Article In Brief
As telehealth continues to gain ground during the COVID-19 pandemic, neurologists discuss the “webside” practices they've adopted to see patients during the pandemic.
As telehealth continues to gain ground during the COVID-19 pandemic, Lee H. Schwamm, MD, FANA, FAHA, stresses the need for neurologists to learn proper “web-side” manner. It's an increasingly valued skill set in the current digital climate.
“Our understanding of what constitutes virtual care competency and how to assess it is actively evolving, especially for those who supervise trainees,” said Dr. Schwamm, chair of vascular neurology and director of the Center for TeleHealth at Massachusetts General Hospital, where he convened a web-based national symposium on this topic in September.
Some elements of that competency are clear. For instance, “successful visits require favorable environmental conditions,” Dr. Schwamm, professor of neurology at Harvard Medical School, explained, citing essentials such as a reliable webcam and microphone, and a quiet, lighted space with undistracting scenery.
A compassionate state of mind is also paramount. From the outset, a clinician should model good eye contact and position oneself in the center of a video's frame. Showing a badge or white coat label would be a welcome gesture to confirm one's own identity, Dr. Schwamm said.
Online training in telemedicine techniques can help foster safe and proficient virtual visits. With experience, he noted that a clinician becomes adept at “demonstrating cognitive resilience to the frequent technology speedbumps.”
Keeping a pulse on innovation has enabled neurologists to adopt digital technology in ways that provide health care to patients and monitor their outcomes for clinical research—both within the scope of virtual visits—in the midst of an unrelenting pandemic.
“Virtual encounters have evolved from limping technological and administrative support to smoother operations certainly from the provider side,” said Heidi Maloni, PhD, NP, national clinical nursing director of the Multiple Sclerosis Centers of Excellence at Veterans Affairs Medical Center in Washington, DC.
“The COVID-19 pandemic ‘hurried up’ this exciting and viable new platform for care delivery.”
Despite advances, challenges persist. “Video images freeze; sound can be staccato. Many a time have I picked up the phone to finish the visit with Ma Bell,” Dr. Maloni said, as “technology on the patient side can remain patchy.” Lately, she remarked that the provider side is operating “with fewer glitches.” That has led her to “speculate that the improvement centers on economic realities—yes, virtual encounters are not just ‘here to stay;’ virtual encounters are the future.”
That stark reality hit New York City hard. When the pandemic shuttered physician offices, telehealth was essential to keeping tabs on patients with movement disorders and other neurodegenerative diseases. For a few months, appointments went virtual, said Joohi Jimenez-Shahed, MD, associate professor of neurology and medical director of movement disorders, neuromodulation, and brain circuit therapeutics at the Icahn School of Medicine at Mount Sinai.
“Even in patients in need of deep brain stimulation (DBS) therapy, these virtual visits have allowed important clinical decision-making to continue during the pandemic,” Dr. Jimenez-Shahed said.
For example, she and her colleagues requested patients' consent to record their movements for motion analysis. She taped them before and after they took their medications, with the intent of making comparisons and contrasts, just as they would during in-person visits. The analytics would guide clinicians in identifying patients for treatment with DBS, she said.
Another digital technology holds promise for assisting in this assessment. “Computer vision-based analysis of patients' movements, captured on video during telehealth visits, can deliver objective metrics of neurologic symptoms such as tremor and bradykinesia, said Dr. Jimenez-Shahed, who expects to be able to use this virtual platform in the care of her patients in early 2021
“Our ability to implement this technology-enabled remote assessment protocol was accelerated by the pandemic but will benefit our patients even after it is well behind us,” she said.
Equipped with smartphones, tablets, and laptops, neurologists are empowered “to remotely and autonomously navigate a hospital environment even thousands of miles away and interact synchronously with audio video and zoom pan tilt cameras,” said Bart M. Demaerschalk, MD, MSc, FRCP(C), FAAN, professor of neurology and medical director of video telemedicine at the Mayo Clinic Center for Connected Care and Center for Digital Health in Scottsdale, AZ.
With the touch of a remote control, a robot responds to a built-in navigation system that has the capability to maneuver around obstacles, Dr. Demaerschalk said. A nurse at the patient's bedside can help the neurologist situated in another location perform an exam.
“Peripheral attachments like stethoscopes, otoscopes, ophthalmoscopes, and pupillometers allow the remote neurologist to listen to the heart and lungs and look at the ears and eyes with ease,” he said.
Remote patient monitoring and video telemedicine also make it feasible to follow patients in clinical research trials directly from their homes. The technology can measure and transmit accurate readings for blood pressure, respiration, temperature, weight, and heart rhythm.
Telemedicine enables neurologists to acquire a history, re-examine patients, apply research scoring systems and scales, and determine adverse effects of experimental medications, Dr. Demaerschalk said. Furthermore, drone delivery and laboratories on wheels can transport diagnostic tests to the patient, saving a trip to a testing site.
Another digital technology holds promise in assisting health care providers caring for patients with Parkinson's disease. After a patient wears a motion-sensing watch for six days, movements are analyzed and summarized in a report that provides detailed interpretation, said Raja Mehanna, MD, associate professor of neurology and assistant director of the movement disorders fellowship at the University of Texas Health Science Center at Houston-McGovern Medical School.
Dr. Mehanna, who is evaluating the wearable device in a clinical trial but said it is available through him and specific providers beyond the research setting, noted that the increasing and expanding use of telemedicine is helping neurologists maintain a watchful eye on patients from wherever they are.
“We are able to reach out to patients who otherwise would have not come because of health concerns” during the pandemic, he said.
Travel would pose hardships for those patients who live hours away, in parts of Texas near the border with Mexico or in Louisiana. Thanks to pay parity, Dr. Mehanna said he has been able to manage their neurological conditions via telemedicine during the pandemic.
