Learning Teleneurology Basics: A Case-Based Approach 3030714772, 9783030714772

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Learning Teleneurology Basics A Case-Based Approach

Swathi Beladakere Ramaswamy Sachin M. Bhagavan Raghav Govindarajan Editors

Learning Teleneurology Basics

Swathi Beladakere Ramaswamy Sachin M. Bhagavan Raghav Govindarajan Editors

Learning Teleneurology Basics A Case-Based Approach

Editors

Swathi Beladakere Ramaswamy Department of Neurology University of Missouri Columbia, MO USA

Sachin M. Bhagavan Department of Neurology University of Missouri Columbia, MO USA

Raghav Govindarajan Department of Neurology University of Missouri Columbia, MO USA

ISBN 978-3-030-71477-2    ISBN 978-3-030-71478-9 (eBook) https://doi.org/10.1007/978-3-030-71478-9 © Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Contents

1 Tele-Neurology Curriculum: A Primer �������������������������   1 Swathi Beladakere Ramaswamy and Raghav Govindarajan 2 Telemedicine and Technology�����������������������������������������  11 Swathi Beladakere Ramaswamy 3 Tele-History and Tele-­Examination�������������������������������  23 Sachin M. Bhagavan, Brandi R. French, and Adnan I. Qureshi 4 Webside Manners and Ethical Issues�����������������������������  47 Lakshmi Digala, Garima Singh, and Kunal Malhotra 5 Medicolegal and Ethical Issues in Telemedicine: Dizziness Case�������������������������������������������������������������������  63 Daniyal Saeed, Haris Zahoor, Keerthivaas Premkumar, and Premkumar Nattanmai Chandrasekaran 6 Licensing and Regulatory Issues�������������������������������������  77 Aisha Abdulrazaq and Mubarak Abdulrazaq 7 Current State of Tele-­Neurology �����������������������������������  91 Shivangi Singh and Niraj Arora 8 Payment Models for Tele-­Neurology (ALS Case)������� 103 Vovanti Tivoli Jones, Swathi Beladakere Ramaswamy, and Raghav Govindarajan v

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9 Parkinson’s Disease and Future Trends in Telemedicine����������������������������������������������������������������� 113 Tejas R. Mehta and Chinedu Obi 10 Remote Monitoring in Tele-Neurology (Sleep Apnea Case) ��������������������������������������������������������� 125 Swathi Beladakere Ramaswamy, Sachin M. Bhagavan, and Pradeep K. Sahota 11 Application of Telemedicine in Research (Clinical Trial Case)��������������������������������������������������������� 139 Tejas R. Mehta 12 Digital Revolution in Tele-Neurology During COVID 19 Pandemic (Neuro-Oncology Case)������������� 151 Swathi Beladakere Ramaswamy and Sachin M. Bhagavan Model Four Weeks Tele-Neurology Clerkship Curriculum for Medical Students (M3/M4) ����������������������� 159 Model Four Weeks Tele-­Neurology Elective for Residents/Fellows������������������������������������������������������������� 160 Index����������������������������������������������������������������������������������������� 161

Contributors

Aisha  Abdulrazaq  Department of Neurology, University of Missouri, Columbia, MO, USA Mubarak  Abdulrazaq Department of Law, University of Lagos, Lagos, Nigeria Niraj  Arora Department of Neurology, University of Missouri, Columbia, MO, USA Sachin  M.  Bhagavan Department of Neurology, University of Missouri, Columbia, MO, USA Premkumar  Nattanmai  Chandrasekaran Neurology Department, University of Missouri, Columbia, MO, USA Lakshmi  Digala Division of Nephrology, Department of Medicine, University of Missouri, Columbia, MO, USA Brandi  R.  French Department of Neurology, University of Missouri, Columbia, MO, USA Raghav Govindarajan  Department of Neurology, University of Missouri, Columbia, MO, USA Vovanti  Tivoli  Jones  Department of Physical Medicine and Rehabilitation, University of Missouri, Columbia, MO, USA Kunal  Malhotra Division of Nephrology, Department of Medicine, University of Missouri, Columbia, MO, USA Tejas  R.  Mehta Department of Neurology, University of Missouri, Columbia, MO, USA vii

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Contributors

Chinedu  Obi Department of Neurology, University of Missouri, Columbia, MO, USA Keerthivaas  Premkumar School of Medicine, University of Missouri, Columbia, MO, USA Adnan  I.  Qureshi  Department of Neurology, University of Missouri, Columbia, MO, USA Swathi  Beladakere Ramaswamy  Department of Neurology, University of Missouri, Columbia, MO, USA Daniyal  Saeed  School of Medicine, University of Missouri, Columbia, MO, USA Pradeep K. Sahota  Department of Neurology, Sleep Disorder Center, University of Missouri, Columbia, MO, USA Garima  Singh Burrell Behavioral Health, Columbia, MO, USA Shivangi  Singh  School of Medicine, University of Missouri, Columbia, MO, USA Haris  Zahoor School of Medicine, University of Missouri, Columbia, MO, USA

Chapter 1 Tele-Neurology Curriculum: A Primer Swathi Beladakere Ramaswamy and Raghav Govindarajan

Discussion Neurology is a branch of clinical medicine that deals with patients with brain, spinal cord, nerves, and muscles disorders. Like any other medical specialty, diagnosing accurately is critical for management of patient [1]. Although the neurological system requires the most complicated examination in medicine, it is the patient history that is the key to making the neurological diagnosis [1]. Tele-neurology is the use of modern communication technology to enable neurology to be practiced when the doctor and patient are not present in the same place, and possibly not at the same time [1]. The emerging field of tele-neurology is delivering quality care to neurologic patients in increasingly numerous technologies ­ and configurations [2]. However, formalized medical training has not caught up with this developing field, and there is a lack of formal education concentrating on the specific opportunities and challenges of tele-neurology [2].

S. Beladakere Ramaswamy (*) · R. Govindarajan Department of Neurology, University of Missouri, Columbia, MO, USA e-mail: [email protected] © Springer Nature Switzerland AG 2021 S. Beladakere Ramaswamy et al. (eds.), Learning Teleneurology Basics, https://doi.org/10.1007/978-3-030-71478-9_1

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Tele-neurology requires specific knowledge and skills that the most common Accreditation Council for Graduate Medical Education (ACGME) milestones might not address [2]. In response, the American Academy of Neurology (AAN) Telemedicine Work Group [2] formed an education subgroup to develop a framework for a formal tele-neurology curriculum in residency programs [2]. Various modules have been suggested by the work group that would align with the next accreditation of ACGME and also has room to modify to suit individual needs [2]. Table 1.1 Table 1.1 Model curriculum and suggested evaluation of equivalencies Timeline Didactics Type of evaluation Vignette-based multiple-­ Module 1 Technological choice questions and journal (2 hours) aspects of tele-­ club neurology, basic implementation, and limitations Module 2 (1 hours)

Licensure and medicolegal issues and ethics

Vignette-based multiple-­ choice questions and journal club

Module 3 (4 hours)

Provider–patient relationship, professionalism, and webside manners

Case-based simulations/ objective structured clinical examination, 360° evaluation including tele-mentoring and journal club

Module 4 (1 hours)

Informed consent and patient privacy

Case-based simulations/ objective structured clinical examination, 360° evaluation including tele-mentoring and journal club. Option of self-­ reflection essay on the future role of tele-neurology at the end of the training modules

Module 5 (4 hours)

History, examination, and documentation in tele-neurology

360° evaluation including tele-mentoring, objective structured clinical examination, and journal club

