COVID-19: Telemedicine Gets Real, Real Fast Across Neurology

For many neurologists, telemedicine is uncharted territory. However, the COVID-19 pandemic has prompted experts in stroke, epilepsy, dementia, Parkinson's disease (PD), and other subspecialties to offer guidance to clinicians trying to pivot to a new era of online consultations.

In the interests of patient and physician safety, COVID-19 is hastening the shift to telemedicine. However, while some neurologic subspecialties lend themselves to this online transition, others face greater challenges.

"One bright spot in the midst of the coronavirus crisis is that our healthcare system was already transforming itself to use telehealth services more widely," Mitchell S.V. Elkind, MD, professor of neurology and epidemiology at Columbia University College of Physicians and Surgeons, New York City, told Medscape Medical News.

Stroke neurologists, he noted, have used technology for remote consultations for many years, sometimes from across the country. However, "the COVID-19 crisis is accelerating the process," said Elkind, who is also president-elect of the American Heart Association.

Now, he said, neurologists are caring for stroke patients within their own hospitals, using telestroke (also called stroke telemedicine) to manage those with and without COVID-19 as a way of stopping its spread.

Technology also helps keep physicians connected to the clinical setting, Elkind said.

Even physicians who test positive for the virus can evaluate and treat patients remotely, so long as they are feeling well enough, said Elkind.

"We have heard a lot about physicians needing to take off from work due to the virus, but this is a way to bring them back into the hospital, even if remotely," he added.

"An Enviable Position"

Epilepsy is another neurology subspecialty of neurology that can easily transition to telemedicine.

"We are in an enviable position," Jacqueline French, MD, director of Epilepsy Translational Research & Clinical Trials at NYU Langone Medical Center, New York City, told Medscape Medical News.

French, who is also chief scientific officer at the Epilepsy Foundation, estimated that 99% of epilepsy evaluations done in the office can be accomplished remotely, based on a careful history and symptom discussion.

However, for subspecialists who typically perform complex examinations more suited to in-person evaluations, telemedicine consultations can be a challenge. For instance, many neurologists use a fundoscopic eye exam to assess patients, including headache specialists.

"Not having a fundus exam is somewhat limiting," Jaclyn Duvall, MD, a neurologist at the Utica Park Clinic in Tulsa, Oklahoma, said during a Facebook Live event on implementing telehealth services that was sponsored by the American Headache Society.

However, "there are a lot of ways we can get creative and still do the neurologic exam," she said.

Duvall asks patients to hold their smartphones up to their eyes, which allows her to view patients' pupils and cranial nerves, and to gauge extraocular motility. Light reflex assessment, however, "would be difficult, even with a phone light."

She also asks patients to smile, stick out their tongue, look side-to-side, turn their head side-to-side, raise their eyebrows, and close their eyes tight during remote consultations.

A Silver Lining?

Assessment of subtle changes in muscle tone can be another challenge posed by telehealth consultations, Bruce H. Cohen, MD, pediatric neurologist and director of the NeuroDevelopmental Science Center at Akron Children's Hospital, Ohio, told Medscape Medical News.

"If I need to assess if someone's muscle weakness is slightly worse or slightly better, that may be difficult to do with telemedicine," he said.

On the plus side, evaluation of gross motor abilities can continue via telemedicine.

"I can ask the patient to lie down on the floor and then stand up for me. Just from that maneuver alone, I would have a pretty good idea if there is some muscle weakness," said Cohen.

Duvall added that some neurologists are asking patients to step back from the camera while they observe them doing a finger-to-nose touch exercise, a squat, or a push-up to evaluate overall muscle strength.

"I would say that telemedicine is going to be a 'silver lining' from this crisis," Michael Okun, MD, national medical director of the Parkinson's Foundation, said in a Facebook Live event.

"We at the Parkinson's Foundation have been working around the clock for a decade on this," he said.

One major challenge has been state licensure restrictions that require physicians and patients be in the same state during a telemedicine consultation. However, on March 17 Congress approved an emergency rule that temporarily removed that stipulation.

"With this crisis, we're seeing the legislation change in real time," Okun said.

New Rules

Telemedicine is well suited for the type of encounter that would normally happen during a regular check-up, such as reviewing symptoms and refilling medications.

"If we can accomplish those things without having [patients] come in and put you at risk, we should do that," said Okun.

Although many hospitals and private practices have reworked their waiting rooms to promote social distancing, patients should still be told to call ahead so physicians and staff can be ready, especially if a patient with Parkinson's disease suspects he or she is infected with COVID-19, Okun said.

Dementia patients and their families can continue seeing their specialist for regularly scheduled appointments via telemedicine as well, Beth Kallmyer, MSW, vice president of care and support at the Alzheimer's Association, told Medscape Medical News.

"I think most doctors are doing this — but take advantage of the CMS telehealth services that are being approved and covered by Medicare," she said.

Earlier this month, the US government relaxed restrictions on telehealth services for Medicare recipients, including issuing a waiver of HIPAA requirements and allowing patients to receive consultations in their own homes.

Although a dementia diagnosis still requires a full cognitive assessment in a physician's office, there are cognitive screening tools that are validated for use via telemedicine, Kallmyer said.

For example, a version of the Mini-Mental State Examination (MMSE) has been validated for smartphone use, as has the Montreal Cognitive Assessment (MoCA).

When patients call asking if they should cancel appointments because of COVID-19, "we tell them they have a choice," Cohen said.

He offers telephone consultation or a non–face-to-face virtual visit if the patient has a smart phone or a computer, and his staff explain, "it's just like an office visit, except you're at home."

Billing, Additional Resources

Cohen added that patients should be advised that they will be billed for telehealth services. CMS provides a fact sheet for advice on billing for telemedicine services, including coding tips.

The federal waiver of certain telemedicine restrictions is temporary and only applies during times of emergency. Therefore, what happens to the service across all neurology subspecialties after the COVID-19 pandemic recedes is unknown.

In a recent story by Medscape Medical News, Neil Busis, MD, also from NYU Langone, described COVID-19 as a "catalyst" for bringing renewed attention to teleneurology — a sentiment that Cohen agrees with.

"Ultimately, it comes down to patient safety issues. If we can deliver safe medical care using this technology, even if it takes us a while to figure it out, then why not? It's going to save people time and money," he said.

Additional resources include updated telemedicine recommendations from the American Academy of Neurology (AAN), which also maintains an online COVID-19 Neurology Resource Center.

The American Heart Association has published a policy statement regarding telehealth services for cardiovascular disease and stroke; and the Epilepsy Foundation is updating its web content on concerns for patients and providers during the pandemic.

In addition, the Parkinson's Foundation is posting updates on coronavirus and maintains a help line for patients with PD at 800-4PD-INFO. The Alzheimer's Association has a webpage for healthcare professionals, as well as a public website dedicated to caring for those with dementia during the COVID-19 outbreak.

Elkind reported receiving some funds for the ARCADIA trial from the BMS-Pfizer Alliance for Eliquis and from Roche. He also receives royalties from UpToDate for chapters on stroke. French, Duvall, Cohen, Okun, and Kallmyer have disclosed no relevant financial relationships.

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