Accepted Manuscript Telemedicine in Pediatric Neurology Charuta Joshi , MBBS PII:
S0887-8994(14)00287-2
DOI:
10.1016/j.pediatrneurol.2014.05.011
Reference:
PNU 8365
To appear in:
Pediatric Neurology
Received Date: 6 May 2014 Revised Date:
12 May 2014
Accepted Date: 13 May 2014
Please cite this article as: Joshi C, Telemedicine in Pediatric Neurology, Pediatric Neurology (2014), doi: 10.1016/j.pediatrneurol.2014.05.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Telemedicine in Pediatric Neurology
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Charuta Joshi, MBBS
Corresponding author:
SC
Charuta Joshi, MBBS, Associate Professor, Division of Pediatric Neurology, Stead Family Department of Pediatrics, 200 Hawkins Drive, University of Iowa Childrens Hospital, Iowa City, Iowa 52242 Telephone: 319-356-1851, Fax: 319-384-8818, E-mail: [email protected]
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Word count: 915
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Key words: telemedicine; telehealth; patient centered medicine; pediatric neurology
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The medical community lags behind other industries in using new technology by at least fifteen years! The fact that health information technology (use of electronic medical records and electronic prescriptions) is not universally implemented is proof. So what is telemedicine? “telemedicine” is the use of the internet between two sites for medical information or image exchange to improve a patient’s clinical health status. “Telehealth” includes additional services like health-related distance learning for patients and health professionals. Telemedicine is thus patient focused whereas health informatics is a support system.
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My experience with telemedicine began in 2001 in a tertiary hospital in Manitoba, Canada. Any patient needing follow-up care for epilepsy (my specialty) at my tertiary care center in Winnipeg from October to May, and residing in the northern reaches of the province, would need to be airlifted. My 30 minute clinic visit became a burden for the family, community and society as a whole. Instead, conducting a virtual clinic visit through real time video conferencing (referred to as telemedicine in this article) assured follow-up, minimized missed school and parental time away from work, decreased cost related to lodging, boarding and travel. Weather or other causes of “no-shows” to a telemedicine clinic were rare. Even the carbon footprint of my virtual visit was minimal. Ultimately, the societal impact, accessibility to specialty care and patient satisfaction was huge.
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Then, in my current position, a level four epilepsy center in the Midwest, perceived workflow difficulty and possibility of inadequate remuneration prevented utilizing telemedicine. A few years later, I sought to change this perception and started a small telemedicine clinic. Two years later, I published my experience as an abstract showing high patient satisfaction, fair remuneration and overall societal cost savings (1). Telemedicine at my institution is now viewed as a laudable activity.
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Telemedicine is not a new health care field, but a health care delivery method for credentialed clinicians to deliver health care to the patient’s doorstep. Various applications of telemedicine include two-way video conferencing between a tertiary care center and rural hospitals (hub and spoke model), e-mail (e-medicine or e-consult using store and forward technology like Picture Archiving and Communications System or PACS), smart phones (m-medicine), wireless tools (remote monitoring to access cardiac rhythm, oxygen saturation) and even robotic surgery. Forty years ago, the American Academy of Pediatrics embraced the concept of patient centered medical care home (2). This concept originally referred to one central source of medical records for children with special healthcare needs but has now transformed beyond data entry to methods of delivering the best quality of care for all children, rural or urban. Comprehensive healthcare delivered in the most efficient manner with the least expense to the patient’s home is the cornerstone of this concept. Telemedicine offers new options for evaluating and treating children with both acute and chronic illnesses, with potential efficiencies for patients, parents, providers, and health systems (3). Telemedicine is better suited to evaluate certain neurological conditions like epilepsy, movement disorders, dementia, and headaches where inspection is more critical than palpation
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or strength testing. Telemedicine is even more uniquely applicable to pediatric neurology where a majority of the exam in an uncooperative toddler is through inspection. Rasmusson et. al. showed that there was no difference in two groups of adult patients with epilepsy, whether seen in an ambulatory epilepsy clinic or by telemedicine, even for the first encounter (4). In adult neurology, after the overwhelming success of telemedicine for stroke care, its use has expanded to movement disorders, headaches, dementia and epilepsy (5, 6). After having appointed a telemedicine working group, the American Academy of Neurology has published its recommendations (7).
