key: cord-0959191-yln7en6x
authors: Fonkem, Ekokobe; Gatson, Na Tosha N; Tadipatri, Ramya; Cole, Sara; Azadi, Amir; Sanchez, Marvin; Stefanowicz, Edward
title: Telemedicine Review in Neuro-Oncology: Comparative experiential analysis for Barrow Neurological Institute and Geisinger Health during the 2020 COVID-19 pandemic
date: 2020-10-15
journal: Neurooncol Pract
DOI: 10.1093/nop/npaa066
sha: d12454d753f3578ba5ec178bb24d7208fe58c616
doc_id: 959191
cord_uid: yln7en6x

Coronavirus disease 2019 (COVID-19) has grossly impacted how we deliver healthcare and how healthcare institutions derive value from the care provided. Adapting to new technologies and reimbursement patterns were challenges that had to be met by the institutions while patients struggled with decisions to prioritize concerns and to identify new pathways to care. With the implementation of social distancing practices, telemedicine plays an increasing role in patient care delivery, particularly in the field of Neurology. This is of particular concern in our cancer patient population given that these patients are often at increased infectious risk on immunosuppressive therapies and often have mobility limitations. We reviewed telemedicine practices in neurology pre-/post-COVID-19 and evaluated the neuro-oncology clinical practice approaches of two large care systems, Barrow Neurological Institute and Geisinger Health. Practice metrics were collected for impact on clinic volumes, institutional recovery techniques, and task force development to address COVID-19 specific issues. Neuro-Oncology divisions reached >67% of pre-pandemic capacity (patient visits and slot utilization) within 3-weeks and returned to >90% capacity within 6-weeks of initial closures due to COVID-19. The two health systems rapidly and effectively implemented telehealth practices to recover patient volumes. While telemedicine will not replace the in-person clinical visit, telemedicine will likely continue to be an integral part of neuro-oncologic care. Telemedicine has potential for expanding access in remote areas and provides a convenient alternative to patients with limited mobility, transportation, or other socioeconomic complexities that otherwise challenge patient visit adherence.

More than 9,720 people infected and 213 dead marked the earliest signs of a late December pneumonia outbreak in the Wuhan, Hubei province of China. 1 By January 31, 2020 there would be an additional 106 people in 19 other countries infected putting the world on high alert. 1 A novel coronavirus would be the culprit in causing the disease now known as coronavirus disease 2019 . While even the most reliable sources debate the origins of this entity now labeled as a severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) based on its near 80% homology to the 2002-2003 highly fatal SARS-CoV epidemic with patient symptoms compatible with acute respiratory distress syndrome. 2 Symptomatic adults have an approximate 14-day incubation period, reliably present with fever and dry cough, and some demonstrate signs of fatigue, myalgias, and dyspnea; however, some patients remain completely asymptomatic. 1, 3 Chest imaging frequently shows bilateral ground glass opacities in positive cases. 3 There has recently been some suggestion of increased stroke or strokelike presentations and this continues to be investigated. 4, 5 Pediatric symptomatology is similar to common upper respiratory tract viral infections but the data is limited in this population with only 2% of the confirmed United states cases involving children under the age of 18-years old. 6 Countries received information about the basic reproduction number (R 0 ), an indicator of the potential for one infected individual to cause new infections in a naïve population, calculated by the World Health Organization (WHO) to range from 1.4 to 2.5 persons. 7 By comparison, R 0 estimates for SARS had ranged from 2 to 5. 7 Subsequent more detailed analysis by the CDC accounting for confounding elements such as reservoir spillover events and low surveillance intensity, however, revealed a much higher R 0 of 5.7 for COVID-19. 8 For symptomatic patients, quarantining and contact tracing were determined to be the most effective approaches to contain A c c e p t e d M a n u s c r i p t 4 the virus; however, with a suspected 20% of transmission being driven by asymptomatic infected persons, social or physical distancing efforts were recommended by the Center for Disease Control (CDC). 8 

