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CHOP: Virtual Neurologic Exams A ‘Best Practice’

By Deborah Borfitz

July 7, 2020 | Researchers at Children’s Hospital of Philadelphia (CHOP) have conducted the first sizable study examining the quality of child neurology telehealth outpatient care and concluded the approach is “feasible and effective” for about 95% of patient visits. Telemedicine was a first-time experience for most of the 83 child neurology providers (physicians, advanced practice providers and graduate medical trainees) comprising CHOP’s division of neurology, mirroring a scenario foisted upon providers nationwide by the COVID-19 pandemic, says Donna Stephenson, M.D., medical director of operations and outreach as well as one of the senior authors of the study.

The manuscript, recently published online in Neurology (DOI: 10.1212/WNL.0000000000010010), suggests that telemedicine may continue to have an important role in clinical care for years to come. The evidence came from a retrospective comparison of 14,780 in-person encounters (Oct. 1, 2019 – March 15, 2020) and 2,589 telehealth encounters (March 16 – April 24, 2020), including 2,093 via audio-video telemedicine and 496 (follow-up visits only) by telephone.

Telemedicine effectiveness research was enabled by newly developed data science techniques, including natural language processing, which mined patient medical records in the Epic EMR “almost in real time,” explains senior study author Ingo Helbig, M.D., a pediatric neurologist at CHOP and director of the genomic and data science core of CHOP's Epilepsy Neurogenetics Initiative (ENGIN). Effectiveness of telemedicine encounters was gauged by a questionnaire embedded in the EMR asking providers about their satisfaction with telemedicine, follow-up plans using telemedicine, the presence of technical issues and concerns requiring sooner in-patient assessment, and the satisfaction of families at the conclusion of encounters.

The data were then analyzed by Arcus, an informatics platform developed by the CHOP Research Institute that longitudinally links biological, clinical, research, and environmental data on patients.

The study reached six broad conclusions:

  • Patient volume quickly rebounded. In the first two weeks after the transition from in-person to telehealth care, clinical volume fell by 41% (to 247.5 encounters weekly) but over the next two weeks increased to 3% over baseline (626.5 encounters per week). Audio-visual visits accounted for 80% of the total telehealth encounters.

  • Patient demographics for telemedicine and in-person cohorts were identical. Age, ethnicity, race, and household income were the same for both groups. The only difference was that the ratio of new to established patients was slightly lower among those receiving telemedicine visits (31% versus 35%).

  • Diagnostic spectrum before and after telehealth holds steady for most common primary diagnoses (epilepsy and migraine). While metabolic disorders were overrepresented in the telehealth cohort and back pain was underrepresented, overall case numbers were too small to draw conclusions, Stephenson says. Possible explanations are that kids with metabolic illnesses tend to be sicker and that back issues might be more easily postponed during a pandemic.

  • High level of provider and caregiver satisfaction with telemedicine. Providers ranked 93% of encounters as satisfying overall and 89% indicated they’d use telemedicine for at least a component of patients’ follow-up plan. In 86% of encounters, providers also report that caregivers were interested in telemedicine as part of future care. For both groups, satisfaction was driven by sense of personal safety during the visit and avoidance of travel while still being able to effectively exchange critical information, says Stephenson. This was despite technical quality impairing 40% of encounters—most often due to poor audio or video quality.

  • Some in-person assessments unavoidable. In 5% of telemedicine encounters, most often epilepsy, providers considered the clinical scenario concerning enough to necessitate an in-person evaluation. Migraine was significantly underrepresented in the visits-of-concern group. In some cases, in-person visits were necessitated because poor internet connectivity made it impossible to adequately assess a child’s symptoms, says Helbig.

  • Structured telephone rather than telemedicine encounters more common among blacks (21% vs. 11%) and Hispanics/Latinos (14% vs. 9%) and those with lower median household income ($72,373 vs. $79,997). Patients with epilepsy were also overrepresented (42% vs. 35%). Similar differences were seen when the telephone and in-person encounter groups were compared.

Given that neurologic conditions can have “less obvious” symptoms, knowing that the majority of patients can be managed via telemedicine without adversely affecting outcomes was big and encouraging news, says Helbig. That means telemedicine is “not just a Band-aid but a valuable tool” which, moving forward, could account for a significant proportion of neurologic care in general.

Standardization Efforts

Neurologic examinations via video are not only doable, but represent a “best practice,” says Stephenson. And it can be mastered by following recommended exam techniques and guidelines of advocacy groups such as the Child Neurology Society and American Academy of Neurology and participating in online discussion groups where professionals share their real-world experiences.

How virtual neurologic exams get done will become much more standardized over time, she says, and pediatricians as well as pediatric neurologists alike will need to be well versed in the particulars. “This will become part of the educational curriculum for residents and students going forward if telemedicine takes hold. We’d like to have everybody working at the same level of excellence.”

With “a little creativity,” a fairly comprehensive neurological examination of patients by visual inspection is possible across age groups, Stephenson continues. “That does lead to a change in your thinking, your diagnosis, your differential, your testing.”

It’s helpful that “kids love screens,” making it fairly easy to prompt a response from them during a video visit, she says. With younger children, she will often have a parent use a ball or other toy to elicit their compliance and cooperation just as she would do in her office.

In many cases, both parents are present for telemedicine visits, Helbig says. “I often have one parent be the dedicated ‘cameraman’ while the other has the child do some task.” Symptoms can be easier to spot when young patients are playing at home with their own toys rather than in the confines of an office. They’re less nervous and more “themselves.”

CHOP has begun opening back up for in-person visits, says Stephenson. But, much like other specialty groups across the institution, the neurology division plans to remain at half capacity for traditional encounters through at least the end of August.

The prevailing sentiment among neurologists at CHOP, and more globally, is that “certain clinical circumstances lend themselves more clearly to telemedicine” than others, says Stephenson. “The general rule in our division is to see new patients in-person. Providers then can determine who is appropriate for telemedicine or really needs to be seen for follow-up care in person.”

Technical difficulties—patients whose computer or internet connection is a limitation or who have difficulty downloading the programming—are for now being dealt with via workarounds, says Stephenson. The longer-term goal is to optimize the Epic platform to enable better connectivity to every conceivable device, which is no small task.

The Unknowns

Helbig primarily sees children through ENGIN, which treats rare forms of genetic epilepsies and attracts patients from across the nation and globe. That can be a large travel burden for families with a sick child, he says. Telemedicine has allowed remote follow-up with patients and their caregivers living in different parts of Pennsylvania so they can avoid both unnecessary exposure to COVID-19 and the stress of the journey.

But until and unless insurance policies and medical-licensing laws change, the advantage ends at the state border, he says. In addition to insurance companies that have been slow to embrace telemedicine consults for regional hospitals, state medical boards continue to operate independent of one another. Serving patients outside of Pennsylvania, remotely or otherwise, currently requires a medical license in their state of residence.

Lack of broadband access is an issue that is bigger than any single institution, Helbig adds, but critical to address if healthcare quality as defined by the Institute of Medicine—safe, effective, patient-centered, timely, efficient, and equitable—is to become a reality. So is understanding the reasons for lower usage of audio-video telemedicine visits among racial and ethnic minority groups.

In the near future, Helbig and Stephenson say they also hope to start compiling quantitative data to demonstrate that telemedicine is cost effective as well as clinically valuable. On the provider side, hundreds of fewer miles are being driven every week when care is rendered virtually rather than in person. Patients also spend less time on the road and away from work. And hard costs, notably for space rental and support staff, come down.

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