key: cord-0824817-rir6jeme authors: Hassan, Anhar; Mari, Zoltan; Gatto, Emilia M.; Cardozo, Adriana; Youn, Jinyoung; Okubadejo, Njideka; Bajwa, Jawad A.; Shalash, Ali; Fujioka, Shinsuke; Aldaajani, Zakiyah; Cubo, Esther title: Global survey on telemedicine utilization for movement disorders during the COVID‐19 pandemic date: 2020-08-24 journal: Mov Disord DOI: 10.1002/mds.28284 sha: 7ebbec8b79ea329865ebde443eba93cbc3fbd08a doc_id: 824817 cord_uid: rir6jeme BACKGROUND: The COVID‐19 pandemic restricted usual healthcare management for movement‐disorders patients, with a consequent upsurge in telemedicine to bridge the gap. OBJECTIVE: To assess global telemedicine usage in the context of the pandemic. METHODS: The MDS Telemedicine Study Group surveyed telemedicine experts from 40 countries across all continents in March‐April 2020. Four domains of telemedicine were assessed: legal regulations, reimbursement, clinical use, and barriers; comparing emerging responses to the pandemic versus the baseline scenario. RESULTS: All forms of telemedicine for movement disorders increased globally, irrespective of country income categorization, as an immediate response to the pandemic. This was aided by widespread availability of technology and updated government regulations. However privacy concerns, lack of reimbursement, limited access, and lack of telemedicine training were barriers highlighted worldwide. CONCLUSION: Questions remain about the longevity and extent of changes in regulations and reimbursement regarding telemedicine in the aftermath of the pandemic. This article is protected by copyright. All rights reserved. COVID-19 was declared a pandemic by the World Health Organization (WHO) on March 11, 2020. (https://www.who.int/news-room/detail/27-04-2020-who-timeline---covid-19) This declaration triggered almost immediate global restrictions to routine healthcare access, principally to limit viral transmission, but also to prioritize healthcare resources to address the novel virus. These restraints threatened continuity of care for patients with chronic medical conditions, including Parkinson's disease and other movement disorders [1, 2] . Escalation of telemedicine presented an obvious alternative to bridge the gap without considerably compromising the quality of medical care [3] . Existing data on global telemedicine use for movement disorders was first collected in 2015 via a survey of members of the International Parkinson and Movement Disorder Society (MDS) [4] . Of over 500 survey respondents from 83 countries, approximately half were engaged in telemedicine for movement disorders, despite barriers such as lack of reimbursement and technological difficulties. Half of respondents planned to use telemedicine in the future, and three-quarters desired telemedicine education. The Telemedicine Study Group within the MDS therefore aimed to conduct an updated assessment of global telemedicine use for movement disorders. In particular, the objective was to assess telemedicine usage and its associated barriers and legislation, just prior to the COVID-19 pandemic and in the face of the emerging pandemic. This article is protected by copyright. All rights reserved. The study was designed and conducted by the Telemedicine Study Group of the MDS. We utilized a structured electronic survey, with the target respondents being members of the Telemedicine Study Group and other active MDS telemedicine experts, to ensure international coverage across the MDS sections (Europe, Pan-America, Asia-Oceania, and Africa). Survey questions were developed via a consensus approach to query four domains of telemedicine: legal regulations, reimbursement and clinical regulations, clinical usage/telemedicine tools, and barriers within that country or region. The survey was completed via email between March and April 2020. The respondents were asked which of these domains had changed in response to the COVID-19 pandemic. The questions asked were: 1) Do you have legal regulations regarding telemedicine practice in your hospital/region/country? 2) Is there reimbursement for telemedicine services? Are there rules regarding office visits versus telemedicine visits? 3) What methods of telemedicine do you use (e.g. telephone calls, emails, text messages, videoconferences) and any specific software? 4) What are the main barriers to telemedicine (e.g. technological limitations, patient rejection, lack of training, privacy concerns)? This article is protected by copyright. All rights reserved. With the COVID-19 pandemic, are neurologists/movement disorder specialists in your country/region using more telemedicine? Has this crisis changed anything in questions 1-4? Responses were thematically summarized within the four domains to enable comparison. Data was obtained from 40 countries within the MDS regional sections: Europe (Ireland, Israel Baseline usage of telemedicine before the COVID-19 pandemic (Table 1) Prior to the COVID-19 pandemic, there were no specific regulations governing telemedicine use in the surveyed countries in Europe and Africa, except for Zambia and Tunisia. This was in contrast with many countries in Pan-America and Asia-Oceania where there was tight regulation of telemedicine. These regulations ranged across a spectrum to facilitate or prevent telemedicine. For example, several Canadian provinces reported a sophisticated telemedicine infrastructure with dedicated telemedicine centers, personnel and reimbursement, in contrast with South Korea where telemedicine was illegal for clinical care. Reimbursement varied considerably between countries, and also varied within the same country, depending on the health care setting utilized (public or private). The most common response was no reimbursement, particularly if no billing code. In many countries, it was available as fee-for- This article is protected by copyright. All rights reserved. service and partially or fully covered by insurance. Telemedicine modalities included emails, telephone calls, message apps, video visits, and teleconferencing. These types of telehealthcare were similar across both low-and high-income countries. Barriers to telemedicine were alike worldwide, including technologic issues, lack