Justin McArthur, MBBS, MPH, FANA, and Steven Zeiler, MD, PhD, discuss the benefits and challenges of teleneurology, especially as the COVID-19 pandemic wears on, and how you can start implementing teleneurology into your own practice.
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Justin McArthur, MBBS, MPH, FANA, is a professor of neurology, director of the Johns Hopkins Department of Neurology, and president of the American Neurological Association.
Steven Zeiler, MD, PhD, is an associate professor of neurology, director of the Vascular Neurology Fellowship Program at the Johns Hopkins University School of Medicine, and clinical informatics director for the Johns Hopkins Department of Neurology.
TRANSCRIPT:
Christina Vogt: Hello everyone, and welcome back to another podcast. I’m Christina Vogt, associate editor of the Consultant360 Specialty Network. Today, I’m joined by Dr. Justin McArthur, who is a professor of neurology, director of the Johns Hopkins Department of Neurology, and president of the American Neurological Association, and Dr. Steven Zeiler, who is an associate professor of neurology, director of the Vascular Neurology Fellowship Program at the Johns Hopkins University School of Medicine, and clinical informatics director for the Johns Hopkins Department of Neurology. Thank you both for joining me today.
Dr McArthur: You’re welcome.
Dr Zeiler: Thank you.
Christina Vogt: Today, we’ll be discussing teleneurology and how it can best be implemented in practice. So first, could you discuss the potential benefits of teleneurology?
Dr McArthur: Yeah, I'd be happy to start discussing that. And I think, you know, clearly, our approach to teleneurology and telemedicine has been catapulted from a relatively small-scale operation pre-COVID to essentially 90% to 95% of what we do in terms of ambulatory practice for our patients with neurologic disorders and, you know, clearly the major advantage in the era of COVID is safety–safety for patients, safety for their family members, and safety for our staff.
Dr Zeiler: So, even independent of the current COVID crisis, there have been a number of people in Johns Hopkins neurology who have been developing teleneurological plans to follow up on patients that may have limitations getting to clinic. So, patients with particular mobility issues–you could imagine, patients with Parkinson disease, with stroke leading to hemiparesis or any sort of neurological process that can limit their mobility and therefore limit access to a clinic. And, this can be both in the chronic situation or, as several of my colleagues have been working on, immediately after discharge, where getting back into the home and situating in the home can be comfortable and following up immediately after discharge can add quite quickly and efficiently to the patient's care.
Dr McArthur: And I think just from my own experience with telemedicine, which I've been doing for a while, obviously ramped up substantially in the last 3 months with COVID. I think another advantage is, and this may sound a little paradoxical, but it's actually quite an intimate experience for the patient and the provider because you're usually seeing the patient and often their family members in their home. They're often much more relaxed, because they haven't been struggling with traffic and with parking to get to your outpatient office, and they're in their own environment, and they feel more comfortable, and it also gives you a window into the home environment. And, you can see how it's set up. You can see safety issues. You can even look at the state of cleanliness of the surroundings. It really is truly a window on somebody's life that we don't get in the ambulatory practice setting.
Christina Vogt: What are some common challenges for teleneurology, and how can they be overcome?
Dr McArthur: So, I'm of a different generation to Steve, and I'm not a digital native, meaning that I didn't grow up with smartphones and computers. So, I think for neurologists of my generation, and obviously I'm generalizing, there are some barriers for the technical side of managing telemedicine. Most of us can overcome those with a little bit of practice and help from people younger people like Steve. I think another issue is, doing a telemedicine visit, just by nature, is very different than being in the office. You're not touching somebody, you're not shaking hands, you're not able to tap them on the shoulder, you're not able to hug them. So, you have to rely on other emotional cues to show that you're paying attention, that you're warm, that you're putting a person at ease, that you're delivering good or bad news in a sympathetic way. So, there are, I think, there’s quite a lot of on-the-job learning with telemedicine and teleneurology.
Dr Zeiler: Yeah, I completely agree, and the fundamental aim of telemedicine is to increase access to care. It can be done perhaps more quickly and more efficiently because we don't have to deal with parking and coming into the clinic, but nevertheless, as Justin points out, there are several big issues with telemedicine, and the 2 biggest that I’ve found are patient access and inability to perform aspects of a clinical exam, and these 2 issues are particularly prevalent in teleneurology, by which I mean the use of telemedicine to accomplish a neurology visit. So, with regards to patient access, teleneurology and especially telestroke–I am a stroke physician–can deal with patients with low socioeconomic resources and older patients or patients perhaps with cognitive decline, that might have little experience with technology, and this can limit access ... to a teleneurological visit, And, equally as important, clinical neurology, perhaps more than any other subspecialty, is shaped by its attendant examination, and this limits providers’ ability to assess patients and can make certain providers sheepish about using teleneurology. There have been many questions about, “can we provide continuing service to our patients without being able to touch them, to assess a reflex, to find out where the sensory limitations actually are?” And this has dominated a number of conversations.
