Patients seeking neurologic care can face physical, geographical and financial challenges as they deal with chronic and disabling conditions.
Telehealth is offering one way forward. In one of the largest studies of outpatient general teleneurology care, a team led by Dr. Linda S. Williams, a research scientist at the Regenstrief Institute and core investigator and clinical neurologist at Richard L. Roudebush VA Medical Center in Indianapolis, evaluated an innovative VA telehealth program that serves patients with many common conditions, including headache, seizures, multiple sclerosis, recent stroke and back pain.
The study addresses use of teleneurology to improve access to outpatient care and other inequity issues. We interviewed Williams to talk about the melding of neurology and telehealth, the comprehensive VA teleneurology program, the results of her study, and much more.
Q. What are the problems in the field of neurology that you feel telemedicine can help overcome?
A. There are two key problems in neurology that telemedicine can help address. First, there are not enough neurologists to care for the growing population of persons with neurologic disease. A report from the American Association of Medical Colleges in 2021 showed only about 1.5% of all practicing physicians in the U.S. are neurologists.
Second, there is a mismatch between where neurologists practice and where people with neurologic conditions live. Another study published in 2021 analyzed the geographic distribution of neurologists actively billing in Medicare and compared this to the geographic distribution of Medicare beneficiaries with neurologic disease.
This analysis demonstrated wide variation in distribution of neurologists, with higher density in large urban centers, but little variation in the distribution of persons with neurologic disease.
Telemedicine can help address both problems. Neurologists may be able to work remotely, which has advantages in terms of flexibility and reducing burnout. This could help address the shortage of neurologists by reducing early retirement of providers. It is also a more efficient way to distribute a scarce specialty.
With telemedicine, a neurologist can accommodate patients without consideration for their location versus the provider driving to a single remote clinic location, often on a reduced or limited schedule. The most direct benefit of telemedicine, of course, is it can help address the geographic disparity where rural-dwelling patients can more easily access specialty neurology care.
Finally, neurologic conditions are unique in that they are more likely than other types of diseases to affect a person’s mobility and ability to drive. This is true for common conditions like epilepsy, Parkinson’s disease, dementia and stroke, and for more rare conditions like amyotrophic lateral sclerosis or muscular dystrophy.
So, for persons with neurologic disease and their families, telemedicine can be a game-changer that increases their access to specialty neurology care and also decreases the burden and barriers that travel imposes.
Q. You and your research team just evaluated a VA telehealth program for outpatient general teleneurology care. Please describe the program and what it aims to do.
A. The VA National TeleNeurology Program (NTNP) was developed in 2019 and funded by the VA Office for Rural Health to help meet the growing gap in access to neurology care across the VA. Building on the VA’s long history in the use of telehealth technology, the NTNP was initially implemented in eight facilities and now has grown to 14 facilities nationwide.
The NTNP hub is located at the Philadelphia VA, with Dr. Jayne Wilkinson as the medical director, but the program teleneurologists are based all around the country and may work at another VA facility or may work fully remotely.
Although this program is based in the VHA, many other health systems are expanding to include more rural hospitals and clinics that partner with a larger urban academic medical center, so this model of specialty care provision is likely relevant to non-VA health systems as well.
NTNP provides general neurology outpatient video visits, either conducted in the veteran’s home or at a nearby VA facility. The clinic works like any outpatient clinic where a primary care provider places a neurology consult, and then an administrative staff member calls the patients to schedule their visit.
Once the visit is set up, an email with a link to their specific telehealth visit time is sent, allowing them to connect directly with their neurology provider at the specified time via that single link. Although in-person neurologic examination is not conducted, much of the neurologic examination can be accomplished virtually, by talking with the patients, asking the patients to perform various tasks on camera, and observing them stand and walk.
In addition, if the veteran is at a VA facility, there are some devices like a telehealth stethoscope that can be used in the physical examination, as well as the direct assistance of a telehealth clinical technician.
In addition to telemedicine visits with the neurologist, the NTNP includes nurse visits and pharmacist visits that may be ordered by the teleneurologist. These additional resources have been vital to patient education and addressing medication adherence and side effects.
Q. What are some of the results this outpatient teleneurology program has achieved, and how did staff achieve them?
A. The primary achievement of the NTNP program is to increase access to highly trained neurologists for veterans who receive care at a facility with little to no neurology resources. In fiscal year 2022, more than 1,700 veterans had a new consultation with NTNP, and almost 4,000 total neurology visits were completed.
