Quality and Safety Analysis of 2,999 Telemedicine Encounters During the COVID-19 Pandemic

Patient Experience Scores for Telehealth Visits at an Outpatient Child Neurology Clinic: A Retrospective Cohort Study

Background: Since the COVID-19 pandemic, telehealth has been widely adopted, and several studies have highlighted the benefits of telehealth. However, there are limited studies in pediatric neurology with a focus on epilepsy. The objective of this single-site retrospective cohort study was to examine patient experience scores of telehealth versus in-person established encounters in an outpatient pediatric neurology clinic. Methods: Data were abstracted from April 1, 2020 through March 31, 2024. Variables included demographics, appointment type (telehealth vs in-person), appointment date, primary diagnosis and net promoter score (NPS) number and category. A subanalysis of epilepsy diagnosed patients, and a matched patient analysis were conducted. Results: There were 2,863 in-person visit encounters and 635 telehealth visit encounters. Telehealth encounters had a statistically greater mean NPS of 9.7, compared with in-person visits (9.5). Both telehealth and in-person encounters had more than 90% of promoter scores, indicating a high score of 9-10. During the COVID-19 time period (defined as April 1, 2020 to May 4, 2023), NPS were higher with a mean of 9.7 for telehealth encounters, compared with in-person encounters (9.5). There were no differences in NPS post-COVID-19. Primary encounter diagnoses of Epilepsy/Seizure had a slightly greater mean NPS for telehealth visits (9.7) compared with in-person encounters (9.5). The matched patient analysis revealed no difference between telehealth and in-person encounter NPSs with means of 9.7 and 9.6, respectively. Conclusion: NPS, which are a measure of patient experience, were superior or equal to in-person visits for pediatric neurology telehealth encounters both during the COVID-19 pandemic and in the postpandemic period.

Telemedicine in Pediatric Neurology: A Survey of Patient and Provider Experience

BACKGROUND

Over recent years there has been a shift in clinical practice to support care delivery via telemedicine. This study aims to highlight the patient and provider experience of telemedicine over 2.5 years within a Canadian Pediatric Neurology clinic.

METHOD

A REDCap survey was sent to all patients/parents and providers with a telemedicine appointment between March 2020 and September 2022.

RESULTS

Seven providers and 272 patients responded. Ninety-one percent of patients and 100% of providers were satisfied with telemedicine. Ninety percent of patients and 100% of providers found telemedicine more convenient. Eighty-seven percent of patients and 100% of providers were interested in future telemedicine appointments. Main challenges were with performing a physical examination and technological issues.

CONCLUSION

Our survey shows that the majority of patients and providers had highly positive experiences with telemedicine and were interested in continuing care via telemedicine. This study supports incorporating telemedicine into future pediatric neurology practice.

The Tell on Telehealth

Objective

Telehealth in epilepsy care is not new. During the COVID-19 public health emergency, telehealth became more readily used to deliver epilepsy care. However, a summarized guidance of use in caring for people with epilepsy utilizing telehealth is needed.

Methods

Existing literature was reviewed to provide guidance on various aspects of telehealth. Billing aspects are reviewed. Recommendations and considerations along with benefits and barriers to telehealth are provided.

Results

Telehealth can be a preferred delivery route of care for people with epilepsy in specific situations. Examples include psychiatric complaints, medication management, and follow-up visits for noncomplicated epilepsy care. In addition, telehealth is useful for patients who need postoperative visits, are not able to travel, or live in residential facilities. In-person care may be more suitable for patients who are medically complex, have language barriers or difficulty with resource access, hearing impaired, or have neurostimulation devices where remote monitoring or programming options are infeasible.

Discussion

Telehealth care for people with epilepsy can be a useful and important method of care delivery. It should remain an option for providers to use in epilepsy clinical care. It is important for the neurology provider to understand the benefits, billing, and barriers to providing telehealth.

Teleneurology and Artificial Intelligence in Clinical Practice

ABSTRACT

As teleheath becomes integrated into the practice of medicine, it is important to understand the benefits, limitations, and variety of applications. Telestroke was an early example of teleneurology that arose from a need for urgent access to neurologists for time-sensitive treatments for stroke. It made a scarce resource widely available via video conferencing technologies. Additionally, applications such as outpatient video visits, electronic consultation (e-consult), and wearable devices developed in neurology, as well. Telehealth dramatically increased during the COVID-19 pandemic when offices were closed and hospitals were overwhelmed; a multitude of both outpatient and inpatient programs developed and matured during this time. It is helpful to explore what has been learned regarding the quality of telehealth, disparities in care, and how artificial intelligence can interact with medical practices in the teleneurology context.

