Clinical Case Study: Telehealth for Neurology

In collaboration with the American Academy of Neurology (AAN), this virtual session explored telehealth use in neurology. Presentations highlight current use telehealth neurology trends, models of care and available resources, while diving into telehealth use for neurology sub-specialty care including sleep medicine, epilepsy and stroke. 

Speakers

• Neil Busis, MD, clinical professor and associate chair, technology and innovation, Department of Neurology at NYU Langone Health; chair, AAN Telehealth Subcommittee
• Anna Marie Morse, DO, director, Division of Child Neurology and Pediatric Sleep Medicine and clinical associate professor at Geisinger Commonwealth School of Medicine
• Nassim Zecavati, MD, director of Epilepsy at the Children’s Hospital of Richmond and associate professor of neurology at Virginia Commonwealth University
• Benjamin Kummer, MD, vascular neurology and stroke at Mount Sinai, AAN Telehealth Subcommittee vice-chair

Hosts

• Bernadette Lim, program manager of digital health strategy, AMA
• Michaela Read, telehealth & practice program manager, American Academy of Neurology
• Laura Fritsche, program administrator, digital health, AMA

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Lim: Morning, everyone, and thank you for tuning in to another telehealth immersion program event. Today's session is focused on telehealth for neurology, and we are honored to host today's event in collaboration with the American Academy of Neurology. Next slide, please.

During our 90 minutes together, we will start off with a presentation from Dr. Neil Busis, chair of the AAN Telehealth Subcommittee, who will provide an overview of telehealth use and neurology. We then have three speakers joining us today: Dr. Anne Marie Morse, Dr. Nassim Zecavati and Dr. Benjamin Kummer, who will each give a presentation on telehealth use for sleep, medicine, epilepsy care and stroke care, respectively.

Dr. Kummer will also speak to several advancements on the horizon for teleneurology, as we start to think about the future. After these four brief presentations will then come together for an interactive panel discussion with the speakers, and we invite you as the audience to ask questions live.

And with that, I'd like to introduce Michaela Read, who will introduce our speakers for today. Michaela is the Telehealth in Practice program manager at the American Academy of neurology. She previously served as the development director at Care Clinic, a nonprofit, free clinic, providing integrated health care for underserved communities in rural Minnesota. Michaela is currently finishing her Master’s in Public Health at the University of Minnesota, where she is researching the funding mechanisms of assisted living and their impact on equitable access on long-term for elderly Minnesotans. Thank you Michaela for making today's session in our collaboration possible. I'll turn the floor over to you.

Read: Thanks so much, Bernadette. On behalf of the American Academy of Neurology, I'd like to thank you and your colleagues at the AMA for inviting AAN to serve as a collaborator in the Telehealth Immersion program. We absolutely appreciate the opportunity to develop valuable telehealth resources for the neurology community. So, without further ado, I'd like to introduce our first speaker. Dr. Busis. Dr. Busis is the associate chair of technology and innovation and the director of telehealth in the Department of Neurology at NYU Langone Health and a clinical professor of neurology at NYU Grossman School of Medicine.

He developed and directs the neurology program at NYU and developed and directed the general teleneurology program at UPMC in Pittsburgh, Pennsylvania. Dr. Busis chairs the American Academy of Neurology Telehealth Sub-committee, is the alternate CPT advisor representing the AAN on the AMA CPT Advisory Committee. He is developing new telehealth and hybrid care models, validating the remote neurological examination and optimizing teleneurology education for learners at all career stages. Dr. Busis has previously chaired or was a member of other committees and subcommittees and has served on the AAN board of directors.

He received the 2021 AAN President's Award for his service. Dr. Busis is also a past president of the American Association of Neuromuscular and Electrodiagnostic Medicine. Recently, he was a member of the planning committee for the March 2022 National Academies of Sciences, Engineering and Medicine workshop on the use of telehealth for disability evaluations in medicine and allied health. Dr. Busis, thank you so much for being here today. And I will turn it over to.

Dr. Busis: Thanks very much. Could we have the next slide? So, Thanks again to the AMA and to Michaela for that introduction, which may actually be longer than my presentation. I'm going to give you an overview of telehealth use and neurology. Next slide. 

I received personal compensation for serving as alternate CPT advisor for the American Academy of Neurology and for AAN speaking engagements. Next slide.

As you know, telehealth can be defined as when health care is provided to participants who are not in the same place, at the same time. While most of us think of telehealth as basically video conferencing, two-way live, real time interactive audio video interactions, there are at least four other modalities of telehealth worth mentioning, and you'll hear references to these other modalities throughout this program. They are telephone or audio only interactions, asynchronous data exchange or digital evaluation and management services, interprofessional consultations where providers speak to other providers and not the patients and various types of remote monitoring. And these are the terms that are used in the CPT manual, by the way. Next slide.

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In November and December 2021, the AMA performed a telehealth survey of physicians. We as collaborators in the telehealth immersion program, were able to get a customized report just on neurologists. And this shows you the key takeaways from what neurologists are doing in November and December of 2021. And it's pretty recent, so it should be pretty reflective of what we're doing now.

Of the survey, 98% of neurologists use telehealth. Per week, neurologists saw 36% of their patients via telehealth. Telehealth enabled neurologists to provide high-quality care for many services. Most used cases were for follow up care, improving access and medication management. And 75% or more of telehealth visits were with established patients. Telehealth visits were mostly conducted from clinic or home on the case of the physician or from home in the case of the patient.

Most neurologists use live audiovisual technology. Some of the other modalities were used, but most of them use the live, two-way, real time, interactive audiovisual technology. What's particularly interesting is that six in 10 could access their telehealth platforms via the air. That means that four out of 10, 40%, had a separate telehealth system from the EHR that they used for in-person visits. Which means there's issues with double data entry scheduling issues, interoperability, information sharing, all sorts of problems. 66% of respondents agreed or strongly agreed that telehealth use has increased their professional satisfaction. And showing that this wasn't just a COVID bubble, practices plan to offer a variety of telehealth services in the future, and we'll talk about some of those possibilities later in the program. Next slide.

This table shows the evidence for teleneurology before COVID. The telemedicine workgroup of the American Academy of Neurology published this paper in January of 2020, which is just a few months before the pandemic. You can see across the top are some quality metrics. You can see down the side, various subspecialties. Note that stroke is not included because the evidence base for stroke is really not in doubt. It's very robust and goes back many years as Dr. Kummer we'll talk about. Note also, something really big is missing.

There's no column for outpatient general teleneurology. Isn't that something? Note also that if you look at the columns for improved access to care and cost savings, there basically, almost no studies or very few high-quality studies. So, there's obviously a big gap at the beginning of the pandemic and we hope that will be filled in as more and more cases are done in the last few years. We hope that organized studies will be done to expand the evidence base so that we can improve evidence-based practice and advocate for evidence-based policy. So how should we do that? Next slide.

The AMA has come up with a really nice framework for measuring the value of telehealth and I hope that this will be used to organize future studies in teleneurology and other types of telehealth. They are domains of clinical outcomes, quality and safety, access to care, patient, family and caregiver experience, clinician experience, financial and operational impact. And then underlying all of these is health equity, because obviously you want all patients who need telehealth to be able to access it. Next slide.

When we surveyed our neurologists on how they are currently measuring telehealth, we found the following results. Most neurologists currently measure telehealth value via patient satisfaction and access. So, the access is not much of a big lift. We're already doing that. Most papers that talked about telehealth during the pandemic first said, here's how we rolled it out, here's how we had access. But you'll notice that quality, the physician experience and costs, financial aspects, are still relatively understudied. So, lots of opportunities. Next slide.

Teleneurology started out really as telestroke in the hospital. And as I'm sure you already know, but it's worth emphasizing, the teleneurology experience in the hospital and at home, which is where outpatient teleneurologists are really very different, the processes are very different in the hospital. You have a proprietary rig with a very high-quality camera, speakerphone, microphone, presumably decent bandwidth. You have an assistant who's trained here. The assistant is giving the NIH Stroke Scale to a patient, their doctors on the screen.

When you move to the home, the patient brings their own device. So that means not only do they have their own device, but they supply their own bandwidth. They supply their own technical support. They supply their own examination. So, the processes are really quite different. So, let's look at the teleneurology encounter. Next slide.

