key: cord-0699382-cf7pvrbm
authors: Blue, Rachel; Yang, Andrew I.; Zhou, Cecilia; De Ravin, Emma; Teng, Clare W.; Arguelles, Gabriel R.; Huang, Vincent; Wathen, Connor; Miranda, Stephen P.; Marcotte, Paul; Malhotra, Neil R.; Welch, William C.; Lee, John YK.
title: Telemedicine in the era of COVID-19: a neurosurgical perspective
date: 2020-05-16
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.05.066
sha: c4b210990cc64b9b43d7cbf38d9e438cd41a6b31
doc_id: 699382
cord_uid: cf7pvrbm

Abstract Despite the substantial growth of telemedicine and the evidence of its advantages, utilization of telemedicine in neurosurgery has been limited. Barriers have included medicolegal issues surrounding provider reimbursement, interstate licensure, and malpractice liability as well as technological challenges. Recently, the COVID-19 pandemic has limited typical evaluation of patients with neurological issues and resulted in a surge in demand for virtual medical visits. Meanwhile, federal and state governments took action to facilitate the rapid implementation of telehealth programs, placing a temporary lift on medicolegal barriers that had previously limited its expansion. This created a unique opportunity for widespread telehealth use to meet the surge in demand for remote medical care. After initial hurdles and challenges, our experience with telemedicine in neurosurgery at Penn Medicine has been overall positive from both the provider and the patients’ perspective. One of the unique challenges we face is guiding patients to appropriately set up devices in a way that enables an effective neuro exam. However, we argue that an accurate and comprehensive neurologic exam can be conducted through a telemedicine platform, despite minor weaknesses inherent to absence of physical presence. Additionally, certain neurosurgical visits such as post-operative checks, vascular pathology, and brain tumors inherently lend themselves to easier evaluation through telehealth visits. In the era of COVID-19 and beyond, telemedicine remains a promising and effective approach to continue neurologic patient care.

Telemedicine can eliminate geographic barriers while adhering to COVID-19 safety guidelines as 1 physicians can reach patients remotely.

(2) Physicians use online examinations of patients in triaging care. For instance, a patient with a 3 medical emergency would be sent to the hospital while a patient with benign radiculopathy may 4 be scheduled for a clinic appointment. Triage of patients prior to arrival at hospitals is vital in 5 current COVID-19 conditions. The success of telemedicine in triaging stroke patients holds 6

promise for the application of telemedicine to other acute neurological emergencies. 9,10 7

(3) Telemedicine can save patients money, travel time, and work lost, as reported by the VHA in 8 a survey of patients who received chronic neurologic care, as well as by parents of pediatric 9

patients receiving neurosurgical care. 5,6 Davis et al. estimated a total saving of over $48,000 in 10 time and travel costs for 354 patients. Patient satisfaction was increased, with 95% of patients 11

reporting that they would like to continue their neurologic care through telemedicine. 5 12

Neurosurgeons working at large hospitals or health systems can easily adopt telemedicine 13 because of the economic capacity of larger institutions, in addition to their capacity to share telemedicine 14 systems across the institution. 3 Telemedicine will not replace in-person procedural or emergency services 15 in neurosurgery. 7 However, it can serve as a vital adjunct to conserve and distribute resources, ultimately 16

improving neurosurgical patient care.

Pre COVID-19 Telehealth Implementation and Medicolegal Considerations 19 20 Before the COVID-19 health crisis, the use of telehealth varied across medical and surgical 21

specialties. In 2012, George et al. surveyed neurology departments in the top 50 hospitals as measured by 22

U.S. News and World Report and found over 85% either used or planned on implementing telemedicine 23 within the following year. 11 liability is similar to that of in-person medical services, malpractice insurance may only cover claims 7

originating from specific jurisdictions. 3,15 8 9

Government Response During the COVID-19 Pandemic 10 11

The COVID-19 crisis has resulted in a surge in telehealth due to increased demand for virtual 12 medical visits as well as a temporary lift on medicolegal barriers that had limited telehealth's expansion in 13 the past. The pandemic has threatened to strain medical resources, prompting governing bodies and 14

professional societies to recommend elective surgeries be cancelled or postponed. 19 This created a unique 15 opportunity for widespread telehealth use to meet the surge in demand for remote medical care.

