Patient and Clinician Perspectives of New and Return Ambulatory Teleneurology Visits

Global Evidence on the Sustainability of Telemedicine in Outpatient and Primary Care During the First 2 Years of the COVID-19 Pandemic: Scoping Review Using the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) Framework

BACKGROUND

The rapid implementation of telemedicine during the early stages of the COVID-19 pandemic raises questions about the sustainability of this intervention at the global level.

OBJECTIVE

This research examines the patient experience, health inequalities, and clinician-patient relationship in telemedicine during the COVID-19 pandemic's first 2 years, aiming to identify sustainability factors.

METHODS

This study was based on a prepublished protocol using the Joanna Briggs Institute (JBI) methodology for scoping reviews. We included academic and gray literature published between March 2020 and March 2022 according to these criteria: (1) population (any group); (2) concepts (patient experience, clinician-patient relationship, health inequalities); (3) context (telemedicine in primary and outpatient care); (4) excluding studies pertaining to surgery, oncology, and (inpatient) psychiatry. We searched Ovid Medline/PubMed (January 1, 2022), Web of Science (March 19, 2022), Google/Google Scholar (February and March 2022), and others. The risk of bias was not assessed as per guidance. We used an analysis table for the studies and color-coded tabular mapping against a health care technology adoption framework to identify sustainability (using double-blind extraction).

RESULTS

Of the 134 studies that met our criteria, 49.3% (66/134) reported no specific population group. Regarding the concepts, 41.8% (56/134) combined 2 of the concepts studied. The context analysis identified that 56.0% (75/134) of the studies referred to, according to the definition in the United Kingdom, an outpatient (ambulatory care) setting, and 34.3% (46/134) referred to primary care. The patient experience analysis reflected positive satisfaction and sustained access during lockdowns. The clinician-patient relationship impacts were nuanced, affecting interaction and encounter quality. When mapping to the nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework, 81.3% (109/134) of the studies referenced the innovation's sustainability. Although positive overall, there were some concerns about sustainability based on quality, eHealth literacy, and access to health care for vulnerable migrants and the uninsured.

CONCLUSIONS

We identified confusion between the concepts of patient experience and patient satisfaction; therefore, future research could focus on established frameworks to qualify the patient experience across the whole pathway and not just the remote encounter. As expected, our research found mainly descriptive analyses, so there is a need for more robust evidence methods identifying impacts of changes in treatment pathways. This study illustrates modern methods to decolonize academic research by using gray literature extracts in other languages. We acknowledge that the use of Google to identify gray literature at the global level and in other languages has implications on reproducibility. We did not consider synchronous text-based communication.

TRIAL REGISTRATION

Open Science Framework 4z5ut; https://osf.io/4z5ut/.

Virtual Compared With In-Person Neurologic Examination Study

Background and Objectives

The COVID-19 pandemic forced a shift to virtual care in several neurologic care settings. Little is known about the validity of the virtual neurologic examination (VNE) for clinical decision making when compared with the in-person neurologic examination (IPNE). The objective of this study was to investigate the utility of the VNE in arriving at an accurate localization and diagnosis in comparison with the traditional IPNE in an ambulatory outpatient setting.

Methods

A retrospective chart review of patients examined virtually and in-person within 4 months at outpatient general neurology and neuromuscular clinics from 2 tertiary academic care centers during the COVID-19 pandemic was conducted. The Cohen kappa coefficient was calculated to test agreement between virtual and in-person assessment results, and descriptive statistical methods were used to compare accuracy, localization, and diagnosis.

Results

A total of 81 patients met the inclusion criteria. Overall, there was fair agreement between VNE and IPNE (64% agreement, p = 0.003). Substantial agreement between VNE and IPNE was observed for gait abnormalities; moderate agreement for extraocular movements, facial weakness, dysarthria, fasciculation, and lower limb weakness; and fair agreement for bulk, upper limb weakness, and sensation. No agreement between VNE and IPNE was seen for hypokinetic or hyperkinetic movements and cerebellar signs. Compared with the IPNE, specificity of the VNE was 86% and sensitivity was 56%. Some cases demonstrated a consistent localization (44%) and diagnosis (57%) after virtual and in-person assessments. The localization was changed in 15% and refined in 41% of cases between visits. The diagnosis was changed in 14% and refined in 30% of cases.

Discussion

The high rates of agreement in detecting an abnormality on the VNE and IPNE for some maneuvers and resultant clinical impressions may support the validity of the VNE for initial consultation depending on the clinical scenario. The VNE seems to be a good surrogate evaluation compared with the IPNE for certain chief complaints. The low sensitivity suggests that a normal VNE should warrant further in-person clinical correlation, especially in the context of a highly concerning history. The IPNE is more sensitive in detecting subtle abnormalities on examination, and a low threshold should be used to bring a patient in for an IPNE if the VNE is normal in certain clinical contexts.