Chapter 1.  Tele-Neurology Curriculum: A Primer

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briefly outlines the various modules and their suggested evaluation of equivalencies. A good foundation of technical knowledge is essential for safe and effective practice [2, 3]. Module 1 focuses on learning about different delivery models, technological basics, and artifacts in the interpretation of tele-neurologic data and reviewing commonly used terminology [2, 3]. The licensure and medicolegal considerations associated with the practice of tele-neurology vary from state to state and are continuously evolving [4]. Module 2 is all about approaching legal issues on a case-by-case basis with involvement of legal and regulatory advisors at the academic hospital [4]. Developing a provider–patient relationship is the key to a successful therapeutic alliance and forms the basis of the art of healing [5]. Overdependence on the technology must not compromise the provider–patient relationship [5]. Module 3 aims at teaching neurology residents the technique and challenges behind developing a provider–patient relationship [6]. A thorough understanding of Health Insurance Portability and Accountability Act and the Health Information Technology for Economic and Clinical Health Act should be observed and followed [7]. Module 4 is all about how neurologists must inform their patients of the security of personal data, including details on what information is being accessed and by whom [8], and disclose information (financial, professional, or personal) that could potentially bias their choices and influence a patient’s understanding or use of the information, products, or services offered on tele-­neurology websites [9]. The neurologic history and examination need to begin with the expectation from the provider that the patient will receive the same standard of care as with any other encounter [10]. Teleneurology is effective for obtaining a complete neurologic history if the provider has clear communication and effective interpersonal skills [10]. Module 5 includes simulations to practice physical examination and certain standardized scores (Mini-Mental State Examination, NIH Stroke Scale, Expanded Disability Status Scale) [11] and familiarize with tele-neurology technology

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like reviewing patient’s records, moving cameras, etc. [12]. Currently, there are certain parts of neurological examination that is not appropriate for tele-neurologic consultation as mentioned in Table 1.2, but with evolving technology and diverse practice of telemedicine, some of these limitations may be overcome in the future [10]. Healthcare professionals, like a registered nurse, physician assistant, nurse practiTable 1.2 Degree of appropriateness for tele-neurological consultation Likely not Appropriate Difficult but possible appropriate Comprehensive Detailed motor Functional strength vestibular testing testing (reliant on testing and sensory (given current the tele-presenter examination peripheral devices to determine tone (spinothalamic tests in existence) and specific grades and vibration with of Medical Research the help of a tele-­ Council grading presenter) scale) Cerebellar and gait testing (movement disorders physicians have been some of the earlier and most successful adopters of telemedicine)

Muscle stretch reflexes testing

Comprehensive neuro-­ ophthalmologic (without requisite peripherals)

Mental status examination including cognitive scales

Proprioception

Comprehensive neuromuscular examination

Cranial nerve examination (the funduscopic examination currently requires peripheral devices that are not always available)

Functional testing for positive psychogenic examination components

Brain death examination

Chapter 1.  Tele-Neurology Curriculum: A Primer

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tioner, telehealth technician, or referring physician, can play the role of tele-presenter who are co-located with the patient and help overcome some difficulties with virtual examination [10]. Once the modular training process is completed, it is important to have a method to evaluate the trainee and measure their performance [2]. Each residency can define their own objectives for the tele-neurology rotation and develop individualized milestones based on the content mentioned in each module [2]. The programs can define a minimum number of tele-neurology patients (both inpatient and outpatient) that each resident needs to evaluate, document, and log to achieve clinical competency [2]. The American Academy of Neurology (AAN) Telemedicine Work Group [2] has identified ways to evaluate the resident’s proficiency in tele-­ neurology, which has been briefly described in Fig. 1.1. The overall goal of any Neurology Clerkship program is to teach the principles and skills necessary to recognize and manage neurologic diseases a general medical practitioner is most likely to encounter in practice [2, 14]. This technology also allows to build a clerkship program that is virtual and helps the medical students to access the information from anywhere, at their convenience, and to have better audiovisual learning through video libraries, simulations, games, podcasts, virtual patient rounds, lectures, webinars, etc. [2, 14]. Social media can also be utilized, for example, Twitter rounds and Facebook webinars. It is possible to categorize these virtual platforms to clinical, nonclinical, independent learning, and peer teaching strategies [2, 14]. The resources that can be included for clinical strategies are clinic video libraries (neuro-examination, neuro-­ ophthalmology videos), AAN and global neurology conferences, comprehensive simulated patient encounters ­ through i-Human and Medscape simulation portals, virtual patient rounds, and telemedicine clinical precepting [13, 14]. Nonclinical strategies include lectures, discussions, demonstrations, webinars, workshops, audio streaming media, podcasting, and games. For effective assimilation of knowledge

Figure 1.1  Methods to evaluate resident’s proficiency in tele-neurology as per the American Academy of Neurology (AAN) Telemedicine Work Group

On teleneurology 360˚ evaluations (where attending, patients, peers, and allied health care professionals asses the residents and residents assess themselves as well as evaluate the rotation) are ideal for the improvement of teleneurolog rotations.

Self-reflection essay on the future role of teleneurology in the trainee’s practice or journal club discussion.

10-20 clinical vignettes with multiple-choice questions to assess resident’s knowledge in technology. medicolegal issues, and professional/ethical standards.

Objective structured clinical evaluation of different teleneurology cases.

Case simulation to assess webside manners.

Direct supervision of the resident’s tele-neurology history and examination skills.

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and understanding concepts, appropriate learning methods need to be inculcated in clerkship programs [13, 14]. One method may be superior/inferior to others based on the topic of discussion. Table 1.3 describes the various learning strategies that can be implemented in virtual clerkship programs. This book is an attempt to shed light on various aspects of tele-neurology through simple case-based approach and to help students, residents, and physicians to adapt telemedicine

Table 1.3 Description of various learning strategies that can be implemented in virtual clerkship programs Methods Description Self-directed Learners taking the initiative for their own learning learning: diagnosing needs, formulating goals, identifying resources, implementing appropriate activities, and evaluating outcomes Independent learning

Instructor- or mentor-guided learning activities to be performed by the learner outside of formal educational settings (classroom, lab, clinic)

Peer teaching

Mutual learning through topic presentations, discussion boards, journal clubs, conferences. May be “peer-to-peer” (same training level) or “near-­ peer” (higher-level learner teaching lower-level learner)

Case-based learning

Use of patient cases (actual or theoretical) to stimulate discussion, questioning, problem solving, and reasoning on issues pertaining to the basic sciences and clinical disciplines

Problem-­ based learning

Use of carefully selected and designed patient cases that demand from the learner acquisition of critical knowledge, problem-solving proficiency, self-directed learning strategies, and team participation skills as those needed in professional practice

Tutorial

Instruction provided to a learner or small group of learners by direct interaction with an instructor

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approach in their practice. This book is arranged as clinical vignettes with tele-neurology approach and the advantages and disadvantages of such encounters. Each chapter then discusses one important aspect of tele-neurology in depth for better understanding.

