Teleneurology: Finding its place in neurology healthcare

As part of the plenary session on controversies in neurology at the 2021 virtual American Academy of Neurology (AAN) Annual Meeting, Dr. Tamika Burrus (SOC Telemed, Virginia, US) and Dr. Amy Guzik (Wake Forest Baptist Health, Winston-Salem, North Carolina, US) entered a scholarly debate on the topic “Teleneurology: Can it replace in-person visits”, with Dr. Burrus advocating for and Dr. Guzik against teleneurology. 

Demand for neurologists exceeds supply: How teleneurology can fill that gap

Dr. Burrus led the debate by presenting the main arguments for teleneurology. She opened with an introduction on access to neurological care. In the words of Dr. Burrus, “Neurology demand will not meet the supply”; she noted that teleneurology has an important role to play in meeting the current demand. Additionally, she commented that the U.S. population is aging with 1 in 7 people being over 65 years of age; this will impact the future demand for neurological care. Because teleneurology models can be different, Dr. Burrus gave an insightful overview into the different models being used, focusing on the success of the U.S. Department of Veterans Affairs (VA) run ATLAS program. Noting that the increased reach of healthcare, particularly to rural areas, is one focus of teleneurology, Dr. Burrus referred to the work of Dr. Leonie Heyworth² which actually showed that there are still disparities in healthcare, with fewer video consultations taking place in older adults and in rural areas. Dr. Burrus also pointed out that accessibility and uptake of teleneurology go hand in hand, with a focus not just being on the neurologist’s availability but also on the infrastructure required. Access to care is paramount in the minds of patients today, with research from the U.S. showing that three-quarters of patients care more about access than human interaction. Although infrastructure is improving, access to the internet still needs improvement and the COVID-19 pandemic has highlighted inequities in internet access. 

Touching on another important aspect of teleneurology, Dr. Burrus reviewed patient and physician engagement, noting that research has shown that both patients and physicians are satisfied with teleneurology. Dr. Burrus closed the first part of her discussion by talking about the neurology exam, the perceived complexity which may be seen negatively when thinking about teleneurology. However, in Dr. Burrus’ opinion the neurological exam lends itself to video, for example quantitative pupillometry, or panoptic devices, and she encouraged the audience to familiarize themselves with available tools and online resources such as those from the Stanford Eye Institute or Mayo Clinic. Indeed, the conduct of the physical exam was the topic of many questions raised by the audience; here, Dr. Burrus acknowledged the difficulties posed in some situations, and advocated for the use of telepresenters who are trained in administering certain parts of the exam. She also encouraged neurologists in subspecialties to develop tools to assist in virtual exams. 

Creating a system that works for patients and telehealth

The counterarguments to teleneurology were actively discussed by Dr. Guzik who focused on some of the limitations currently seen. One of the main topics was regarding infrastructure. Dr. Guzik stressed that broadband coverage in the U.S. is disparate, and there is an incongruence in download and upload speeds. This hinders the ability for a neurologist to see a patient on a screen, and ultimately preventing them from performing a remote physical exam, and as Dr. Guzik said, “this is not a feasible model of care”. Thinking further about feasibility, Dr. Guzik stated that the shift to teleneurology is not sustainable in the long-run without changes to the existing systems. Further, Dr. Guzik pointed out that the technology investment is high; large institutions may be able to invest in the technology required and enable teleneurology to be cost effective, but there is still the question of how the initial start-up costs would be funded. In the U.S. reimbursement of telemedicine is also a hot topic, and this is still not fully clarified outside of the COVID-19 pandemic situation. 

With regard to access, Dr. Guzik discussed how access is not universal; research has shown that certain groups of patients have lower telehealth use such as those with limited English proficiency.⁴ Also, although it is thought that telemedicine may be a solution for rural health, lower telemedicine use was also seen in patients in non-metropolitan areas. In the opinion of Dr. Guzik, telemedicine is not feasible yet, and is also not available to all patients. She noted that “rather than addressing access to care, for some populations, transition to telemedicine will widen disparities”. 

Finding the right population for teleneurology

The discussion following the debate revealed a need to identify how teleneurology can be placed in healthcare, particularly which populations would benefit from remote consultations and in which situations. Dr. Guzik noted that some aspects of teleneurology will be sub-specialty specific, and in other cases the in-person physical exam may be more important. However, in her opinion, teleneurology could feature in follow-up consultations and in triage.

In summary, the arguments for teleneurology revealed that there are many positives, including ameliorating access to care in some cases and providing a tool which enhances both patient and physician engagement. However, the arguments against teleneurology show that there are still improvements to be made in terms of infrastructure and that the outcomes of teleneurology with regards to its effect on healthcare are still not well understood. Teleneurology does not have to replace in-person visits, but its place in healthcare needs to be defined and established.