Telemedicine is broadly defined as medicine delivered from a distance, and has been modified over time to better define video versus telephonic and provider-at-home versus patient-at-home encounter types. 9 In the COVID-19 era the definition continues to be expanded as there is a growing need for flexibility in health care delivery, the use of both video and telephonic virtual visits, and the necessity for adjusted reimbursement patterns by insurers. Over the past 20-30 years, digital technology has been classified by functionality (consultation, diagnosis, monitoring, and mentoring), application (medical specialty, disease entity, site of care, or treatment modality), and type of technology. 9 The expansion was driven primarily by a need to increase access to care for military personnel, prisoners, rural populations, and has been extended to address the needs of low-income communities. 10 Global or regional natural disasters have also motivated the development of telemedicine, as evidenced by the Multinational Telemedicine System (MnTS) program funded by the North Atlantic Treaty Organization (NATO) from 2013 to 2017. 11 Telestroke was one of the earliest applications of synchronous digital telemedicine, developed in 1999 to increase patient access to time-sensitive and neurologic function preserving fibrinolytic therapies after a presumed stroke. 10 Tissue plasminogen activator (tPA) was approved for stroke in 1996, but had been underutilized in certain geodemographic regions. 12 The institution of telemedicine improved the use of tPA as well as patient outcomes in these areas and expanded to more than 50 networks across the United States within the first decade. 12 Remarkably, use of the M a n u s c r i p t 5 telestroke system to measure the NIH Stroke Scale was demonstrated to have a comparable interrater reliability to that of in-person measurements. 12 In order to proceed with a telemedicine visit with video conferencing, Internet access and a device with a webcam are required. Examples of HIPAA-compliant audiovisual platforms include Zoom, InTouch, Cisco WebEx, Doxy.me, Thera-LINK, and TheraNest to name a few. 13, 14 With the temporary waiver of HIPAA penalties in the setting of the COVID-19 pandemic, FaceTime, Google Duo, WhatsApp, Doximity, and Skype are alternative options. 15 These technology requirements as well as the need for a private space in which to conduct the visit would pose challenges for the most vulnerable in our society including the homeless and those unable to afford costly high-tech devices and access to the internet. This has undoubtedly resulted in significant access and health provision disparities along socioeconomic lines. People who are older, live in rural areas, have lower incomes, are less educated, or have more chronic conditions are all less likely to have internet access, with only 58% of people over the age of 65 stating that they use the internet. 10 

While the use of telemedicine in stroke neurology has been well-established, there is limited data for telemedicine in other neurological specialties. There have been studies on use in traumatic brain injury, dementia, epilepsy, headache, movement disorders, multiple sclerosis, neuromuscular, and inpatient neurology, although the neuromuscular subspecialty was largely restricted to patients with established diagnoses. 16 Reliance of neurologists on the physical exam for the diagnostic process has posed a unique challenge in adapting to this new method.

While intractable epilepsy may be diagnosed with inpatient continuous EEG monitoring, spell characterization in an epilepsy monitoring unit is considered non-urgent and were deferred at many institutions, requiring treatment using best clinical judgment. 17, 18 Additionally, non-urgent A c c e p t e d M a n u s c r i p t 6 epilepsy surgery has also been postponed. 17, 18 Electrodiagnostic studies and muscle and nerve biopsies for diagnosis of neuromuscular disease, as well as non-urgent treatment with botulinum toxin injections have also been cancelled, with outpatient pulmonary function tests not always performed due to increased risk. Outpatient physical and occupational therapists tend to see only essential postoperative patients, with the remaining patients sent photographs or videos of exercises. In some regions, delivery of medical equipment such as wheelchairs and Hoyer lifts has been significantly delayed. 19 Anecdotally, the fear surrounding the perceived or actual risk for contracting COVID-19 has impacted not only the patient's willingness to present for medical care but also the flexibility of practitioners to treat conditions that are equivocal for emergent need. Given that many cancer patients are on immunosuppressive treatment, they are at particularly increased risk of developing COVID-19 and having poorer outcomes if they were to contract the disease. 20 There have been discussions around how standards of care in cancer patients might be modified to limit the risk for COVID-19. 21, 22 One report from the Hubei province demonstrated a greater than 20% reduction in oncologic and hematologic drugs being administered. 23 Several registries, such as COVID-19 and Cancer Consortium (CCC19) and American Society of Hematology (ASH), have been developed to capture cancer patients with COVID-19 diagnosis with a goal to assess patient outcomes and analyze clinical practice in this patient population. 24 Telemedicine is likely to play an important role in reducing risk of exposure in vulnerable populations, particularly in neuro-oncology where most oral therapies are prescribed on an outpatient basis. However, many patients may still be required to present to clinic with special precautions taken in order to receive chemotherapy infusions or remain compliant with clinical trial protocols.