References 1. Patterson V. Teleneurology. J Telemed Telecare. 2005;11(2):55–9. 2. Govindarajan R, Anderson ER, Hesselbrock RR, et  al. Developing an outline for teleneurology curriculum: AAN Telemedicine Work Group recommendations. Neurology. 2017;89(9):951–9. 3. The American Telemedicine Association. Telemedicine, Telehealth, and Health Information Technology. Available at: http://www.who.int/goe/policies/countries/usa_support_tele. pdf?ua51. Accessed Mar 2020. 4. Federation of State Medical Boards. Myths and facts about the interstate medical licensure compact. Available at: fsmb.org/ Media/Default/PDF/Licensure/InterstateCompactMyths.pdf. Accessed Mar 2020. 5. Wallan SW.  AAFP still searching for right stance on telemedicine. MedPage Today. Available at: medpagetoday.com/ MeetingCoverage/AAFP/53886. Accessed 1 Dec 2015. 6. Stewart M, Roter D.  Which facets of communication have strong effects on outcome? A meta-analysis. In: Stewart M, Roter D, editors. Communicating with medical patients (SAGE series in interpersonal communication). Newbury Park: Sage Publications; 1989. p. 183–96. 7. US Department of Health & Human Services. HITECH Act enforcement interim final rule. Available at: hhs.gov/hipaa/ forprofessionals/special-­t opics/HITECH-­a ct-­e nforcement-­ interimfinal-­rule/index.html. Accessed Mar 2020. 8. Johnson ML, Warner D.  Telemedicine services and the health record. J AHIMA. 2013 update. Available at: library.ahima.org/ PB/Telemedicine#.WFrh0VUrKpo. Accessed Mar 2020. 9. Vermont Board of Medical Practice. Policy on the appropriate use of telemedicine technologies in the practice of medicine. Available at: http://www.healthvermont.gov/sites/

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default/files/documents/2016/12/BMP_Policies_Vermont%20 Telemedicine%20Policy_05062015%20.pdf. Accessed Mar 2020. 10. Craig JJ, Mcconville JP, Patterson VH, Wootton R. Neurological examination is possible using telemedicine. J Telemed Telecare. 1999;5:177–81. 11. Kane RL, Bever CT, Ehrmantraut M, Forte A, Culpepper WJ, Wallin MT.  Teleneurology in patients with multiple sclerosis: EDSS ratings derived remotely and from hands on examination. J Telemed Telecare. 2008;14:190–4. 12. Loh PK, Ramesh P, Maher S, Saligari J, Flicker L, Goldswain P.  Can patients with dementia be assessed at a distance? The use of telehealth and standardised assessments. Intern Med J. 2004;34:239–42. 13. Chhetri SK.  E-learning in neurology education: principles, opportunities and challenges in combating neurophobia. J Clin Neurosci. 2017;44:80–3. 14. Genes to Society: A Curriculum for the Johns Hopkins University School of Medicine. https://www.hopkinsmedicine.org/som/curriculum/genes_to_society/year-­three/core-­clerkship-­neurology. html. 11 Aug 2020.

Chapter 2 Telemedicine and Technology Swathi Beladakere Ramaswamy

Case Ms. Smith, a 28-year-old female, presented to her primary physician with complaints of headache, which is insidious onset, gradually progressing, present for the last 4 weeks, and located bi-frontally; has no radiation or reference; is often associated with nausea and vomiting; worsens with bending over, coughing, and laying down; and has no relief from any over-the-counter pain medications. Over the last 1-week period, the patient has also noted poor peripheral vision in both eyes. She denied any retro-orbital pain, pain with eye movements. She has no significant past medical history, except facial acne for which she is on oral tretinoin. She also has no personal or family history of migraine, cluster, or tension headache. The closest institution where a neurologist is available is 2 hours away.

S. Beladakere Ramaswamy (*) Department of Neurology, University of Missouri, Columbia, MO, USA e-mail: [email protected] © Springer Nature Switzerland AG 2021 S. Beladakere Ramaswamy et al. (eds.), Learning Teleneurology Basics, https://doi.org/10.1007/978-3-030-71478-9_2

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Tele-Neurology Consult Approach Using video conferencing system, complete history and examination, including higher mental function, cranial nerves, motor system, and coordination examination, was performed. Close-up images allowed evaluation of pupillary light reflexes. But fundoscopy was not performed. Based on the information obtained from the encounter, there was high suspicion that the patient’s headache was secondary to idiopathic intracranial hypertension (IIH). The patient was immediately referred for ophthalmology evaluation, which noted grade 1 papilledema. Magnetic resonance imaging (MRI) of the brain, which was obtained near the patient’s residence, showed no space-occupying lesion when reviewed remotely. She underwent outpatient lumbar puncture by intervention radiology with an opening pressure of 27 cm H2O. The patient was educated about weight loss with dietician referral, discontinued tretinoin, and started acetazolamide 500  mg bid. Her medication was titrated every 3–4  weeks based on response, and she was scheduled with ophthalmology every 3–6  months for papilledema and visual field follow-up. The patient’s headache significantly improved in the next few weeks; her papilledema was gradually resolved. Advantages  The patient could obtain specialty advice from home. All the investigations and results of the consultations performed were reviewed remotely. Her medication titration was done remotely, and she didn’t miss any work days to keep up with clinic appointments. This early encounter with a tele-­ neurologist led to timely diagnosis and appropriate medical management, preventing the development of inadvertent complications of IIH like blindness secondary to optic atrophy, ischemic optic neuropathy, or retinal vascular occlusion associated with papilledema. Disadvantages  There is a technological limitation in performing fundoscopy and lumbar puncture remotely, and at some

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point, the patient had to physically go to the hospital/clinic to complete the evaluation. There was no one access point which provided all the services at the same time. Solution  The solution is to use appropriate peripherals (e.g., panoptic ophthalmoscope) and to choose the right patients for telemedicine consultation to overcome the technological limitations during consultative visits. The following discussion helps us understand the different kinds of telemedicine physician and patient encounter models, their advantages/disadvantages, and the new innovations that are being explored to overcome such technological limitations.

Discussion Telemedicine focuses on the clinical application of medical practice. There is however a large technical component that needs to be set up and needs close relationship with information technology (IT). The selection of best options is dependable on cost, sustainability, and scalability. It is important for all the selected technological platforms to be Health Insurance Portability and Accountability Act (HIPAA) compliant [1–3]. Different types of patient-physician interface are described in Fig. 2.1.

Types of visits

Remote monitoring

Consulative visits

Facilitated visits

Figure 2.1  Different types of patient-physician interface

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Remote Monitoring This program includes self-administered diagnostic tools. Software algorithms are used to process the electronic data obtained from user to provide feedback. This application is used only for the most basic and error-tolerant methods and devices. If the values obtained are misread or out of the patient’s target range, the software alerts the providers, leading to a follow-up contact by phone. These platforms aim to reduce avoidable hospital readmissions by identifying medical conditions early enough to be effectively treated at home [3–6].

Consultative Visits This program involves interaction of both parties (physician-­ patient or physician-physician) through video conferencing, at the end of which opinion is offered. When one clinician consults another through this portal, it is known as teleconsultation. These platforms are easier to arrange as it doesn’t require compliant medical devices, facilitation, or a patient to go to a clinic [7–8].