A Comparison of Patients' and Neurologists' Assessments of their Teleneurology Encounter: A Cross-Sectional Analysis

Background and Objectives: To better understand patients' and neurologists' assessments of their experiences regarding effectiveness of teleneurology encounters. Methods: Following an audio-video telehealth visit, neurologists asked patients to participate in a survey-based research study about the encounter, and then, the neurologists also recorded their own evaluations. Data were analyzed using standard quantitative and qualitative techniques for dichotomous and ordered-category survey responses in this cross-sectional analysis. Results: The study included unique encounters between 187 patients and 11 general neurologists. The mean patient age was 49 ± 17.5 years. Two thirds of the patients (66.8%, 125/187) were female. One third (33.2%; 62) were patients new to the NYU Langone Health neurology practices. The most common patient chief complaints were headache (69/187, 36.9%), focal and generalized numbness or tingling (21, 11.2%), memory difficulty (15, 8%), spine-related symptoms (12, 6.4%), and vertigo (11, 5.9%). Most patients (94.7%, 177/187) reported that the teleneurology encounter satisfied their needs. Patients and their neurologists agreed that the experience was effective in 91% (162/178) of encounters, regardless of whether the visit was for a new or established patient visit. Discussion: More than 90% of new and established patients and their neurologists agreed that teleneurology encounters were effective despite some limitations of the examination, the occasional need for patient assistance, and technical difficulties. Our results provide further evidence to justify and to expand the clinical use of teleneurology.

Telehealth Use and Access to Neurology Outpatient Clinical Services for Children: An Observational Cohort Study

Background

Access to neurology services is important for children's well-being. We sought to evaluate the effects of telehealth on pedi-atric neurology appointment outcomes for children.

Methods

Using electronic health record (EHR) data, information about children with pediatric neurology appointments in a tertiary care children's hospital in North Carolina was collected. Appointment outcomes (completion, cancellation, and no-show rates) were calculated for children who had a neurology appointment scheduled both in the pre-pandemic (March 10, 2019, to March 9, 2020) and pandemic (March 10, 2020, to March 9, 2021) periods. "Telehealth user" was a child who had at least one telehealth appointment scheduled between March 10, 2020, and March 9, 2021. In bivariate and multivariate analyses, we compared appointment outcomes for telehealth users and non-users.

Limitations

EHR data were limited to a single institution and could have missed children's clinical encounters elsewhere. Since this study used secondary data that were not collected for research purposes, it is possible that there were unmeasured confounders. Because of the observational nature of the study, the association between telehealth use and appointment outcomes does not indicate causation.

Results

A total of 2110 children had 11,194 pediatric neurology appointments scheduled. Telehealth users compared with non-users were more likely to be White, non-Hispanic, have private insurance, and live farther from the children's hospital. There was a statistically sig-nificant decrease in completion (66% versus 57%) and increase in cancellation (27% versus 33%) and no-show (7% versus 10%) rates in the pandemic when compared to the pre-pandemic period. In the pre-pandemic period, telehealth user and non-user groups had similar cancellation and no-show rates. In the pandemic period, there was a statistically significant decrease in cancellation and no-show rates in the telehealth user group when compared to the non-user group.

Conclusions

Pediatric neurology outpatient clinic visits decreased substantially during the pandemic. Telehealth mitigated these problems. Children belonging to a minority race/ethnicity are less likely to use telehealth, increasing their risk of poor access to neurology services.

Audio or Video? Access to Pediatric Neurology Outpatient Services Varies by the Type of Telehealth, Especially for Black Children

BACKGROUND

Children of minority race/ethnicity face barriers to accessing specialty services. During the COVID pandemic, health insurance companies reimbursed telehealth services. Our objective was to evaluate the effect of audio versus video visits on children's access to outpatient neurology services, particularly for Black children.

METHODS

Using Electronic Health Record data, we collected information about children who had outpatient neurology appointments in a tertiary care children's hospital in North Carolina from March 10, 2020, to March 9, 2021. We used multivariable models to compare appointment outcomes (canceled vs completed, and missed vs completed) by visit type. We then conducted similar evaluation for the subgroup of Black children.