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The barriers to the practice of telemedicine include healthcare provider licensure and credentialing (for patients not in the same state), malpractice insurance, health information portability and privacy act and provider reimbursement. Similarly, the change in “how the patient is seen” is a concern for both the provider and the patient. Many states do not reimburse telemedicine visits as these are not “face to face”. Figure 1 shows a current map of states that have a legislated mandate requiring coverage by private insurance (or Medicare/Medicaid) for telemedicine visits the same way as they would for an in person visit – known as telemedicine parity law. This map was published by the American Telehealth association (ATA). A survey of the top 50 hospitals ranked by U.S. News and World Report demonstrated that reimbursement was the biggest hurdle in the implementation of telehealth services in neurology (8).
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Telemedicine for stroke care trumped all other barriers, because “time is brain”. It therefore generated overwhelming robust data to support its utility. However, for chronic neurological disorders such as dementia and epilepsy, the number of robust studies is limited, leading to weak evidence of reliability, validity, safety, efficacy and cost effectiveness (9). The American Telemedicine Association and Joint Commission Standards have incorporated telehealth and developed standards to address technical applications and clinical practice guidelines. These guidelines have been endorsed by specialty societies (10).
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Traditional clinic visits are here to stay; however, with spiraling health care costs, we need to be at the forefront of our field and increase the implementation of telemedicine for neurological disorders. Telemedicine allows greater provider efficiency, decreases no-shows, reduces societal cost, betters partnerships and research opportunities between centers, increases outreach and referral opportunities and reduces the need to set up expensive satellite clinics. We need to be forward thinkers in our specialty and make a quick transition from “face-to-face” visits to “FaceTime” visits.
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Acknowledgements:
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The author wishes to thank Dr Abhay Divekar MD for critical review of this essay.
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References:
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1. (High Satisfaction With Telemedicine in Pediatric Epilepsy. Medscape. Nov 14, 2013. http://www.medscape.com/viewarticle/814365 ). 2. Herendeen N, Deshpande P. Telemedicine and the patient-centered medical home. Pediatr Ann. 2014;43(2):e28-32. 3. Herendeen NE, Schaefer GB. Practical applications of Telemedicine for pediatricians. Pediatr Ann. 2009;38(10):567-569.
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4. Rasmusson KA, Hartshorn JC. A comparison of epilepsy patients in a traditional ambulatory clinic and a Telemedicine clinic. Epilepsia. 2005;46(5):767-770.
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5. Larner AJ. Teleneurology: An overview of current status. Pract Neurol. 2011;11(5):283288. 6. Ahmed SN, Mann C, Sinclair DB, et al. Feasibility of epilepsy follow-up care through Telemedicine: A pilot study on the patient's perspective. Epilepsia. 2008;49(4):573-585. 7. Wechsler LR, Tsao JW, Levine SR, et al. Teleneurology applications: Report of the Telemedicine work group of the american academy of neurology. Neurology. 2013;80(7):6706. doi: 10.1212/WNL.0b013e3182823361.
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8. George BP, Scoglio NJ, Reminick JI, et al. Telemedicine in leading US neurology departments. The Neurohospitalist. 2012;2(4):123-8. 9. Rubin MN, Wellik KE, Channer DD, Demaerschalk BM. Systematic review of teleneurology: Neurohospitalist neurology. The Neurohospitalist. 2013;3(3):120-4.
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10. Rheuban KS. Telehealth: 'necessity is the mother of invention'. Pediatr Ann. 2009;38(10):570-573.
