Article In Brief
As the COVID-19 public health crisis continues to evolve, neurologists are gaining more experience with telehealth. Neurologists share their experiences in making telehealth successful and why they believe the specialty is so well-suited for virtual visits.
More than seven months into the COVID-19 public health crisis, telehealth continues to thrive in neurologic practices, bolstered by loosened regulatory limitations, continued insurance coverage, as well as steady patient demand. According to a J. D. Power 2020 US telehealth satisfaction survey released on October 1, patient satisfaction with telehealth services increased during the pandemic, and most people cited safety as the reason. With neurologists gaining more experience with this mode of care delivery, Neurology Today asked telehealth enthusiasts on Twitter why they believe our specialty is so well-suited to virtual visits and to share their experience in making them successful.
Transportation Hassles Are Solved
The most common advantage cited was the relief from onerous travel. “Travel costs including fuel, hotel, and restaurants, as well as time away from work, can be avoided with telehealth,” said Jessica Gautreaux, MD, assistant professor of neurology at the Louisiana Health Services Center in New Orleans, who has some patients who travel from hours away in order to come to the tertiary care center at Louisiana State University. “And for those patients on ventilators at home, appointments can take place without arranging for ambulance transport,” the child neurologist added.
“I have come to realize that, in some ways, I am able to take more attentive care of my patients, especially during what has been an unbearably difficult time for so many people.”—DR. STEPHEN KRIEGER
Ima M. Ebong, MD, MS, assistant professor of neurology at the University of Kentucky, who sees both epilepsy and neuromuscular patients, said, “Not having to drive matters most to my patients who live in rural Kentucky, many of whom would have had to drive two hours or more to a clinic appointment. This is most critical to those who have seizures and are prohibited from driving by law because public transportation is not readily available in many parts of Kentucky.”
“Quite a few of my patients had canceled prior appointments or had not been seen in over a year,” admitted Amy K. Guzik, MD, associate professor of neurology at Wake Forest Baptist Medical Center, who directs the institution's Comprehensive Stroke Center and the Telestroke Network. When she inquired about those lapses, they told her about the difficulty they had with transportation to the medical center as many were coming from surrounding counties and relied on caregivers to drive.
“This is even more relevant for my patients with post-stroke disability or seizure limiting their ability to drive, and has led to missed opportunities for secondary stroke prevention measures or management of long-term effects of stroke, such as spasticity or cognitive decline,” she explained. “And for those patients who are unable to take time off of work, a phone or video visit can be fit in during a break—critical to maintaining their livelihood during the economic strain of the pandemic,” she added.
Reluctance to inconvenience the patient may also prevent neurologists from arranging in-person visits for non-neurologic or less urgent issues. “While I might not have asked a patient to travel back to the office for a return visit in four weeks if she seemed particularly depressed or anxious, I've had no hesitation to offer such monthly visits to several patients over the past months, and all have readily agreed,” said Stephen Krieger, MD, FAAN, associate professor of neurology at Mount Sinai, a multiple sclerosis specialist. “I have come to realize that, in some ways, I am able to take more attentive care of my patients, especially during what has been an unbearably difficult time for so many people,” he revealed.
More Flexible Schedules Are a Plus
Neurologists and patients alike appreciate that telehealth imposes fewer rigid restrictions than face-to-face visits. “Personally, I have enjoyed having more flexibility with my schedule through telemedicine,” said Daniel G. Larriviere, MD, JD, FAAN, who works as a neuromuscular specialist at the Inova Health System in Fairfax, VA.
One of his patients, newly diagnosed with myasthenia gravis, had reached out to him on a Friday afternoon to report increasing bulbar weakness, and when he was unable to reach the patient by phone, Dr. Larriviere created an on-the-fly link for a telemedicine visit and awaited the notification that his patient had arrived in the waiting room before returning to his computer to conduct the visit.
Weather also makes travel prohibitive at times, as Dr. Gautreaux discovered when Hurricane Laura, a category 4 storm, made landfall near Lake Charles, LA, on the morning of August 27. Her clinic in the Lafayette area had been converted to telehealth several months earlier due to the COVID pandemic. “We saw one family from the hotel room to which they had evacuated with two children scheduled for that day,” Dr. Gautreaux recalled. “Their most pressing concern—like that of others with whom I spoke by telephone thanks to COVID-19 allowances—was running out of medication, and we were able to troubleshoot a plan to ensure no lapses.”
“There have been innumerable instances where I was able to see that patients were checking in from their cars, parked outside coffee shops and fast-food restaurants, so they could take advantage of their Internet.”—DR. CLARIMAR BORRERO-MEJIAS
Olivia Begasse De Dhaem, MD, who has been using telehealth for two years, having started while she was in her PGY-4 year of residency, now sees 50 percent general neurology and 50 percent headache patients at Stamford Hospital in Connecticut.
“I was recently able to witness on video the aphasia that one of my migraine patients experienced during an attack after she casually contacted me via the patient portal to let me know her headaches were worsening.” Her patient also lived far away, was busy at work, and wanted to avoid coming to the clinic. “Thanks to telehealth, we could talk the same day, and I was able to determine that this was a new type of headache and expedite a workup,” Dr. Begasse De Dhaem said.
“With traditional ambulatory care, we offer patients a set time for an appointment and require them to rearrange their schedule, travel, park, and wait (often for extended periods) until we are finally ready to see them,” said Andrew M. Southerland, MD, executive vice-chair in the department of neurology at the University of Virginia.
“Not only is this disruptive to patients but also taxing for providers who are often playing catch up in busy clinics,” he continued. Telemedicine provides the opportunity to rethink traditional brick-and-mortar approaches to care delivery, he explained.