A c c e p t e d M a n u s c r i p t 7

Telemedicine may seem somewhat impersonal, particularly when engaging in difficult conversations such as providing a new diagnosis of brain tumor or discussing goals of care. Small physical gestures that routinely express sympathy or otherwise comfort that patient such as sitting close, leaning in, or offering a facial tissue are lost. 25 Comforting the patient is also a critical component to patientphysician trust and rapport building. 26, 27 During telemedicine visits, subtle changes in body language, facial expressions, voice intonation, and hand gestures are potentially misinterpreted. Concern for privacy violation and issues of patient mistrust of technology might also play a role and hamper patient-physician communication. 25 On the other hand, the convenience of telemedicine may allow for more frequent visits to be scheduled in order to develop greater rapport. Physicians need to remain cognizant of these issues when meeting with patients via telemedicine. There may also be a resistance to learn new technology, particularly among older patients and more senior providers.

Access and optimal use of telemedicine may be limited, particularly for the demographic groups previously described. Telemedicine is also disruptive and complex, demanding that healthcare providers learn new methods of consultation and requiring operational telemedicine networks, policies and procedures, and technology infrastructure to be put in place. 28 Furthermore, limitations on performing the neurological exam may hamper the detection of subtle exam findings which may suggest progression of disease. As providers become more accustomed to the technological variability and the interpersonal etiquette of telemedicine, patient satisfaction will likely continue to improve.

Telemedicine has been useful in neurology to minimize the time and costs associated with patient access to critical neurologic care by allowing for rapid video-based assessments and has been of longstanding utility in rural, veteran and populations with otherwise limited mobility. 29 This is an especially useful tool in geographic regions where neurologists are limited and is a growing option M a n u s c r i p t 8 utilized in hospitals, home health agencies, and specialty practices. 29, 30 While we presume there are measurable differences in the length of time required to complete virtual versus in-person neurological examinations, it is likely highly dependent upon the technology used and the experience of the practitioner. Issues in development of workflows and procedural codes might also influence these outcomes in the COVID-19 era. 31 To our knowledge, there are no published reports that directly compare this metric in neurology.

Pre-telemedicine visit calls with nursing can be completed to assist with gathering most recent vital signs as available in the chart or completed at home by the patients with access to measuring devices (temperature, blood pressure and weight). Coordination. Assessed by instructing the patient to complete finger-to-nose and heel to chin testing. Gait. With appropriate space and range of the camera, gait is tested readily. In cases where the patient is using a cell phone for video conferencing and unable to prop up the device, the proper assessment may be difficult to perform. A very limited objective neurological assessment for cognitive, language, speech, and hearing are possible via telephonic medicine visits.

Importantly, we noted that the time required to complete a routine neurological exam via telehealth was extended as compared to the in-person visit. This time was further extended for telehealth visits complicated by slow internet connections and other communication and 2-way video problems between the patient and the provider. Furthermore, patients with hearing or vision deficits, cognitive decline, and poor range of video view (i.e., desktop computer camera, cell phone camera, etc.), led to extended exam times. We did not formally measure the exam times between virtual and in-person visits, and believe this would be an important metric to capture as it might have implications on clinical scheduling and billing practices.

Multiple teams including clinical teams, administrators, business operations, and IT (Figure 1) worked in tandem to implement a system of telemedicine office visits using Zoom (BNI) vs. InTouch (Geisinger Health) Video Communications software. Weekly or daily standing calls were held with the full leadership team to ensure alignment in efforts and to address areas of concern with a broad group to bring more ideas to the table for resolution. Pre-telemedicine calls with nursing and technology support teams helped to preempt technological issues. Robust documentation and training materials were provided for patients, trainers, and staff. Dissemination of educational PowerPoint presentations on Health Insurance Portability and Accountability Act (HIPAA) compliance and proper execution of the neurology telemedicine visit was common between the institutions. Use A c c e p t e d M a n u s c r i p t 10 of uniform "dot" or "smart" phrases and notes that include key points within the billable telemedicine document were provided. Regular check-ins with staff and leadership were implemented for continued optimization of the system. Redeployed personnel from areas of a lesser demand during the early phases of the pandemic were helpful to fulfill the above responsibilities.

Using Zoom, providers received an e-mail invitation once the appointment was confirmed.