RESULTS

A total of 1250 children accounted for 3829 scheduled appointments. Audio users were more likely to be Black and Hispanic, and to have public health insurance than video users. Adjusted odds ratio (aOR) for appointments completed versus canceled was 10 for audio and 6 for video, compared to in-person appointments. Audio visits were twice as likely as in-person visits to be completed versus missed; video visits were not different. For the subgroup of Black children, aOR for appointments completed versus canceled for audio was 9 and video was 5, compared to in-person appointments. For Black children, audio visits were 3 times as likely as in-person visits to be completed versus missed; video visits were not different.

CONCLUSIONS

Audio visits improved access to pediatric neurology services, especially for Black children. Reversal of policies to reimburse audio visits could deepen the socioeconomic divide for children's access to neurology services.

Child neurology telemedicine: Analyzing 14 820 patient encounters during the first year of the COVID-19 pandemic

AIM

To determine the long-term impact of telemedicine in child neurology care during the COVID-19 pandemic and with the reopening of outpatient clinics.

METHOD

We performed an observational cohort study of 34 837 in-person visits and 14 820 telemedicine outpatient visits across 26 399 individuals. We assessed differences in care across visit types, time-period observed, time between follow-ups, patient portal activation rates, and demographic factors.

RESULTS

We observed a higher proportion of telemedicine for epilepsy (International Classification of Diseases, 10th Revision G40: odds ratio [OR] 1.4, 95% confidence interval [CI] 1.3-1.5) and a lower proportion for movement disorders (G25: OR 0.7, 95% CI 0.6-0.8; R25: OR 0.7, 95% CI 0.6-0.9) relative to in-person visits. Infants were more likely to be seen in-person after reopening clinics than by telemedicine (OR 1.6, 95% CI 1.5-1.8) as were individuals with neuromuscular disorders (OR 1.6, 95% CI 1.5-1.7). Self-reported racial and ethnic minority populations and those with highest social vulnerability had lower telemedicine participation rates (OR 0.8, 95% CI 0.8-0.8; OR 0.7, 95% CI 0.7-0.8).

INTERPRETATION

Telemedicine continued to be utilized even once in-person clinics were available. Pediatric epilepsy care can often be performed using telemedicine while young patients with neuromuscular disorders often require in-person assessment. Prominent barriers for socially vulnerable families and racial and ethnic minorities persist.

Neurologists' Evaluations of Experience and Effectiveness of Teleneurology Encounters

Background and Objectives: To better understand neurologists' assessments of the experiences and effectiveness of teleneurology encounters. Methods: After completing an audio-video telehealth visit with verbally consenting patients, neurologists recorded their evaluations of the encounter. Data were analyzed using standard quantitative and qualitative techniques. Results: The study included unique encounters between 187 patients and 11 neurologists. The mean patient age was 49 ± 17.5 years. Two thirds of patients (66.8%, 125/187) were female. One third of patients (33.2%; 62) were new patients. The most common patient complaints were headache (69/187, 36.9%), focal and generalized numbness or tingling (21, 11.2%), memory difficulty (15, 8%), spine-related symptoms (12, 6.4%), and vertigo (11, 5.9%). Neurologists reported that they completed a virtual examination that provided enough information for medical decision-making in 94.9% of encounters (169/178, 9 missing responses). Fourteen of 25 examination elements important for medical decision-making could be performed sufficiently during virtual encounters. Examination assistance was needed for 16.4% (30/183) of patients, who were, on average, 17.3 years older than those who did not require assistance (62.9 years vs. 45.6 years, p = 0.0002). In 19.1% (34/178) of encounters, neurologists learned clinically relevant information from seeing patients in their homes. Neurologists' assessments of the effectiveness of encounters were not related to the presence (97.2%, 35/36 effective) or absence (95%, 134/141 effective) of technical difficulties (p = 0.5729) in 177 encounters (10 missing responses). Discussion: Neurologists reported that nearly 95% of teleneurology encounters were effective despite limitations of the virtual examination, occasional need for patient assistance, and technical difficulties.