Just like an in-person encounter, the teleneurology encounter has certain basic elements. There's history. There's examination, medical decision making. When you think about it, history is really not all that different in a two-way, real-time audio video encounter, which is really what we're going to talk about here, because you're talking. You're showing and you’re talking. And as William Osler said, just listen to your patient. He or she is trying to tell you the diagnosis. Medical decision making is not all that different either, because basically you take the data that you have acquired during that encounter and before that encounter. You put it together, you synthesize it with your knowledge and experience, and you come up with an assessment plan. So, the big difference is the examination, because you are not right there, able to touch the patient. Next slide.

So, we went from zero teleneurology visits on March 18th, 2020, at NYU, to 100% virtual on March 19, 2020. So, we had to figure out how to do a remote exam. And what we did was we crowdsourced it. We talked to all our colleagues in the department, said, how should we do this? Because at that point there was really nothing written about a general teleneurology exam. There was the NIH Stroke Scale and a few things like the mini metals, that had been validated for remote use, but nothing else. So as an organizing principle, we took the 23-element neurology single specialty examination, which has been used by CPT and CMS since 1997.

We laid it out. We said, OK, which of these 23 elements can you do, to some degree? And the answer is that we could do about 21 of them. We really can't do the cardiovascular exam because we don't have remote stethoscope or robot fingers to feel pulses. And we can't do the ophthalmoscopy examination because we don't have remote ophthalmoscope. But everything else can be done, one way or another. Next slide.

We then had a study, which is in press, looking at general neurology and headache patients, examined by neurology. And we asked our providers, our physicians, what were the most useful elements of the virtual neurological examination that you can do to have enough information for medical decision making? And these are the 14 elements that we decided worked. It's not surprising that five of them are mental status, because it's mainly verbal. Most of the cranial nerves, with the exception of cranial nerve two and some less important cranial nerves. Muscle strength, but not tone. Coordination, not so much reflexes. Sensation and gait and station. Next slide.

To illustrate the adaptations that we made for the virtual motor examination, I show you this slide. You can think of it as four different elements: inspection, self or assisted examination, functional testing and objects. So, inspection. This fellow has a right peripheral distribution of facial palsy.

You probably wouldn't do that much different if you were in the room with this patient. You look at them, you'd say, raise your eyebrow, close your eye, smile, frown, et cetera. And you can also use inspection fatigue or weakness in myasthenia. Look up for 60 seconds and see if you develop ptosis or double vision. Self-assist examination. Here the physician on the screen is telling the patient how to examine their hand. If there's an assistant there that you can train, so much the better but not necessary. Functional testing.

We do this to some extent in the office. I found that legs are stronger than my arms in almost every case, so I do a lot of this, but you do more of it virtually here. This woman was asked to stand up from a chair without using your hands, and she can't. So, she either has some lower extremity weakness or imbalance or something like that. And then if you want to try to quantitate strength remotely, you can use objects.

If patients have barbells at home, you can say, well, you can lift this barbell and not that one or cans of food or abduct your fingers with this rubber band, et cetera. So, this gives you an idea of the adaptations that we can make, and you can examine most things that you need to examine, in most cases, by using these kinds of principles. Next slide.

Now, in addition to the ophthalmoscopic examination or the cardiovascular examination, there are other limitations of the teleneurology exam that may not be quite apparent, even though I showed you those lists. Vestibular testing, for example, while you can get patients to change positions; lie on your side, the bad ear down is the one that makes you dizzy, and BPPV, for example. They may be reluctant to change positions because that makes them symptomatic, they're not going to want to do it.

For certain detailed assessments of strength or muscle tone or reflexive sensation, especially when you're getting some inconsistent results, in-person is better. And then they're also patient factors to consider. If patients have trouble with cognition, vision, hearing or using the technology, if they don't have someone onsite to assist them, it won't be a successful encounter. And then remember that certain rating scales, such as the NIH Stroke scale, are designed to be used with an onsite assistance. So, if you don't have that person there, you can't do the rating scale. Next slide.

I think that most of you are going to be familiar with elements in this slide, but I wanted to mention them for completeness’ sake. So, in addition to the physical examination, there are a number of barriers to telehealth encounters being successful. The biggest one for years and years has been insurance coverage and payment policy. Although there have been some flexibilities with COVID, there's uncertainty how long they'll last.

Different insurers have different policies at different times. You only have to check constantly. There's the issue of technology, literacy and digital divide, and the AMS survey respondents rated that very high as a limitation of telehealth. There's location side of service issues, which have been present for a long time, urban versus rural, home versus office. In the past, rural and office were favored.

Obviously, we know that telehealth is useful in other settings. We hope the legislation will allow that flexibility after COVID. They’re data and privacy concerns. It's not just computer hackers, they’re privacy concerns in the home. If you live in a crowded environment, you literally, as a patient, may not have privacy to give an unfiltered version of your history to your physician. I have had patients leave their home and sit-in their car to talk to me because that's the only place they had privacy.

There are workflows just like there's check in and check out at the desk when you come to an office. How do you do that virtually to make sure that they're checked in correctly? They're using the equipment correctly? They have a correct follow up? There's education. Education at all levels. That's a big thing that we're doing at NYU. Not only have we educated patients and learners, but we've educated everybody else because almost no one knew how to do this before we had to. And that is, of course, the issue of the telehealth evidence base, which I've talked about, and we'll talk about again. Next slide.

Basically, if you are not face-to-face with a patient. You are not face to face. So, all of the things we're talking about are variations of non face-to-face services. And what's really good news that in CPT 2022, non face-to-face services are better supported than ever before. The biggest change is in addition to the care management services family of codes, and those are principal care management codes. In the past, the chronic care management codes required you to take care of two or more problems.

Most specialists want to stay in their lane and take care of their patients’ neurologic problem. The ability to do that now, the principal care and management codes, is a game changer. We're going to talk about that a little bit later in a couple of these talks. And the other thing is that all of the digital medicine services that I've talked about and some that I haven't that we'll be talking about later, such as artificial intelligence, are now organized in a wonderful appendix, Appendix R, that gives you a broad overview of the entire field of digital medicine, and it gives you an idea of where we are and obviously gives you an idea of where we can go. Next slide.

Much of outpatient neurological care is chronic care management. And I submit that the future of chronic care management is hybrid care because there are lots of ways to bridge the gap between in-person visits. We envision hybrid care as consisting of a combination of in-person care, the principal care management services and various types of telehealth services, with the exact mix of all of these services customized for the patient's needs, their ability to access and use technology and the evidence base.

And as the editor of Modern Health Care stated, one of the best things about virtual care is caregivers’ family and medical team all can be on the same screen. It's actually easier to get all of the stakeholders, all the different therapists, caregivers for the family, the family members, the patient, the provider on a screen, than it is to get them in one place. Medicine is a team sport and hybrid care supports team-based care better than in-person care. Next slide.

So, I hope as you go through this program and the other webinars in the series, you realize that telehealth is the practice of medicine. It's really not about the technology, it's about workflows and operations. It's a care delivery model. And just like every other tool, you use it when it's appropriate. You don't use it when it's not appropriate. The medicine is exactly the same. The appropriate comparator is not in-person visits, it’s the alternative.

The alternative often is getting no care at all. You are doing a physical exam. You may have to adapt it, but you are doing a physical exam. Every time you just look at the patient, you're doing an exam. And in fact, as we mentioned, you might get more information than from an office visit, in terms of getting the whole team together, and also you can see the patient in their home and understand challenges to their safety, perhaps to their social support system, et cetera. And you should focus on actionable information and possible triage.

So, if you see the patient and you realize, look, I really need to see you in person or you need to go to a facility or this an emergency, you need to go to an emergency room, you can triage. The point is, you are starting the care journey earlier than you would have otherwise, even if you can't necessarily complete it. Next slide.

So, my final slide is to point you to AAN resources on telehealth. They can be found at aan.com/telehealth. And I particularly want to stress the American Academy of Neurology telehealth position statement because we're using this as a stimulus to give us a road map for developing evidence-based practice and policy in the future. Next slide.

So, this is the first of four talks. And I will turn it over to Michaela, who will then turn it over to Dr. Morse. And thank you for your attention.

Read: Thank you, Dr. Busis, for that excellent introduction to teleneurology. Our next speaker is Dr. Anne Marie Morse. Dr. Anne Marie Morse is a board-certified neurologist with special qualifications in child neurology and is a sleep medicine specialist. She is the director of Child Neurology and Pediatric Sleep Medicine at Janet Weiss Children's Hospital with Geisinger Health System in Danville, Pennsylvania, and is the program director for the child neurology residency program. She has significant clinical experience and interest in pediatric and adult patients with central disorders of hypersomnolence.