In response to the crisis, federal and state governments took action to facilitate the rapid 17

implementation of telehealth programs across the country's health systems. Retroactive to March 1, 2020, 18

and for the duration of the public health emergency, provisions temporarily removed the requirement that 19

Medicare telehealth reimbursements be limited to beneficiaries seeking care at designated health centers 20

in rural areas, thereby extending telehealth coverage to all. 20 This waiver affects reimbursement for 21 federal healthcare programs, including Medicare, Medicaid, and the Children's Health Insurance 22

Program. These visits are considered the same and reimbursed at the same rate as all in-person visits. In 23 addition, Medicare also expanded the list of eligible services provided via telehealth, including audio-only 24 telephone calls and emergency department visits. Physicians may utilize telehealth for both new and 25 established patients. 21 Expanded Current Procedural Terminology (CPT) codes applicable to telehealth 26

have been summarized to guide providers. 22, 23 As some private payers are following the CMS guidance, 27

providers are encouraged to check with specific payers as well as state laws and regulations regarding 28 eligible coverage. 24 In an effort to limit licensure restrictions, 44 states have implemented waivers 29 modifying in-state licensure requirements for telehealth services. 26 Telehealth providers have also been 30 temporarily allowed to issue prescriptions for controlled substances without in-person evaluations, 31

provided certain requirements are met. 27 These factors have all likely contributed to an increase in the 32

proportion of neurosurgeons who have begun to use telehealth during the COVID pandemic.

Considerations in the Implementation of Telehealth 35 36

Maintaining patient privacy is a ubiquitous concern with electronic data transfer. Prior to the 37 COVID-19 pandemic, telemedicine was provided only on HIPAA-compliant platforms, such as Zoom for 38

Healthcare, BlueJeans, Doxy.me, and Vidyo. 28 Video communication vendors with the necessary security 39 capabilities to prevent data interception ensured electronic patient health information (PHI) protection, as 40 stipulated by the HIPAA business associate agreement (BAA). Non-public facing communication 41

products employ end-to-end encryption of information. Examples include FaceTime, Facebook 42

Messenger video chat, Google Hangouts, as well as texting applications such as Whatsapp and iMessage. 43

In contrast, public-facing communication applications (e.g. Facebook Live, TikTok or Twitch) are 44 unacceptable platforms for the provision of telehealth. Although providers are still encouraged to use 1 HIPAA-compliant vendors they will not be penalized for using previously unsanctioned products during 2 the COVID-19 emergency. 25 3

The most imperative element of a remote clinical evaluation is arguably the technology used to 4 transmit information. The most readily available technology are smartphones, owned by 77% of 5

Americans in 2020. 29 Furthermore, ongoing developments in videoconferencing software promise fewer 6 technical issues, decreased latency, and higher video quality. 30 7

Even before the COVID-19 pandemic, telemedicine had been successfully implemented for 8 neurosurgical care in select settings. Video and image from smartphones are largely of sufficient quality, 9

mitigating some concerns about decreased exam quality. 31-34 Although outcome data are limited, one 10 study showed no significant difference in emergency room visits and 90-day readmission between 11

patients who had undergone elective neurosurgery and received either in-person or remote follow-up. 35 12

Notably, another study found that any potential reduction in efficacy may be offset by the cost-13 effectiveness and utilitarian benefits of telemedicine. 36 14

