TELENEUROLOGY

TELENEUROLOGY

DR .M A ALEEM MD,DM,(Neuro)

HOD & Professor of Neurology

KAPV Govt Medical College And MGM Govt Hospital

Trichy.

Teleneurology is an evolving branch of telemedicine. It may be defined as neurological consultation at a distance, or not in person, using various technologies to achieve connectivity, including the telephone and the internet. Teleneurology, encompassing teleconsultation, teleconferencing and tele-education, may be clinician- or patient-initiated. Neurologists have reported on telemedicine applied to specific neurological conditions, including headache, dementia, epilepsy, stroke, movement disorders and multiple sclerosis. Clinician initiatives have perhaps been most notable in stroke, stimulated by the urgency of patient assessment prior to decisions on thrombolytic treatment. The use of patient-initiated teleneurology is increasing through the widespread availability of the internet and the use of search engines—resources that may impact on the traditional clinician–patient relationship. Teleneurology will increasingly impact on all neurologists.

Introduction

Telemedicine is medicine at a distance, wherein medical consultation is undertaken not 'in person'; it thus leads to 'remote diagnosis' or telediagnosis. Although the term is modern, probably dating from 1969, the concept is far from new, dating back to antiquity. What has changed over the millennia is the technological means by which connectivity is achieved. Whereas in the past connectivity was achieved by word of mouth, letter or even smoke signals, the modern era has brought us the telegraph, telephone, television and the internet. These technologically based modalities of care have the potential capacity to 'collapse the boundaries of time and space' and to address issues of access to, cost of, and quality of healthcare.

Telemedicine has been enthusiastically taken up in some, but not all, medical specialties. Visually oriented disciplines such as radiology, pathology and dermatology have frequently used telemedicine; telepsychiatry has also flourished, perhaps because patients find it less inhibiting to divulge personal information in this way. Likewise, the discipline of teleneurology has been developing in recent years, some features of which are briefly summarised here.

Teleneurology: Potential Uses

Teleneurology uses might be broadly divided into those that are 'clinician (health provider)-initiated' and those that are 'patient (health consumer)-initiated'. The term 'telemedicine' is sometimes reserved for the sharing of information between healthcare providers, while the terms 'telecare' and 'telehealthcare' describe interactions between patients and healthcare professionals. However, this nomenclature is recognised to be somewhat arbitrary, since practitioners and patients may be characterised as denizens of—to paraphrase the late Marshall McLuhan—the 'Global Health Village'.

Teleconsultation

The number of neurologists per head of a population is uneven globally, often posing problems for patient access outside major metropolitan centres. Teleneurology may obviate such difficulties. Neurological consultation by real-time interactive videolink is useful for both outpatient and inpatientsettings. The consultations are conducted similarly to face-to-face consultations, with an on-site health worker (junior doctor, professional allied to medicine) performing an examination, witnessed and directed over the videolink. All such consultations should be appropriately documented (letter to the referrer, copy in hospital notes) as for face-to-face consultations. With the appropriate technical support, teleconsultation works well as regards accuracy of diagnosis, in part because telemedicine-enabled neurological examination can be as good as bedside examination. It also reduces inhospital stay. Patient satisfaction with teleconsultation, as assessed by questionnaires, is high, although some patients have concerns about confidentiality. Follow-up rates for videolink consultations are similar to those for face-to-face assessment, although they may generate more investigations. Advantages of teleconsultation include reduced patient travel requirements (a major issue for patients with epilepsy, who may be ineligible to drive) and hence carbon footprint, and increased likelihood of family members attending the teleclinic, thus providing clinicians the opportunity to gain collateral history pivotal for a correct diagnosis. Teleconferencing across continents has proved possible; it is one way of bringing distant expertise to areas that are neurologically poorly served.

In contrast to real-time (synchronous) links, the store and forward (asynchronous) forms of telemedicine may increasingly be used for email consultations with remote patients. This has many potential advantages, particularly in saving clinician time and patient time. Of course, email contact precludes the immediate interaction of history taking, the observation of non-verbal factors, and the physical examination. These issues might in the future be addressed by Skype, although again there are potentially significant legal implications. It is good practice to ensure that copies of all emails are included in the hospital notes (in the future, these may be replaced with electronic personal health records). Certain treatment options may also be initiated and supervised at a distance ('e-therapy'). All these options require provision of appropriate infrastructure, technical backup, and clinician training for their optimal application.

Tele-education

Dissemination of medical knowledge through websites and e-learning modules has become increasingly popular for education and training. This may include continuing medical education—for example by videoconferencing of grand rounds (with appropriate patient consent) and broadcasting of other educational events. Internet search engines assist with neurological diagnosis ('Google neurology'), although its efficacy depends partly upon prior knowledge to facilitate an appropriate search strategy and to interpret the relevance of accessed material.

Teleneurology in Specific Conditions

Some examples of the current use of telemedicine in common neurological conditions are considered from the perspectives of both the clinician and the patient.

Headache

Recruitment of headache patients to research studies via the internet may prove feasible since such patients appear to have valid self-reported diagnoses. The facility for two-way communication via the internet may be exploited for the delivery of relaxation or problem-solving techniques to patients with headache.

For patients, internet sites with information on headache are available, although some may be biased, inaccurate and potentially problematic. One study found internet-based information on headache to be extensive but poorly organised. 

Dementia

Telephone interviews can potentially replace face-to-face interviews for administering cognitive measurement scales adapted for telephone use (eg, Telephone Interview for Cognitive Status, Blessed Telephone Information–Memory–Concentration Test, Structured Telephone Interview for Dementia Assessment). They have been used for the diagnosis of dementia, including poststroke dementia (see below). Internet-based care giver support schemes, which may reduce care giver burden, have also been reported.