In addition, her research interests extend more broadly to include investigating the relationship of sleep with neurologic disease. Some of her current research includes participation in studies evaluating neurodevelopment, cognition, behavior and sleep, novel therapeutics for central disorders as hypersomnolence and validation of novel sleep assessment tools. In terms of community-based efforts, Dr. Morse has developed a school-based, virtual sleep education and surveillance program called Wake Up and Learn.

This program was developed to provide education about sleep health and perform school-based sleep screening to improve recognition and mitigation of pediatric sleep disorders. Dr. Morse envisions a world where sleep can be acknowledged as a vital sign of health, wellness and performance. Thank you, Dr. Morse for your leadership in this space, and I will turn it over to you.

Dr. Morse: Thank you so much and I really appreciate the opportunity to be able to present alongside such an incredible panel of speakers and following after Neil is going to be a tough act, but I'm going to try. So, today I want to talk about the virtual sleep medicine practice and really just building on a foundation that Dr. Busis has already placed with saying that telemedicine is not the end all, be all when we're talking about virtual sleep medicine.

And so, we'll start off there. But some of the things that I do want to go over are going to be reviewing peer-to-peer consultation. How has it done? What have we done at Geisinger and how can it prove to demonstrate value not only to the patient, but also to providers?

Synchronous telemedicine care, individual versus group, telemedicine programs that have been implemented, remote patient monitoring as well as reviewing some of the school-based sleep education and screening models that may further disrupt or challenge our current practices and sleep medicine. So, when we're talking about the peer-to-peer model, at Geisinger we have a program called Ask-a-Doc.

This has been implemented for many years now, and it's something that allows for virtual consultation services that can either be from a primary care provider to a specialist or specialist to specialist. This is in those circumstances where you have a patient in front of you and you're going, I think you might need an endocrine or a cardiology or a neurology practice referral.

However, the patient maybe has limitations in terms of being able to get to that referral, or it's just a question of, is it really just an acknowledgment from that specialist to give you some guidance or do they actually need to be seen? Ask-a-Doc has been extraordinarily successful with 99.9% of questions being answered and more than 84% of Geisinger primary cares are using Ask-a-Doc on a regular basis, really saving that kind of, kicking it down the road and just referring patients and really being able to help and getting an answer more quickly.

The turnaround time typically is one of three days. So, if I had a patient in front of me today and I put it an Ask-a-Doc to a specialist, the specialist typically is going to respond, most commonly, within 24 hours, but typically do have the leeway of being up to three days. And the part that makes this most successful is that no one likes to do work for free. The reality is that everyone wants to experience value in their day.

And so, if I were to say to my docs, you're going to have to also see patients and do all this additional work, but we're not going to assign any value to it. Many times, I would be met with initial enthusiasm, but generally turns into resentment and feeling as though that they're not being recognized for the work that they're doing.

So, there is an RVU value assigned to the work performed, and so that allows for us to have some understanding of the volumes that they're doing. So, when this has been studied, we looked at almost 22,000 physician consultations where there were about 2,000 Ask-a-Doc consults versus almost 20,000 traditional face-to-face consultations. When this was evaluated, what was identified was that number one, Ask-a-Doc significantly decreased turnaround times between primary care and specialty physicians.

So about 6 and 1/2 hours, compared to what traditional referrals are. And so, I can say as a neurologist many times, although our goal is a time to be seen within 10 days, many times new patients may be waiting for several weeks to several months. So, 6 and 1/2 hours is really quite a significant improvement. In addition to that, there was cost savings, about 14% reduction in total cost of care in the first month of the program.

And that only continued to grow when it was continued to be followed. And we saw that grow to about 20% cost of care. So, health care utilization was also positively impacted by this. The reasons why were because the fact that we saw that emergency room visits and physician office visits had decreased and then we also saw that there was a 74% drop in inappropriate specialist utilization.

So, this is just an illustration of how we actually follow Ask-a-Doc metrics. So not only are we looking at, what are the RVUs assigned to the work being done, but we also create an opportunity for accountability of the work being done, meaning that the quality of what we're answering is also being evaluated.

So, looking at is the actual process being done correctly? Was it being done in the appropriate time frame? Was there the appropriate smart data elements that were being included in it? And then measuring the turnaround time that really was measured. In addition to that, the person who's requesting the Ask-a-Doc consultation is also able to give feedback as to was this helpful? Did this answer the question that I was asking? And so, there was a rating system that was implemented for this.

So, when you move on to, we talked about the peer-to-peer consultation; I think we're all very familiar with telemedicine and utilization of asynchronous, audiovisual type of care. This is a paper that was from 2018, where clearly this is before COVID, and it does give an illustration that sleep medicine was already primed for doing telemedicine.

However, most of the times there really were pilot projects being done. During COVID, we saw that there was 100% conversion during the first wave of COVID. We saw then in 2021, that reduced to about 75%. I would say that still was a very significant amount of telemedicine being performed, as we saw most of the country retreat, very quickly, to about 15% to 25% of their encounters being telemedicine. We currently are still having about 50% of completed visits being performed via telemedicine.

One of the things that I want to highlight is that when we're talking about telemedicine, we must typically are talking about this one-to-one, individual kind of consultation. Dr. Busis had raised the consideration of being able to get all the key stakeholders and that's one way of engaging more people.

However, in our sleep psychology services, this has even been more broadened by being able to allow for cognitive behavioral therapy, specifically for insomnia, to be performed in a group setting, versus individual setting. And so, it allows for multiple patients, coming from different walks of life and different availability, to be able to engage from the comfort of their home and be able to get this more on the schedule that is going to be appropriate for them. So, this really has increased not only the access, because I think everywhere in this country is experiencing a mental health crisis of being able to have the providers to fill the need, but also being a value in terms of convenience.

So, some additional lessons learned in Central Pennsylvania is that the weather definitely can impact whether or not telemedicine is going to be more widely utilized or not. So, we make a comparison of telemedicine usage during inclement weather in January and then we're going to compare it to a little bit later on in a year. One of the things that we recognized was that there was an increase in utilization of telemed services across all service lines.

So, there was about 17% of use in January. For those of you who are unfamiliar with central Pennsylvania, we very frequently look at those Northeast areas where there is tons of snow and many times creating whiteout conditions that it's unsafe to travel for our patients and even for our providers. When you look forward and go past January, you see that there was an increased utilization and uptake of using telemedicine. Why was that? Because now, many times, the directors of these departments have learned that instead of waiting for the snow day to happen, when it would be predicted, they actually flipped these patients into telemedicine sooner and many times that was met, by the patients, with much appreciation because of the safety parameters that they then were able to experience.

As we move forward and look at a more broad way of considering how remote patient monitoring has been considered in sleep medicine in the past. Most typically, we would be reflecting on things like home sleep studies or in this case, I think something that would be most akin to remote patient monitoring, in a way that we think about it now, would be activity devices.

Which, in here this is giving an illustration of what we would use which is a wrist worn device and what you're seeing on a computer is exactly what we typically would see from an interpretation of this. It uses accelerometry to really get a sense as to whether or not the person is lying or sitting, and if there's any types of movements and gives a pretty close approximation of the amount of time being spent asleep; giving us an idea of duration of sleep and timing of sleep. Now, this was all fine and dandy, but the reality is, is that what we now have been exposed to is the fact that we may be able to utilize this same mindset of thinking about timing, duration, quality of sleep, but integrate it with a broader spectrum of remote patient monitoring. We currently at Geisinger are establishing a partnership with a company that will be able to help us in doing this exact thing.

Being able to take the broader spectrum of remote patient monitoring and looking at all of the other vital signs, in combination with sleep monitoring, to be able to actually utilize sleep for that homeostatic process for which it is. Being able to not look at sleep as a medical comorbidity, but part and parcel of the neurologic or other medical morbidities that may exist and utilize it as a part of the treatment package.

And so now, this is really creating a new and novel opportunity. One of the things that very frequently we see and in fact, the American Medical Association telehealth survey had demonstrated that, 76% of physician respondents had frustration and difficulty with where does this actually create a central repository? How do we not have duplication of efforts? One of the things I'm proud to say is being a part of Geisinger is that we're currently working on a playbook for this and really trying to create those guiding principles and a rationalization process in order to reduce all of those challenges, avoid the operational confusion and increase ease of use. Really operating on the principles of interoperability, accountability, a secure system that is simple, able to be personalized, accessible, and is also engaging, creating that patient need to want to continue utilizing it.