Facilitated Visits This program is designed for more detailed physical examination and integrates medical devices into the live visit. Applications used are referred to as Provider Access System (PAS). Class 1 (devices that have a low to moderate risk to the patient and/or user) and sometimes class 2 (devices that have a moderate to high risk to the patient and/or user) medical devices are integrated into the live video stream. The advantage of these platforms is that they have a full range of visit options in one portal rather than the need to switch between interfaces to have the same experience [9]. A facilitator or clinician is required to help patients with operating these integrated medical devices. Their role is to ensure the proper use of devices and to perform sanitation

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tasks at completion. With technological advancements, there are now devices available which can be operated by the patient at home without the help of a facilitator [10]. These platforms aim to increase access to convenience or frequency of diagnostic, specialty, or follow-up care and to reduce avoidable hospital readmissions. Because of the equipment and staffing requirements of this platform, patients must still travel to the examination site, but that site should be close to them compared to the traditional point of care. Proximity to skilled and specialty care can be greatly enhanced in captive (jails and prisons) or semi-captive (schools, workplaces, skilled nursing facilities) patient settings using this type of platform [11]. Table 2.1 summarizes the various models and respective financial coverage for the same. Table 2.1  Different delivery and financial models Technological Delivery model Description model Remote patient Remotely Data collected monitoring collecting serial or through various continuous data sentences over self-­injury and data trends are monitored in real time Mobile health

Application on person completing devices designed to collect health information, provide personal head guidance, and facilitate interactions with remote providers

Financial model Medicaid and third-­ party cover. Medicare does not cover

Personal smart Variability phone connected in coverage. to applications Most third party does of work, not cover information available through authenticated with portal access, or exported to an electronic or personal health record (continued)

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Table 2.1 (continued) Delivery model Description Store and forward

Services delivered remotely but not requiring the patient to be present during implementation

Teleconsultation Video conferencing to provide remote and direct patient care

Technological model

Financial model

Data obtained/ Medicaid and most recorded and stored for review third party at a later date. cover. Medicare Synchronous does not patient care cover Two-way, interactive, real-time view sessions at a band with sufficient to allow for synchronous patient care

Supported by Medicare, Medicaid, and major third-­party payers in most states

Grant-­ Group of Multisite Medial funded specialists at co-management conferencing systems are used University Medical Center to connect live multisite meeting contact with between specialists primary care and providers to providers in rural or discuss complex underserved area patients but patients may not or correctional necessarily be seen facilities to discuss care

Methods of Video Conference Delivery There are two main ways of video conferencing in telemedicine and administrative setting. One is to purchase a solution from a vendor and have it installed in a practice’s data center

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Table 2.2  Videoconferencing solutions On-premises solution Hosted solution Purchase a solution from a Buying video conferencing as a vendor and have it installed in service from a vendor a practice’s data center Security control of solution and management by own staff

Vendor hosts all of the hardware in their own data center and provides maintenance for the equipment

Requires IT staff with the expertise and resources to maintain and administer complex video systems in addition to their existing duties

Important to engage your legal team to see if a Business Associate Agreement (BAA) is appropriate or required before a patient visit takes place over a hosted video solution

The deployments can come in many sizes and flavors, including the possibility of going off network to communicate with other systems. It takes time to fully evaluate all of the available options

More flexibility for growth since it reduces the need to upgrade a set of equipment that you own. Instead, you can simply increase your agreement with the vendor, and it is their responsibility to provide the necessary upgrades

known as “on-prem” solution, and the other is a hosted solution, which is buying video conferencing as a service from a vendor. The differences between these solutions are compared in Table 2.2 [3]. The current technological evolution will result in a time where all the hardware-based video room systems (video codecs) will be replaced by software solutions with the medical devices that support USB. Software solutions will be more cost-effective [3]. Software-defined wide-area network (SD-WAN) technology allows all of the features that used to be locked into the hardware to be dynamically configured in software instead. This also allows remote administrators and

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monitoring systems to keep an eye on connections and make configuration changes by simple, menu-driven interfaces. It is now possible for a telemedicine system on the network at a distant facility, owned by another organization, to use their existing Internet connection while remaining completely isolated from all other devices on their network. This turns an otherwise complex IT project into a phone call to answer a few simple questions [10, 12].

Telemedicine Carts and Peripherals Telemedicine carts are systems that integrate cameras, displays, and network access to bring remote physicians right to the side of the patient. Telemedicine peripherals are clinically focused products that seamlessly connect to telemedicine carts and existing devices to share diagnostic data with remote providers and empower informed assessments. Figure  2.2 shows telemedicine cart and peripherals, respectively.

Fig. 2.2  Telemedicine cart (left), telemedicine peripherals: digital stethoscope (middle) and otoscope (right)

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Systems of Operation Early in the process of building a telemedicine program, it is important to decide whether open or closed system of operation will be used as this would significantly affect the direction of the program’s growth. Table 2.3 briefly describes the stark differences between the two systems [10, 12].

Technical and Support Staff Supporting a telemedicine program requires a unique set of skills compared to a standard IT position. The support staff should have excellent communication skills and should have the ability to speak in a plain, nontechnical language that end users can understand. The skill set should also include a good

Table 2.3  Different types of building telemedicine programs Open system Closed system Hardware and software Hardware and software are from third parties and can designed, developed, provided, and come as a turn-key system supported by a single manufacturer or be sold as a component as a turn-key product and that does of a telemedicine system not support the use of third-party that can be self-assembled devices or components Very flexible and dynamic. There is freedom to use the devices and software of your choosing, while maintaining the ability to change direction without starting over. Upgrades can be more incremental, and workflows can be designed to map closely to your existing clinical procedures

Very polished with highly specialized workflow and target specific clinical modalities. But will have to scrap the entire workflow in case it does not match the latest clinical operating style

Users will appreciate the fact that the system adapts and responds to them, rather than being told to work the way the system requires

User experience is more congruous and easier

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understanding of how video works, networking, firewall, and basic PC skills. This aspect of telemedicine if overlooked can result in ultimate failure, as lack of support makes a platform seem unfriendly. Existing IT department along with a telemedicine specialist as the leader can form a great support staff for users [3, 12].

References 1. Akiyama H, Hasegawa Y. A trial case of medical treatment for primary headache using telemedicine. Published online 2018 March 2. https://doi.org/10.1097/MD.0000000000009891. 2. Müller K, Alstadhaug KB, Bekkelund SI.  A randomized trial of telemedicine efficacy and safety for nonacute headaches. Neurology®. 2017;89:153–62. 3. Baker J, Stanley A.  Telemedicine and technology: a review of services, equipment and other aspects. Published online: 26 September 2018. Springer Science+Business Media, LLC, Part of Springer Nature 2018. 4. Barrett M, Combs V, Su JG, Henderson K, Tuffli M, Collaborative AIRL, et al. AIR Louisville: addressing asthma with technology, crowdsourcing, cross-sector collaboration, and policy. Health Aff (Millwood). 2018;37(4):525–34. https://doi.org/10.1377/ hlthaff.2017.1315. 5. Merchant RK, Inamdar R, Quade RC. Effectiveness of population health management using the propeller health asthma platform: a randomized clinical trial. J Allergy Clin Immunol Pract. 2016;4(3):455–63. https://doi.org/10.1016/j.jaip.2015.11.022. 6. Chan DS, Callahan CW, Sheets SJ, Moreno CN, Malone FJ. An Internet-based store-and-forward video home telehealth system for improving asthma outcomes in children. Am J Health Syst Pharm. 2003;60(19):1976–81. 7. Kim MY, Lee SY, Jo EJ, Lee SE, Kang MG, Song WJ, et  al. Feasibility of a smartphone application-based action plan and monitoring in asthma. Asia Pac Allergy. 2016;6:174. 8. Lai F.  Robotic telepresence for collaborative clinical outreach. Stud Health Technol Inform. 2008;132:233–5. 9. Waller M, Stotler C. Telemedicine: a primer. Curr Allergy Asthma Rep. 2018;18:1–9. https://doi.org/10.1007/s11882-­0 18-­0807-­5.

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10. A review of the regulatory issues surrounding the practice of telemedicine. Shih J, Portnoy J.  Tips for seeing patients via telemedicine. Curr Allergy Asthma Rep. 2018;18(10):50. https:// doi.org/10.1007/s11882-­0 18-­0807-­5. An overview of how to see patients using facilitated telemedicine. 11. Matimba A, Woodward R, Tambo E, Ramsay M, Gwanzura L, Guramatunhu S. Tele-ophthalmology: opportunities for improving diabetes eye care in resource- and specialist-limited sub-­ Saharan African countries. J Telemed Telecare. 2016;22(5):311–6. https://doi.org/10.1177/1357633X15604083. 12. Taylor L, Capling H, Portnoy J.  Administering a telemedicine program. Curr Allergy Asthma Rep. 2018;18:1–7. https://doi. org/10.1007/s11882-­0 18-­0807-­5. A discussion of issues regarding the administration of a telemedicine program.

