VIEWPOINT www.nature.com/clinicalpractice/neuro
How can teleneurology improve patient care? Victor Patterson* and Richard Wootton
V Patterson is a consultant neurologist at the Royal Victoria Hospital in Belfast, UK, and R Wootton is the Head of Research at the Centre for Online Health at the University of Queensland in Brisbane, Australia.
Correspondence *Teleneurology 1st Floor Education Centre Royal Victoria Hospital Belfast BT12 6BA UK
[email protected] Received 26 July 2005 Accepted 12 April 2006 www.nature.com/clinicalpractice doi:10.1038/ncpneuro0219
Telemedicine uses modern communication technology to enable a medical consultation to take place when doctor and patient are in different places, and even different time zones. Over the past 20 years, telemedicine has been promoted as an important change in the way that medicine is practiced, because of its potential to make medical care both more efficient and more equitable in terms of access. Neurology was slow to adopt telemedicine in comparison with specialties such as radiology, psychiatry and dermatology, but interest has increased in the past few years. It is timely, therefore, to ask whether teleneurology will last the course to become an integral part of the neurological practice of the 21st century. The use of modern communication to deal with a patient who is at a different location to the doctor is nothing new—neurologists have done this for many years using the telephone. Interestingly, although this approach is firmly embedded in the day-to-day practice of almost all neurologists, there is no evidence base to indicate that it is safe, effective or cost-effective. Although used much less frequently, email and videoconferencing, which provide the thrust of modern teleneurology, are providing some of the evidence base lacking with the telephone-based approach. Email essentially replaces the letter, and a video link is an improvement on the telephone, allowing neurologists to take a history and watch an examination being performed. The rationale for teleneurology is twofold: first, to provide services that cannot easily be provided face-to-face; and second, to improve the efficiency or effectiveness of existing services. An example of the former is the provision of an acute neurology service by video link to a rural district general hospital; when compared with a cohort of patients managed principally by local physicians, additional video-link consultation with a neurologist reduced bedstay significantly without increasing readmissions, investigations or review appointments.1 Video link to a stroke neurologist is the only feasible way in which rural
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patients with acute stroke can receive intravenous tissue plasminogen activator within the necessary 3 h time window; the effectiveness and safety of this method have been shown in a number of studies.2,3 Email might be the only way in which patients in the developing world can receive expert neurological advice. For example, a neurologist in the UK diagnosed a wheelchairbound patient in Bangladesh with a dysimmune neuropathy, and the patient recovered completely with appropriate treatment.4 Management by video link of patients with epilepsy in rural communities is an example of the way in which teleneurology might increase the efficiency of existing services. In a recent study, there was no difference in seizure frequency, hospitalization or emergency room visits between face-to-face and video-link cohorts managed by the same neurologist.5 Furthermore, new neurological outpatient referrals seen by video link had similar investigation and review rates to patients seen conventionally, but with reduced travel time for neurologist and patient.6 A community stroke rehabilitation program delivered by video link improved balance and physical functioning in treated patients.7 Email triage by a neurologist of new referrals from general practitioners was safe and reduced the number of people needing to attend clinics by about a half.8 Given the reported efficacy of teleneurology, why is it not more widely practiced? There are three main reasons. First, potential teleneurologists have to be able to deal with the technology. Email, despite its wide adoption in society, is still relatively underused in hospital care, and many doctors are not familiar—or indeed comfortable—with its use. Videoconferencing technology is another step up in complexity and is likely to be unfamiliar to most practitioners, and distinctly off-putting to those who are reluctant to embrace new technologies. Videoconferencing equipment also depends on the availability of digital lines, which can be expensive. This situation might change with the