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Figure Legend:
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Fig 1: Status of United States laws governing private insurance coverage of telemedicine. Figure reproduced by permission of the American Telehealth Association
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ACCEPTED MANUSCRIPT
S0887-8994(14)00287-2
DOI:
10.1016/j.pediatrneurol.2014.05.011
Reference:
PNU 8365
To appear in:
Pediatric Neurology
Received Date: 6 May 2014 Revised Date:
12 May 2014
Accepted Date: 13 May 2014
Please cite this article as: Joshi C, Telemedicine in Pediatric Neurology, Pediatric Neurology (2014), doi: 10.1016/j.pediatrneurol.2014.05.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Telemedicine in Pediatric Neurology
RI PT
Charuta Joshi, MBBS
Corresponding author:
SC
Charuta Joshi, MBBS, Associate Professor, Division of Pediatric Neurology, Stead Family Department of Pediatrics, 200 Hawkins Drive, University of Iowa Childrens Hospital, Iowa City, Iowa 52242 Telephone: 319-356-1851, Fax: 319-384-8818, E-mail: [email protected]
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M AN U
Word count: 915
ACCEPTED MANUSCRIPT
AC C
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TE D
M AN U
SC
RI PT
Key words: telemedicine; telehealth; patient centered medicine; pediatric neurology
ACCEPTED MANUSCRIPT
RI PT
The medical community lags behind other industries in using new technology by at least fifteen years! The fact that health information technology (use of electronic medical records and electronic prescriptions) is not universally implemented is proof. So what is telemedicine? “telemedicine” is the use of the internet between two sites for medical information or image exchange to improve a patient’s clinical health status. “Telehealth” includes additional services like health-related distance learning for patients and health professionals. Telemedicine is thus patient focused whereas health informatics is a support system.
M AN U
SC
My experience with telemedicine began in 2001 in a tertiary hospital in Manitoba, Canada. Any patient needing follow-up care for epilepsy (my specialty) at my tertiary care center in Winnipeg from October to May, and residing in the northern reaches of the province, would need to be airlifted. My 30 minute clinic visit became a burden for the family, community and society as a whole. Instead, conducting a virtual clinic visit through real time video conferencing (referred to as telemedicine in this article) assured follow-up, minimized missed school and parental time away from work, decreased cost related to lodging, boarding and travel. Weather or other causes of “no-shows” to a telemedicine clinic were rare. Even the carbon footprint of my virtual visit was minimal. Ultimately, the societal impact, accessibility to specialty care and patient satisfaction was huge.
TE D
Then, in my current position, a level four epilepsy center in the Midwest, perceived workflow difficulty and possibility of inadequate remuneration prevented utilizing telemedicine. A few years later, I sought to change this perception and started a small telemedicine clinic. Two years later, I published my experience as an abstract showing high patient satisfaction, fair remuneration and overall societal cost savings (1). Telemedicine at my institution is now viewed as a laudable activity.
AC C
EP
Telemedicine is not a new health care field, but a health care delivery method for credentialed clinicians to deliver health care to the patient’s doorstep. Various applications of telemedicine include two-way video conferencing between a tertiary care center and rural hospitals (hub and spoke model), e-mail (e-medicine or e-consult using store and forward technology like Picture Archiving and Communications System or PACS), smart phones (m-medicine), wireless tools (remote monitoring to access cardiac rhythm, oxygen saturation) and even robotic surgery. Forty years ago, the American Academy of Pediatrics embraced the concept of patient centered medical care home (2). This concept originally referred to one central source of medical records for children with special healthcare needs but has now transformed beyond data entry to methods of delivering the best quality of care for all children, rural or urban. Comprehensive healthcare delivered in the most efficient manner with the least expense to the patient’s home is the cornerstone of this concept. Telemedicine offers new options for evaluating and treating children with both acute and chronic illnesses, with potential efficiencies for patients, parents, providers, and health systems (3). Telemedicine is better suited to evaluate certain neurological conditions like epilepsy, movement disorders, dementia, and headaches where inspection is more critical than palpation
ACCEPTED MANUSCRIPT
RI PT
or strength testing. Telemedicine is even more uniquely applicable to pediatric neurology where a majority of the exam in an uncooperative toddler is through inspection. Rasmusson et. al. showed that there was no difference in two groups of adult patients with epilepsy, whether seen in an ambulatory epilepsy clinic or by telemedicine, even for the first encounter (4). In adult neurology, after the overwhelming success of telemedicine for stroke care, its use has expanded to movement disorders, headaches, dementia and epilepsy (5, 6). After having appointed a telemedicine working group, the American Academy of Neurology has published its recommendations (7).