Chapter 3 Tele-History and Tele-­Examination Sachin M. Bhagavan, Brandi R. French, and Adnan I. Qureshi

Case Mr. Sol, a 60-year-old gentleman, was out in the woods, enjoying vacation with his children and grandchildren in a cabin. He went inside the cabin to get some water and his family heard a loud sound; when they checked on him, he was on the ground. He was awake and started complaining that he was not able to move his left arm and left leg and felt kind of heavy. This was around 8 pm, before which he was completely normal. His family also noticed that his left side of the face was drooping and that he had a slurring speech. His family then called 911, and EMS (emergency medical services) arrived in 15 minutes. His medical history is significant for atrial fibrillation (not on any anticoagulation), hypertension, and diabetes mellitus. He has significant smoking history (30 pack-years). A code stroke was activated by EMS following evaluation, and the patient was taken to the nearest ER (emergency room) by 8:45  pm. The hospital was a small 20-bed hospital with no neurologist on site but had

S. M. Bhagavan (*) · B. R. French · A. I. Qureshi Department of Neurology, University of Missouri, Columbia, MO, USA e-mail: [email protected] © Springer Nature Switzerland AG 2021 S. Beladakere Ramaswamy et al. (eds.), Learning Teleneurology Basics, https://doi.org/10.1007/978-3-030-71478-9_3

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tele-­stroke facility in association with a tertiary center. The nearest in-house neurology service was about 2.5 hrs away.

Tele-Neurology Consult Approach On-call neurologist at the tele-stroke center was contacted via video conference call. There was a technician (tele-­ presenter) in the room who had already set up the video call 5 minutes prior to the patient’s arrival. The neurologist was briefed about the patient’s presentation, and last known well was confirmed at 8  pm. Point-of-care glucose was 112. The National Institutes of Health Stroke Scale (NIHSS) was 8, which was completed with the help of a tele-presenter. Computed tomography (CT) head was obtained immediately, and the images were reviewed by a tele-stroke specialist remotely. CT head was negative for intraparenchymal hemorrhage or early changes of ischemic stroke. After ruling out absolute contraindications for alteplase and with the consent of the patient and his family, intravenous (IV) alteplase was initiated at 9:15  pm. CT angiography of the head and neck was obtained, which showed right distal M1 occlusion. Neuro-­ interventionist at the closest comprehensive stroke center was contacted via multipoint video conference; the decision to proceed with mechanical thrombectomy was made. The patient was then airlifted and underwent procedure by 11 pm. Post-IV alteplase and post-procedure patient’s symptoms significantly improved with NIHSS 2. Advantages  The biggest advantage in this encounter was immediate and timely availability of a specialized consultant. This reduces time to diagnosis for rapid treatment. For hospitals who do not have an in-house neurological expertise and those present in underserved areas, tele-stroke creates a virtual bridge offering expertise at critical times. It has been seen that only about one-third of Americans live an hour from a stroke center and only about 27% of patients arrive at the hospital within 3.5 hours of symptom onset [1, 2]. Due to

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the concept of tele-stroke, geographical barrier has been reduced, thereby catering to more population than before. Due to tele-stroke, there is improved rate of administering alteplase. Lastly, there is reduced cost by decreasing strokerelated disability and cost of inpatient rehabilitation. The recent analysis showed that the use of tele-stroke saves about $2227 per patient in the cost of nursing home alone [3]. A study predicted that about $358,435 per year could be saved with a tele-stroke network as compared to without tele-stroke during the first 5 years [4]. Disadvantages  Even though tele-stroke evaluation is reliable for performing standardized NIHSS, few components of the NIHSS cannot be performed remotely. Tests like complex visual field testing and limb ataxia and sensory evaluation cannot be performed. Also, the NIHSS is not a substitute for complete neurological examination, and hence physical assessment of tone, motor strength, reflexes, and vestibular apparatus cannot be tested. Patients with posterior circulation strokes presenting with dizziness and vertigo have very subtle exam findings like mild nystagmus, which could be missed. Stroke mimics, like migraine, seizures, or functional disorders, can be easily missed, given the absence of complete neurological exam. With very little time available during a code stroke to make a decision, sometimes inappropriate administration of alteplase to stroke mimickers is a possibility. Solution  Few disadvantages can be decreased by having neurologically trained tele-presenter on site, who can actually perform full neurological examination. The training should include eliciting special signs like nystagmus, head impulse test, Hoover’s test, etc. Although this might not be completely accurate, it could bridge the gap to an extent. Also incorporating TeleStroke Mimic Score (TM-Score) to the evaluation of stroke mimics could minimize the treatment of stroke mimics as this score is based on factors independently associated with mimics [5, 6].

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Discussion The field of tele-neurology has been expanding in the current times. It has been accepted as a legitimate method of delivery in many areas. Development of advanced digital equipment and the experience of incoming generation to the digital world are decreasing the gap between in-person and distant communication. Therefore, it is of utmost importance to develop a good history taking and examination skills for everyone to adapt to this change. This section will deal with how to take history, do a physical examination, and document the findings during a tele-visit with emphasis on stroke case. History taking has been an important part of patient encounter since the inception of medicine. Although the method of history taking feels no different as compared to previous times, special emphasis has to be given on certain aspects. Before beginning a tele-neurology encounter, it is best to emphasize on the expectations from this encounter [7]. Having a tele-presenter (registered nurse, telehealth technician, physician assistant, or nurse practitioner present in the same location as the patient and trained to assist with tele-­ visit) would be very beneficial; however, some places might not have any tele-presenter. Tele-neurology may not be a hurdle for chronic follow-ups as the patient already has a rapport with the doctor, but new establishment of care may be difficult. Patients may not be forthcoming in a new encounter; hence, special emphasis needs to be given to break that barrier, and all attempts should be made to make the patient feel at ease and welcome. History taking also depends on the encounter; a clinic encounter with an alert, oriented patient who is able to respond appropriately would be an ideal encounter for tele-visit, while a clinic encounter with demented patient might be challenging and further collaboration from family might be required. Basic history should focus on the onset, duration, progression, and aggravating and relieving factors. In an emergency setting like an acute stroke, focused history including last known well should be clarified before proceeding with management. In any situa-

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tion, collateral information from the family must be emphasized to gain insight into the patient’s problems for accurate diagnosis, as there may be limitation in eliciting specific signs on examination. Physical examination is the next step after history taking in a patient encounter. It is always good to know the tele-­ presenter experience and level of training as it plays a vital role in providing critical portion of examinations, although there is no evidence as to what level of training is required for an ideal tele-presenter [8]. Examination must be done in as much detail as possible.

General Physical Examination Pulse can be measured by light-emitting diode (LED) sensors and smartphone cameras which can send data wirelessly to the clinician office [7]. Automated upper arm blood pressure devices are available, which can be put on independently or with the help of a tele-presenter. Wireless smartphone applications paired with a wireless blood pressure monitor, thereby turning them into a cuffless monitor, can also be used [9]. Multiple parameter monitoring devices, known as medical tricorders, are available, which can record body temperature, pulse oximetry, single-channel ECG, and blood glucose and transmit data wirelessly [9]. New signs like average steps taken, daily calorie count and wearable ambulatory blood pressure monitors can be considered while educating healthy lifestyles and comorbid management like obesity [10]. Digital stethoscopes are available for use by the patient themself or with the help of a tele-presenter at different sites on the chest for respiratory and cardiac examination [11]. The abdomen can be inspected for any scars or any protuberance. There are applications which give feedback on matching the depth and compression performed by the patients themselves to give comparable results to physician palpation. Also, integrated micro-electromechanical accelerometers can be used to measure the motion through various applications [11].

