Teleneurology as a Solution for Outpatient Care During the COVID-19 Pandemic
Introduction
The coronavirus disease of 2019 (COVID-19) pandemic and the need for social distancing have dramatically changed health care delivery. Telehealth is an emerging field that is currently the best alternative to standard in-person care.1 The United States Congress passed the Coronavirus Preparedness and Response Supplemental Appropriations Act that included provisions to improve access and coverage for telehealth services. Medicare will now cover telehealth services under broader circumstances. Per current guidelines, telehealth visits are primarily defined as an interactive audio and video connection that permits real-time communication between the provider and the patient at home. Additional telehealth services covered by Medicare include virtual check-ins (brief synchronous communication) and e-visits (asynchronous patient-initiated communications through an online portal).
In the field of neurology, the adoption of teleneurology for outpatient care has been slow, but the recent need for social distancing, lessening of regulations, and improved coverage has the potential to facilitate increased utilization.2,3 At Cleveland Clinic, teleneurology services were implemented in 2015 with recent changes to the workflow to facilitate increased utilization.4 The infrastructure established over the past 5 years was leveraged to provide outpatient neurology services during the COVID-19 pandemic. In this study, we report the dramatic shift from in-person care to a virtual care delivery model that was utilized for nearly all patients.
Materials and Methods
A retrospective observational study was performed to examine the changes in teleneurology practices before and after the COVID-19 pandemic. All nonprocedural in-person and teleneurology visits conducted in the Neurological Institute at Cleveland Clinic from January 5, 2020, until April 4, 2020, were included. Practice patterns were compared before and after March 15, 2020, as this was the date a major statewide closure (including schools) occurred in Ohio. The number of visits was assessed by week. The providers who conducted the visits included neurologists, neurosurgeons, physiatrists, psychiatrists, advanced practice providers, and psychologists. Neurological specilities included were headache, epilepsy, spine, movement disorders, psychiatry/psychology, autonomic, cerebrovascular, neuro-oncology, neuroimmunology/multiple sclerosis, cognitive, sleep, vestibular, pain, neurosurgery, neuromuscular, and physical medicine and rehabilitation.
The virtual visits were primarily completed using Cleveland Clinic Express Care Online® (ECO) platform supported by American Well. For patients unable to use the ECO platform, visits were completed through different mechanisms including other widely available applications (e.g., Facetime® and Google Duo®) or telephone only. The number of visits was assessed by week.
Analyses examined the change from in-person visits to teleneurology visits over time. Testing was conducted to determine differences in the mean proportion of visits completed through telehealth per week before and after March 15 using a chi-squared test, statistical significance was set at 0.05. This study was approved by the Cleveland Clinic Institutional Review Board.
Results
The total number of in-person and teleneurology visits for each week in 2020 is presented in Figure 1. The mean in-person visits per week before and after March 15 was 5129.4 and 866.7, respectively. The mean teleneurology visits per week were 209.1 and 2619.3 for the same time periods. The overall teleneurology visit volume in the 3 weeks after March 15 increased by 533%.
Fig. 1. Number of in-person and teleneurology visits completed each week in 2020.
The mean proportion of visits completed virtually was 3.9% before March 15, 38.8% the week of March 15, 85.4% the week of March 22, and 94.6% the week of March 29 (chi-squared, p < 0.001). Within 3 weeks of March 15, visits reached 82.6% of the average weekly visits before the stay-at-home order. The percentage of virtual visits that were completed outside the ECO platform was 39.8% after March 15. The overall no-show rate for the entire study period was 13.6% for in-person and 2.2% for virtual visits. The majority of teleneurology visits were completed between a patient and provider with an established relationship (6,098, 89.4%), but 722 visits (10.6%) were conducted by providers assessing an individual for the first time.
Discussion
This study highlights the ability for a large medical system to rapidly shift virtually all care to telehealth-based delivery of care. The results presented here show that teleneurology until the pandemic was a small proportion of outpatient care (3.9%) likely related to limited reimbursement, lack of provider familiarity, and patient preference. At our institution, the COVID-19 pandemic and the need for social distancing accelerated the use of teleneurology in a short period of time. To facilitate the >500% increase in teleneurology, multiple practical and technical changes occurred. Providers and patients needed to be registered and instructed on the utilization of the technology. Nearly all appointments needed to be rescheduled and all future appointments scheduled as teleneurology visits. In addition, some patients were unable to utilize the Cleveland Clinic ECO platform for a variety of reasons (e.g., poor internet connectivity and insufficient time to download the application), and alternative methods including widely available technologies such as Facetime, Google Duo, and phone services were employed. There were also a variety of technical changes (e.g., increasing the number of servers utilized) that occurred to accommodate the increased volume.
There is a need to care for chronic neurological conditions during the pandemic and this study shows teleneurology was implemented as a solution for care with limited in-person exposures. There are several limitations to this study including data from a single site, only visit level data were included, and lack of provider and patient satisfaction data. Although this study had limited data, prior work from our institution utilizing the same platform had a high patient satisfatction.4 In addition, visit duration was not avalaible for this study, but in prior work on the same platform, the mean duration was 19.7 min and providers were satisfied with the visits. Anecdotally, providers did mention that in a small number of cases, in-person neurological examinations were needed.
Beyond the COVID-2019 pandemic, teleneurology is of value given the overall lack of neurological providers in different geographic areas, difficulty with transportation (especially for those with neurological disability), and a general increase in the demand for virtual care.5,6 As the 1952 polio pandemic triggered the creation of intensive care units, perhaps COVID-19 will be the trigger for a more widespread adoption of telehealth.7
Disclosure Statement
M.P.M. has served on scientific advisory boards for Genzyme and Genentech, and received research support from Novartis, and receives funding from a KL2 (KL2TR002547) grant from Clinical and Translational Science Collaborative of Cleveland, from the National Center for Advancing Translational Sciences (NCATS) component of the NIH. D.O. has received research support from the National Institutes of Health, National Multiple Sclerosis Society, Patient Centered Outcomes Research Institute, Race to Erase MS Foundation, Genentech, Genzyme, and Novartis. He has also received consulting fees from Biogen Idec, Genentech/Roche, Genzyme, Novartis, and Merck. The following authors have nothing to disclose: Z.W., M.W., S.S., and M.S.
R.B. has served as a consultant for Biogen, Genzyme, Genentech, and Novartis and receives research support from Biogen, Genentech, and Novartis.
Funding Information
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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