The final piece that I would like to cover is really, I think, one of the more disruptive kind of thoughts in regards to how can digital transformation and telehealth really be implemented in a way that maybe we haven't really considered previously, and that's meeting the patients where they are. For me, as a primary pediatric person, that may mean meeting them in a school district. However, broader areas that we're currently exploring as well, is talking about meeting them at their work environment or meeting them somewhere else where they're spending a majority of their time. When you think about children and adolescents, many times the place that they're spending, the majority of time is in school.

This is where we've conceptualized the program called Wake up and Learn. Believe it or not, this was a program that was conceptualized before COVID was a thing. We created the game plan on this in 2019 and received philanthropic grant funding in 2020 between Geisinger, Janet Weiss Children's Hospital and Jazz Pharmaceuticals, to develop this program. This is a virtually delivered, school-based, sleep education and surveillance program.

And part of the reason we developed this was really to educate on the symptoms of sleep disturbances and try to help in redirecting the care pathways for these patients. We recognize when looking at the amount of times that children and adolescents are actually being recognized for their sleep problems, it's a small percentage based on how many children are actually impacted. We wanted to define the consequences of inadequate and problematic sleep, but also utilize it again as a tool to mitigate risk for other things. One of the things in the United States that we have seen as an alarming statistic is a very substantial increase in the amount of suicide attempts and completions in our children and adolescents.

And we've seen over the course of the past 10 years a 50% to 80% increase in the amount of suicide attempts and completions. We recognized that insufficient sleep in this age group increases risk taking behaviors and also is considered a risk factor for suicidality in individuals who are depressed. So again, thinking about this as a part of the overall medical care of the patient versus medical comorbidity. This also created that opportunity, as Dr. Busis said earlier, of involving the key stakeholders and meeting people where they are.

When looking at this, we created a website to create that access to information and education, but we also provided universal screening. When reviewing the data that I will have in the next couple of slides, you'll also find that this meets the criteria that the World Health Organization lays out as what is appropriate for school-based health screenings and interventions.

And that is disorder needs to be prevalent, needs to be screenable and needs to be actionable. So, we use validated scales to put patients, put individuals and kind of the buckets of is there concerning features or not? If there were concerning features there then was the opportunity to opt into a more comprehensive digital delivery of information gathering for us to be able to provide that guidance as to what can be done in order to direct your care.

Because of anti-Stark laws, we are not referring patients back directly to Geisinger and again, this wasn't to drive consumerism to our hospital but really to shift the delivery of care to where our students were most of the time. When we did this, as I mentioned earlier, we were then reflexing it to a more comprehensive screener, and then we also were able to give as needed screening throughout the year.

When we did this, we had a very successful initial pilot, where it was 87% completion of these screening surveys. And one of the things that was very remarkable is how staggering the prevalence of sleep pathology is. It's about 62% had pathologic screening on one of the surveys, 17% on sleepiness surveys and overall there was about a 64% presence of high risk sleep pathology. Just to give a comparison, when you're looking at the medical literature for sleep pathology, we typically will quote 25% to 30% of children and adolescents will have a sleep problem.

However, the most recent CDC statistics are demonstrating that 58 to 73% of middle school and high school students are experiencing at least insufficiency. And this data is more reflective of those patterns. When we're looking at this, one of the additional pieces that I think is really important to call out is that when you're talking about sleep and especially school performance and health, many times we're usually reflexively having that conversation about the late school start times.

I'll inform you that this school that we are giving the pilot data on right now is a school that already has established, delayed school start times. And one of the patterns that we're seeing is that we're identifying that there is a clear difference in terms of grade stratification. And so we see that those seventh and ninth graders tend to have a little bit better preservation of their sleep hours compared to our 10th or 12th graders.

The reason this is important is because, remember, I stated that insufficient sleep increases risk-taking behavior and being able to conceptualize this data that you have your 10th and 12th graders who are most likely going to be more autonomous and potentially be driving, may be at higher risk for significant injury related to this. And as much as everyone would like to say that they're catching up on sleep on the weekends with this data is demonstrating is that no one is catching up on sleep. They're still just as sleep deprived.

The final piece that I'll just say again, because of using a delivery system that is needing students at the school and allowing the opportunity to look at how they evolve over the school year, we were also able to identify two patterns. One, that the majority of students who had pathologic sleep at the beginning of the year tended to maintain abnormal sleep throughout the year, based on these surveys.

But there was a small percentage, about 5% to 10% of students who developed sleep pathology across the year. Again, creating opportunities to intervene at the time that the student needs it, versus predefined, arbitrary measures that we typically will say of: I'll see you in three months; I'll see you in six months; I'll see you in a year.

So just to kind of give some more information about the program, one of the things I'll say is that we have successfully scaled this in additional middle school and high schools. We also have created an adult program that is similar to this, that is being delivered to medical schools, as well as our residency and fellowship programs.

We also have a pilot in one of the universities and we now are also implementing this to our Geisinger Health Plan, specifically for our members to be able to, again meet one of those needs that potentially isn't being evaluated as well as providing us through a clinical implementation through our subspecialty services as well. Thank you.

Read: Thank you so much, Dr. Morse. Next, we have Dr. Nassim Zecavati. She is an associate professor of neurology at Virginia Commonwealth University and the director of epilepsy at the Children's Hospital of Richmond. She is a fellow of the American Academy of Neurology, serving on the Leadership Development Committee and the Telehealth Subcommittee under the Medical Economics and Practice division.

She has a special interest in the implementation of telehealth solutions to improve access to neurological care, particularly in underserved communities. Dr. Zecavati advocates nationally and internationally for issues that affect children with neurological conditions, having served on advocacy committees at both, Child Neurology Society and the American Academy of Neurology. Thanks so much for sharing your expertise, Dr. Zecavati. And I'll turn it over to you.

Dr. Zecavati: Thank you so much, Michaela, for that. And thank you so much, Dr. Morse, for that powerful presentation. And also, just wanted to thank the American Academy of Neurology and the AMA for bringing this wonderful panel together and recognizing that telehealth affects all ages and is really a service that we offer across the lifespan, to both young patients and to elderly patients. And so today I'm going to be speaking with you a little bit about telehealth and specifically how to utilize telehealth for patients with epilepsy. Here are my disclosures.

So, our objectives in the next few minutes are to really discuss techniques to leverage telehealth and the care of patients with epilepsy and to talk about the office workflow to maximize the benefit of telehealth services. And lastly, to summarize information on reimbursement. Really always the question at the end of the day is are these services reimbursable?

So, let's talk a little bit about epilepsy. This is a condition that is responsible for 1% of the global burden of disease. More than 50 million people have epilepsy, worldwide and there are many barriers to care that include shortage of human resources, medical facilities and resources. And certainly, those have all been exacerbated by the public health emergency. 80% of people with epilepsy live in low- and middle-income countries.

And if you look sort of to this image on the left that 60% of these individuals in other countries do not receive treatment for their epilepsy. So, telehealth has tremendous potential of addressing these limited resources and improving access to individuals with epilepsy, not only within the United States, but really thinking larger about our global community.

So, in a 2021 telehealth survey that Dr. Busis referenced earlier in the talk, what we found was post pandemic, most physicians, and certainly neurologists are no exception to this, were using primarily audio visual, interactive telehealth visits. But if you look at this bar graph, you'll also find that a substantial number of neurologists were using telephone and audio only calls with patients as well.

And these are really relevant for potentially patients that are older, that have difficulty with AV and who have poor broadband access. You'll also see that there's asynchronous telehealth and remote patient monitoring being utilized to a lesser extent. But certainly, those are the futures and Dr. Kummer is going to talk about those modalities today as well.

So, epilepsy is a chronic condition, and it truly lends itself to care in a virtual environment. In the same survey that I referenced earlier, we found that most respondents are using telehealth for established patients, and these are patients in whom the physical exam is unlikely to change management.

Now, there are exceptions to that rule. Certainly, pediatric exam patients, younger patients or encephalopathy agent patients will benefit from alternating with in-person visits to really be able to gauge those types of changes. But also, really just medication management and safety monitoring that can be very effectively performed in a telemedicine encounter.