Self-Reported Patient and Provider Satisfaction With Neurology Telemedicine Visits After Rapid Telemedicine Implementation in an Urban Academic Center: Cross-Sectional Survey

BACKGROUND

Many clinics and health systems implemented telemedicine appointment services out of necessity due to the COVID-19 pandemic.

OBJECTIVE

Our objective was to evaluate patient and general provider satisfaction with neurology telemedicine implementation at an urban academic medical center.

METHODS

Patients who had completed 1 or more teleneurology visits from April 1 to December 31, 2020, were asked to complete a survey regarding their demographic information and satisfaction with teleneurology visits. Providers of all specialties within the same hospital system were given a different survey to gather their experiences of providing telemedicine care.

RESULTS

Of the estimated 1500 patients who had completed a teleneurology visit within the given timeframe, 117 (7.8%) consented to complete the survey. Of these 117 respondents, most appointments were regarding epilepsy (n=59, 50.4%), followed by multiple sclerosis (n=33, 28.2%) and neuroimmunology (n=7, 6%). Overall, 74.4% (n=87) of patients rated their experience as 8 out of 10 or higher, with 10 being the highest satisfaction. Furthermore, 75.2% (n=88) of patients reported missing an appointment in the previous year due to transportation issues and thought telemedicine was more convenient instead. A significant relationship between racial or ethnic group and comfort sharing private information was found (P<.001), with 52% (26/50) of Black patients reporting that an office visit is better, compared to 25% (14/52) of non-Black patients. The provider survey gathered 40 responses, with 75% (n=30) of providers agreeing that virtual visits are a valuable tool for patient care and 80% (n=32) reporting few to no technical issues. The majority of provider respondents were physicians on faculty or staff (n=21, 52%), followed by residents or fellows (n=15, 38%) and nurse practitioners or physician assistants (n=4, 10%). Of the specialties represented, 15 (38%) of the providers were in neurology.

CONCLUSIONS

Our study found adequate satisfaction among patients and providers regarding telemedicine implementation and its utility for patient care in a diverse urban population. Additionally, while access to technology and technology literacy are barriers to telemedical care, a substantial majority of patients who responded to the survey had access to devices (101/117, 86.3%) and were able to connect with few to no technological difficulties (84/117, 71.8%). One area identified by patients in need of improvement was comfortability in communicating via telemedicine with their providers. Furthermore, while providers agreed that telemedicine is a useful tool for patient care, it limits their ability to perform physical exams. More research and quality studies are needed to further appreciate and support the expansion of telemedical care into underserved and rural populations, especially in the area of subspecialty neurological care.

Telemedicine and Patient Experience Ratings at an Academic Integrative Medicine Practice: Retrospective Examination

BACKGROUND

The use of telemedicine (TELE) increased exponentially during the COVID-19 pandemic. While patient experience with TELE has been studied in other medical disciplines, its impact and applicability to integrative medicine practices remain unknown.

OBJECTIVE

The aim of this study is to assess the impact of visit modality, TELE versus face-to-face (F2F) encounters, on patient experience at an integrative medicine practice at a single academic medical center. Given the significant role of the patient-physician relationship, therapeutic presence, and touch in integrative medicine, we hypothesized that TELE would result in reduced patient experience compared to traditional F2F encounters.

METHODS

A retrospective examination of Press Ganey surveys at an academic, consultative, and integrative medicine practice was conducted. Anonymous surveys completed by patients, older than 18 years of age, who had TELE or F2F appointments from April 1, 2020, to March 31, 2023, were included. At our medical center, patients commonly travel in from out of state for complex care. We examined percentage "top box" scores (ie, the percentage of respondents who selected the most positive response category on the survey, "very good"), across a variety of experience metrics. ANOVA and chi-square analyses were completed, with a significance threshold of P<.05.

RESULTS

Over the 36 months, a total of 1066 surveys were completed and returned (TELE: n=333; F2F: n=733). Overall, 73% (n=778) of respondents were female with an average age of 57.6 (SD 13.84) years. Most patients were English-speaking (n=728, 99.3%), White (n=1059, 92.7%), and not Hispanic or Latino (n=985, 92.4%). There was significantly higher satisfaction with access to care for TELE visits compared to F2F visits. There were no differences in satisfaction with the care provider or in overall experience. When examining the specific aspects of using technology during TELE visits, there were no differences in audio quality, visual quality, or ease of talking to the care provider based on sex. There was, however, a difference in video quality based on age, where those 80 years and older rated significantly lower video quality compared to all other age groups.