M AN U
SC
The barriers to the practice of telemedicine include healthcare provider licensure and credentialing (for patients not in the same state), malpractice insurance, health information portability and privacy act and provider reimbursement. Similarly, the change in “how the patient is seen” is a concern for both the provider and the patient. Many states do not reimburse telemedicine visits as these are not “face to face”. Figure 1 shows a current map of states that have a legislated mandate requiring coverage by private insurance (or Medicare/Medicaid) for telemedicine visits the same way as they would for an in person visit – known as telemedicine parity law. This map was published by the American Telehealth association (ATA). A survey of the top 50 hospitals ranked by U.S. News and World Report demonstrated that reimbursement was the biggest hurdle in the implementation of telehealth services in neurology (8).
TE D
Telemedicine for stroke care trumped all other barriers, because “time is brain”. It therefore generated overwhelming robust data to support its utility. However, for chronic neurological disorders such as dementia and epilepsy, the number of robust studies is limited, leading to weak evidence of reliability, validity, safety, efficacy and cost effectiveness (9). The American Telemedicine Association and Joint Commission Standards have incorporated telehealth and developed standards to address technical applications and clinical practice guidelines. These guidelines have been endorsed by specialty societies (10).
AC C
EP
Traditional clinic visits are here to stay; however, with spiraling health care costs, we need to be at the forefront of our field and increase the implementation of telemedicine for neurological disorders. Telemedicine allows greater provider efficiency, decreases no-shows, reduces societal cost, betters partnerships and research opportunities between centers, increases outreach and referral opportunities and reduces the need to set up expensive satellite clinics. We need to be forward thinkers in our specialty and make a quick transition from “face-to-face” visits to “FaceTime” visits.
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Acknowledgements:
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M AN U
SC
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The author wishes to thank Dr Abhay Divekar MD for critical review of this essay.
ACCEPTED MANUSCRIPT
References:
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1. (High Satisfaction With Telemedicine in Pediatric Epilepsy. Medscape. Nov 14, 2013. http://www.medscape.com/viewarticle/814365 ). 2. Herendeen N, Deshpande P. Telemedicine and the patient-centered medical home. Pediatr Ann. 2014;43(2):e28-32. 3. Herendeen NE, Schaefer GB. Practical applications of Telemedicine for pediatricians. Pediatr Ann. 2009;38(10):567-569.
SC
4. Rasmusson KA, Hartshorn JC. A comparison of epilepsy patients in a traditional ambulatory clinic and a Telemedicine clinic. Epilepsia. 2005;46(5):767-770.
M AN U
5. Larner AJ. Teleneurology: An overview of current status. Pract Neurol. 2011;11(5):283288. 6. Ahmed SN, Mann C, Sinclair DB, et al. Feasibility of epilepsy follow-up care through Telemedicine: A pilot study on the patient's perspective. Epilepsia. 2008;49(4):573-585. 7. Wechsler LR, Tsao JW, Levine SR, et al. Teleneurology applications: Report of the Telemedicine work group of the american academy of neurology. Neurology. 2013;80(7):6706. doi: 10.1212/WNL.0b013e3182823361.
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8. George BP, Scoglio NJ, Reminick JI, et al. Telemedicine in leading US neurology departments. The Neurohospitalist. 2012;2(4):123-8. 9. Rubin MN, Wellik KE, Channer DD, Demaerschalk BM. Systematic review of teleneurology: Neurohospitalist neurology. The Neurohospitalist. 2013;3(3):120-4.
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10. Rheuban KS. Telehealth: 'necessity is the mother of invention'. Pediatr Ann. 2009;38(10):570-573.
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Figure Legend:
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Fig 1: Status of United States laws governing private insurance coverage of telemedicine. Figure reproduced by permission of the American Telehealth Association
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