And, of course, reducing the burden, the cost of seeking care, particularly with inflation and gas prices being what they are, it is very challenging for our families to have that transportation to clinics that oftentimes are sometimes hours away from their home. And then of course expediting those hospital follow ups and those ER follow ups.

So, a day in the life of, what is an audio video, visual audio, video visit workflow look like? Well in general an MA or provider launches the appointment and ensures that the patient can connect. In our recent rollout of epic, I would say that a critical piece of our success was the work that went into ensuring that families were able to sign up to the portal and had access to the portal.

And our nursing staff really did a fantastic job in ensuring our success in being able to connect with families to perform that virtual video visit, which is then followed by an after-visit summary which is generated electronically, the documentation is completed, the charges dropped, and the encounter is signed. And it all sounds so easy. Now for me personally taking care of younger patients and patients with refractory epilepsy, one of the things that I always have to remind families is the patient has to be present.

So, for pediatric patients, we have to have them present in order to be able to perform the visit. For patients that are very complex, in which there's many issues to address, I find it helpful to have a list of questions and prioritize them in case our signal drops for whatever reason. And in my experience, I've also found it very helpful to have a second AV modality, and so, although we launch from MyChart, I also sometimes will revert to Zoom if I have to, and then if both of those fail, I convert to an audio only visit, which I think many of us are used to doing now. It's very helpful for this particular patient population to have a seizure log that's available for review. There are many free apps that can do this and generate beautiful reports. Ideally, these are all imported into the electronic medical record before the visit.

So, what does this look like? Well, I have a few vignettes that I thought we would just run through. And the first is a relatively uncomplicated patient, an eight-year-old male with childhood epilepsy, with central temporal spikes, the condition we commonly see in children who remain seizure free on levetiracetam for one year. On the day of the visit, the patient is checked in electronically.

Our front desk staff will confirm consent for ambulatory care, confirm the consent for the telehealth encounter and then the patient is roomed. In our institution, we receive, sort of the way I communicate with our staff, is through a secure chat via Microsoft Teams. No pager for this neurologist, Teams really works well for us. And then the visit is started. We do an interval history. I find it helpful to do the exam early in the visit, particularly for younger patients with a limited attention span so that they can then go and eat the rest of their breakfast or lunch or do something else.

I then confirm the medications. I find it helpful to review COVID exposure and who in the family currently has COVID or is recovering from COVID? A recent weight is really important for this patient population. The seizure log, which we talked about. And then, really revealing those signs and symptoms and side effects and medication compliance. All of this can be done really easily in a telemedicine encounter.

I then, for this particular patient, will electronically send a three-month supply of levetiracetam. I'll adjust the dose for weight. I'll review any prior safety labs order new safety labs, if needed. Ensure that a seizure rescue drug is available at home and this particular patient who's old enough, intranasal diazepam would be the drug of choice. Update the seizure action plan, which we can send electronically to the patient via the portal. I'll then complete the ambulatory visit summary and mark the patient for follow up in six months.

So, documentation. Many of us sort of have this down. I've included my telemedicine dot. phrase here. It's quite long, but I think having a robust dot phrase just makes it really easier. You put in your dot phrase at the end or beginning of your notes, depending on how you structure your note and ensure that all the key elements of a telemedicine encounter are present.

So, we talked about an uncomplicated patient. Let's talk about a little bit more complicated patient and how this patient can be cared for in a virtual environment. This is a seven-month-old male, born at 32 weeks gestation with bilateral grade 3 intraventricular hemorrhage, severe hypoxic ischemic encephalopathy and myotonic epilepsy. This patient has demonstrated a failure to respond to clobazam, levetiracetam and phenobarbital. This is a patient that I would like to consider for the ketogenic diet as our next sort of treatment modality. And so, prior to the visit, realizing that that's the direction I'm headed, I'm going to order all of those ketogenic labs.

I'm going to make sure that they're drawn and reported before the visit. On the day of the visit, I'll have a pre meeting with our fabulous nutritionist and that will then be followed by a virtual visit; a telemedicine encounter with the patient, the parents, myself, the neurologist, and then the nutritionist. An extensive, it's a very detailed visit and it really is family education on how to prepare the formula, the equipment that's needed, including the use of a gram scale, body care. All glucose, including body care, lotions and toothpastes have to be carbohydrate free. A stick day management. What to do in the event that your child gets sick. Calculator programs and seizure and therapy logs. So, there's a lot that goes into initiating the ketogenic diet or a dietary therapy in a patient with medically refractory epilepsy.

And so historically, what we've seen is that, this is a care team, right? I mean, there's a lot of individuals that are involved in this process. And the Keto team typically consists of not only dietitians and physicians, but also parents, nurses, social workers and schools, as well. And in a virtual environment, what that looks like is very similar. Physician or nurse practitioners are physician assistants are dietitians, social workers and psychologists. And remember that there is no change in eligible telehealth providers under the Medicare waiver. All of the individuals that were providing care to these patients before can continue to provide care in a telemedicine encounter.

So, without going into too much detail, we want to make sure that our documentation is appropriate. So, each of us is providing that documentation the same as a regular note specifying any limitations. And the exam. For me as a neurologist, I'm going to identify medical decision making. I typically utilize time-based billing when possible, so I'll report the visit duration, not for the time that everybody spent with the patient, but the time that I personally spent with the patient and that telehealth encounter. And then I'll drop the appropriate charge.

Now, one of the really cool things that Dr. pieces alluded to earlier is principal care management codes. So, these are almost certainly being underutilized right now, and it really represents a shift away from fee for service and recognizing value-based care and appropriately valuing this type of team-based approach to care.

These are the services that are non face -to-face and are designed for patients, such as those with refractory epilepsy who have one chronic condition manifested by a single complex chronic condition, expected to last at least three months with a significant risk for morbidity and mortality. Patients have to be aware that this service is being rendered. They have to provide consent. And the care that then takes place in a calendar month of establishing that ketogenic care plan, implementing it, revising the plan, and then reviewing the log. So as a patient is sending you their logs with their blood glucose levels and their urine ketone levels, those are all perfectly suited to a principal care management billing.

And so, I want to talk about a different type of patient in vignette number three. So, in our first vignette, we talked about the uncomplicated patient. The second one we talked about a refractory patient requiring a multidisciplinary approach. And in this vignette, we have a 43-year-old, right-handed male with focal epilepsy since age eight, who now calls with increased frequency of breakthrough seizures. He continues to experience three focal unaware seizures lasting up to several minutes. He has completed an extensive presurgical evaluation and would like to discuss the results. He also needs a refill of his oxcarbs and levetiracetam.

So, this is a phone visit. A phone visit in which we're going to review this patient's concerns. The documentation for a visit should indicate that the patient initiated the contact. So, as Dr. Morse sort of mentioned earlier, we want to all be valued for that time. Returning that phone call, it's going to be a detailed conversation, right? This is a patient that's undergoing a surgical evaluation. And so, documenting the chief complaint and the response and the method of contact, detail what occurred during the communication that you refilled medications; all of this is to establish medical necessity. You want to ensure that the documentation indicates that this was not tied to a face-to-face encounter or to a telemedicine encounter within the past seven days. You want to ensure that the patient consents to having that service provided over the phone. As always, document the time that you spent with the patient and include the location of the patient as well, for billing purposes.

And this brings me to my fourth and final vignette, which is a 10-year-old patient with Lennox Gastaut Syndrome, with daily atonic seizures. He recently had implantation of a vagal nerve stimulator. The patient is on clobazam, valproic acid and levetiracetam. This patient was seen in the office two weeks following surgery, at which time the VNS was auto programmed.

Telehealth visits can then be scheduled on the day of each setting change, at which time the changes can be reviewed for side effects, labs ordered, medications refilled. And so, really thinking beyond our traditional in-person encounters and the future of what epilepsy care in a virtual environment can look like for patients, including patients in whom neuro stimulators are being used.

Neurostimulation and telehealth I think, is sort of the next frontier. And this includes not only vagal nerve stimulation but RNS and DBS as well. So how do we develop that workflow? How do we incorporate neurostimulation when all of this information is typically being uploaded to a cloud? How do we review that information and communicate effectively with our patients? And Dr. Kummer is going to have, I think, some wonderful things to talk with us in that regard. And with that, I'm going to sort of pass the baton on to him.