How has the COVID-19 pandemic affected the utilisation of online consultation and face-to-face medical treatment? An interrupted time-series study in Beijing, China

OBJECTIVE

The COVID-19 pandemic has had a major impact on healthcare utilisation. This study aimed to quantify how the online and face-to-face utilisation of healthcare services changed during this time and thus gain insights into the planning of future healthcare resources during the outbreak of infectious diseases.

DESIGN

This work is an interrupted time-series study.

SETTING

Monthly hospital-grade healthcare-service data from 22 tertiary first-class public hospitals managed by the Beijing Hospital Authority and online-consultation data from GoodDoctor were used in this study.

METHODS

This is an interrupted time-series study about the change in face-to-face and online healthcare utilisation before and after the COVID-19 outbreak. We compared the impact of COVID-19 on the primary outcomes of both face-to-face healthcare utilisation (outpatient and emergency visits, discharge volume) and online healthcare utilisation (online consultation volume). And we also analysed the impact of COVID-19 on the healthcare utilisation of different types of diseases.

RESULTS

The monthly average outpatient visits and discharges decreased by 36.33% and 35.75%, respectively, compared with those in 2019 in 22 public hospitals in Beijing. Moreover, the monthly average online consultations increased by 90.06%. A highly significant reduction occurred in the mean outpatients and inpatients, which dropped by 1 755 930 cases (p<0.01) and 5 920 000 cases (p<0.01), respectively. Online consultations rose by 3650 cases (p<0.05). We identified an immediate and significant drop in healthcare services for four major diseases, that is, acute myocardial infarction (-174, p<0.1), lung cancer (-2502, p<0.01), disk disease (-3756, p<0.01) and Parkinson's disease (-205, p<0.01). Otherwise, online consultations for disk disease (63, p<0.01) and Parkinson's disease (25, p<0.05) significantly increased. More than 1300 unique physicians provided online-consultation services per month in 2020, which was 35.3% higher than in 2019.

CONCLUSIONS

Obvious complementary trends in online and face-to-face healthcare services existed during the COVID-19 pandemic. Different changes in healthcare utilisation were shown for different diseases. Non-critically ill patients chose online consultation immediately after the COVID-19 lockdown, but critically ill patients chose hospital healthcare services first. Additionally, the volume of online physician services significantly rose as a result of COVID-19.

A Multicenter Study of Adherence to Best Practices and Application of Epilepsy Quality Metrics in a Pediatric Telemedicine Encounter

Objective: To assess Epilepsy Quality Metrics (EQM) and guideline implementation in new pediatric patients seen in telemedicine. Methods: Multicenter, cross sectional, retrospective analysis. Results: Patients were similar across 3 centers for age, gender, and insurance type. Eighty-one percent presented for spells. One hundred sixty patients with epilepsy formed the EQM cohort. Results: Seizures described: 95%; frequency: 67%, last seizure documented: 81%, epilepsy syndrome documented: 67%; epilepsy diagnosis: 77%, medications reviewed: 56%, adverse events discussed: 73%. Quality of life discussed: 3%. Anticipatory guidance was described as follows: seizure safety, 57%; driving, 47%; SUDEP, 11%; vitamin D discussion, 19%; pregnancy and folic acid counseling, 4% and 10%. Epileptologists were 4 times as likely as generalists in discussing driving safety (odds ratio 3.93, 95% confidence interval 1.7-8.9; P = .001) for all ages. Significance: Performance on EQM and guideline implementation in pediatric epilepsy telemedicine encounters can be improved.

Risk of Admission to the Emergency Room/Inpatient Service After a Neurology Telemedicine Visit During COVID-19 Pandemic

BACKGROUND

We compared emergency department (ED) and overnight inpatient admission (admission) rates within eight weeks of home-based telemedicine visits during COVID-19 in 2020 with in-person visits (conventional visit) in 2019. This was a quality improvement project prompted by an adverse event after a telemedicine visit.

METHODS

We reviewed all completed telemedicine and conventional visits from March 26 to June 1 of 2020 and 2019 to identify patients who required an ED visit or hospital admission within eight weeks after the visit.

RESULTS

In 2020, the overall rate of ED visits of hospital admission within eight weeks of a neurology visit was less than 5%. Comparing 2020 with 2019: (1) cohorts were similar for age, payor, state of residence, medical complexity, recommendation for close follow-up, new medications, or new tests ordered; (2) it took longer to present to the ED (by 10 days) or to be hospitalized (by three days); (3) planned admissions were approximately 50% lower; (4) on multivariate analysis, risk factors for any ED/admission included a patient call within seven days before the ED/admission (P = 0.0004) or being seen by an epilepsy specialist (P = 0.02); (5) a presenting complaint of worsening symptoms had a lower odds ratio of subsequent ED visit/admission (P = 0.005).