Like other neurologists who became accustomed to virtual visits, Dr. Mehanna approached it with a learning-by-doing philosophy. Over time he figured out how to hone his skills in examining patients via video. “You adapt with experience,” he said.
“We have to develop our own kind of tricks to get the information we need, given that we only see the patient in a limited field” of the camera's view, he added. “This is where we have to be creative.”
Dr. Mehanna suggested that it would be beneficial for neurologists to collaborate on the development of online instruction in performing a virtual movement disorders exam. Each presenter would share best practices to learn from one another, and ultimately, come to a consensus on standards for a uniform evaluation.
A host of functions and symptoms can be observed and analyzed via video. Dr. Schwamm said a virtual exam can gauge mental function, memory, speech, vision, gaze, strength, sensation, balance, and coordination. Slightly more difficult to assess are muscle tone, subtle eye movements, visual fields, or a detailed sensory examination, he noted. Sometimes it's necessary to request the assistance of a family member or friend at the patient's side.
Dr. Maloni of the VA Medical Center recommends that patients prepare for virtual visits by donning loose-fitting pants or shorts, footwear that can be easily removed, and a short-sleeved shirt. She also suggests that they sit in an upright chair and have a few objects within reach—for instance, a toothpick, metal spoon, ear swab, rubber band, sandwich-sized bag of ice, or soup can—to evaluate sensation.
It's also useful to have patients position a camera to show them rising from a seated position, as well as record their gait and arm swing. The Timed Get-Up-And-Go test or a 25-foot walk are observable virtually. If balance poses safety concerns, patients can attempt these movements near a wall, Dr. Maloni said. However, video does not lend itself to obtaining an accurate reading of rigidity in patients with movement disorders, so the scales for this type of evaluation require modification, Dr. Mehanna said.
In-person visits for participants of research studies were suspended at the beginning of the pandemic, when investigators held out hope that the coronavirus could be curtailed within a few months. But as the pandemic continued to engulf the nation, most clinical trials amended their protocols to permit video visits, sparing patients the need to travel to academic medical centers, he said.
Indeed, the protocol has to be revised for study investigators to shift from in-person appointments to telemedicine. Otherwise, “we can't do it,” said Deborah I. Friedman, MD, MPH, professor in the departments of neurology and ophthalmology at the University of Texas Southwestern Medical Center in Dallas.
“However, my research coordinator performed visits with our study participants when they pulled up and parked in their cars,” said Dr. Friedman, a neuro-ophthalmologist who is chief of the division of headache medicine. “She was outside the car. She had on a mask.”
There are limitations to telemedicine. While Dr. Friedman can determine via telemedicine if a patient's eyelids look symmetrical, she said it is not possible to perform ophthalmoscopy without an examiner on site.
Epilepsy, migraine, and Parkinson's disease should be relatively straightforward to diagnose and monitor in virtual visits. When well characterized, “Parkinson's disease can be diagnosed at a glance,” said Ray Dorsey, MD, MBA, professor of neurology and director of the Center for Health + Technology at the University of Rochester Medical Center.
On the other hand, an in-person exam and specialized testing would be necessary to establish a diagnosis of myasthenia gravis, multiple sclerosis, or amyotrophic lateral sclerosis (ALS). The office-based exam is much more critical to gauge reflexes and eye movement abnormalities, Dr. Dorsey said.
“When you're on a Zoom call, you can't see somebody's eyes as well as sitting next to them,” he said. Many subtle features, such as a slightly drooped eyelid and small movements in the legs, are difficult to observe in a clothed person on video. In addition, “rigidity is hard to appreciate remotely.”
But once a patient has received a diagnosis, follow-up visits can be done remotely. In fact, with compromised respiratory functions, a patient with ALS would be best served by avoiding an environment where they could contract COVID-19, Dr. Dorsey said.
Much of the neurological evaluation involves collecting a very detailed history and reviewing complex imaging and test results. At many academic medical centers, these visits are for second opinions in patients who have already had tests, said Dr. Schwamm of Massachusetts General.
One aspect that is different with telehealth pertains to the visit's aftermath. Dr. Schwamm had this advice to offer: “Always end with a recap of what was explained, and make sure the patient understands the follow-up procedures, as there is often no check-out staff member to fill in any gaps.”
Tips for Conducting the Telemedicine Exam
Barney J. Stern, MD, FAAN, vice chair for strategic planning and professor of neurology at Johns Hopkins University, has been conducting neurologic exams via telemedicine since mid-March. Here he offered some tips for conducting the virtual neurologic exam.
Dr. Stern said he uses a metal spoon (for perception of cold temperature) and a fork prong (for pain perception). For touch, he asks the patient to move their finger lightly over the skin and asks if it feels normal or “has hardly any touch at all” or is uncomfortable. If there is a companion, he said he finds that he can quickly teach them to help with a toe proprioception exam.
For finger strength and dexterity, he asks the patient to “play the piano” and if there is a companion to see if that person can “break” an “O” made between the thumb and pointer finger and thumb and little finger.
When he suspects the patient has a normal exam but wants to confirm this impression after the usual items are completed, he asks the patient to hop on one leg and then the other, with eyes open and closed. “I don't think I have missed anything major on a patient who can hop with eyes closed,” he said.
“You can see the eye movements fairly well when the face is near the camera,” Dr. Stern said. “However, unless the patient has very light eyes, I cannot assess the pupils. Also, even with a good internet connection, it is virtually impossible to assess smooth pursuit, square wave jerks, etc.”
Still, Dr. Stern said, “I think the future is working with bioengineering gurus (including NASA, perhaps) to define apps that can make a smart phone into a digital neuro exam device. It is time to retire our cherished analog legacy neurology exam!”