Read: Thank you so much Dr. Zecavati. As Dr. Zecavit mentioned, our final case study presentation is from Dr. Ben Kummer. Dr. Ben Kummer is an assistant professor and director of clinical informatics in the Department of Neurology at the Icahn School of Medicine at Mount Sinai. A board-certified stroke neurologist and clinical informaticist, Dr. Kummer serves as a subject matter expert and applications of health care IT neurological care processes at Mount Sinai, which encompasses telehealth, aggregated data visualizations and development of machine learning models to support neurological decision making.

Dr. Kummer was instrumental to his institution's shift to video teleneurology during the COVID-19 pandemic and currently serves as the vice chair of the Telehealth Subcommittee at the American Academy of Neurology. Additionally, Dr. Kummer leads the implementation of various asynchronous technology, excuse me, teleneurology initiatives such as remote data collection and interprofessional consultations at his home institution. Thanks so much, Dr. Kummer, and I'll turn it over to you.

Dr. Kummer: Thanks, Michaela. And Thanks to the AMA for putting this terrific program together. I'm really honored to be here speaking alongside my distinguished colleagues. It's really very large shoes to fill to, to follow all of that excellent material. Today, I'll be talking mainly about telestroke and the global 30,000 or maybe 10,000-foot view of the future of teleneurology. And I want to leave some time for questions, so let's jump right into it. Next slide, please.

These are my disclosures. So, talking about stroke first. Next slide, please. We're going to go over some brief definitions first. Telestroke is really the application of synchronous, audio video telemedicine to stroke neurology. And it's almost this sort of classic archetypal teleneurology use case. It was first described in a very, very influential paper in Stroke in 1999. Steve Levine and Mark Gorman sort of wrote an opinion piece around it.

And shortly thereafter, in the same year, also in Stroke, a paper was published that compared NIH Stroke Scale assessments, which is the physical exam assessment in Stroke to video NIH Stroke Scale assessments, and basically found that both of those were essentially accurate and related, if you will. So since then, we've seen a steady increase in telestroke programs worldwide and in the United States. Given that physical examination over video and in person were essentially the same. And as of 2019, at least a quarter of U.S. hospitals have access to telestroke programs, and this comes from a recent paper from 2020, and that's probably an understatement, given the fact that a lot of that was survey data from teleneurology company networks and teleneurology academic centers. Next slide, please.

So, the basic components of a telestroke system are very similar to the components of other systems. But as Dr. Busis mentioned, the setting in which stroke care typically occurs is not typically at home. So, there's always going to be a remote physician who's initiating the call for telestroke to, oh sorry, the remote physician is going to be handling the call for telestroke from an onsite physician or other provider who's typically located in an ED or a mobile stroke unit and more rarely on a hospital floor. There also needs to be some kind of synchronous AV communication, technology and infrastructure and system to work that technology. And finally, a staffing model needs to be present as well. Next slide, please.

I want to just spend a little bit of time talking about why telestroke is sort of a classic, excellent use case in neurology. And it really comes down to access to specialist stroke care, which is a huge problem in our country and worldwide, really. First acute ischemic stroke, which is the most common cause of stroke, arguably in this country, affects about 700,000 patients every year. And as we all know, strokes can be completely devastating.

And this disease imposes a huge social cost and burden to the public health system. The standard treatment for acute ischemic stroke, which is known colloquially as tPA, it's generic name is alteplase, which is an IV medication given as a bolus and then a drip over a specific period of time, is really underutilized in the community, either because of misconceptions around the evidence supporting tPA use, but also because there's a very, very big shortage of stroke neurologists and stroke capable centers, especially in rural areas of the United States.

And you add to that the fact that tPA has a very, very narrow therapeutic window. You really should be giving tPA, if you're practicing by the guidelines, at least between 0 and 4 and 1/2 hours from stroke onset or last known well. And the benefit of tPA tends to go down the further you get from the onset of the stroke and the greater the risk of hemorrhagic complications. And finally, one of the reasons that makes us such a good use case is that you can really make the decision as to whether you want to give a patient tPA or whether they're eligible or not, really easily over audio, video, telehealth. Next slide, please.

So, telestroke care models are basically divided into two general buckets: the hub-and-spoke model and the so-called hub-less model. The hub-and-spoke model refers to the analogy of a wheel, if you will, where there's a central hospital at the hub of the wheel that then is connected via telehealth relationships or audio/video connections to spoke hospitals that are on the periphery. You can see that in panel A right there on the top left. And within the hub-and-spoke model, there are really two different paradigms of treatment. One is called drip & ship, and the other one is called drip & keep. I did not make these descriptions up.

These are actually, legitimate descriptions and published literature, as you can see in the upper right-hand side there. Drip & shift just refers to treatment of a patient with tPA at a stroke hospital and then transfer to a hub hospital, as you can see in panel A. And drip & keep is just the patient gets tPA at the stroke hospital and is kept at the stroke hospital for further evaluation, workup, placement, et cetera; whereas in drip & ship, that occurs at the hub hospital. Then to contrast that, you have the hub-less model, which can sort of take two forms.

One is either around a private practice group and another is around a telemedicine company, which is kind of, functionally the same as a private practice organization. But if you think about it at a higher level, basically a hub-less system is where the decision making is central, but the transfers of patients is a distributed process. So, you can sort of see that in panel D, to the right, where there's a private practice group that is covering a bunch of spoke hospitals for decision making as to whether patients get treatment or whether they need to be transferred. And then those transfers occur to other hub hospitals that are not necessarily related to the central private practice or, in panel C, the central telemedicine company. Next slide, please.

So, Dr. Busis did mention some of the evidence briefly in his presentation, but there is a lot of very good quality data supporting the use of telestroke throughout the last two decades, since its appearance and its publication in Stroke in 1999. So, as I mentioned before, neurological exams done over telestroke are really accurate and basically the same, in terms of their accuracy compared to in-person examinations. And telestroke, in a nutshell, increases access to specialized stroke care and that includes treatment, workups, stroke units, et cetera.

So unsurprisingly, in the literature, telestroke has been found to be associated with increases in thrombolytic rates in the stroke hospitals or other types of arrangements. And because tPA improves mortality in patients with acute ischemic stroke and also results in improved functional outcomes at 90 days and further out in patients with ischemic stroke, it's because your access is increased through telestroke. It's unsurprising that telestroke is really associated with improved mortality profiles and better effectiveness, compared to in-person care in hospitals that do not have in-person stroke coverage.

So, it's really, essentially echoing what Dr. Busis had mentioned, telestroke is the practice of stroke. So, it really increasing access and so the literature really reflects that. I think it's important to mention that most research on telestroke does come from single center academic institutions, many of which are at the center of a hub-and-spoke model. So, while those things are, there's very robust evidence and I didn't list all of it in the slide because it would probably be a whole topic of an hour long talk if I did, all this information should be taken with a tiny little bit of a grain of salt. But next slide, please.

So, I'm going to shift gears here and talk about asynchronous teleneurology in the future, where we're going with neurology. And what I'm going to do in the next few minutes is I'm going to, sort of talk about what's happening now in asynchronous teleneurology and various asynchronous services and try to come up with a prediction in the following slide around what I think is going to be happening in terms of general themes. Next slide, please.

So, I think we're all witnessing a global shift of the health care system to going from synchronous care delivery systems to asynchronous care delivery systems. And we're seeing a shift that has been seen in banking and retail already, and health care is just a little bit behind that. And we're also seeing a convergence of telehealth and telehealth systems onto mobile device platforms.

Essentially, as you can see in this graph here, we're moving from a conventional sort of centralized, synchronous hospital-based, sort of live, one-on-one, and audio-visual interaction, to a system that's more distributed, more convenient, less centralized and asynchronous; that doesn't involve live interactions one on one in the way that it sort of has been previously. This graph is actually from a excellent review of neurology from about five years ago in Nature Reviews Neurology by Ray Dorsey. I highly recommend it if anybody's interested in reviewing sort of thought pieces on teleneurology, it's really excellent.

This graph actually chronicles the RCTs that have been done in telehealth, according to the setting in which they've been conducted. And in orange below you can see the year of the first RCT inception where they actually started. And you can see just chronologically there's a shift from hospitals to clinics to home to the mobile phone. And that's very similar to what we've seen in finance or in retail, where you have something happening, a transaction happening at the teller or at a store, then moving to an ATM or a mall, then web-based transactions.

And finally converging onto smartphone transactions. So, health care is really kind of going in the same direction where we're not going to be dealing with physicians as much face-to-face in asynchronous fashion. Next slide, please.