CONCLUSIONS

Top-level patient experience can be attained with TELE integrative medicine visits. Additional studies, particularly those correlating positive experience findings with specific behaviors used during TELE visits, would further our understanding of the integrative medicine patient experience. In the meantime, efforts should be made to ensure a policy that promotes the ongoing provision of TELE in integrative medicine.

Provider Impressions of Inpatient Teleneurology Consultation

Background and Objectives

Teleneurology usage has increased during the severe acute respiratory syndrome coronavirus 2 pandemic. However, studies evaluating physician impressions of inpatient teleneurology are limited. We implemented a quality improvement initiative to evaluate neurologists' impression following individual inpatient teleneurology consultation at a satellite hospital of a large academic center with no in-person neurology coverage.

Methods

A REDCap survey link was embedded within templates used by neurologists for documentation of inpatient consultations to be completed immediately after encounters. All teleneurology encounters with completed surveys at a single satellite hospital of the University of Pennsylvania Health System Neurology Department between May 10, 2021, and August 14, 2022, were included. Individual patient-level and encounter-level data were extracted from the medical record.

Results

A total of 374 surveys (response rate of 54.05%) were completed by 19 neurologists; 341 questionnaires were included in the analysis. Seven neurologists who specialized as neurohospitalists completed 231 surveys (67.74% of total surveys completed), while 12 non-neurohospitalists completed 110 (32.36%). The history obtained was rated as worse (14%) or the same (86%) as an in-person consult; none reported the history as better than nonteleneurology encounters. The physician-patient relationship was poor or fair in 25% of the encounters and good or excellent in 75% of visits. The overall experience was judged to be worse than in-person consultation in 32% of encounters, the same in 66%, and better in 2%. Fifty-one percent of providers responded that there were elements of the neurologic examination that might have changed their assessment and plan of care if performed in-person. Encounters with peripheral or neuromuscular-related chief complaints had the most inadequate examinations and worse overall experiences, while the most positive impressions of these clinical experiences were observed among seizure-related chief complaints.

Discussion

Determining best practices for inpatient teleneurology should consider the patient chief complaint to use teleneurology in scenarios with the highest likelihood of a positive experience. Further efforts should be made to the patient experience and to improve the remote examination to enhance the applicability of teleneurology to the full spectrum of inpatient neurologic consultations.

Linked Patient and Provider Impressions of Outpatient Teleneurology Encounters

Background and Objectives

Teleneurology is common in clinical practice partly due to the SARS CoV-2 pandemic. Impressions about teleneurology from patients and providers alike are generally favorable; some of the reported benefits include ease of access to specialized health care, savings of time and money, and similar quality of care as an in-person visit. However, comparisons between patient and provider impressions about the same teleneurology encounter have not been described. In this study, we describe patient impressions about a teleneurology encounter and evaluate concordance with provider impressions about the same encounter.

Methods

Patients and providers at the University of Pennsylvania Hospital Neurology Department were surveyed about their impressions of teleneurology between April 27, 2020, and June 16, 2020. A convenience sample of patients, whose providers completed a questionnaire, were contacted by telephone to solicit their impressions about the same encounter. Unique questionnaires for patients and providers focused on similar themes, such as adequacy of technology, assessment of history obtained, and overall quality of the visit. Summaries of patient responses are reported with the raw percent agreement between patients and providers for similar questions.

Results

One hundred thirty-seven patients completed the survey; 64 (47%) were male and 73 (53%) were female. Sixty-six (47%) patients had a primary diagnosis of PD, 42 (30%) a non-PD/parkinsonism movement disorder, and 29 (21%) a nonmovement disorder neurologic disease. One hundred one (76%) were established patient visits and 36 (26%) were new patient visits. Provider responses from 8 different physicians were included. Most of the patients responded that the ease of joining their visit, their comfort engaging with their physicians during their visit, understanding their plan of care after their visit, and the quality of care from their teleneurology visit were satisfactory. Patients and providers agreed about their impressions of the quality of the history obtained (87% agreement), patient-provider relationship (88% agreement), and overall quality of their experience (70% agreement).

Discussion

Patients had favorable impressions about their clinical experience with teleneurology and expressed an interest in incorporating telemedicine visits into their ongoing care. Patients and providers were highly concordant for the history obtained, patient-provider relationship, and overall quality.

Evaluating clinician-led quality improvement initiatives: A system-wide embedded research partnership at Stanford Medicine

Introduction

Many healthcare delivery systems have developed clinician-led quality improvement (QI) initiatives but fewer have also developed in-house evaluation units. Engagement between the two entities creates unique opportunities. Stanford Medicine funded a collaboration between their Improvement Capability Development Program (ICDP), which coordinates and incentivizes clinician-led QI efforts, and the Evaluation Sciences Unit (ESU), a multidisciplinary group of embedded researchers with expertise in implementation and evaluation sciences.