Approximately 15 minutes prior to the appointment time, the medical assistant logged into Zoom and completed a review of systems (ROS), medical reconciliation, and pharmacy updates. 32 Using InTouch, providers are notified of the patient's admission into a virtual waiting room, where the provider can click on the "connect" link to initiate the visit. 33 Usually, medical assistants or nursing teams perform a final technology check, ROS, medication review and vital signs on the day of visit prior to the appointment with the provider. In both cases, two patient verifiers are used to confirm the patient's identity and consent for telemedicine visit is obtained.

Changes in billing, such as expansion of the list of Medicare-covered telehealth services by the Centers for Medicare & Medicaid Services in 2019, have further opened opportunities for teleneurology 16 in the home and in the clinical space.

Prior to COVID-19 pandemic, billing, coding and reimbursement for telemedicine were limited to telemedicine used within the hospital or clinic. Home video visits were not reimbursed by any insurance companies and the outpatient use of hospital or clinic telemedicine was restricted by some payors. Today, patients can benefit from the use of telemedicine by seeing a provider from the safety and comfort of their own home while provider offices can seek reimbursement for services rendered that previously would not have been paid.

In the post-pandemic setting, billing, coding and reimbursement for telemedicine has not been formally decided upon yet as a plan for future direction. Currently, the expansion of covered A c c e p t e d M a n u s c r i p t 11 services is still active, and patients can still seek new or established care from their home or the clinical space. What is evolving is the providers' preference on when and how to use telemedicine. Now that COVID-19 positive cases are decreasing and businesses are opening up, more patients are being seen in person as needed. The use of telemedicine is still fully reimbursable by payors and is being recommended to be permanently mixed in to everyday practice. These decisions will be heavily influenced as payors evaluate their payment models.

BNI is an internationally renowned center for neurology and neurosurgery since 1962, and has been recognized for having performed the largest number of neurosurgeries annually in the US. BNI has seen patients from Arizona, neighboring states, and internationally for within its nine Barrow Brain and Spine satellite locations, and employs 5,000 faculty and staff across the system. With over 460 active clinical trials, Barrow is a true leader in innovations and was the first institution to offer Phase 0 Clinical Trials for brain tumors. Barrow has five residency programs and 12 fellowship programs; noting having one of the top recognized neurosurgery residency programs nationally and trains some of the most brain and spine surgeons than any facility in the US.

Metrics for the Barrow's neuro-oncology ambulatory clinics. From January 5, 2020 to March 16, 2020, the number of in-person visits ranged from 40 to 65 per week, averaging 54 visits per

week. The first telemedicine visit was held on March 19, 2020. The number of telemedicine visits per week rapidly increased to 36 visits per week (67% of pre-pandemic visit capacity) by the week of April 5, 2020 to April 11, 2020, and it reached the pre-pandemic average by the week of April 19, 2020 to April 25, 2020, with 55 visits per week. By May 1, 2020, the clinic experienced a slightly increase visit numbers above that of the pre-pandemic visit numbers.

Geisinger, founded more than 105 years ago, is one of the nation's largest rural health systems employing over 36,000 faculty to staff 15 Geisinger hospital campuses across telemedicine. By May 2 nd , 6.5 weeks post initial closure, the clinic saw an average of 50 patients per week, 90% telemedicine visits and 10% in-person, with a 94% slot utilization rate -1% higher than the COVID-19 pre-pandemic rate. Interestingly, by this time the neuro-A c c e p t e d M a n u s c r i p t 13 oncology subspecialty clinic averaged a better slot utilization overall as compared to the combined neurology department clinics (94% versus 83.3%, respectively) slot utilization. We are currently in the process of evaluating our satisfaction survey reports as supported by Press Ganey Associates to assess the patient experience during telemedicine for the following metrics: (1) Ease of scheduling access, (2) Care provider professionalism, caring, explanations, discussion, (3) Connectivity and technology issues, and (4) Overall assessment and willingness to recommend the services. It is too early to report this data but we note this will be an important metric to capture.