of reimbursement, privacy issues, and lack of familiarity by both patients and physicians. In some countries, broadband data charges or cost of devices was a significant limitation for patients and physicians to conduct telemedicine visits. In response to the COVID-19 pandemic, telemedicine usage increased across almost all of the surveyed countries, including those with little to no prior usage. Telephone calls, messaging apps, or video visits replaced or supplemented outpatient clinics. In South Korea, the illegal status was lifted to follow established patients through telemedicine. In Canada, legislative changes varied significantly depending on the province: established telemedicine centers shut down to limit viral transmission and transitioned to telephone calls instead, paradoxically resulting in a reduction in telemedicine, whereas other provinces increased telemedicine because of new reimbursement and looser regulations. Governments from several countries initiated legislation to promote and regulate telemedicine and/or amended their prior restrictive regulations. Privacy issues and technical limitations mostly remained unchanged. However a number of selected countries across all MDS sections reported improved reimbursement. This article is protected by copyright. All rights reserved. This survey demonstrates the vast global increase in utilization of all forms of telemedicine for movement disorders consultations across countries, irrespective of income categorization, as an immediate response to the COVID-19 pandemic. This uptake appears to have been facilitated by a combination of urgent governmental responses (i.e. modifying regulations and initiating telemedicine legislation) and pre-existing global availability of technology (i.e. smart devices and internet connectivity). However privacy concerns, lack of reimbursement, technical and technologic issues, and lack of training in use of telemedicine for virtual visits were issues highlighted worldwide. In contrast to the baseline survey in 2015, where about half of the respondents personally used telemedicine [4] , we pre-selected respondents who were more likely to be well-informed and engaged in telemedicine for movement disorders. This was to ensure that the data obtained regarding the work-place and in-country standards (regulations, reimbursement, modalities and barriers) would be trustworthy, both pre-COVID-19 and in the face of the emerging pandemic. Importantly, their responses highlight several key points. Firstly, the barriers to telemedicine identified in 2015 largely remained unaddressed in early 2020 and even during the COVID-19 pandemic. This is despite all stakeholders, i.e. patients, physicians, and government, now relying on this service for healthcare delivery. Secondly, in spite of these barriers, telemedicine use for movement disorders increased amongst countries and physicians that already used it, as well as those with limited to no prior use. While necessity for sustaining healthcare access probably drove this increase of telemedicine, the barriers that remain are likely burdening both physicians and patients. Thirdly, the increased uptake of Accepted Article telemedicine in many countries seemed to be uneven, whereby a subgroup of patients or healthcare providers are better positioned to engage with it. For example, elderly persons or those unfamiliar with telemedicine, restricted internet connectivity (remote locations, unaffordable data or device costs) and lack of physician reimbursement were major limitations to using telemedicine for movement disorders. The implication is that existing disparities in access to healthcare may potentially be increased if these barriers remain unexplored and unaddressed. Fourthly, a small number of countries reported rapid and substantial government relaxation of regulations, demonstrating that bureaucratic changes are feasible, even where previously very stringently controlled. Lastly, even a sophisticated telemedicine infrastructure may have a weak link exposed by the pandemic, rendering it ineffective as was evidenced in Canada. The findings from this survey flag opportunities for improvements that can transform telemedicine for movement disorders to a more user-friendly and satisfactory experience. For instance, the MDS Telemedicine Study Group created a "step-by-step" webinar to conduct a telemedicine visit for movement disorders clinicians worldwide, publicly available, and posted on the Movement Disorders Society website. (https://www.movementdisorders.org/MDS/About/Committees--Other-Groups/Telemedicinein-Your-Movement-Disorders-Practice-A-Step-by-Step-Guide.htm). In addition, a patient brochure "How to Prepare for Telemedicine Visit" has been created and will be available in English, and translated to several other languages (under publication). Addressing the common issues related to telemedicine utilization across the various world regions would take concerted efforts and advocacy. The need for accessible telemedicine services, globally demonstrated Accepted Article may exist. Therefore endeavors to conduct detailed country-specific surveys of telemedicine before and after COVID-19, and deeper exploration of barriers, would help to provide more granular detail about the findings captured in this study. The importance of this survey is the insight it provides into the current use of telemedicine across all continents for movement disorders, delivering a truly global view. This data can be used to help address barriers raised by both physicians and patients, and to continue to enhance the experience of telemedicine for all stakeholders. Questions remain about the longevity of changes in regulations and reimbursement practices as the world moves past the COVID-19 pandemic. Accepted Article Impact of the COVID-19 Pandemic on Parkinson's Disease and Movement Disorders Accelerating Telemedicine for Cerebral Palsy During the COVID-19 Pandemic and Beyond Implementation of Telemedicine for Urgent and Ongoing Healthcare for Patients with Parkinson's Disease During the COVID-19 Pandemic: New Expectations for the Future J Parkinsons Dis Telemedicine Use for Movement Disorders: A Global Survey Accepted Article The