Teleneurology in Resource-Poor Settings: Is It Here to Stay?
In March 2019, when I was a junior doctor in my home country, Nepal, the COVID-19 pandemic hit and a strict lockdown came into effect. To ensure continuity of care, the Department of Neurology at Tribhuvan University Teaching Hospital, the largest hospital in Nepal, launched a teleneurology service. I frequently responded to patients’ questions via phone, gathered information on their signs/symptoms, performed neurological exams, and reported it to the neurologist, who would then follow up with the patients about treatment recommendations. Overall, our team offered free virtual consultations to hundreds of patients via smartphone video conferencing, and more than 90% of them considered teleneurology equivalent to in-person consultations and stated they would welcome it in the future.
Now that pandemic restrictions have largely loosened, however, the question of whether teleneurology will continue to play a role in our healthcare systems remains. In my opinion, the answer is an unmistakable ‘yes’ for its added convenience of time and travel savings and similar levels of patient satisfaction as in-person consultations. In Nepal, there are fewer than 30 neurologists for a population of over 30 million, mostly serving the urban population. Teleneurology helps address this shortage of neurologists and overcome physical barriers. Secondly, it helps prevent delays in diagnosis and treatment of neurological conditions, allowing for continuity of care. This can be especially useful for acute conditions like stroke, where it may help narrow the therapeutic time window for thrombolysis by reducing door-to-needle time. Physicians located in a peripheral center, for instance, can conduct a rapid clinical assessment and contact a neurologist at the stroke center to potentially initiate thrombolysis, and if necessary, refer the patient for potential neurovascular intervention. At the same time, studies investigating the usage of teleneurology for patients with chronic neurological conditions (e.g. Parkinson’s disease) are also emerging. Regular exercise, which can be performed under telemedicine supervision, has been shown to slow the progression of PD, demonstrating that its utility extends beyond diagnostic and therapeutic realms to rehabilitation as well. Finally, remote assistance in the interpretation of neuroimaging and EEG is also becoming increasingly feasible.
Nevertheless, there are always doubts that a telemedicine consultation can fully replace in-person appointments. In particular, clinical examination is the backbone of evaluating any neurological condition, but how feasible is it to conduct a comprehensive neurological exam virtually? Through the pandemic, we have seen clinicians all around the world adopting remote consultations, and studies have shown that neurologists are able to perform a significant portion of the examination virtually. Personally, I found certain components of exams difficult through a telehealth platform, including assessing the rigidity of PD patients or testing reflexes/sensory functions, but found caregiver assistance particularly useful in such circumstances. For instance, NIHSS scoring for stroke patients in the telestroke unit and remote versions of the movement disorders rating scale are being increasingly used in practice.
Another source of limitation for teleneurology is the technical infrastructure. Ideally, a teleneurology setup would require a cloud-based video conferencing platform, scheduling software, secure rooms, stable internet, and a command center for patient and provider questions – at the very least. Setting all of this up can be costly and a particularly major hindrance in establishing teleneurology clinics in low- and middle-income countries (LMIC). However, my experience suggests mobile phone-based applications and cellular data can provide an optimal teleneurology experience at a fraction of the cost. At an individual level, socioeconomic determinants can prevent access to smartphones or internet connectivity, and variability in patients’ ability to operate their smartphones can be an impediment. But over the past two decades, there has been a strong mobile phone penetration across Asia and Africa, and I believe it has tremendous potential in improving access to neurological care. Several case studies from India, for instance, demonstrate that low-cost smartphones can be employed to deliver stroke care and other neurological conditions and can be a viable option in other LMICs.
However, high setup costs and the ability to virtually examine a patient are not the only barriers to teleneurology. Maintaining privacy, data security, and other legal issues surrounding teleneurology are some of the most pressing challenges that must be addressed. Within our service in Nepal, we used WhatsApp or Viber, which uses end-to-end encryption and made our conversations with patients secure. Proper documentation of the conversation is required for future use and implementation of electronic health records (EHR) is important in this regard. While still in its infancy, efforts are being made in several LMICs, including Nepal, to establish a functional EHR. Physician reimbursement/billing, licensing restrictions, credentialing requirements, and coordination with local health agencies are other building blocks in establishing effective teleneurology services.
Last but not least, it is essential that neurologists taking part in teleneurology develop an understanding of the local culture so that they can build a good patient-physician relationship and are aware of the resources available at the local level. Thus, introducing teleneurology as a part of medical training, especially in LMICs, will increase its adoption among clinicians and make them efficient.
In my humble opinion, teleneurology is here to stay. As time passes, it will gain widespread acceptance, and with the democratization of new technologies, it will only improve. It is essential to accommodate virtual encounters in a routine workflow and that LMICs invest in it in order to increase access to neurological services especially in remote rural settings, ultimately helping bridge treatment gaps and promote health equity.
Dr. Jayant Yadav is an aspiring neurologist from Nepal. He earned his medical degree from the Tribhuvan University, Institute of Medicine in Kathmandu, Nepal. He serves as an Associate Blog Editor for the WNFO Blog.