CONCLUSIONS

Telemedicine is safe, with a similar likelihood of ED or hospital admission during the pandemic in 2020 versus before the pandemic in 2019. In 2020, even if patients described worse symptoms at the time of their clinic visit, the odds of ED or hospital admission were lower than in 2019, but those who called after the telemedicine visit were more likely to be seen in ED or require hospitalization.

Satisfaction of Telehealth in Patients With Established Neuromuscular Disorders

Introduction/aims: Determine established neuromuscular disease patients' satisfaction with telehealth during the COVID-19 pandemic. Methods: We received 50 completed Utah telehealth satisfaction surveys from a cohort of 90 from April 2020 to June 2020. Returning neuromuscular disease patients rated seven aspects from 1 (strongly disagree) to 5 (strongly agree): Communication, timeliness of physician, picture quality, sound quality, protection of privacy, the comfort of the physical exam, the ease of healthcare, and whether patients would prefer "in-person" visits despite safety precaution. A favorable response was defined as a response of "Agree" or "Strongly Agree" to the survey questions. An independent t-test, Fisher's or chi-square test were used to compare demographic factors on outcomes for each survey question. Results: The average age was 47.54 ± 20.63, 54% were female, 70% from rural areas, 60% had family present "webside," and 14% had family present remotely. The majority of patients reported "Agree" or "Strongly Agree" to each survey question assessing their telehealth satisfaction, except for whether patients preferred in-person appointments. Demographic factors, including location and clinical diagnosis, did not influence survey responses. Discussion: The vast majority of established neuromuscular disease patients responded favorably to their telehealth experience during the COVID-19 pandemic.

Telemedicine in Pediatric Headache: A Review and Practical Implementation

Purpose of Review

The purpose of this review was to summarize the current literature about telemedicine in pediatric headache and to provide practical guidance for its implementation.

Recent Findings

There are few studies dedicated to telemedicine in pediatric headache, and existing studies are small. Patients and families report high levels of satisfaction with telemedicine, and most are willing to continue telemedicine visits in the future. Telemedicine demonstrated similar reductions in headache frequency, severity, and duration as patients treated in-person. Remotely delivered psychologic interventions have some utility in reducing headache severity acutely. Families feel telemedicine reduces geographic and financial barriers to care.

Summary

Telemedicine in pediatric headache is a growing field. While there is limited research available, it appears safe, efficacious, and feasible. Headache-related outcomes, including frequency, severity, and duration, were similar amongst telemedicine and in-person visits. Future studies should include larger sample sizes and detailed analysis of adverse outcomes.

How to manage with telemedicine people with neuromuscular diseases?

INTRODUCTION

COVID-19 pandemic radically transformed our daily clinical practice, raising the need not to lose close contact with patients without being able to see them face-to-face. These issues are even more felt and evident in fragile patients, as those affected by neuromuscular disease. An important help came from new digital technologies that allow clinicians to remotely monitor health status and any deterioration of chronically ill patients.

METHODS

In this mini-review, an initiative of the "Digital Technologies, Web and Social Media Study Group" of the Italian Society of Neurology, we propose to analyze the approach to neuromuscular patients by looking over raising evidence on the main cornerstones of Telemedicine (TM): clinician-patient interaction, remote clinical assessment, remote monitoring, and digital therapeutics. In particular, we explored the strategies developed by researchers and their impact on the physical and emotional status of the patients, with particular focusing on their adherence to the program of virtual monitoring.

RESULTS

TM plays an important role in each of four stages of approach to neuromuscular disease, having demonstrated validity in keep close clinical patient interaction, clinical assessment, remote monitoring, and telerehabilitation. Nevertheless, there is no remote alternative to electrophysiological testing neither validate tools to assess disability.

CONCLUSION

The role of TM in neuromuscular care is yet underestimated but is crucial, beyond the pandemic era. Further development of TM is advisable, through making specific apps, remotely controlled by clinicians, and making more engaging clinicians-patients interaction. Last, it is necessary to ensure adequate internet access to everyone.