NTNP staff worked closely with clinic and telehealth managers and schedulers at participating sites to ensure smooth implementation, resulting in significant improvements in the time to schedule and to complete a neurology consultation compared to referral to the community.
NTNP visits, for example, were completed on average 73 days from the date the consult was first placed but community consults were completed on average 99 days from the date the consult was placed.
Satisfaction of veterans and the referring providers is important, because even if a service can be done timely, it is not effective if the patients or the referring doctors do not feel it is high quality. More than 300 veterans were surveyed and satisfaction ratings with the NTNP care was very high (average score 6.3 on a 1-7 scale).
Similarly, referring providers also were highly satisfied with NTNP consults (average score 8.9 on 1-10 scale). Interestingly, we also found there were no differences in satisfaction based on the neurologic condition and that patients with greater medical comorbidity were more satisfied with teleneurology care, suggesting telehealth may be especially useful in increasing access among those with high medical complexity who may have greater barriers to care.
Because NTNP cannot solve the problem of too few neurologists overall, we were interested to see if implementing the program led to a significant reduction in referrals to community neurologists, since this would be one measure of whether our program was making an appreciable difference for the facility that chose to implement the program.
Our model showed even controlling for the size of the facility, how rural the facility was and how long they had been in the program, NTNP implementation led to a significant reduction in the monthly volume of community care neurology referrals compared to similar VA facilities that did not implement NTNP.
Further, this difference persisted throughout the first year of implementation, suggesting the benefit was sustaining as NTNP referrals increased over time.
Q. What is the component of this program that addresses health equity, and how has it done so far?
A. The NTNP is specifically targeting rurally residing veterans, so it is implemented at sites that not only have little to no local neurology care, but sites where a significant proportion of veterans are rurally residing.
As a result, this program directly addresses access issues that these patients experience. Because NTNP accepts consultations for any type of neurological problem, it also helps address disability-related and socioeconomic disparities that result from patients’ difficulties traveling or family members’ difficulties in getting time off work to assist their loved ones to get to an appointment.
If veterans need help with a device that can be used for telehealth care, there is a consult that can be placed for a device to be sent to the veterans and someone from VA to assist them in setting it up for telehealth use. This is a unique feature that the VA has put in place to try to ensure that anyone who wants telemedicine care but is limited by access to an appropriate electronic device can get it.
Q. What is the future of telemedicine in neurology?
A. Although there are challenges related to credentialing and payment at the national level, I expect the use of telemedicine will increase in neurology due to the ongoing imbalance between where neurologists and patients are located, the ongoing unmet needs for neurological care, and the growing demand for patients’ choice around how and where they receive their medical care.
One area of great interest is in the use of devices that gather neurologic information at home and transmit it to the neurologist for review and integration into the care plan. The VA and other health systems are using in-home electroencephalograms (EEG) where a technician places the EEG leads and the digital study is sent to a remote neurologist for reading.
Another device recently put into use in the VA is the personal kinetograph (PKG), which is worn by a patient with Parkinson’s disease to help the neurologist identify whether medication changes are effective at improving movements or decreasing tremors.
Devices like these can extend the reach of the neurologist and help provide additional clinical data that may be important for patient management.
Finally, as advances are rapidly progressing in the evaluation and management of neurologic conditions, there is an increasing need for subspecialty input to help general neurologists effectively manage their patients.
One example of this type of care is acute telestroke care, which has been implemented for decades, where a stroke specialist evaluates a patient via video, reviews imaging, and can make acute stroke treatment recommendations via telehealth.
The addition of subspecialty neurologists to either conduct outpatient teleneurology visits or to provide an e-consultation opinion to address the general neurologist’s question is another developing type of telemedicine care that can provide high-quality specialized care recommendations to the primary neurologist who will continue to provide ongoing patient care.
This can help, for example, with selecting among the many new medications used to treat multiple sclerosis, or to make medication suggestions for patients with worsening Parkinson’s disease. The NTNP has recently implemented a subspecialist e-consult program and thus far, consults for multiple sclerosis and movement disorders are most frequently requested.
All told, the future of telemedicine in neurology is an exciting one, with many possibilities to scale and distribute highly specialized care in a patient-centered, convenient and efficient system.
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