The cognitive demand imposed on users by different video conference platforms may be a key 15

consideration in selecting the appropriate platform. Agnisarman et al. compared the usability of four 16

platforms -Doxy.me, Vidyo, VSee, and Polycom -with a sample clinical scenario that included a log-in 17

sequence, changing to full screen, muting the microphone, disabling video, communicating over chat, and 18

concluding the session. 37 Although there were no significant differences in errors, the authors found 19

significant differences in task completion time, workload, cognitive demand and effort, level of 20 frustration, overall satisfaction, and user interface quality across platforms. 37 The primary factor for 21

whether a patient will accept a telemedicine invite is their comfort in initiating the call, 38 which argues for 22

choosing a platform with more widespread daily use over platforms specifically designed for 23

telemedicine. Furthermore, with the increasing use of telemedicine, vendors are incentivized to achieve 24 HIPAA compliance. Skype for Business, Zoom, and GoToMeeting are examples of popular video 25

conferencing software with HIPAA-compliant options. 26

Preceding the COVID-19 pandemic, the telehealth market share was dominated by Teladoc 27

Health, Amwell, and Doctor On Demand. The two main types of telemedicine vendors are those with 28 integrated electronic medical records (EMR) and ones that provide standalone telemedicine service. 29

Stand-alone telemedicine platforms have the flexibility to be employed in conjunction with any EMR. 30

Companies like Zoom, Amwell, and Vidyo have partnered with EPIC to allow direct integration. The ease 31

of use and integration of these traditional video conference platforms, relaxed HIPAA regulations, and the 32 surge in telehealth utilization have all contributed to their rapid adoption in the telehealth space. 39 33

Smaller centers without the capability for video-platforms have implanted telephone-only visits. 34

While this type of encounter has inherent difficulty and limited examination, it can be effective for certain 35 visits such as long term follow-up and evaluation of some incidental radiographic findings.

Institutional Experience 38 39

Penn Medicine recently adopted BlueJeans as its telemedicine platform in conjunction with the 40 university-wide licensing of the software for the purpose of all remote communication. Since its 41

implementation, BlueJeans has had overall positive feedback from both providers and patients. Prior to 42

the scheduled clinic visit, the patient is contacted by a clinic staff member to assist in setting up the 43

BlueJeans call, ensuring any technological issues are addressed, and that all radiological data has been 44 received and uploaded. On the day of the clinic visit, the patient first enters the virtual "room" with the 1 medical assistant, similarly to a conventional clinic. After the basic patient information is gathered, the 2 provider will "enter" the virtual clinic room. Patient history and physical examinations are completed and 3 radiology findings are shown to the patient via the screen share function. Additional need for followup or 4

intervention is discussed with the patient, and after all the patient's questions are answered, the visit is 5 completed. 6

While the satisfaction with the implementation of telemedicine has been overall quite positive, 7 some difficulties have been encountered, including initial set-up for first-time telemedicine users and 8 difficulty navigating the tele-health platform, acclimation to the new clinic work-flow, and patients 9

without access to videoconferencing capabilities. For some patients, videoconferencing is done over a 10 smartphone or tablet rather than a computer. We have found that while it is possible to effectively 11 complete a visit this way, the physical examination is more difficult, particularly in regards to cranial 12 nerve testing, and video conferencing with a computer is preferable. If a patient is sitting next to a bright 13 window, the dynamic range of the small sensor camera can present a problem, particularly when 14 examining the eyes, sclera and face. It is best to have a patient sitting with the light source in front, rather 15 than behind, of them. Additionally, it is important that the camera is not too zoomed into the patient's 16 face, limiting the extremity exam, or too wide angle, limiting the cranial nerve exam. For patients without 17

a smartphone or computer camera, an audio only visit significantly limits the ability for examination.

Certain neurosurgical visits and pathology inherently lends itself to easier assessment through 19

telehealth visits, such as post-operative checks, vascular pathology, and brain tumors. Other pathologies 20

that have more subtle exam findings, such as peripheral nerve and certain spinal pathologies, and 21

therefore are more difficult to asses via telemedicine.

Efficacy of the Telemedicine Neurologic Exam 24 25 Some argue that the most obvious weakness of telemedicine is the inability for providers to 26 perform a face-to-face physical examination. However, as detailed above, physicians can perform an 27 accurate and comprehensive neurologic exam even through a telemedicine platform. (Figure 1 ) 28

Currently, perhaps the most common telemedicine service is the field of acute stroke management, a field 29 which demands rapid neurologic evaluation and treatment of patients within the window for 30

intervention. 46 Through tele-neurology and tele-stroke, the reliability of remotely administered neurologic 31 assessments, particularly the NIHSS, has been well established across the full range of stroke severity. 47-32 51 Further, telestroke care has been proven to shorten duration of hospital stay, as well as to facilitate rapid 33 access to rehabilitation assessments and other diagnostic testing and imaging, when compared to standard 34 stroke unit care. 47 

There have been pilot trials for chronic neurologic care delivery for patients with Parkinson's 36

Disease (PD), Multiple Sclerosis (MS), and essential tremor (ET). PD is the most common indication for 37 deep brain stimulation (DBS). 52 Remote exams are particularly valuable in patients with PD, as the age 38

and level of disability in this patient population poses difficulties in traveling from their residence to 39 clinic appointments. The current standard for evaluating PD is the Unified Parkinson Disease Rating 40

Scale (UPDRS), 43,44 consisting of four subscales: 1) mentation, behavior and mood; 2) activities of daily 41 living (ADLs); 3) motor examination, typically assessed by clinicians; and 4) complications of therapy. 42

Among these, sub-scale 3 is the most pertinent part for tracking disease severity over time. 53 Several 43 studies have concluded that sub-scales 1 & 2 can be effectively self-administered by patients or 44 caregivers, producing consistent results to provider-administered ratings. 54-56 Furthermore, the possibility 1 of remote administration of a modified version of sub-scale 3 (without rigidity and retropulsion pull 2 testing) has been proposed and found to be reliable. 45 One small randomized controlled trial comparing 3 remote versus face-to-face neurologic examinations in patients with PD indicated comparable 4 assessments of speech, facial expression, postural stability, gait, balance (arising from a chair), resting 5 tremor, and hand and body bradykinesia; and a fair degree of inter-rater reliability for finger taps and 6 action tremor. Further, patients in the same study that followed up via telemedicine reported improved 7

quality of life and enhanced motor performance compared to patients receiving usual care. 47 8

Similarly encouraging results have been reported in MS. In a comparison of remote and hands-on 9

neurologic examinations of 20 patients with MS, Kane et al. found no significant increase in inter-10 specialist disagreement in ratings of neurologic function when the neurologic exam was observed 11

remotely. 57 Lastly, for patients with spinal cord injuries, tele-neurology visits were shown to be as 12 effective as in-person rehabilitation and to offer significant additional benefits in quality of life and long-13 term health outcomes. 58 14

Remote neurologic examinations are also vital in the evaluation and clinical management of 15 essential tremor, the most common movement disorder. 59 For the evaluation of essential tremor, the Fahn-16

Tolosa-Marin (FTM) Clinical Rating Scale for Tremor (CRST) is recommended by the Movement 17

Disorders Society and has been adopted as the gold standard in most clinical research trials in this 18

domain. 40 The CRST scale consists of three parts: Part A quantifies tremor severity at rest, with posture 19

holding, and with action for nine parts of the body; Part B assesses action tremor of the upper extremities 20 during writing, drawing, and pouring; and Part C assesses functional disability. 41 Notably, in a recent trial 21

published in the New England Journal of Medicine, the most pertinent portions of the CRST (extracted 22

from parts A & C) were effectively assessed by movement disorder neurologists using videos of patients, 23

suggesting the potential for using telemedicine on components of this scale. 42 

Certainly, some aspects of the neurological examination may be more difficult to assess remotely 25 than others, notably, deep tendon reflexes, 58 rigidity, 47,60 retropulsion pull testing, 45 minor reductions in 26 facial animation, subtle dyskinesia, and limb bradykinesia. 61 Other studies noted mildly weaker inter-rater 27 agreement when examining cerebellar, brainstem, and sensory functions. 57,60 However, performing an 28 accurate and comprehensive neurologic exam remotely is certainly feasible. 29

Though the remote neurologic exam may have minor weaknesses, amidst the current global 30 COVID-19 pandemic and healthcare crisis, a remote exam is likely to provide access to care for patients 31 who otherwise would be unable to be examined or seen for follow-up at all. These remote visits can be 32

incredibly efficacious, especially if aided by a trained individual (tele-examiner) or family member on the 33 patient's end, or if being used for follow-up after an initial face-to-face neurologic exam. Telemedicine 34 has proven to be a clinically acceptable and cost-effective approach that not only improves patients' 35

quality of life but also increases efficiency and conserves healthcare resources. 5,61 In the era of COVID-36 19, a time in which social distancing and limited patient contact are imperative, telemedicine is a 37

promising and effective approach to continue neurologic care. 38 39

Our institutional experience has demonstrated the feasibility and acceptability of incorporating 42

telehealth into neurosurgical ambulatory practices, even after social distancing restrictions are lifted. As 43 with all new programs, an initial period of refinement was needed prior to arriving at our current 44 workflow, but so far it has proven effective and efficient. During the ten weeks prior to the COVID-19 1 pandemic our department averaged 139 new patient and 220 return patient visits per week. (Figure 2 ) No 2 recorded telemedicine visits were conducted during that time period. Although there was an initial decline 3 in the number of visits immediately after implementation of COVID-19 related policies, during our fifth 4

week using our telemedicine workflow, our department recorded 111 new patient visits, 110 of which 5

were conducted via telemedicine. Return patient visits followed a similar trend, with a sharp drop off and 6 gradual recovery, although the number of return patient visits has not rebounded as robustly as new 7 patient visits with 109 total return visits (95 telemedicine, 14 in-person) recorded during the fifth week 8

following our policy change. 9

Although the neurologic exam is a useful adjunct, much of the decision-making in neurosurgery 10 hinges on the clinical history and the review of relevant imaging findings, particularly in cranial surgery, 11

which is entirely available via telehealth. In our practice, this has opened up the possibility of high-12 throughput screening of patients based on pathology, urgency, and need for intervention. For instance, our 13 multidisciplinary Spine Access Center already involves the collaboration of neurosurgeons, orthopedists, 14

physiatrists, and anesthesia pain specialists. Through telehealth, patients can be appropriately screened 15

based on their symptomatology, along with past medical and surgical history, and identified as potential 16

candidates for surgical intervention or more conservative measures, including a trial of physical therapy 17

and/or epidural steroid injections. The physicians can order more focused radiographic or 18

neurophysiological studies in preparation for a subsequent telemedicine or in-office visit. In an elective 19

practice, such an approach can reduce lag time for patient evaluation, improved patient satisfaction, lower 20 cost at the system and individual levels, more efficient use of in-person specialist time, and higher 21

conversion of ambulatory visits to surgical cases. The approach is arguably more resource efficient in that 22

we are utilizing fewer examination rooms and decompressing the waiting room. 23 Similarly, telehealth clinics in neurosurgery offer a unique opportunity to augment the 24 educational experience for residents and other trainees. Due to service obligations and limited training 25 time, the primary emphasis of surgical subspecialty training across the country is hands-on experience in 26 the operating room. However, one of the difficulties in transitioning to an independent practice after 27 residency training is learning how to manage a clinic independently. Telehealth offers significant 28 flexibility in incorporating this kind of learning into the current training paradigm, so that learners can 29 gain much greater exposure to a variety of teaching and communication styles, including how to handle 30 shared decision-making and informed consent for a wide range of pathologies. Similarly, residents can 31 also gain access to aspects of patient follow-up that may not have been feasible without the widespread 32 adoption of telehealth, including observing patient outcomes in the rehabilitation setting or following 33 patients for whom they helped care for, either in the operating room or in the inpatient setting.