So, as Dr. Morse mentioned, there's a lot of activity around remote patient monitoring and collection of data by sensors and actigraphs and other types of devices and wearables and sending those data streams to responsible providers that then make decisions or assessments on that data. And I think it's important to mention that a lot of those systems are not well integrated into EHRs, and that's something that's definitely a gap that needs to be further explored.

And I'm contrasting remote data sharing and patient monitoring here in the sense that patient monitoring, really, there's an expectation of frequent data monitoring and decision making that may be more relevant in a blood pressure management program where there's much more fluctuation and remote data sharing, where the data is being transmitted but there's no expectation that the data is being monitored in real time or quasi real time.

And so, sort of to address this gap of integration, we've actually piloted something at Sinai where we are using the Apple HealthKit and Google Fit architecture, and I'll talk about that in a second, to collect step counts in patients with multiple sclerosis.

And step counts have been shown in the literature to be associated with disability in multiple sclerosis. And the beauty of the system is that it actually leverages the patient's own device and essentially connects Epic through a flow sheet and my chart to a patient's individual device and to their Apple Health or Google Fit app, which then can connect to other wearables that you may have or that already exist in the sensors of the phone itself.

So, it starts with a physician order that gets sent to my chart. The patient then syncs their device to my chart, and then once that happens, there's passive data flowing into the EHR. So, we're getting, for about 20 patients over the last year, we're collecting daily step counts in MS patients that they don't even think about. It just uses the standard step counts that they already have. And patients get that information reviewed by the MS physician at the time of their visit. So, it's not real time monitoring, but it's more remote data sharing. Next slide, please.

This is just our cumulative enrollments. So, we're up to 20 patients at this point, since April of 2021. Next slide, please. But I think towards the future we're going to be talking about and seeing many new types of data being integrated and incorporated into our decision making, into our armamentarium of patient assessments.

And I think one of the main categories that we're going to be seeing this in is an imaging. I think we're going to be seeing a lot more transmission and analysis of video data, namely of physical examination and neurology and other phenomenology, such as paroxysmal events like dystonia or seizures. We're also going to be seeing a sort of higher-level integration of complex, time locked physiologic data streams of wearables. Right now, there's a lot of integration or just single streams of data from single wearables or single sensors.

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But I think we're going to be seeing a lot of computationally complex integration of all of those different wearable signals to phenotype, different motor disorders, for example, or standardized assessments and diseases. And that's actually that's already starting to happen in Parkinson's disease. We're also going to be seeing the digitization of social network activity, sociability and displacement and what somebody's digital life space actually is and what it means for their condition.

This can be particularly relevant for patients that have cognitive disorders or visuospatial disorders. And we're going to be seeing a lot of integration of more treatment data, namely around symptom diaries, responses to various therapies and adverse events. Next slide, please.

There was some mention in a number of my esteemed colleagues’ presentations on interprofessional consultations, which are a form of asynchronous teleneurology. And we've actually launched an e-Consult program in neurology in October of 2019, which is all Epic-integrated, similar to the Ask-a-Doc program at Geisinger, where the Epic order basically is initiated by the requesting physician that contains a clinical question. It's pictured in the lower left-hand corner here. It has a lot of clinical history, very, very detailed clinical history for a variety of different symptoms.

This, once the order is signed, routes to an in-basket pool, which is pictured right here on the lower right-hand side, that's staffed by five different neurologists for each of the day of the week. And the consultant will then field the question, complete any consult, note and Epic and then drop a bill, the exact code is 99451, for interprofessional consultation and the note will actually route back to the individual requester. We've been pretty successful in this program. We've done about 430 consultations since we started. Most of these referrals for consults really come from Medicaid internal medicine clinics in the Sinai system. Next slide, please.

This is actually a graph I wanted to show. So out of all of the interprofessional consultations that we've done in neurology, the majority have actually resulted in an electronic recommendation, and the majority of those electronic recommendations basically avoided a referral for an in-person visit in our neurology clinics; which are chronically overbooked and the wait times for which are extremely long. So, I think this is a big win in the sense that we're reducing, we're improving access to neurological services without worsening the patient experience, if you will, and a number of other important outcomes. Next slide, please.

I think we're going to be seeing many different modes of interacting between patients and providers and communicating between both parties as we move towards the future. I think the technology of chat bots is going to become much more sophisticated than what it is now, namely because the artificial intelligence algorithms and natural language processing algorithms that are developing and will be developed are going to be much more sophisticated in handling and parsing text and illness scripts and triaging, such that patients will really have 24/7 availability to asynchronous care; if they have a question about their medication or they have a symptom that they don't really know what to do with.

And I think there's also going to be the leverage of more accessible, traditional technologies like texts and SMS to do digital outreach and surveillance in vulnerable populations. That may be on the other side of the digital divide, which I'll speak about in a few slides. Sort of in parallel, I think digital patient journeys are already starting to be developed and will continue to become much more important around symptoms. I think patients are going to stop going through their physician networks to kind of get referrals, and I think they're going to start with technology to find a referral in an intelligent way and to be connected to resources.

So, a few examples of that are apps that are so-called digital front doors. Health systems are going to be developing their own apps, which are basically health system, all things health system on an application on your mobile phone. And patients will start to search for their symptoms in these apps and then be connected to resources, providers, different tools to manage their disease, as opposed to going through the traditional channels.

Again, this is entirely asynchronous. It does not have to take place during an audiovisual or a face-to-face encounter with the physician. So again, just kind of going back to that slide with the Ray Dorsey figure, we're really going towards a more sort of distributed model. And we're also going to be seeing, similarly in the private sector, doctor-on-demand services for specific disease verticals like Ro® and HIMS®. Ro® and HIMS® have established themselves really in the male urology and sort of pattern baldness vertical. But they're very shortly going to be branching out into additional verticals so that patients can be connected to providers immediately, based on symptoms and requests. Next slide, please.

I want to briefly talk about PCM, since a number of my colleagues mentioned this. Just to reiterate, PCM is a service that essentially leverages the entire health team, which can comprise providers, APPs, PTs, SLPS, what have you, for the care coordination and management of one chronic condition, for at least three months per team. And this is a time-based service, so you have to accrue a certain number of minutes every month before you can bill a service.

But we've actually built a PCM module in Epic and are piloting this at Sinai, with a number of different neurological conditions. And we've received an $80,000 Office of Well-being & Resilience grant to build this module. And this is from scratch, because Epic does not actually have anything like this out of the box. This allows the assignment of care plans and goals, care targets, task tracking. It's very complex. Very cool. I'm very proud of it, personally.

And on the right-hand side here, you can see the enrollment form because as Dr. Zecavati and Dr. Busis mentioned, consent and sort of patient involvement and decision making is key in enrolling a patient to the program. And then in the bottom, you see a smart form where you can track your time for the services that you may render. So, we've launched this in ALS, Q4 of last year, and we just started doing this in MS. And if you can just scroll through the next animation, there's a accrual graph here, where you can see we're up to about 23 patients in ALS and 6 team members that have been trained. So, let's go to the next slide, please.

And shifting towards the future to echo something that Dr. Zecavati said, principle care management obviously requires care planning. That's part and parcel of the PCM service. There's goal setting around those and embedded in those care plans. But I think an important thing to mention is that PCM doesn't really specify how the provider, or the care team interacts with the patient.

It can be asynchronous, it can be synchronous, it can be on the phone, it can be a digital E/M service, it can be a variety of different things. And that includes data review of asynchronous wearable information like we're doing in step counts and MS. That may not be billable by the traditional, sort of by the book, CPT coding guidelines for remote patient monitoring because it's not an FDA approved device and so on. You can actually count those services towards PCM time spent and towards PCM billing.

So, I think to echo Dr. Zecavati’s point, what we're going to be seeing in the future is that PCM and these care coordination services are really going to be blazing a path towards value-based care and value-based payment models, which have been talked about for a very long time and are really the minority of a lot of services in the United states, but will probably become more and more important as we go forward. Next slide, please.

We're also going to be seeing a lot more high-quality evidence on the value proposition, in teleneurology in the COVID pandemic context and sort of after the COVID pandemic or in the COVID pandemic that we're obviously living through. And we'll also be seeing a lot more alignment of professional societies like the AAN with the evaluation of teleneurological care and care quality with formal quality frameworks like that developed by the NQF, as well as the framework that you all have developed at the AMA and an increasing shift towards digital patient reported outcome measures to measure effectiveness of teleneurological care. Next slide, please.