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Neurological Examination Coming to specific neurological exam, there are certain exams that can be done by a tele-neurologist alone, and most of the exams can be completed if a skilled tele-presenter is available. Evaluations and validations have to be done for accurate examinations. Besides, the tele-neurologist has to develop a good rapport and have excellent communication and interpersonal skills to obtain maximum examination from the tele-presenter. This section will deal with the different components of neurological examination that can be done through tele-neurology in detail.

Higher Mental Functions Higher mental functions can be assessed with the help of a few questions. The ability to give history can be used to gauge the level of consciousness. Alertness can be assessed by spelling the word “world” backwards or reverse counting from 10 to 1. Orientation can be assessed with the help of a few questions and their responses like patient’s age, sex, date of birth, current month, year, and president. For language, comprehension can be checked by one-step/two-step/three-step commands and seeing how they perform, for example, closing/ opening eyes or touching the left ear with the right hand. Repetition can be assessed by asking the patient to repeat a few words/sentences like “mama,” “tip-top,” “basketball player,” or “Today is a bright and sunny day.” Naming can be assessed by asking the patient to name a few popular objects like watch, gloves, or paper, which are readily available during a tele-visit. Reading can be checked by asking them to read a specific sentence on the paper provided to them. The provider can tell a patient to write a sentence on a paper and show it to the screen to evaluate writing. For detailed cognitive testing, Montreal Cognitive Assessment (MoCA) has been validated for evaluation of cognitive impairments [12]. This assessment can be per-

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formed by video teleconferencing. With the help of a tele-­ presenter, the patient can be positioned in front of the screen. The provider can simultaneously view the participant and material of the neuropsychological tests by picture-in-picture display. Visuospatial/executive component of the test can be performed by observing the patient drawing a cube and clock by the camera on the screen. Naming part can be tested by displaying animal picture one by one on the patient’s monitor by two-screen display mode [13]. Memory can be evaluated by reading the words to the patient and asking them to repeat and then recall after 5 minutes. Attention can be assessed by asking the patient to read the digits forward and backward by displaying them on the screen, instructing them to tap their finger on the table when they hear the alphabet “A,” and performing serial subtractions. Although there are limited studies to investigate the reliability and feasibility of video teleconference-mediated MoCA, the results show that they are a viable alternative to face-to-face administration [13]. Higher mental functions can be easily assessed by the above method if the patient is conscious and cooperative. For altered patients, not all examinations can be performed, and the presence of a tele-presenter would be very valuable in such circumstances.

Cranial Nerve Examination Anosmia can be evaluated crudely by having products like moth balls, camphor, or coffee in a small container and asking the patient to close their eyes and trying to identify the product from one nostril at a time with the help of a tele-presenter. Visual acuity can be evaluated by asking the patient to face a phone having multiple front-facing cameras which have the capability of face and depth detection and can automatically evaluate and scale a Snellen chart to detect abnormalities [14]. Fundus can be visualized when the patient faces smartphone-­based retinal cameras that can be used to obtain fundus images [15]. Flashlight or phone light can be held

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under each eye to observe for pupillary response. Ishihara plates can be used by the patient with one eye at a time for evaluation of color vision. Red desaturation can be evaluated by looking at a red-tipped pin or a red pen [16]. Extraocular movements can be seen when the patient faces the camera on smartphones and looks side to side and up and down [17]. Convergence can be assessed by having the patient look at a pen held in front of their face or just by looking at their nose [16]. Sensory evaluation of face can be performed crudely by the patient using icepack and comparing both sides or can be done by a tele-presenter. Ptosis, facial asymmetry, can be visualized through the camera, although subtle changes may be missed. Facial strength can be assessed by having the patient raise eyebrows and closing eyes tightly. Palatal movement can be seen when the patient can open their mouth in front of camera and say “ahhhh.” Drooping of shoulder can be seen by having the patient extend their arms in front with palms touching and the fingertips on the affected side extending beyond those on the healthy side in case of unilateral spinal accessory nerve paralysis [18]. For evaluation of strength of sternocleidomastoid muscle, the patient can place their hand on their cheek and then try to turn their head with their hand, providing resistance and looking for sternocleidomastoid contraction. Tongue deviation, fasciculations, can be seen by asking the patient to protrude his/her tongue in front of the camera. For evaluation of corneal reflex, gag reflex, Rinne test, and Weber test, a tele-presenter would be required.

Motor Examination Part of the motor examination can be performed by the provider through video teleconference. The patient can lie down on the examination bed, and the provider can see if the patient is able to lift his upper and lower extremity against gravity. Pronator drift can be assessed by extending both arms and looking for drift. Mild hemiparesis can be elicited

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by Alter sign, where the patient is asked to extend arms and fingers with palms down; the fifth finger is abducted on the side of mild hemiparesis [19]. This test would not have clinical significance if the fifth fingers of both hands are abducted. Postural tremors can be elicited by outstretched arms. Rest tremors can be seen by both arms resting on the lap, closing eyes, and stating months of the year in reverse. Other movements like chorea, myoclonus, and dystonia can be visualized with the help of video teleconferencing. Functional disorders can also be evaluated by eliciting variability and distractibility by a set of commands like counting months backward and looking for the change in movements. Muscle bulk can be assessed grossly but would need assistance of a tele-presenter for accurate measurement and reporting. For muscle tone and accurate MRC (Medical Research Council) grading of strength, a tele-presenter’s help is essential.

Motor Reflexes It is difficult to elicit motor reflexes by the patient themselves. Patients can use the side of the hand or a long-handled rubber headed spatula to check their patellar reflex. Some patients can be skilled to elicit biceps, triceps, brachioradialis, and gastrocnemius reflexes; however, the tele-neurologist needs to demonstrate the tests [16]. These test results need to be interpreted with caution. Assistance with a tele-presenter is needed for a proper examination and elicitation of these signs.

Sensory Examination This exam is very challenging; the patient can try eliciting numbness by the use of icepack or cotton ball. The use of safety pin or other sharp objects should be avoided as there is concern of injury due to it [16]. Romberg’s sign can be

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checked, but appropriate caution needs to be taken to prevent any falls. Having a family member during the encounter would help in preventing falls during this examination. The presence of a tele-presenter would help not only in eliciting sensory loss to pinprick but also in assessing vibration by tuning fork and proprioception in a more systematic way.

Cerebellar Signs and Gait Examination Finger-to-nose test can be done by asking the patient to aim for the lens of the camera; if they miss the target, their image will not be blocked out fully on screen. The patient can perform heel-to-shin test by facing the camera down and by demonstration of the test by a tele-neurologist. For assessment of gait, it is better to have a family member or a tele-presenter available in the encounter to prevent the patient from having any falls. First, make the patient stand on the chair with arms crossed to assess for proximal lower extremity weakness. If there is no concern, the tele-­neurologist can proceed with gait examination. The patient needs to adjust the angle of the camera so that their whole body is seen [16]. It is ideal to see the patient walking down the hall to and from the camera; gait parameters like stride length, arm swing, or normal or wide-based gait can be assessed, which would be helpful in diagnosing different types of gait like shuffling gait, spastic gait, hemiplegic gait, Parkinsonian gait, or scissor gait.

