key: cord-0745311-nf9osb1s authors: Greven, Alexander C M; Rich, Christopher W; Malcolm, James G; Bray, David P; Rodts, Gerald E; Refai, Daniel; Gary, Matthew F title: Letter: Neurosurgical Management of Spinal Pathology Via Telemedicine During the COVID-19 Pandemic: Early Experience and Unique Challenges date: 2020-04-28 journal: Neurosurgery DOI: 10.1093/neuros/nyaa165 sha: 985edd73e03c4e96ed76883950437360c5173929 doc_id: 745311 cord_uid: nf9osb1s nan Telemedicine is executed via 3 mediums: video with audio, telephone only, and electronic communication only. The application Zoom (San Jose, California), which had previously been used by our neurosurgery department for remote conferences, is our preferred method for delivering telemedicine due to its HIPAA compliance and familiarity of use. This technology also has features like "breakout rooms," which allow telemedicine visits to closely mimic the workflow of an in-office clinic visit, complete with a waiting room, different examination rooms, and a common hub for providers. When audio-visual visits are not possible secondary to connectivity issues, then telephone calls without video are a backup option. Lastly, electronic communication (such as email or medical record messaging) can be used to maintain contact with patients but is suitable only for nonurgent needs of established patients. New changes allow for billing of these electronic communications (see Table 2 for a virtual visit billing guide). The first step in establishing a telemedicine visit is scheduling the appointment. Caring for our established patients and seeing new patients during this time allows us to provide conservative treatments, evaluate new patients for surgery, and decrease the rush of in-person encounters once the COVID-19 pandemic is over. To this end, we are encouraging all patients who were already scheduled to be seen in clinic to change their appointment to a telemedicine visit instead of postponing their clinic visit for months. Thirty minutes prior to the scheduled appointment, the medical assistant (MA) calls the patient to gather information, including patient identification, estimated height and weight, chief complaint, pain level and location, and current medications. In addition, the MA obtains special consent for the telemedicine visit, which includes confirming the patient's location and that they are in the same state or a state that has waived licensing requirements during the pandemic, consenting the patient to participate in a telemedicine visit, directing the patient to call 911 or seek the nearest Emergency Department in the event of a medical emergency, and advising that the patient should plan to see the attending physician at least once for an office visit within the next year. Due to the novelty and potentially confusing nature of remote clinic visits, the MA is instrumental in informing the patient on what to expect. The patient is told to login or "checkin" at least 15 min prior to their appointment, to conduct the visit in a quiet room with good lighting, to wear clothes that are easily removed should a direct examination of the spine or an extremity be needed, and to have someone else available to hold the camera, if possible, to facilitate capturing physical examination findings. Clinicians are now able to prescribe schedule II to V controlled substances to patients seen using telemedicine communication It is also important for the documenting physician to record the time of the encounter, as billing is done by time. Recording the patient's history is straightforward, and it can be obtained by a resident or advanced-practice provider (APP) just like in clinic. The physical examination is nuanced, and relies on good lighting, adequate space for the patient to move, the ability for the patient to position the camera in a way that allows for appropriate visualization, and clear specific instructions on the part of the healthcare provider. A pain diagram can be shared to the patient's screen to correlate the location of pain on examination. One major component of neurosurgical telemedicine visits that differs from general practice telemedicine is the importance of imaging for evaluating and diagnosing disease. Acquiring that imaging poses a unique challenge to neurosurgeons, particularly for new patients who have had imaging done at outside facilities. Traditionally, new patients are instructed to bring compact discs (CDs) to clinic to have them uploaded into the Emory system via LifeImage (Newton, Massachusetts). During the COVID-19 crisis, we have developed several workflows for acquiring outside imaging: (1) the outside imaging center can push images directly to our PACS via PowerShare (Burlington, Massachusetts), (2) the imaging center can upload images to LifeImage and then we transfer them to PACS, (3) the imaging center can give the patient a CD or USB of the images, which the patient can upload from their own computer to LifeImage, or (4) the patient can mail the CD or USB to clinic prior to their telemedicine appointment. We have created "imaging teams" with personnel that expedite image retrieval with the patient prior to their telemedicine visit. During the actual visit, Zoom's screenshare capability facilitates reviewing images with patients, and the ability to draw on the scan in real time allows for effective communication and patient education. Although the American College of Surgeons and the Surgeon General of the United States have recommended postponement of elective spine surgery during the COVID-19 crisis, 6 telemedicine visits for these patients are crucial for triaging urgent issues during this time of crisis; managing patients conservatively with pain medications, steroids, and remote physical therapy recommendations while their procedure is delayed; following up on postoperative patients; and signing patients up for a surgery waitlist to temper the flood of clinic visits that will occur once the COVID-19 pandemic has resolved. Once the COVID-19 crisis is over, neurosurgeons will need to address this inevitable backlog: perhaps by decreasing clinic time (since we can theoretically see more clinic patients now) and increasing operative time. Regardless, scheduling patients for surgery without an in-office visit has interesting moral, legal, and ethical implications, which have largely never been thought of until this point. The obvious benefit of telemedicine visits during the COVID-19 pandemic is the ability to continue patient care in a safe way that decreases the risk of transmission of the virus. Other benefits, like socioeconomic impact, have implications that extend beyond this time of crisis. Telemedicine has the potential to relieve the burden of travel for patients who seek expert opinions at tertiary medical centers but live far away. Reduced in-office clinic visits could lead to less overhead with decreased demand for electricity, parking, front desk staff, and waiting/examination room space. A good motor examination is critical for the evaluation of a neurosurgical spine patient. Completing a thorough physical examination via telemedicine is not yet possible. In the future, we will need to support innovative technologies that will allow for more accurate remote neurological evaluations. At present, there is no substitution for the subtleties of an in-office visit, such as detecting the odor of tobacco on a patient who claims they are a nonsmoker, but time will tell whether telemedicine visits taking the place of in-office visits has any impact on patient outcomes. The potential good that can come from incorporating telemedicine into neurosurgery is immense. Questions remain whether the relaxed regulatory regulations that have enabled the 4 | VOLUME 0 | NUMBER 0 | 2020 www.neurosurgery-online.com widespread implementation of telemedicine services will return to more stringent regulations once the pandemic has resolved. Future research investigating patient outcomes, patient satisfaction, and socioeconomic effect will give neurosurgeons insight into the feasibility of making telemedicine visits standard of care for the evaluation and management of spine pathology. The evolution of telehealth: where have we been and where are we going? In: Board on Health Care Services; Institute of Medicine Telemedicine for neurotrauma in Albania: initial results from case series of 146 patients Prospective and retrospective study of videoconference telemedicine follow-up after elective neurosurgery: results of a pilot program Socioeconomic patient benefits of a pediatric neurosurgery telemedicine clinic Remote treatment delivery in response to the COVID-19 pandemic American Association of Neurological Surgeons United States Department of Justice: Drug Enforcement Administration Issue Brief: COVID-19 and Telehealth Changes Key-Issues/Other-Issues/Issue-Brief-COVID-19 Medicare Telemedicine Health Care Provider Fact Sheet Copyright C 2020 by the Congress of Neurological Surgeons The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.