), inpatient consultations, and outpatient consultations. Another main application is the transmission of test results (eg, EEG) to a remote neurologist who can interpret them and provide a diagnosis or recommend treatment. Finally, teleneurology could facilitate outreach such as patient-education programs, caregiver education, and recruitment for clinical trials.

A teleneurology program is most commonly designed according to a hub-and-spoke model, said Dr. Houghton. For the hub hospital, a teleneurology program may increase market share, strengthen ties with an underserved population, and increase the number of patients received as transfers. The program’s advantages for a spoke hospital include a reduction in costs associated with patient transfers, an increase in the number of patients who can stay at their local hospital, improved quality of care, and increased patient satisfaction.

Teleneurology Reduced Stroke Recurrence

In 2013, a working group of the American Academy of Neurology reviewed the literature on telestroke programs and identified five main principles. First, they noted that physicians and nonphysicians can administer the NIH Stroke Scale reliably by telephone. Second, they found that remote neurologists can interpret CT images reliably for the purpose of confirming the diagnosis of acute ischemic stroke and for establishing eligibility for IV t-PA. Third, t-PA can be administered safely through telemedicine with outcomes comparable to those of traditional medicine. Fourth, audio–video telemedicine evaluations are safer than telephone-only consultations and often result in better decision making. Finally, telestroke networks are cost-effective.

In the Victorian Stroke Telemedicine Program, Australian neurologists examined 62 patients with suspected stroke who presented within 4.5 hours of symptom onset. The program allowed the neurologists to increase their IV t-PA use from 17% of patients at baseline to 26% of patients. The result approached, but did not reach, statistical significance. The researchers also improved their door-to-CT time by 29 minutes and improved their door-to-needle time by 21 minutes.

In Ochsner’s telestroke program, emergency physicians evaluate a patient quickly at an external facility, order a telestroke evaluation, and immediately bring the patient for a CT scan and for insertion of an IV line. The average time between the order for the evaluation and the evaluation is 12 minutes, said Dr. Houghton. Physicians at Ochsner review the patient’s CT scan, make the diagnosis, and decide to deliver treatment as needed. In the most recent quarter, the Ochsner telestroke program had between 160 and 175 calls per month. Approximately 70% of patients stay at their local hospitals.

Ochsner’s telestroke program appears to have reduced the rate of stroke recurrence over three years from 20% to 2.2% over a four-year period. The 30-day stroke readmission rate is 1.9% at Ochsner, compared with a national average of 12.7%. “We’re proud of the fact that we have 95% of our patients at blood-pressure control,” said Dr. Houghton.

Teleneurology May Decrease Length of Stay

Inpatient care may be the most difficult application for teleneurology, Dr. Houghton continued. “We miss having the ability to swing that reflex hammer and bang a tuning fork.” But teleneurology sometimes may be the best option. Northern Ireland has 12 neurologists to serve a population of 1.6 million people. To address this disparity, researchers compared teleconsults plus usual care with usual care alone for 292 patients who were admitted with neurologic symptoms at two rural hospitals. Patient complaints (eg, altered mental status, weakness, and headache) were similar between the two groups. Length of stay, however, was improved for teleconsults, compared with standard care (7.2 days vs 10 days). For patients who had teleconsultations and were followed up in person, no diagnosis was subsequently changed by the in-person exam.

Neurologists from Vanderbilt University Medical Center published a study of their 13-month experience with an inpatient teleneurology program. Of 976 consultations at six hospitals, 13% of patients were transferred and 87% stayed at their local hospital. The most common diagnosis was stroke, followed by seizure and headache. Of patients surveyed, 92% said that the care provided through the teleneurology program was satisfactory or excellent. The average time between the order for the teleconsultation and the teleconsultation was 6 minutes.