Some websites relevant to Alzheimer's disease (AD) may not be easy to use for cognitively impaired individuals. However, in view of patient age and cognitive impairment, it is more likely that carers, rather than patients with AD per se, will be keen on accessing web-based services. One observational study found that in a quarter of consultations with patients with AD, relatives had searched for information.^[There are telephone helplines dedicated for dementia, such as the Counselling and Diagnosis in Dementia service; in its first 2 years, this service recorded that more than 50% of calls were 'generic', emanating from the public and from health professionals seeking information and advice, rather than from those attending the hospital outpatient clinic.

Epilepsy

The modern era of telemedicine may be dated to Einthoven's 1905 transmission of an ECG by telephone link. A similar approach may be taken with EEG to assist with interpretation. Teleconferencing across continents to facilitate epilepsy care has proven feasible. Nurse-led epilepsy clinics, supported by a distant neurologist contacted by telephone and, if necessary, by videolink, have proven feasible and acceptable, if more expensive, than 'face-to-face' clinics. A witness account is often more readily available, and travel (difficult for people with epilepsy) is avoided. Epilepsy nurse specialists may be able to give medication advice, as well as information and support, to patients by telephone

Patients with epilepsy have been reported to make use of the internet for health information, although not all seem willing to entertain the possibility of web-based interventions to manage seizures.

Stroke

Levine and Gorman coined the term 'telestroke' in 1999 to denote the use of telemedicine for stroke management, prompted at least in part by the need to expedite thrombolytic treatments. Real-time videolink was the chosen medium of connectivity (of particular relevance to underserved areas) but was also applicable to clinical trials and for education. A web-based system has also been proposed. The National Institutes of Health Stroke Scale has been validated as a reliable measure in videolink studies, with high correlations between bedside and remote scoring. Cognitive testing by telephone may be used to diagnose poststroke dementia.

Telestroke has become routine in some locations, for thrombolysis and for overall stroke management. It may be of particular utility in underserved and/or rural areas. Such have been the developments in telestroke that recommendations for the implementation of telestroke programmes, predicated on the existing evidence base, have been agreed on.

Parkinson's Disease and Movement Disorders

Videorecording of movement disorders may be useful for remote diagnosis.

Patients with Parkinson's disease (PD) have been reported to access the internet for medical information. However, another aspect of internet use by patients with PD has attracted more clinical attention, namely PD-related impulse control disorders such as pathological gambling, particularly associated with the use of dopamine agonist drugs.

Multiple Sclerosis

Measurement of disability in multiple sclerosis using the Expanded Disability Status Scale may be assessed by telephone interview or videoconference link, although the remote and face-to-face raters may differ in their assessments of cerebellar and brainstem functions.

Most patients with multiple sclerosis seek online information but are surprisingly unlikely to discuss their findings with clinicians, something also observed in general neurological outpatient settings.

IN INDIA

In our countries, increasing population and a very low doctor-patient ratio is a difficult challenge. About 1500 neurologists in a country with a population of over 1 billion is very inadequate and it will take more than 20 years to achieve a ratio of one neurologist per 50,000 population at the rate of 100 neurologists produced per year; but it is not only the number which is important. Increasing specialization has reduced the number of physicians who are good at managing emergencies. Although the number of emergencies is increasing, there is growing anxiety about medical errors and the increasing number of medical negligence cases.

          There is no single solution for upgrading the emergency services; but a favored model has been a large central hospital with associated local hospitals to which patients are discharged; but it may make the services worse rather than better. Medical emergencies usually occur in a patient's home and are followed by a journey to the hospital, assessment, admission, treatment and then discharge. A large central hospital means a long journey, which may delay treatment and influence the outcome as in status epilepticus, stroke etc. In India the road and transportation are far from satisfactory. Increased distance also causes a problem for visiting families and weakens the link with primary care, which is crucial for discharging the patients. A large number of patients in large emergencies lead to long waiting periods, usually in a trolley. The local hospitals do not share care or staff with a large hospital and have poor nursing and medical infrastructure and are uncomfortable managing serious patients. They thus assume the role of nursing homes rather than hospitals.

Black has proposed a reversing model in which patients are admitted to a local hospital, which would be an assessment area of the big hospital. The medical and nursing staff would be part of the team working in the central hospital and would rotate between the hospitals. The local unit would have imaging (CT) and laboratory (EEG, ECG, biochemistry) support and high-quality electronic links with the central hospital that would allow the specialist to know almost as much about the patients as if they were examining them directly. Such a system would result in avoiding delay in treatment. Those who don't need admission could be quickly discharged, maybe within one day, and some patients would not need to go to the central hospital; those who go to the central hospital would not need to be assessed again, the transfer and admission would be faster.

Legal questions: 

Application of telemedicine has raised several legal questions. Data security being the most important and accidental loss and occurrence of faults must be prevented by providing effective data control management and artefact recognition. As personal data are involved, the possibility of intended or criminal abuse must be taken into account and prevented. Special encryption mechanisms that secure data against unauthorized access and even modification are therefore necessary. Patients' rights to confidentiality are paramount. Unless the regulation for special situations has been agreed upon by both sides, the liability is on the side of the consulting rather than advising physician. Procedures for reimbursement of logistic costs or payment offers need to be developed. 

Conclusion

Yesterday's innovations become today's normalcy. Accordingly, teleneurology is now an integral part of neurological practice for both clinicians and patients, and is here to stay. Like all medical interventions, it brings both risks and benefits, necessitating that proposed applications be subjected, where possible, to randomised controlled trials to assess efficacy and cost-effectiveness versus conventional modes of practice. Clinician awareness of patient-initiated use of teleneurology resources is also important, since this may shape patient health beliefs and expectations, sometimes erroneously.