Potential Shortcomings of Telemedicine 36 37

As with all new technologies, it is important to consider how barriers to healthcare access may 38

affect the growing use of telehealth. Healthcare systems must be vigilant to ensure that the 39 implementation of telehealth does not inadvertently limit access to neurosurgical care along 40 socioeconomic or cultural lines. This may require more up-front investment and regulation at the 41 institutional and policy levels to ensure equal access to care. 42

Some patients will not participate in telemedicine visits because of they do not have access to the 43 infrastructure required. For example, internet access may not be fully robust in certain geographic 44 locations or patients may not have a compatible camera. Also, we have identified a small group of 1 patients who are uncomfortable with the technology, have security concerns or simply want to be seen in 2

person. 3

There is the potential for missing a significant neurological deficit with a telemedicine visit. We 4 generally increase the time spent on history acquisition being sensitive for descriptors consistent with a 5 neurological deficit (e.g. double vision, reduction in keyboard skills). Our neurological examination can 6 then be focused and extended to explore the areas of concern. While we have not identified any 7 significant neurological deficits missed during the telemedicine examination and subsequently identified 8

at follow-up, we do recognize this as a possibility. 9

The time commitment for a successful telemedicine visit is significantly extended for the 10 practitioners. We have noticed that the communication techniques change during telemedicine visits, 11

especially if there are more than two access portals. Specifically, the slight verbal delay in 12 communication requires that all participants allow a slight delay in their responses. Also, the entire 13 process for the medical team is extended by the need to get the telemedicine connection established. 14 In our experience, this delay in response as well as the overall experience of the platform can lead 15

to an unfortunate informality and loss of the typical provider/patient relationship that has been so 16 important in developing a therapeutic relationship. This may be as obvious as observing ongoing 17 unrelated activities in the camera background with associated visit interruptions. We have also noticed a 18 tendency to lose focus during the examination with an associated need to re-establish priorities and 19

timelines with the patient. 20 21 22 Conclusion 23 24 While it is difficult to predict how the post-COVID-19 world would look like, current 25 circumstances and changes in policy have encouraged and will likely encourage more physicians to set up 26 telehealth as part of their practice. With the new infrastructure in place, policy makers and providers 27

should work together to sustain the positive changes and paradigm shift in the delivery of healthcare. 62 28 29 30 31 32

Disclosures: The authors have no disclosures

Lessons learned from the usability assessment of home-based telemedicine 11 systems

Perceptions of Video-Based Appointments from the Patient's Home: A Patient 13

Telehealth Capacity of US Hospitals in Response to COVID-19: Cross-Sectional Analysis of Google 16 Search and National Hospital Survey Data

Task force report: scales for screening and evaluating tremor: critique and 18 recommendations

Clinical rating scale for tremor

A Randomized Trial of Focused Ultrasound Thalamotomy for Essential Tremor

Randomized Delayed-Start Trial of Levodopa in Parkinson's Disease

Outcomes of Tele-neurology: A Review

Telemedicine for delivery of health care in Parkinson's disease

COVID-19 is catalyzing the adoption of teleneurology

Figure 1: Tips for Performing the Adult Neurologic Exam in a Telemedicine Visit 26,46 19 Note: elements of the exam that may be more difficult to perform are marked by * 20 21 22 Figure 2: In-Office visits vs Telehealth

https://www.ama-assn.org/system/files/2020-04/covid-19-coding-advice.pdf (2020). 2 23. AMA quick guide to telemedicine in practice. https://www.ama-assn.org/practice-3 management/digital/ama-quick-guide-telemedicine-practice (2020). 424. American Academy of Neurology. Telemedicine and COVID-19 Implementation Guide. 5 https://www.aan.com/siteassets/home-page/tools-and-resources/practicing-neurologist--6 administrators/telemedicine-and-remote-care/20-telemedicine-and-covid19-v103.pdf (2020). • Look for pupil symmetry