key: cord-0881369-wsi9cyq0
authors: Daggubati, Lekhaj C.; Eichberg, Daniel G.; Ivan, Michael E.; Hanft, Simon; Mansouri, Alireza; Komotar, Ricardo J.; D’Amico, Randy S.; Zacharia, Brad E.
title: Telemedicine for Outpatient Neurosurgical Oncology Care: Lessons Learned for the Future During the COVID-19 Pandemic
date: 2020-05-22
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.05.140
sha: 8cb2d83e167098e3adfce8eee659d02295e872bf
doc_id: 881369
cord_uid: wsi9cyq0

Abstract Background The 2019 Coronavirus pandemic has drastically disrupted the delivery of Neurosurgical care, especially for the already at-risk neuro-oncology population. The sudden change to clinic visits has rapidly spurned the implementation of telemedicine. A recommendation care paradigm of neuro-oncologic patients limited by telemedicine has not been reported. Methods A summary of a multi-institution experience detailing the potential benefits, pitfalls and the necessary considerations to outpatient care of neurosurgical oncology patients. Results There are limitations and advantages to incorporating telemedicine into the outpatient care of neuro-oncology patients. Telemedicine-specific considerations for each step and stakeholder of the appointment (physician, patient, scheduling, pre-visit, imaging, and physical examination) are examined. Conclusions Telemedicine, pushed to prominence during this COVID-19 pandemic, is a powerful and possibly preferential tool for the future of outpatient neuro-oncologic care.

The emergence of the 2019 novel coronavirus disease has drastically impacted the 23 delivery of medical care worldwide. Its long incubation period, high transmission rate, and 24 estimated 3% mortality has quickly made it a global pandemic. 1, 2 As physical distancing 25 measures take hold and medical resources are directed towards COVID-19, the traditional 26 patient-physician visit has been revisited with the rapid acceleration of telemedicine. 27 28 Telemedicine during the COVID-19 pandemic 29 An emerging technology for over 25 years, telemedicine uses electronic and digital platforms to 30 exchange medical information for improved consumer health. Widespread use had been 31 restricted, in part, by limitations in reimbursement, 2-5 which curtailed the adoption for clinic 32 Centers for Medicare & Medicaid Services (CMS) to provide an emergency waiver for 34 telemedicine as billable consultations. Codes 99201-99215 for outpatient telemedicine visits 35 were approved into Medicare within days of the federal state of emergency announcement. 6 In 36 addition to established patients, the waiver allows for new patient consultations to be billed with 37 these codes. Historically resistant, but currently mobilized by the COVID-19 pandemic, some of 38 the largest health insurance providers (Aetna, Cigna, and Humana) have announced telehealth 39 reimbursement to parallel the evolving CMS reimbursement structure. 7 The reimbursement 40 structure of private insurances still vary on a state level and local guidelines should be reviewed 41 by practitioners. Prior to this, neurosurgical use of telemedicine has been limited, albeit 42 extremely successfully, to telestroke programs. 8 Its use in neurosurgical oncology has been 43 limited to institutional collaborations, rehabilitation and psychological support. 9-12 This 44 knowledge gap poses a challenge to optimal delivery of outpatient care, particularly in the 45 current pandemic. Given our institutions' early adoption of telemedicine, we summarize the 46 necessary capabilities and recommendations for the incorporation of telemedicine in outpatient 47 surgical neuro-oncology sparked by the COVID-19 pandemic, with the expectation that this 48 technology continues to be optimized and utilized beyond this period. 49 50

The current recommendations for neuro-oncology during the COVID-19 pandemic have focused 52 on disease prioritization, inpatient management, and healthcare worker protection. [13] [14] [15] [16] Consensus 53 regarding optimal evaluation of new patients and established follow-up has yet to be reached. In 54 these rapidly changing times, approaches have included limiting visits to urgent patients only, 55 incorporating telemedicine and complete cancellation of outpatient neurosurgery clinics. With 56 limited prior experience, lessons learned in telemedicine practices adopted during this pandemic 57 will dictate protocols for neuro-oncology in the future. 58 59 Especially critical during the COVID-19 pandemic, telemedicine visits reduce external exposure 60 of these immunocompromised patients, family, carepartners, and staff. For individuals with a 61 neuro-oncological diagnosis, challenges prior to the pandemic have included neurological clear advantage for these individuals, as it facilitates complete consultations and follow-up visits 65 from the comfort of their homes. While legislation does not currently allow multiple subspecialty 66 practitioners to bill simultaneously for a visit, patient care-teams of various subspecialties may 67 be consolidated into consecutive appointments to optimize patient-centered care. This reduces 68 total time dedicated to the appointments as well as unnecessary wait-times, which are frequently 69 quoted as the worst components of a clinic visit. 17, 18 In addition, telemedicine can decrease 70 reliance on carepartners. Current in-person appointments can present a unique cost to the patient 71 and family though carepartner loss of productivity during the appointment and external transport 72 services. [17] [18] [19] Moreover, telemedicine offers unparalleled flexibility; carepartners can be either at 73 the patient's side or physically distant and easily be conferenced via voice or video into the visit. 74 75

Despite the clear advantages of telemedicine, concerns remain regarding adverse effects to 77 patient privacy, physician-patient relationship and completion of a thorough physical and 78 neurologic examination. Telemedicine is an obstacle for those with limited access to 79 telemedicine platforms and experience with internet-based technologies. The proliferation of 80 smartphone ownership, improved broadband coverage and technologically adapt population has 81 broken down the traditional barriers to telemedicine. In the long-run, the benefits of providing 82 telemedicine services to neuro-oncology patients likely outweigh these limitations, but studying 83 the effects on patient outcome and patient-provider satisfaction will be paramount. We 84 encourage a thoughtful approach to the continuous evaluation of telemedicine in the 85 neurooncology patient to ensure optimal patient care 86 87