I think I would be remiss if I didn't mention the buzzword that is techequity. Teleneurology, I think is also going to increasingly attempt to address the digital divide and the issues of equity, diversity and inclusion that we experienced during the massive shift to digital medicine and digital neurology by that extension, during the COVID pandemic. I don't think this is something that health systems and practitioners can really ignore anymore.

This is a very, very hot topic right now. And I think what we're going to be seeing, in teleneurology specifically, is efforts towards increasing accessibility to very well established technologies like texting for vulnerable populations, as well as decreasing barriers to newer technologies that may require a greater digital literacy or a greater access to broadband or other technologies such as synchronous video platforms and other wearable devices. Next slide, please.

And finally, I want to sort of close with the future state of teleneurology with respect to artificial intelligence, which is going to be increasingly present in our world, not just in neurology, but really everywhere in medicine. I want to break down different conceptual categories of artificial intelligence. There are three of them: namely, assistive AI, analytic AI and autonomous AI. Assistive AI is really stuff that you've probably seen in your practice or even in your daily routines. It's really the pattern recognition and automation of simple processes.

One really, really good example of that, which is still kind of in its experimental phase, is detection of seizures automatically from an EEG waveform. It's not making decisions. It's not acting independently of a human being, but it's recognizing a pattern and maybe it alerts you of it, for example, Analytic AI is a little bit more complex in the sense that it sort of enhances or adds to human decisions. A good example of that could be a chat bot that detects an illness script of a headache, a specific type of headache, and suggests multiple choice of diagnosis or hones in on the diagnosis of migraine or trigeminal neuralgia and then notifies the physician. 

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It suggests something but does not make the decision that this is trigeminal neuralgia and have to start carbamazepine, for example. And then finally, the sort of more aspirational, further off and almost slightly scary AI, to be perfectly honest, is the autonomous AI, which is designed to act independently of humans and really make decisions on its own. I think a good example of this, which we're going to be tending towards in the future, is a smart home or a smart exam room that has multiple cameras, voice recognition technology that sort of leverages the same technology that we use for Amazon and Alexa and Siri and motion sensors.

I think that's going to be increasingly prevalent in cognitive disorders and movement disorders. For example, a smart home could identify that a patient's fallen and automatically activate EMS, automatically make some referrals, automatically notify the care team and sort of act independently, to a certain extent. So that's still a ways off, but it's something that's coming on the horizon and we're going to have to talk about it to increasing degrees. Next slide, please.

I think it's very important to mention that AI in the future, I don't visualize this and this may be a topic for debate, but my opinion is that AI is not going to replace providers. I think it's really going to enable providers to practice at the top of their license. It's going to be able to automate a lot of the rote, sort of less complicated stuff that physicians have to do day to day and really allow them to focus on the real nuances of their specialties or taking care of their patients. Clinically, I think patients will still need human touch, that's inevitable. And so, in that sense, AI is not here to replace providers. I think it's really here as a supportive technology. And I think we're going to be seeing an increasing amount of consideration being devoted to equity and ethics in AI model design.

I know that there's, at Sinai, for example, there is a committee on artificial intelligence equity that was recently formed to regulate the way that we kind of put together our models and integrate them into the health system to make sure that this is equitable for everyone.

I will say, though, that as we move towards more asynchronous, distributed services with increasing amounts of touchpoints between in-person visits and I do, I would argue that the frequency of in-person interactions may decrease because our touch points outside of these synchronous visits will increase. But again, I do want to make the point that patients will still need that human touch and they still will, AI will not be replacing providers, in my opinion. So, let's go to the next slide.

I think I'm actually finished there, so I'll stop there. And I just want to thank everybody for their attention. This is an amazing opportunity. I'm so honored to be here and I wanted to thank the AMA and the AAN, as well as my colleagues, for some excellent presentations and hopefully they were informative for you all. So, I will stop there and turn it over for discussion.

Lim: Great thanks, Dr. Kummer. And I know we're running a little bit behind, so if you have a heart stop, feel free to drop off. But we will take a few audience questions now. So, Laura, if we can just turn off the slides quickly here. And if you have a question, feel free to raise your hand. Use the raise hand function. It's under the reactions. And we can start with this first one. This one's for Dr. Morse, and it's in reference to the Ask-a-doc service. And this lady's asking, who pays for the service. Does insurance pay or is it self-pay?

Dr. Morse: Ok so with the Ask-a-doc service, there was a specific plan not to do billing. So, the RVUs that are assigned to it, is to create a value for the provider that gets accommodated into when we're looking at the productivity of the provider. So there isn't necessarily a billing that we've chosen to do with it in order to just make sure that there's no barriers in terms of who would be able to have access to it and not putting that additional burden on the patient.

Because we viewed it as being something that may reduce the likelihood of utilizing a service and just further increasing the health care utilization because people would decide, I'll just go see the specialist. I don't want to pay for just the opinion without actually seeing them.

Lim: Great thank you. Any questions from the audience? We had one in the registration report.

Dr. Morse: By creating Ask-a-doc, it does not create a doc patient relationship because it's a peer-to-peer consultation. The specialist who is providing feedback does not now have a patient relationship. So that patient is now not able to MyGeisinger or MyChart me or something like that. So, it doesn't create that kind of formalization, nor does it create that liability of now assuming the care of that patient.

Elaine: I have a question and I'm sorry I don't have the chat feature on my phone.

Lim: Yes, go ahead.

Elaine: My question is, with regard to research for supporting the future use, what are the highest priorities for trying to document the benefits? We were just at AAN NOH and the biggest concern was cost and adding to cost of health care. What are what's going on with research and what are the biggest areas that should be focused on?

Dr. Busis: I can take that, Elaine. Elaine is one of the pioneers in teleneurology, and I'm so thrilled that you could join us, Elaine. So, there have been, I think, two big questions from payers about teleneurology. Not so much stroke because that's pretty well established, but everything else. One is that the quality would be bad.

And two, that just like they thought email would replace fax machines, they figured, but now people go both fax and email the same thing in some states. The payers are afraid that every teleneurology visit will lead to an in-person visit and so you'll actually double the costs. So, I think that those are the two things we need to look at is utilization. Is it substitutive or additive to in-person visits? What are the outcomes? Does it work? So those, I think are going to be the two focuses. And there are some clever ways to get at this.

For example, if there's already quality information being collected and analyzed in your health system. If you look at a claims database or a big database like that, you can say, OK, look at the in-person ones, look at the telehealth ones and compare them if the outcomes are the same, plus prospective studies. So, I hope that answers your question.

Lim: Feel free to reach out if there's any questions. Laura, I'll ask you to pull up the slides here quickly. We have just a couple of housekeeping items to wrap up today's event. You must have received a feedback survey to three question survey. We appreciate your feedback in advance. And then, Michaela, do you want to share resources from the AAN?

Read: Yeah, absolutely. The AAN is working to revamp our telehealth web page, which will look like the image here on the right. Much of the information is there already. But later this summer, members of the telehealth subcommittee, in combination with some subject matter experts, have developed a guide to practicing teleneurology.

And given the uncertain legislative and regulatory future, this guide was really created to apply to clinicians, regardless of the patient population or geography. And to supplement that guide, we will also release two tips and tricks guides for telehealth for patients with the neuromuscular as well as an oculomotor or vestibular disorder. And later this fall, we will release best practices for training residents into teleneurology. So, we look forward to that. So feel free to visit our website AAN.com/telehealth and explore there and feel free to reach out with any questions and our [email protected] email address as well. Thank you.

Lim: Great next slide.

Fritsche: And just to keep you updated on upcoming telehealth immersion program events, this is the next one will be June 21, Accelerating Behavioral Health Integration through Telehealth and these links and registrations will be shared following this presentation. And if you have not already been on the Physician Innovation Network, this is an online social networking platform. If you'd like to connect after this discussion, if you have more questions that you weren't able to ask and we welcome you to go to the site. You can use the QR code here and we can let the presenters know if you have questions and they can tune in and answer. Again, thank you again. Here is our contact information. I'll give you a second to look at that. And thank you all for joining.

Lim: Thank you so much and special Thanks to Michaela, Dr. Busis, Dr. Morse, Dr. Zecavati and Dr. Kummer. Thank you so much, everyone. We will see you next time.

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Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.