Aim

To describe the ICDP-ESU partnership and report key learnings from the first 2 y of operation September 2019 to August 2021.

Methods

Department-level physician and operational QI leaders were offered an ESU consultation to workshop design, methods, and overall scope of their annual QI projects. A steering committee of high-level stakeholders from operational, clinical, and research perspectives subsequently selected three projects for in-depth partnered evaluation with the ESU based on evaluability, importance to the health system, and broader relevance. Selected project teams met regularly with the ESU to develop mixed methods evaluations informed by relevant implementation science frameworks, while aligning the evaluation approach with the clinical teams' QI goals.

Results

Sixty and 62 ICDP projects were initiated during the 2 cycles, respectively, across 18 departments, of which ESU consulted with 15 (83%). Within each annual cycle, evaluators made actionable, summative findings rapidly available to partners to inform ongoing improvement. Other reported benefits of the partnership included rapid adaptation to COVID-19 needs, expanded clinician evaluation skills, external knowledge dissemination through scholarship, and health system-wide knowledge exchange. Ongoing considerations for improving the collaboration included the need for multi-year support to enable nimble response to dynamic health system needs and timely data access.

Conclusion

Presence of embedded evaluation partners in the enterprise-wide QI program supported identification of analogous endeavors (eg, telemedicine adoption) and cross-cutting lessons across QI efforts, clinician capacity building, and knowledge dissemination through scholarship.

Telemedicine in epilepsy and encephalitis: previous research and indication guidelines in Korea

Telemedicine is an emerging field of medicine that has become more important during the coronavirus disease 2019 (COVID-19) pandemic era and is being studied actively in various medical fields. In neurology, the introduction of telemedicine is accelerating worldwide under the label of teleneurology. So far, few studies have been conducted on telemedicine for patients with epilepsy. In nonmetropolitan areas, video-based clinics have been demonstrated to be effective for seizure control, and smartphone-based diagnosis has also been confirmed to be accurate. Indeed, after the onset of the COVID-19 pandemic, telemedicine has been used to treat patients with epilepsy around the world. Few studies have examined the use of telemedicine for patients with autoimmune encephalitis. One showed that telephone-based evaluation is sufficient to assess the cognitive reserve of leucine-rich glioma inactivated-1-antibody encephalitis patients, thereby diagnosing their dementia. Telephone-based outpatient clinics are temporarily permitted under Korean medical law, and telemedicine can be attempted for clinically stable patients with epilepsy in Korea. In addition, patients with autoimmune encephalitis in stable or improving status may also be candidates for treatment with telemedicine. This review presents evidence for the safety and efficacy of telemedicine to treat epilepsy and encephalitis patients and discusses indication guidelines. Based on our literature review and current Korean medical law, we suggest tentative guidelines for telemedicine in the fields of epilepsy and autoimmune encephalitis.

Feasibility and acceptability of virtually coaching residents on communication skills: a pilot study

BACKGROUND

Developing communication skills is a key competency for residents. Coaching, broadly accepted as a training modality in medical education, has been proven a successful tool for teaching communication skills. Little research is available thus far to investigate virtual coaching on communication skills for telemedicine encounters. The purpose of the study was to test the hypothesis that virtually coaching residents on communication skills is feasible and acceptable. We surveyed 21 resident-faculty pairs participating in a "fully virtual" coaching session (patient, coach, and resident were virtual).

METHODS

We asked 50 neurology resident-faculty coach pairs to complete one "fully virtual" coaching session between May 20 and August 31, 2020. After each session, the resident and coach completed a 15-item survey, including Likert-style scale and open-ended questions, assessing feasibility and acceptability. Descriptive statistics and qualitative content and thematic analyses were performed.

RESULTS

Forty-two percent (21/50) of all eligible residents completed "fully virtual" coaching sessions. The overall survey response rate was 91 % (38/42). The majority of respondents agreed that the direct observation and debriefing conversation were easy to schedule and occurred without technical difficulties and that debriefing elements (self-reflection, feedback, takeaways) were useful for residents. Ninety-five percent of respondents rated the coach's virtual presence to be not at all disruptive to the resident-patient interaction. Virtual coaching alleviated resident stress associated with observation and was perceived as an opportunity for immediate feedback and a unique approach for resident education that will persist into the future.

CONCLUSIONS

In this pilot study, residents and faculty coaches found virtual coaching on communication skills feasible and acceptable for telemedicine encounters. Many elements of our intervention may be adoptable by other residency programs. For example, residents may share their communication goals with clinic faculty supervisors and then invite them to directly observe virtual encounters what could facilitate targeted feedback related to the resident's goals. Moreover, virtual coaching on communication skills in both the in-person and telemedicine settings may particularly benefit residents in challenging encounters such as those with cognitively impaired patients or with surrogate decision-makers.