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advent of different types of broadband connection, and videoconferencing might also become integrated with personal computers. The second problem is that teleneurology requires a change in the way in which neurologists practice. Neurologists have to be able to express an opinion without examining the patient directly, and for some this is a serious problem—many neurologists have an attachment to the hands-on neurological examination that might, admittedly, be more sentimental than evidence-based. The willingness of neurologists to change their practice has also been severely strained by the continual changes in health-care systems around the world, which might have made them reluctant to embark on yet another change unless it brings them obvious benefits. In teleneurology, the benefits accrue mostly to the patients rather than to the neurologists, and this might be one reason why it has not gained more rapid acceptance. As the main beneficiaries are the patients, political forces might be expected to drive the wider introduction of teleneurology. They have so far failed to do so, however, apart from the example of acute stroke care in the US: in some states, for hospitals to be funded, they must be able to manage acute stroke cases, and for some this can only be done using teleneurology. Lastly, some doctors might be concerned about medicolegal issues if they give advice by email or video link, through which methods they cannot, for example, examine the optic fundi. These concerns are no different from those that apply to telephone consultations, which ironically most doctors perform regularly. The way of managing legal concerns when consulting patients by email or video link is the same as when giving medical advice by telephone— namely, that if a face-to-face examination is thought necessary, then it should be performed. Teleneurologists also need to ensure that they are licensed to practice medicine in the hospital, state or country in which the patient is located. These ethical and legal requirements are exactly the same in other branches of telemedicine and have recently been reviewed.9 What would health care look like if teleneurology was widely used? Primary care physicians could email a neurologist and obtain advice or have appropriate tests arranged, or the neurologist might decide that the patient
needs to be seen. Patients could attend their local ambulatory health center, where, with the help of a teleneurology assistant, they could be video linked to a neurologist who could decide on further management. If further supervision was required, the patient could be followed up by the appropriate specialist nurse and a local neurologist. There is no requirement for the video-neurologist to be in the same region, or indeed the same country, as long as he or she has a licence to practice medicine in the country in which the patient is based. Acute presentations to hospital with neurological symptoms could be assessed by neurologists using a video link within an hour of admission. If the admission was at night, it would be possible to contact a neurologist in a country where it was daytime. Scans could be reviewed, appropriate acute treatment and management started, and progress checked by repeat video links after a day or two. All of these elements have already been shown to be feasible,10 so this scenario is not as futuristic as it might appear. Globalization and outsourcing are terms not generally thought applicable to neurology, but wider adoption of teleneurology could make them essential words in the neurologist’s vocabulary.
Competing interests The authors declared they have no competing interests.
References 1 Craig J et al. (2004) A cohort study of early neurological consultation by telemedicine on the care of neurological inpatients. J Neurol Nerosurg Psychiatry 75: 1031–1035 2 Schwamm L et al. (2004) Virtual TeleStroke support for the emergency department evaluation of acute stroke. Acad Emerg Med 11: 1193–1197 3 Audebert HJ et al. (2005) Telemedicine for safe and extended thrombolysis in stroke: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria. Stroke 36: 287–291 4 Vassallo DJ et al. (2001) An evaluation of the first year’s experience with a low-cost telemedicine link in Bangladesh. J Telemed Telecare 7: 125–138 5 Rasmusson KA and Hartshorn JC (2005) A comparison of epilepsy patients in a traditional ambulatory clinic and a telemedicine clinic. Epilepsia 5: 767–770 6 Chua R et al. (2002) Telemedicine for new neurological outpatients: putting a randomized controlled trial in the context of everyday practice. J Telemed Telecare 8: 270–273 7 Lai JC et al. (2004) Telerehabilitation—a new model for community-based stroke rehabilitation. J Telemed Telecare 10: 199–205 8 Patterson V et al. (2004) Email triage of new neurological outpatient referrals from general practice. J Neurol Neurosurg Psychiatry 75: 617–620 9 Stanberry B: Legal and ethical aspects of telemedicine. J Telemed Telecare, in press 10 Patterson V and Conneally P (2005) Intercontinental telemedicine for acute neurology. J Telemed Telecare 11: 320–322
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