“The concept of patient-centered scheduling is borrowed from other service industries and applied to ambulatory telemedicine visits,” Dr. Southerland said. “Specifically, patients or family members are provided a window of time in which they will be seen, followed by a just-in-time alert (via text or email) when the provider is officially ready to see them. In this way, patients and family members could schedule their day accordingly without the expectation that they will be seen at a specific time, avoiding the dissatisfaction of waiting when providers are inevitably running behind,” he explained. Dr. Southerland pointed out that this solution also allows providers to gather themselves between appointments and not be burdened by the consummate stress of patients waiting to be seen.
One of the unexpected joys of telemedicine described has been the feeling of being welcomed into patients' homes, many said. “I have enjoyed meeting family members who live with my patients, but also those who live in other cities, but can be brought into the video visits,” said Dr. Larriviere. “It's a great opportunity to answer questions and talk about their family member's diagnosis and treatment plans, as well as hear the concerns of everyone involved in caring for the patient.”
“One of my patients, a 30-year-old woman I had been taking care of for ten years or so, carried her laptop downstairs, in her parent's home where she was sheltering during COVID, so I could meet them, and it was delightful for all of us,” Dr. Krieger said. “I was initially reluctant to hold video visits, as I do think that there is something ineffable and essential about in-person interaction and the physical exam in neurology,” admitted Dr. Krieger, whose MS practice has been almost completely virtual since March. “But I have been struck by the level of genuine human connection, even intimacy, that can be achieved between doctor and patient over video.”
“Even if family members are not there, I get to see their lovely photos,” said Ana C.G. Felix, MBBCh, FAAN, who has a dual appointment in neurology and internal medicine at the University of North Carolina Chapel Hill. “I had always hoped to be a “fly on the wall” to better understand patients who might present diagnostic or therapeutic challenges, and telemedicine has brought that ability into my daily work,” said Dr. Felix. “Virtual home visits let me see if their rooms are neat or messy if they have carpets that may be fall risks, and furniture that can get in their way,” she said.
“I was recently able to witness on video the aphasia that one of my migraine patients experienced during an attack after she casually contacted me via the patient portal to let me know her headaches were worsening.”—DR. OLIVIA BEGASSE DE DHAEM
“Not having to drive matters most to my patients who live in rural Kentucky, many of whom would have had to drive two hours or more to a clinic appointment. This is most critical to those who have seizures and are prohibited from driving by law because public transportation is not readily available in many parts of Kentucky.”—DR. IMA M. EBONG
“The concept of patient-centered scheduling is borrowed from other service industries and applied to ambulatory telemedicine visits.”—DR. ANDREW M. SOUTHERLAND
“True human connection is needed more than ever,” said Dr. Begasse De Dhaem, who recently co-authored an article in the journal Headache on webside manners1. “People have a lot to process—both emotionally and physically this year—physical distancing, loss of loved ones, financial difficulties, perduring racism, and violence.”
Cognizant of social isolation that affects those patients who live alone, in particular, Dr. Begasse De Dhaem has tried to increase the frequency of communications with this vulnerable group so that they feel supported and cared for.
Legislative Changes Needed
“There have been innumerable instances where I was able to see that patients were checking in from their cars, parked outside coffee shops and fast-food restaurants, so they could take advantage of their Internet,” said Clarimar Borrero-Mejias, MD, a general pediatric neurologist at Barrow Neurologic Institute at Phoenix Children's Hospital.
Dr. Borrero-Mejias discovered that many of her patients did not have reliable connectivity or had to discontinue the service as a cost-saving measure when they were laid off due to the pandemic. She supports an internet-for-all public utility and hopes that policymakers will consider broadband infrastructure a national priority.
“The failures of telehealth which we are seeing are related to lack of infrastructure,” said Dr. Guzik, whose telestroke network just hit the milestone of 10,000 network activations. “Particularly relevant in North Carolina is the lack of consistent broadband, especially upload speeds which are not generally considered in large-scale broadband rollouts,” she explained.
“There are disparities in our telehealth population that need to be addressed going forward; specifically, older, Black, male patients and those with government insurance tended to use the telephone, rather than video visits, which could be a limiting factor in diagnosing and treating more complex neurologic conditions.2”
Enacting regulations that cover telephonic communication was especially helpful during the public health emergency, as Dr. Gautreaux discovered during the hurricane. “Another family was at home without power or Wi-Fi but wanted to keep their appointment, and we were able to ensure that their medications were in order as well,” she said. “Legislation that would allow telephonic visits any time an area is declared to be under a state of emergency would benefit many patients, as would allowing practice over state lines for evacuees,” she continued. “Payment parity for telemedicine will be a crucial issue for which we, as physicians, will need to advocate in order to keep it a viable option for outpatients after the pandemic,” she concluded.
“For those patients who are unable to take time off of work, a phone or video visit can be fit in during a break—critical to maintaining their livelihood during the economic strain of the pandemic.”—DR. AMY K. GUZIK
“As the demand for teleneurology grows in the wake of the COVID-19 pandemic, it is imperative that we continue to beckon our leaders and policy makers to help sustain the practice of telemedicine by incentivizing favorable reimbursement and regulatory pathways,” urged Dr. Southerland. “We must also advocate for adequate broadband and technology for all our patients, particularly in rural and low access areas.”
Dr. Larriviere, who summed up the sentiment of all those interviewed, said, “I hope that it's really difficult for all of us—providers, policymakers, and elected officials—to put this genie back in the bottle when the pandemic ends.”