Other Tests Specific tests for certain neurological conditions can be performed by a tele-neurologist alone or with the help of a tele-­ presenter. Evaluation of sleep apnea by Epworth Sleepiness Scale (ESS), National Institutes of Health Stroke Scale (NIHSS) for evaluation of acute stroke, Expanded Disability Status Scale (EDSS) for multiple sclerosis, and Mini-Mental

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Status Examination (MMSE) for higher mental functions are some tests which can be performed via telehealth. Specific tests for myasthenia gravis can also be elicited by telehealth like sustained upward gaze and looking for fatigable ptosis, holding the arms outstretched for 1 or 2 minutes, and looking for arm drop. Grip myotonia can be elicited by asking the patient to hold a door knob and release it. Split-hand sign in amyotrophic lateral sclerosis (ALS) can be elicited by visualization of the hand on the camera. Table 3.1 shows examinations that can be done by a tele-neurologist and with assistance from a tele-presenter and the exams that might not be appropriate for a tele-neurology encounter [8]. Awadallah et al. showed that a remote neurological examination of core items, which is performed by high-level audiovisual telemedicine, produces very similar results to a bedside examination of an examiner with the same level of experience even in acute scenario [20]. Although there have been a very few studies for testing reliability in tele-neurology in general, tele-stroke examination has more studies with ­similar results. Alasheev et  al. found out that discrepancy between bedside and remote NIHSS scores of no more than a total of 3 points was 85.6% (95% CI: 76.6–92.1) in a total of 90 patients [21]. Evaluation of NIHSS by tele-stroke on the patient described in the case above is shown in Table 3.2.

Documentation Documentation is a very important component of a patient encounter. It not only is important for patient care but also becomes an important tool in medicolegal situations. Documentation is a little different in a tele-neurology encounter as compared to in-person encounter [22]. Firstly, names of everyone involved in the encounter (tele-neurology provider, consulting provider, tele-presenter) must be documented. Informed consent should be obtained depicting the nature of encounter, limitations, etc. The patient must understand that the tele-neurologist will determine whether the condition

Assess facial muscles strength like orbicularis oculi, buccinator Assess hearing by Rinne and Weber tests Assess corneal, gag reflex Assess strength of sternocleidomastoid and trapezius muscle Fasciculations and atrophy in tongue

Extraocular movements and convergence testing

Pupil assessment

Fundoscopy

Visual acuity and color vision assessment

Palatal assessment

Assessment of tongue deviation

Drooping of shoulder

Sensation in face at different trigeminal distribution

Assessment of smell

Cranial nerve examination

Neuro-­ophthalmic evaluation

Comprehensive vestibular testing

Unable to do in teleNeeds assistance with tele-­presenter neurology If patient has altered mental status, can elicit some signs with help of tele presenter (like arousal to pain)

Able to do by tele-­neurologist Examination independently Higher mental Assess consciousness, alertness, and function orientation by simple questions

Table 3.1  List of examination that can be performed by tele-­neurologist alone, with the help of tele-presenter and examination that are not suitable for tele-neurology encounter

34 S. M. Bhagavan et al.

Other tests

Comprehensive neuromuscular examination

Specific exams like grip myotonia, split hand sign, eliciting fatigable eye, and arm weakness

Specific exams like percussion myotonia

Brain death assessment

Gait assessment in a patient with frequent falls

Sensory assessment of crude touch, fine touch, vibration, proprioception

Some components of Mini Mental All components of MMSE, NIHSS, EDSS can be Status Examination (MMSE), performed National Institute of Health Stroke Scale (NIHSS), Expanded Disability Status Scale (EDSS), Epsworth Sleepiness Scale (ESS) be performed independently

Cerebellar and Gait assessment gait Finger to nose, heel to shin test

Romberg sign

Crude assessment of sensory loss

Sensory

Functional strength testing based on MRC grading

Alter sign All deep tendon and superficial reflex testing

Muscle tone evaluation

Any abnormal movements like tremor, dystonia, chorea, myoclonus

Patient can try knee reflex

Muscle bulk evaluation

Gross strength evaluation

Reflexes

Motor exam

Chapter 3.  Tele-History and Tele-Examination 35

Best gaze

Visual fields

Facial paresis

Motor arm: left

2

3

4

5a

He was not able to raise it against gravity at all but noted to have some movements

Was able to do so

“Can you raise your eyebrow”?

“Can you raise your left arm straight ahead and keep it until I count to 10?”

Mild left facial droop was noted

Said yes to wiggling finger in all 4 quadrants of both eyes

Was able to do so

“Can you show me your teeth”?

Asked the technician to wiggle his fingers on all 4 quadrants of each eye and asked the patient “Can you look to tip of his nose and say if you can see his fingers wiggling”?

“Can you look to the right and then can you look to the left”?

Was able to make a fist and let go

“Can you make a fist and let go?”

LOG commands

1c

Was able to close and open eyes

60

“What is your age?”

“Can you close and open your eyes?”

May

“What is the current month we are in?”

LOG questions

1b

Response by patient Was alert and responsive

What the neurologist asked Obtaining history from patient

NIHSS component Level of consciousness

S. No. 1a

3

1

0

0

0

0

0

0

Score 0

Table 3.2  Sample NIISS performed and documented in tele-­neurology encounter of the model case depicted above

36 S. M. Bhagavan et al.

Limb ataxia

Sensory

8

“Can you feel him touching you on your forehead, cheeks, below the angle of mouth, arm, and leg. If so, is it equal on both sides?”

He was able to feel sensation on his face equally but had decreased sensation in left arm and left leg

1

0

0

0

(continued)

He was able to perform with his right leg but not able to do so with his left

“Can you raise your left leg and slide it along the shin of your right leg and then repeat the same with your right leg?”

He was to raise his right leg against gravity and keep it for 5 sec He was not able to raise his left arm but was able to do it successfully in right

Asked the technician to touch his forehead, cheeks, and below the angle of mouth, arm and leg bilaterally

0

He was able to raise it against gravity, but the 2 leg dropped down to bed before 5sec

He was able to raise it against gravity and no drift was noted until count to 10

“Can you raise your left arm, make a pointer with your index finger, and touch your nose and touch the tip of the technician finger and repeat with the right arm?”

“Can you raise your right leg high and try to keep it until I count to 5?”

Motor leg: right

7

“Can you raise your left leg high and try to keep it until I count to 5?”

Motor leg: left

6a

“Can you raise your right arm straight ahead and keep it until I count to 10?”

Motor arm: right

5b

Chapter 3.  Tele-History and Tele-Examination 37

NIHSS component

Best language

Dysarthria

Extinction and inattention

S. No.

9

10

11

Table 3.2 (continued)

Could name all objects

Could repeat words and sentences

Response by patient

Was able to detect simultaneous crude touch Was able to mention number of people in the picture card

Description of picture as depicted in 9 for visual extinction

Mild dysarthria noted

Double simultaneous crude touch as elicited by technician

Evaluated while repeating the words in section 9

Showed him the picture on NIHSS stroke card Could describe the picture with normal word for description fluency

Showed him the images of objects for naming as per NIHSS stoke card

“Mama,” “Tiptop,” “Fifty-fifty,” “Today is a bright and sunny day”

“Can you repeat after me?”