Ochsner instituted a temporary program that allowed its neurologists to perform rounds remotely at another hospital. Calls for rounds arrived during the afternoon, and each neurologist was scheduled to perform rounds for two hours during the following morning. Physicians at the remote hospital would roll a cart from room to room, and Ochsner’s neurologists saw as many as four patients during rounds. The average amount of time with each patient was 24 minutes, and the neurologist also spent time documenting the consultation afterwards. Ochsner plans to revisit the program this year, said Dr. Houghton.

The Challenges of Teleneurology

Teleneurology can improve response times and the efficiency of care, but it also poses several challenges. For example, the approach disrupts the traditional doctor–patient relationship, and some health care providers consequently are reluctant to adopt it. A teleneurology program will fail if physicians are forced to accept it, said Dr. Houghton. It is better to convince neurologists of the program’s potential benefits before instituting it, he added.

Perhaps the biggest concern that teleneurology entails is the limitation that it imposes on the neurologist’s ability to perform a detailed neurologic exam, said Dr. Houghton. Teleneurology also could hinder the transmission and interpretation of clinical data. The communication system must be capable of transmitting tests such as EEGs clearly. “With data, it’s garbage in, garbage out, so you have to make sure that there’s not garbage in,” said Dr. Houghton.

In addition, billing and reimbursement can be limited in a teleneurology program. Many contracts, however, include retention fees that cover expenses and protect providers’ time. A teleneurology program also entails high startup costs because of equipment that must be purchased.

Licensing also can pose difficult questions, particularly if a neurologist will be seeing patients in more than one state. In addition to requiring a license to practice medicine, many states require a telemedicine license. In some states, a telemedicine license does not permit a neurologist to interpret radiographic images; these states require the neurologist to have a traditional medical license.

Randomized controlled trials are needed for a complete assessment of the care provided through teleneurology, he continued. To take full advantage of teleneurology, hospitals should collaborate and form larger partnership networks. International collaborations also could be beneficial, although they may raise questions about licensure and liability. Finally, teleneurology should be reimbursed at the same rate as traditional, in-person care, Dr. Houghton concluded.

—Erik Greb

RIVIERA BEACH, FL—Teleneurology is a disruptive approach that could change the way neurologists think about providing care, according to a lecture given at the 42nd Annual Meeting of the Southern Clinical Neurological Society. Teleneurology could make specialized care available for everyone at any time or place, but the approach “needs greater acceptance by providers, patients, and payers,” said David J. Houghton, MD, MPH, Chief of the Division of Movement and Memory Disorders at Ochsner Health System in New Orleans.

Teleneurology may be defined as the provision of neurologic care from a distance using various technologies. One factor that could indicate a need for teleneurology is the unavailability of neurologic care in certain, especially rural, areas. Half of American hospitals have fewer than 100 beds and do not routinely have neurology services available because of low demand. Teleneurology could meet the urgent need to provide specialty expertise, such as epileptology, throughout a given geographic area, said Dr. Houghton. Also, teleneurology can contribute to a patient-centered model of care by allowing individuals to avoid inconvenient or expensive travel.

Major applications of teleneurology include emergency services (eg, for stroke or status epilepticus), inpatient consultations, and outpatient consultations. Another main application is the transmission of test results (eg, EEG) to a remote neurologist who can interpret them and provide a diagnosis or recommend treatment. Finally, teleneurology could facilitate outreach such as patient-education programs, caregiver education, and recruitment for clinical trials.

A teleneurology program is most commonly designed according to a hub-and-spoke model, said Dr. Houghton. For the hub hospital, a teleneurology program may increase market share, strengthen ties with an underserved population, and increase the number of patients received as transfers. The program’s advantages for a spoke hospital include a reduction in costs associated with patient transfers, an increase in the number of patients who can stay at their local hospital, improved quality of care, and increased patient satisfaction.

Teleneurology Reduced Stroke Recurrence

In 2013, a working group of the American Academy of Neurology reviewed the literature on telestroke programs and identified five main principles. First, they noted that physicians and nonphysicians can administer the NIH Stroke Scale reliably by telephone. Second, they found that remote neurologists can interpret CT images reliably for the purpose of confirming the diagnosis of acute ischemic stroke and for establishing eligibility for IV t-PA. Third, t-PA can be administered safely through telemedicine with outcomes comparable to those of traditional medicine. Fourth, audio–video telemedicine evaluations are safer than telephone-only consultations and often result in better decision making. Finally, telestroke networks are cost-effective.

In the Victorian Stroke Telemedicine Program, Australian neurologists examined 62 patients with suspected stroke who presented within 4.5 hours of symptom onset. The program allowed the neurologists to increase their IV t-PA use from 17% of patients at baseline to 26% of patients. The result approached, but did not reach, statistical significance. The researchers also improved their door-to-CT time by 29 minutes and improved their door-to-needle time by 21 minutes.

In Ochsner’s telestroke program, emergency physicians evaluate a patient quickly at an external facility, order a telestroke evaluation, and immediately bring the patient for a CT scan and for insertion of an IV line. The average time between the order for the evaluation and the evaluation is 12 minutes, said Dr. Houghton. Physicians at Ochsner review the patient’s CT scan, make the diagnosis, and decide to deliver treatment as needed. In the most recent quarter, the Ochsner telestroke program had between 160 and 175 calls per month. Approximately 70% of patients stay at their local hospitals.

Ochsner’s telestroke program appears to have reduced the rate of stroke recurrence over three years from 20% to 2.2% over a four-year period. The 30-day stroke readmission rate is 1.9% at Ochsner, compared with a national average of 12.7%. “We’re proud of the fact that we have 95% of our patients at blood-pressure control,” said Dr. Houghton.

Teleneurology May Decrease Length of Stay

Inpatient care may be the most difficult application for teleneurology, Dr. Houghton continued. “We miss having the ability to swing that reflex hammer and bang a tuning fork.” But teleneurology sometimes may be the best option. Northern Ireland has 12 neurologists to serve a population of 1.6 million people. To address this disparity, researchers compared teleconsults plus usual care with usual care alone for 292 patients who were admitted with neurologic symptoms at two rural hospitals. Patient complaints (eg, altered mental status, weakness, and headache) were similar between the two groups. Length of stay, however, was improved for teleconsults, compared with standard care (7.2 days vs 10 days). For patients who had teleconsultations and were followed up in person, no diagnosis was subsequently changed by the in-person exam.

Neurologists from Vanderbilt University Medical Center published a study of their 13-month experience with an inpatient teleneurology program. Of 976 consultations at six hospitals, 13% of patients were transferred and 87% stayed at their local hospital. The most common diagnosis was stroke, followed by seizure and headache. Of patients surveyed, 92% said that the care provided through the teleneurology program was satisfactory or excellent. The average time between the order for the teleconsultation and the teleconsultation was 6 minutes.

Ochsner instituted a temporary program that allowed its neurologists to perform rounds remotely at another hospital. Calls for rounds arrived during the afternoon, and each neurologist was scheduled to perform rounds for two hours during the following morning. Physicians at the remote hospital would roll a cart from room to room, and Ochsner’s neurologists saw as many as four patients during rounds. The average amount of time with each patient was 24 minutes, and the neurologist also spent time documenting the consultation afterwards. Ochsner plans to revisit the program this year, said Dr. Houghton.

The Challenges of Teleneurology

Teleneurology can improve response times and the efficiency of care, but it also poses several challenges. For example, the approach disrupts the traditional doctor–patient relationship, and some health care providers consequently are reluctant to adopt it. A teleneurology program will fail if physicians are forced to accept it, said Dr. Houghton. It is better to convince neurologists of the program’s potential benefits before instituting it, he added.

Perhaps the biggest concern that teleneurology entails is the limitation that it imposes on the neurologist’s ability to perform a detailed neurologic exam, said Dr. Houghton. Teleneurology also could hinder the transmission and interpretation of clinical data. The communication system must be capable of transmitting tests such as EEGs clearly. “With data, it’s garbage in, garbage out, so you have to make sure that there’s not garbage in,” said Dr. Houghton.

In addition, billing and reimbursement can be limited in a teleneurology program. Many contracts, however, include retention fees that cover expenses and protect providers’ time. A teleneurology program also entails high startup costs because of equipment that must be purchased.

Licensing also can pose difficult questions, particularly if a neurologist will be seeing patients in more than one state. In addition to requiring a license to practice medicine, many states require a telemedicine license. In some states, a telemedicine license does not permit a neurologist to interpret radiographic images; these states require the neurologist to have a traditional medical license.

Randomized controlled trials are needed for a complete assessment of the care provided through teleneurology, he continued. To take full advantage of teleneurology, hospitals should collaborate and form larger partnership networks. International collaborations also could be beneficial, although they may raise questions about licensure and liability. Finally, teleneurology should be reimbursed at the same rate as traditional, in-person care, Dr. Houghton concluded.

—Erik Greb

RIVIERA BEACH, FL—Teleneurology is a disruptive approach that could change the way neurologists think about providing care, according to a lecture given at the 42nd Annual Meeting of the Southern Clinical Neurological Society. Teleneurology could make specialized care available for everyone at any time or place, but the approach “needs greater acceptance by providers, patients, and payers,” said David J. Houghton, MD, MPH, Chief of the Division of Movement and Memory Disorders at Ochsner Health System in New Orleans.

Teleneurology may be defined as the provision of neurologic care from a distance using various technologies. One factor that could indicate a need for teleneurology is the unavailability of neurologic care in certain, especially rural, areas. Half of American hospitals have fewer than 100 beds and do not routinely have neurology services available because of low demand. Teleneurology could meet the urgent need to provide specialty expertise, such as epileptology, throughout a given geographic area, said Dr. Houghton. Also, teleneurology can contribute to a patient-centered model of care by allowing individuals to avoid inconvenient or expensive travel.

Major applications of teleneurology include emergency services (eg, for stroke or status epilepticus), inpatient consultations, and outpatient consultations. Another main application is the transmission of test results (eg, EEG) to a remote neurologist who can interpret them and provide a diagnosis or recommend treatment. Finally, teleneurology could facilitate outreach such as patient-education programs, caregiver education, and recruitment for clinical trials.

A teleneurology program is most commonly designed according to a hub-and-spoke model, said Dr. Houghton. For the hub hospital, a teleneurology program may increase market share, strengthen ties with an underserved population, and increase the number of patients received as transfers. The program’s advantages for a spoke hospital include a reduction in costs associated with patient transfers, an increase in the number of patients who can stay at their local hospital, improved quality of care, and increased patient satisfaction.

Teleneurology Reduced Stroke Recurrence

In 2013, a working group of the American Academy of Neurology reviewed the literature on telestroke programs and identified five main principles. First, they noted that physicians and nonphysicians can administer the NIH Stroke Scale reliably by telephone. Second, they found that remote neurologists can interpret CT images reliably for the purpose of confirming the diagnosis of acute ischemic stroke and for establishing eligibility for IV t-PA. Third, t-PA can be administered safely through telemedicine with outcomes comparable to those of traditional medicine. Fourth, audio–video telemedicine evaluations are safer than telephone-only consultations and often result in better decision making. Finally, telestroke networks are cost-effective.

In the Victorian Stroke Telemedicine Program, Australian neurologists examined 62 patients with suspected stroke who presented within 4.5 hours of symptom onset. The program allowed the neurologists to increase their IV t-PA use from 17% of patients at baseline to 26% of patients. The result approached, but did not reach, statistical significance. The researchers also improved their door-to-CT time by 29 minutes and improved their door-to-needle time by 21 minutes.

In Ochsner’s telestroke program, emergency physicians evaluate a patient quickly at an external facility, order a telestroke evaluation, and immediately bring the patient for a CT scan and for insertion of an IV line. The average time between the order for the evaluation and the evaluation is 12 minutes, said Dr. Houghton. Physicians at Ochsner review the patient’s CT scan, make the diagnosis, and decide to deliver treatment as needed. In the most recent quarter, the Ochsner telestroke program had between 160 and 175 calls per month. Approximately 70% of patients stay at their local hospitals.

Ochsner’s telestroke program appears to have reduced the rate of stroke recurrence over three years from 20% to 2.2% over a four-year period. The 30-day stroke readmission rate is 1.9% at Ochsner, compared with a national average of 12.7%. “We’re proud of the fact that we have 95% of our patients at blood-pressure control,” said Dr. Houghton.

Teleneurology May Decrease Length of Stay

Inpatient care may be the most difficult application for teleneurology, Dr. Houghton continued. “We miss having the ability to swing that reflex hammer and bang a tuning fork.” But teleneurology sometimes may be the best option. Northern Ireland has 12 neurologists to serve a population of 1.6 million people. To address this disparity, researchers compared teleconsults plus usual care with usual care alone for 292 patients who were admitted with neurologic symptoms at two rural hospitals. Patient complaints (eg, altered mental status, weakness, and headache) were similar between the two groups. Length of stay, however, was improved for teleconsults, compared with standard care (7.2 days vs 10 days). For patients who had teleconsultations and were followed up in person, no diagnosis was subsequently changed by the in-person exam.

Neurologists from Vanderbilt University Medical Center published a study of their 13-month experience with an inpatient teleneurology program. Of 976 consultations at six hospitals, 13% of patients were transferred and 87% stayed at their local hospital. The most common diagnosis was stroke, followed by seizure and headache. Of patients surveyed, 92% said that the care provided through the teleneurology program was satisfactory or excellent. The average time between the order for the teleconsultation and the teleconsultation was 6 minutes.

Ochsner instituted a temporary program that allowed its neurologists to perform rounds remotely at another hospital. Calls for rounds arrived during the afternoon, and each neurologist was scheduled to perform rounds for two hours during the following morning. Physicians at the remote hospital would roll a cart from room to room, and Ochsner’s neurologists saw as many as four patients during rounds. The average amount of time with each patient was 24 minutes, and the neurologist also spent time documenting the consultation afterwards. Ochsner plans to revisit the program this year, said Dr. Houghton.

The Challenges of Teleneurology

Teleneurology can improve response times and the efficiency of care, but it also poses several challenges. For example, the approach disrupts the traditional doctor–patient relationship, and some health care providers consequently are reluctant to adopt it. A teleneurology program will fail if physicians are forced to accept it, said Dr. Houghton. It is better to convince neurologists of the program’s potential benefits before instituting it, he added.

Perhaps the biggest concern that teleneurology entails is the limitation that it imposes on the neurologist’s ability to perform a detailed neurologic exam, said Dr. Houghton. Teleneurology also could hinder the transmission and interpretation of clinical data. The communication system must be capable of transmitting tests such as EEGs clearly. “With data, it’s garbage in, garbage out, so you have to make sure that there’s not garbage in,” said Dr. Houghton.

In addition, billing and reimbursement can be limited in a teleneurology program. Many contracts, however, include retention fees that cover expenses and protect providers’ time. A teleneurology program also entails high startup costs because of equipment that must be purchased.

Licensing also can pose difficult questions, particularly if a neurologist will be seeing patients in more than one state. In addition to requiring a license to practice medicine, many states require a telemedicine license. In some states, a telemedicine license does not permit a neurologist to interpret radiographic images; these states require the neurologist to have a traditional medical license.

Randomized controlled trials are needed for a complete assessment of the care provided through teleneurology, he continued. To take full advantage of teleneurology, hospitals should collaborate and form larger partnership networks. International collaborations also could be beneficial, although they may raise questions about licensure and liability. Finally, teleneurology should be reimbursed at the same rate as traditional, in-person care, Dr. Houghton concluded.

—Erik Greb