The Evolution of Care and Cost in Teleneurology

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The role of teleneurology can grow far beyond critical stroke care, but only if medical liabilities and insurance steps out of the way.

The Evolution of Care and Cost in Teleneurology
The Evolution of Care and Cost in Teleneurology

Despite its association with modern technology, telemedicine has actually been around since the 1940s and has been used to extend the reach of such specialties as psychiatry, cardiology, and radiology. Neurology has been a slow starter, but there are many reasons why telemedicine is a natural fit for this field, namely the growing disparity between the need for neurologic care and the availability of neurologists.1

“The gap between demand and availability is projected to increase over the next decade. Due to an aging population, diseases like Alzheimer's and Parkinson's will become more common. Add in an increased ability to access care through the Affordable Care Act,” and you've got a lot of people seeking care from neurologists, said Lawrence R. Wechsler, MD, professor and chair of neurology at the University of Pittsburgh.

“The use of any telecommunication or email could be loosely defined as teleneurology, but what we are talking about today is video and audio communication in real time that provides on-site interaction,” said Steven R. Levine, MD, professor of neurology and emergency medicine at SUNY Downstate Medical Center in Brooklyn, New York.

The most commonly used technology is a moving cart with a pan-tilt-zoom camera, display screen, and a computer, which can be positioned at the site of patient care. A neurologist at a distant site can connect, control the camera, communicate, examine, and interact with the patient, family members, and attending caregivers.1,2

Telestroke

Improving access to thrombolysis with tissue plasminogen activator (tPA) early in the evolution of an ischemic stroke is the key goal and advantage of using teleneurology, or telestroke in this case, in stroke management.3 “Stroke is 100%the number one application of teleneurology, not just to get tPA into a patient earlier but also to triage patients who do not respond to tPA and to get hemorrhagic stroke patients to a higher level of stroke care,” said Levine.

Several studies have shown that telestroke improves tPA use and outcomes in ischemic stroke in rural areas and community hospitals.1 The same positive effects have been seen in urban settings as well. In a study of 498 patients at urban hospitals, the rate of tPA use at each hospital increased two to six fold compared to the rate of use before the study.3

Teleneurology for Routine Outpatient Care

Teleneurology can also save time and money in non-emergency situations. In a study conducted by the Veterans Health Administration, 354 patients with conditions including Parkinson's disease, Alzheimer's, multiple sclerosis, cognitive impairment, and epilepsy living in remote areas of the Southwest were connected from satellite clinics to neurologists at the VA Medical Center in Albuquerque, where they would previously travel for care.4

Ninety percent of patients were fully satisfied with their visits, and more than 90 percent said they saved time and money. The researchers on the study, published in Telemedicine and e-Health in 2014, calculated that an average patient saved five hours of travel time per clinic appointment. The treating neurologists were satisfied and the number of ER visits or hospitalizations was similar to patients attending the neurology clinics at the major medical center.4

Teleneurology for Teaching: Telepresence and Monitoring

“There is absolutely an important role for telemedicine in teaching and supervision.  Teleneurology can be used to teach or supervise neurology residents. A neurologist may also monitor and teach another doctor or caregiver to help them through an examination or a procedure,” said Wechsler.

Telepresence is use of a robotic audiovisual platform that can maneuver around an examining room and give the remote observer a sense of being present. Telepresence was used as a neurology training tool in a 2014 study published in Telemedicine and e-Healthto supervise training during neurologic consultations over 29 months at a teaching hospital. When in-person supervision is not practical, telepresence provided more than 90% of trainees sufficient support and facilitated clinical care, the researchers concluded.5

Limitations

A significant amount of a neurology exam can be performed with teleneurology, including a mental status exam, cranial nerves exam, looking for nystagmus, and evaluating speech and motor functions. “What's missing is a hands-on exam. You can't test reflexes or muscle tone, and you may miss subtle nystagmus. Teleneurology is the next best thing, but it is not the best thing,” said Levine.

“It is not hands on, but if you have an expert assistant at the site, you can get around some of these limitations. There are cases when telemedicine is not good enough, and a neurologist needs to be able to make that call. There is also special training that can avoid some of the limitations. Neurologists should learn how to make eye contact, where to look, and how to position themselves in front of their screen. Some basic skill for troubleshooting the technology also comes in handy,” said Wechsler.  

Cutting Through the Red Tape

The VA study estimated that veterans and the VA saved about $48,000 dollars in travel costs during the study, based on distance saved traveling. That savings did not include meals, motels, and lost wages for the patients or traveling companions.4 It is also likely that the short-term increased cost of telestroke technology and use of tPA will be more than offset by years of disability avoided. Ultimately, teleneurology can save money.1,4

“There is a bit of buyer beware. This technology is expensive. There are lots of for-profit companies that are hiring neurologists and selling their services to hospitals. You always need to be careful that the technology is not being oversold,” said Levine.

“I think the hub and spoke model, where community and rural hospitals work together is a better model than the purely commercial model. Teleneurology works best when there is a relationship between the central site and the distant site,” said Wechsler.

Wechsler and Levine both agree that teleneurology is here to stay and will only grow and evolve. “The American Stroke Association and the American Academy of Neurology have come out with guidelines for teleneurology, but there is no Holy Bible yet,” said Levine.

Indeed, there are still some stumbling blocks standing in the way of mass adoption, the biggest being reimbursement, liability, and licensing. “Medicare does not cover telemedicine, except in remote areas where physician shortage is documented, and many private insurers only cover in-person services,” said Wechsler.

Additionally, “a neurologist who uses teleneurology to evaluate a patient at a distant hospital may need to get privileges at that hospital. These issues are evolving and they can vary on a state-by-state basis,” Levine noted.

“In Pittsburgh, we treat patients from Ohio, West Virginia, and Maryland. If we treat using teleneurology, we need to be licensed in those states. And as far as liability goes, you may be just as liable using telemedicine as you are in person, so you better make sure you are just as good,” warned Wechsler.

But these obstacles, like those that came before them in traditional medicine, will be overcome. “There will come a time when the ‘tele' part of teleneurology or telemedicine is dropped and this technology is just part of the routine practice of medicine,” said Wechsler.

Chris Iliades, MD, is a full-time freelance writer based in Cape Cod, Massachusetts. This article was medically reviewed by Pat F. Bass III, MD, MS, MPH.

References

  1. Wechsler LR. Advantages and Limitations of Teleneurology. JAMA Neurol. 2015;
  2. Timpano F, Bonanno L, Bramanti A, et al. Tele-Health and neurology: what is possible?. Neurol Sci. 2013;34(12):2263-70.
  3. Cutting S, Conners JJ, Lee VH, Song S, Prabhakaran S. Telestroke in an urban setting. Telemed J E Health. 2014;20(9):855-7.
  4. Davis LE, Coleman J, Harnar J, King MK. Teleneurology: successful delivery of chronic neurologic care to 354 patients living remotely in a rural state. Telemed J E Health. 2014;20(5):473-7.
  5. Kramer NM, Demaerschalk BM. A novel application of teleneurology: robotic telepresence in supervision of neurology trainees. Telemed J E Health. 2014;20(12):1087-92.
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