What the neurologist asked

0

1

0

Score

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being diagnosed or treated is appropriate for a tele-­neurology encounter [8, 23]. Documentation of examination should be clear, depicting components of exam elicited by the tele-­ neurologist (e.g.. ptosis, extremity drift) and by a tele-­ presenter (e.g., muscle tone, muscle strength, reflexes) separately. Any pertaining exam (e.g., fundoscopy for papilledema) that could not be done due to limitation of the encounter must also be documented. For neuroimage interpretation, documentation must be clear if images were reviewed by the tele-neurologist or a report was provided by the tele-presenter without image transfer. Any error that ­limits or delays the encounter like poor Internet connection, instrument malfunction, ora poor signal quality should be documented appropriately [24]. In case of an emergency service, documentation of time of contact for the mentioned service, time of tele-connect, and time of critical treatment (like alteplase) should be documented very clearly because if there is delay due to any reason, documentation will help in undertaking future studies for a better patient care [25]. Finally, documentation about discussion of assessment and treatment with family should be done very similar to face-to-­ face encounter. Therefore, documentation in a tele-neurology encounter not only is very essential for patient care but also helps us to understand the process of workflow and to identify areas for improvement. Figures 3.1, 3.2, and 3.3 are sample documentations of the abovementioned case. In conclusion, tele-stroke and tele-neurology is increasingly accepted as a mode of health delivery in the United States. Given the current data showing promising results, it would not be long when this method of healthcare would gain popularity involving predominant population of healthcare providers. Therefore, it is important to adapt the skills necessary to perform a tele-neurology encounter as a healthcare provider. This chapter deals with how a tele-stroke encounter should be conducted in an emergency situation through an exemplary case and discusses about the history taking, examination, and documentation of the encounter, which are an important part of the tele-visit.

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10th August 2020 Teleneurology encounter details: Pateinet name/Age/Sex: john doe/60 Male Teleneurologist: Dr Smith, MD Telepresenter: Mary Lewis Referring physician: none Informed consent: verbal consent for this telehealth vist was obtained from patient or guardian prior to beginning this encounter Risks (tech failure, pricacy and security, incomplete examination) and benefits (reduced exposure to infectious disease, convenience) of using a virtual platform were reviewed and addresses prior to beginning this encounter. Chief complaint: sudden onset left upper and lower extremity weakness, left facial droop, slurred speech since about 45 min. History of presenting Illness : 60-year-old gentleman comes to xxx ER with symptoms of sudden onset left upper, lower extremity weakness,left facial droop, slurred speech that started about 8PM. Last known well 8PM on 8/10. He was enjoying his vacation with children and grandchildren at the cabin, at about 8 PM he went to kitchen for a glass of water when he was suddenly had a fall and was complaining of heaviness in his left ar and left leg, was not able to move them. He felt numb in his left upper and lower exremity. family also noticed that his left part of the face was drooping and he started developing slurring of speech. 911 was called and he was brought to the hospital at about 8:35 PM. He denies any chest pain, shortness of breath nausea, vomiting, blurry vision, double vision, word finding diffcully, difficulty swallowing, numbness of tingling in right upper and lower extremity. Past medical history : Atrial fibrillarion not on anticogulation, hypertension, diabetes mellitus Past surgical history: None Personal history: Social history:smokes 1 pack/day for about 30 years Denies alcohol consumption Denies any illicit drug use Family history: No family history of stroke/MI.

Examination: Examination of the teleneurologist: General:Pt is conscious, alert oriented to time, place, person. sitting comfortably in bed. Eye: EMOMI. Respiratory: Respirations are non-labored Cardiovascular: unable to assess Gastrointestinal: unable to assess Extremities: No edema, Psychiatric: Cooperative, Approprita mmood & affect. Neurological exam: Level of consciousness: Conscious, awake and alert Orientation: oriented to time, place and person Language: Repetition intact, naming intact, reading intact, Speech: fluency normal, mild dysarthria noted

Figure 3.1  Sample documentation in a tele-neurology encounter

Chapter 3.  Tele-History and Tele-Examination

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Cranial Nerves EOMI, No Ptosis left facial droop noted. Midline tongue protrusion. Motor No abnormal movements noted Coordination: Normal finger to nose, heel to shin test bilaterally Pronator Drift: negative Examination performed and interpreted by tele-presenter Eyes: PERRLA, anicteric, no pallor HENT: Normocephalic, atraumatic, oral mucosa moist, No JVD. Respiatory: Lungs are clear to auscultation, Breath sounds are equal, no wheeze or crackles Cardiovascular: Regular rate & rhythm, No murmur/ rubs or gallops. Gastrointestinal: Soft, Non- tender, Non-distended, No organomegaly, No palpable mass, normal bowel sounds, Extremities: No cyanosis, no clubbing, Distal pulses are felt B/L and are equal. Neurological exam: Cranial nerves No visual deficits and visual fields full to confrontation, Pupils 3 mm size b/l. round, reactive to light and accommodation No nystagmus, No APD, smooth pursuit withour saccadic intrusion, conjugate horizontal gaze intact. Hearing to finger tapping intact Symmetrical palate elevation, uvula in midline No fasciculations or atrophy noted. gross sensation intact in V1, V2 and V3 distribution to crude touch B/1 good eye closure. hearing intact in both ears per finger rubbing Symmetrical palate elevation, uvula in midline. Sensory: Decreased sensation in left UE to crude Decrased sensation in left LE to crude touch Vibration and proprioception sense intact in B/L UE and LE> Motor: Normal tone, bulk withour atrophy Strength Shoulder Abduction/Adduction Biceps/Triceps Hip Flextion/Extension Knee Flexion/extension Dorsiflexion/Plantarfelxion

Rt 2/5 2/5 3/5 3/5 3/5

Lt 5/5 5/5 5/5 5/5 5/5

DTRs: Biceps Triceps Brachiroadialis Patellar

Rt 2+/4 2+/4 2+/4 2+/4

Lt 2+/4 2+/4 2+/4 2+/4

Figure 3.2  Sample documentation in a tele-neurology encounter continued

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S. M. Bhagavan et al.

Plantar: Downgoing bilaterally Clonus: Not seen. Gait: Deferred due to acute stroke NIHSS: 1a-Level of consciousness:0 1b- what is month/Age:0 1c-open/close Eyes&Hand:0 2-Bext Gaze:0 3-visual Fields:0* 4-Facial Palsy:1 5a-Motor-Right Arm:0 5b-Motor-left Arm:0 6a-Motor-Left leg:2 6b-Motor-right leg:0 7-Limb Ataxia:0 8-Sensory:1* 9-Best Language:0 10-Dysarthria:1 11-Extinction/Inattention:0 NIHSS:8 *:performed by interpreter Imaging: I reviewed the images personally CT head: No acute intracranial pathology noted, no hyperdensity indication of any intraparenchymal bleed CT angios head and neck: Right distal M1 segment of MCA occlusion seen. Assessment: 60-year-old gentleman with PMH A. fib (not on enticogulation), HTN,DM, significant smoking comes to xxx ER after experiencing sudden onset left upper and lower extremity weakness, numbness, left facial droop and slurred speech. Last known well 8 PM on 8/10. NIHSS: 8 Vitals: BP 170/80mm Hg, HR 68/min, RR 22/min, spo2 94%. On examination has strength left upper extremity 2/5, Left lower extremity 3/5,Left facial droop, mild dysarthria numbness to crude touch left upper and lower extremity. Labs remarkable for POC 112, CBC, CMP unremarkable. CT head was obtained which did not show any acute intracranial pathology , CT angios head and neck showed right distal M 1 divsion of MCA occlusive thrombus. Discussed the diagnosis of a possible stroke and explained risks and benefit of TPA. Patient and family consented and TPA was started at 9:15 PM. on call neuro interventionist was contacted via multi video conference and the case was explained. He was transferred to the nearest comprehensive stroke center for possible mechanical thrombectomy.

Impression: –Possible right MCA territory acute infarct likely cardioembolic secondary to atrial fibrillation –Right distal M 1 segment of MCA occlusive thrombus Plan: –IV Tpa for possible Right MCA terrioty infarct -BP goals: