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April 24, 2020

The Coronavirus Disease 2019 Crisis as Catalyst for Telemedicine for Chronic Neurological Disorders

Author Affiliations
  • 1Radboud University Medical Centre, Department of Neurology, Centre of Expertise for Parkinson & Movement Disorders, Nijmegen, the Netherlands
  • 2Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands
  • 3Center for Health + Technology, Department of Neurology, University of Rochester Medical Center, Rochester, New York
  • 4Fixel Institute for Neurological Diseases, Program for Movement Disorders and Neurorestoration, Department of Neurology, University of Florida, Gainesville
JAMA Neurol. Published online April 24, 2020. doi:10.1001/jamaneurol.2020.1452

The unfolding coronavirus disease 2019 (COVID-19) pandemic is transforming neurological care more than any other crisis in modern history. Social distancing and quarantine have cut off access to routine medical care for numerous individuals with neurological diseases. Many are at increased risk when coinfected with COVID-19 because of their advanced age (eg, those with Alzheimer disease), comorbid conditions (eg, those with respiratory impairment in amyotrophic lateral sclerosis), or immunosuppressive treatments (eg, those with multiple sclerosis). The current COVID-19 crisis is catalyzing the use of telemedicine and remote home monitoring to ascertain a continuation of care for these vulnerable populations.

To mitigate the risk of becoming infected, patients with neurological conditions should avoid traditional outpatient visits if possible, especially in crowded hospitals. There are unavoidable situations for hospital visits, such as a need for thrombolysis in acute stroke. There are also less critical indications that require physical contact, such as continued chemotherapy infusions or (less urgently) botulinum toxin treatment for dystonia or headache. Elective in-house treatments have been postponed, sometimes leading to extended disability (eg, delayed surgery for painful radiculopathies) and precipitating anxiety (eg, evaluation of new-onset seizures).

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    4 Comments for this article
    Strong support for teleneurology
    Edmund Messina, MD | The Michigan Headache and Neurology Clinic, East Lansing MI
    Because many of my patients come from a radius of 4 to 6 hours, my practice has been doing remote visits for about four years. Many patients have elected to bypass their insurance and go out of pocket because it made more sense than driving.

    As a classically trained neurologist with over 40 years of experience, I am a very strong believer in thorough history taking. There is no shortcut during a visit, either in person or remotely, and we need to basically talk to our patients. Functional questioning often takes the place of physical observation although I can
    do a pretty thorough examination using the patient's web camera.

    I was very pleased to see that the American Academy of neurology had established standards for a remote neurological examination and I strongly support it.

    Bottom line: I urge my colleagues to adopt this method for the many reasons outlined in this article, and I hope the insurance companies will realize that this is indeed a good way for us to practice medicine, especially with patients having chronic neurological disorders.
    Confidentiality of Home-Based Consultation
    William Garmoe, Ph.D. | MedStar NRN
    Many good points are made in this Viewpoint. However, we shouldn't presume that in-home tele-health consultation offers greater privacy than the office. The clinician cannot always be certain no one is listening in on the consultation out of sight. In my experience doing tele-video sessions there have been numerous instances where another person may have been attempting to listen to the appointment. This risk to privacy can be particularly relevant for vulnerable populations, including those needing physical assistance to set up the technology and behavioral health patients discussing very sensitive information; even more so for behavioral health patients who may need to share information potentially threatening to others in the home. Each tele-health situation needs to be carefully examined to determine whether it offers more or less privacy protection relative to an office setting.
    Chronic Neurological Disorders as a Complex Problem
    Anatoly Zhirkov, Professor | Saint Petersburg State University
    I read the article with great interest. The authors absolutely correctly determine the vector of development of this type of medical care. Electronic sensors are important. But I would like to draw attention to the need to consider the issue in the triangle: doctor - nurse - patient. Often, chronic neurological disorders have a pronounced functional component. We must not forget about the role of the nurse in the process of monitoring such patients.
    Let us also count the cost!
    Mamta Singh, MBBS MD DM FAAN | Dept of Neurology, All India Institute of Medical Sciences, New Delhi, India
    In favor of telemedicine, authors add a fifth C of contagion to the previously described Cs of better access to care, convenience, comfort, and better confidentiality. For Indian patients and for millions of others from low and middle-income countries, there is another C and I would rank it first - cost. In India, 70% of the population lives in smaller towns and villages with almost no access to healthcare, especially specialist care. One of the main barriers to getting neurological care is the cost of travel to a big city that can provide this care. If the pandemic pushes neurologists to convert at least part of their clinical practice to telemedicine, this would be a significant silver lining. In fact, for India, it can truly be a game-changer.

    A few years back, we realised how difficult and unaffordable travel was for many of our patients. Telemedicine existed but was not used. There was ambiguity about its legal status and no government guidelines were available. In fact the government neither permitted nor opposed it. There was a void. We conducted a randomised controlled trial evaluating telephonic follow-up for epilepsy patients. We found that telephonic follow-ups were not just feasible and safe but that they saved money and were preferred by patients.

    Unfortunately, in spite of generating first class evidence, translating it into routine clinical practice proved to be an insurmountable hurdle. I agree with authors about our reluctance to accept change. Most colleagues were quite wary of the idea and foresaw numerous problems with adopting telemedicine for patient reviews. The pandemic has fast tracked telemedicine in India like in the rest of the world. The government guidelines appeared almost overnight and we have taken our first collective tentative baby steps in this direction.