A comparative analysis of the two institution's ambulatory neuro-oncology clinics during the early COVID-19 pandemic period between March 16, 2020 to May 2, 2020 is provided ( Table 1) . Here we have an overview of the early pandemic ambulatory clinic metrics such as the evaluation period, number of practicing neuro-oncology providers at each institution, and identify each institutions' patient visit types: (1) New patients/Hospital discharges, (2) Return patients, and (3) Procedural/Chemotherapy infusion clinic visits. This information was important to capture the type of patients being seen between the two institutions. Barrow's neuro-oncology clinic routinely sees a larger volume of patients and has twice the number of providers available as compared to Geisinger.

We evaluated the percent of patient visit types to better compare the institutions over a matched time period. Geisinger saw a slightly larger percentage of new/hospital discharge patients as compared to Barrow, while Barrow saw a higher percentage of return patients ( Table 1) . Overall, however, the trends between the two institutions were similar. We were able to note the largest reduction from the pre-COVID-19 period to the early pandemic visit types was for the new patient/hospital discharge post-operative patients for both institutions (data not shown). This is inline with the mandate for limited elective neurosurgical procedures, patient reluctance to present to clinics, and reduction of available hospital beds that was observed nationally during this time. being delayed by ten days after Pennsylvania (PA, Geisinger) mandated closures (Figure 2) . Early closure by PA allowed for earlier transition to telehealth visits which presumably better matched the patient reluctance to present to in-person clinic appointments, thus allowing for Geisinger's slightly lower reduction in slot utilization during the early pandemic period. Conversely, AZ reopened earlier than PA, thus presumably meeting the increasing demand for more in-person visits -resulting in a near 100% slot utilization by the first week in May. Geisinger achieved a 94% fill-rate by this same time. These regional differences likely account for the state-imposed closure and reopening dates.

However, it should be noted that Geisinger Health is a large rural integrated health care system which routinely uses telehealth and virtual meetings, thus allowing for a more rapid transition with less challenges and less provider educational lag-time. On the other hand, Barrow is located in a large metropolitan area and had some prior experience with telemedicine in stroke, movement disorders, and traumatic brain injury clinics -lending to its overall rapid implementation in telehealth in neuro-oncology.

Both institutions experienced an April 2020 decline in slot utilization to approximately 67% (Barrow) and 84% (Geisinger) of pre-pandemic visit capacity for both institutions (Figure 2) 

Overall Assessment Implementation of the system was facilitated by quick contracting turnaround allowing for rapid deployment, as well as quick access to all signatories, which expedited the administrative process.

Vocal champions were selected as first users and were an asset for educating providers on using the system. There was efficient redistribution of personnel to help ease the transition, as well as active participation and collaboration of these personnel. A mainstream vendor was used which people know and recognize as easy to use.

Our experiences with telemedicine have demonstrated that much of the neurological exam can be effectively performed using video conferencing. Telehealth offers added benefit for the patients as it saves transportation time and cost especially in cases of routine patient well-checks when critical decision-making can be done virtually. This is also of particular benefit for patients with advanced disease and profound focal neurological deficits which limit their mobility. It also improves efficiency by avoiding delays with rooming patients, as medical assistants do not need to wait for rooms to become vacant. Furthermore, there is potential for expanding catchment area and providing services to patients in remote areas, as it eliminates geographical limitations. There is an interesting potential to improve patient outcomes as several studies in cancer care have demonstrated an association be poorer clinical outcomes with increasing distance from the cancer facility. 35 A c c e p t e d M a n u s c r i p t

There are yet many caveats to telemedicine as part of the clinical practice model; however, it is our impression that telemedicine is here to stay to some extent as a vital complement to the in-person clinic visit. A more permanent integration of the practice models will serve to broaden the scope of the neuro-oncology practice and allow for smoother transition during future crises. As access to Internet expands and technologies continue to develop, telemedicine is likely to play an increasing role in the delivery of healthcare across medical specialties and geographic regions to change the way we view and deliver health care. 

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We would like to thank the members of the BNI and Geisinger Health COVID-19 Task Forces as well as our respective Clinical Operations teams for their support with data collection and contributions in review of this manuscript. We would like to also acknowledge the late Mr. Donald DeGrasse Teleneuro-oncology clinic (Barrows Neurological Institute), and Mr. Jeff Erdly (Geisinger Health) for their program support. Finally, we thank our respective departmental Chairs, Dr. Jeremy Shefner (Barrows Neurological Institute) and Dr. Neil Holland (Geisinger Health).

A c c e p t e d M a n u s c r i p t A c c e p t e d M a n u s c r i p t 25 Figure 2