Synchronous platforms allow for the patient and the neurosurgery team (physician, advanced 89 practice clinician, nurse, resident, and/or fellow) to connect at the same time, while 90 asynchronous platforms afford distant electronic communication and monitoring at different 91 times. Asynchronous forms of telemedicine including e-mail and secure messaging have been 92 increasingly utilized, but the rapid expansion of video conferencing capabilities and smartphones 93 have paved the way for synchronous forms of telemedicine. The current platforms available 94 range from simple telephone voice conferences to more immersive video conferencing. While billing waivers allow for voice-only telephone visits, the inability to perform a neurologic 96 examination and lack of direct patient-provider visualization is limiting. We feel these should be 97 reserved for the most routine follow-up visits when alternative means are not feasible. Video 98 conferencing affords improved communication, the ability to perform a reasonable neurologic 99 examination, sharing of imaging directly with the patient and likely leads to a better rapport and 100 patient satisfaction. 101

We foresee a rapid rise of platforms as telemedicine becomes an established option. There are 103 important criteria that each system must fulfill prior to enabling safe medical alternatives. While 104 relaxed regulations during the current COVID-19 pandemic allow non-Health Insurance 105

Portability and Accountability Act (HIPAA) compliant interfaces (i.e. Facetime). 20 We 106 strongly recommend the transitioning to a HIPAA compliant platform (i.e. OhMed, Doxy.me, 107

American Well, Mend, VSee) for the continued use of telemedicine following the COVID-19 108 crisis. 21 Useful additional features offered include E-prescribing capabilities, billing capabilities, 109 integration with internal electronic health records (EHR), and digital patient intake. Blood work, 110 medications, and imaging orders will remain similar to in-person visits; they will be ordered 111 electronically via the EHR and communicated directly to the patient 112 113 Vital to neurooncological disease evaluation, neuroimaging needs to be available for 114 comprehensive care. Current standard practice is in-system imaging prior to a clinic visit. While 115 varied by region, the COVID-19 pandemic has likely decreased overall neurosurgical oncology 116 visits and has limited access to timely imaging. Patient triage is being performed on a case-by-117 case basis, and those requiring urgent imaging evaluation have not been delayed. 118 benign surveillance imaging, however, has been rescheduled for patient safety and optimization 119 of resource utilization. Patients may also obtain imaging at centers closer and more convenient to 120 their homes and transfer the images to their physician prior to the appointment. This is most 121 often completed via mail, but cloud-based secure imaging systems are becoming more 122 commonplace. In addition, incorporation of imaging onto a shared screen during the 123 appointment, offered by many platforms, improves patient satisfaction and understanding of the 124 pathology and plan. 125

Scheduling 128

New consultations and transitioning patients to telemedicine visits should be contacted by office 129 staff to confirm willingness to participate in a virtual visit and that the patient's software and 130 hardware meet the necessary requirements for the proposed platform. Patients are notified that 131 these visits are billable to insurance and they will incur a co-pay similar to an in-person visit. . 132

Patients who are unable to complete a video-based visit and require wound evaluation should be 133 instructed to provide digital pictures, if possible. Patients with concerning neurologic or imaging 134 findings should be referred to the medical staff for an additional screening. Those with urgent 135 clinical or imaging findings (hydrocephalus, hemorrhagic lesions causing significant acute mass 136 effect, signs of decreased arousal or concern for airway protection) should be directed for urgent 137 evaluation. Thus, telemedicine encounters should be thoroughly screened for patients that can be 138 The current pandemic will end and we need to ensure appropriate measures are taken for 189 continued growth of telemedicine. We believe that as the country opens up, we will begin to see 190 a cohort of patients who have relatively late tumor presentation secondary to a variety of factors 191 at play during the pandemic, including limited primary care and ER visits, reluctance to pursue 192 medical evaluation for insidious symptoms and concerns regarding finances and family safety. 193

The permanent establishment of current temporary waivers will be critical for the sustained 194 adoption of telemedicine. Beyond Medicare/Medicaid, private insurances will need to reimburse 195 these codes for wide-spread adoption. The natural evolution of technology hastened by the 196 pandemic-induced focus on remote connectivity will continue the proliferation of high-speed 197 internet, smart devices, and patient familiarity. To this end, many hospital systems and practices 198 have begun devoting substantial effort to get patients "up to speed" regarding telemedicine. 199

While telemedicine will never be appropriate for all patients and all conditions, we believe it will 200 continue to play a significant role in neurosurgical oncology long after the virus is gone. 201 202

The COVID-19 crisis has forced all of medicine, including neurosurgery, to rapidly incorporate 204 telemedicine into standard clinical care. Rushed to adoption, there are benefits and limitations in 205 neuro-oncological patients that a neurosurgeon must understand. We believe that telemedicine 206 will remain integral to the care of neuro-oncology patients, well past the COVID-19 pandemic. It 207 is vital that the current waiver allowing telemedicine reimbursements should continue 208 unhindered. There is no doubt that telemedicine will play an expanding role in the outpatient 209 management of neuro-oncology patients, with in-person appointments limited to pathology 210 requiring detailed physical examination and in persons who lack telemedicine accessibility. 211 

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