Dr McArthur: I’d add another piece, which is perhaps on a broader level outside of teleneurology, but it applies to all telemedicine, and that’s the digital divide. And, if you look at Baltimore, the survey in 2017 showed that over 30% of households in Baltimore did not have access to broadband internet. So clearly, those are individuals and households that would not be able to participate in in telemedicine, at least as it's set up now.
Christina Vogt: What are some good beginning steps to take for physicians who have not yet implemented teleneurology as a regular component of their practice, especially as the COVID-19 era progresses?
Dr Zeiler: Well, Christina, in our department when COVID hit, we closed access to aspects of our clinic. We lived this, and one of the first things that had to happen was to make sure that providers understood how to actually perform a teleneurological visit, which meant just starting from the beginning and understanding what our technology was. And luckily, we have some fabulous people in our telemedicine division and support staff, but perhaps even more than that, a number of us were very associated with it and comfortable with teleneurology and with the technology. But, one of the things that came out was, again, “how do we actually interact with our patients?” And, we were lucky enough to have a number of people where we could share our ability to perform a teleneurological examination. We helped to codify this and place this on a website, such that all of our clinicians were able to read this, access this, and build an exam that they felt would be appropriate for their patient population. That was the first thing that we did.
Dr McArthur: And, it's amazing how creative neurologists have become at finding ways to do the neurological exam which, as Steve said, is really an important part of the neurological evaluation, but to do it either by proxy, do cognitive testing remotely by using family members to check a balance sensory exam–even I've had patients do their own reflexes, and while this may not be as good as in the office, in an emergency situation, it works well.
Dr Zeiler: And, it's been quite remarkable how the group of neurologists at Johns Hopkins have quickly shared these innovative ideas, and we've become quite comfortable quite quickly on how to do this.
Christina Vogt: How can neurologists help patients who might be a bit hesitant about teleneurology, especially if they're not as familiar with technology or, as you mentioned earlier, those who might not have access to the technology needed to actually carry out a telemedicine appointment?
Dr McArthur: I think the first thing is to sort of lay the groundwork as to what they can expect to see from a telemedicine visit. The first hurdle is really getting over the technology. Once the patient's done it once or twice, it's actually pretty straightforward. We use either medical office coordinators–or some people would call them clinical secretaries–or our CMAs from the clinic to help guide patients to go through the different steps that they need. We used an epic platform to put the epic platform in their hands so that they know what to do, which buttons to push, and when to push them so that they can connect with their provider–the neurology provider.
The second is, I think, as you would at any in-person visit, remind the patient what we're going to do: we're going to ask some questions, we're going to talk a little bit about the history and symptoms, we want to address their questions, and then we're going to do a neurological examination of some type. And another thing I do is, I remind the patient that looking in their eyes is very helpful, and particularly, some of our older patients don't necessarily remember where the camera is on the laptop or the tablet that they’re using. So, you have to kind of guide them to keep eye contact and also remind them that you're not going to be able to make eye contact continually unless you're a touch typist because you'd be looking down, taking notes. So, just to set the ground rules, if you will.
Dr Zeiler: I can't stress that enough. Within about 10 to 15 minutes of a visit, even the most skittish of patients seems to enjoy the visit sitting at home, realizing that the technology is merely a bridge to the provider, and I've not had a single visit where it went off the rails because of an uncomfortableness with technology.
Christina Vogt: And finally, what key takeaways do you hope to leave with neurologists on this topic?
Dr McArthur: Well, I'm going to dive in, because one of the reasons obviously that telemedicine has exploded, and teleneurology in particular, is the relaxation of some of the CMS–the Centers for Medicare and Medicaid Services–regulations around reimbursement for telemedicine, and at the current state of play, those regulations may come back into force when the state of emergency with COVID goes away. So, I think it's really important that we continue to pressure CMS and patient groups to allow telemedicine to be part of our future in terms of neurological care.
Dr Zeiler: Yeah, I couldn't agree more. Even if the COVID emergency were to go away tomorrow, we would not return to business as usual seeing patients. That is to say, we have found a particular comfort and efficiency with telemedicine that certainly wouldn't be as prevalent in the future as it is right now, but will nevertheless play a significant role. And so, to find an equilibrium with CMS is going to be very important. Additionally, as we move forward, many groups, including our team at Johns Hopkins neurology, is looking to develop new technology and new ways that will allow providers and patients to interact more efficiently and with a greater ability to, for example, acquire physiologic data that could enhance a telemedicine visit.
Christina Vogt: Thank you both again for joining me for today's podcast.
Dr McArthur: Thank you very much.
Dr Zeiler: Thank you very much.
Christina Vogt: For more podcasts like this, visit Consultant360.com.
