Tele-technology has been around for a long time. The earliest use of tele-technology in the United States was smoke signals by Native Americans. The use of the telegraph and the invention of the telephone are all examples of tele-technology. The use of telehealth technology has steadily increased over the past several years. However, the recent severe acute respiratory system corona virus-2 (SARS-CoV-2) pandemic hurdled telehealth technology to the forefront of health care delivery. In a matter of weeks after a national health care emergency was declared in the USA by the Department of Health and Human Services (HHS), the delivery of health care was transformed under the Corona Virus Aid, Relief, and Economic Security Act (CARES Act) passed on March 20, 2020 by allowing telehealth technology to be used instead of the in-office visit without the typical restrictions and limitations that were in place for tele-technology pre-COVID-19.
Neuropsychology (NP) has been particularly transformed by televisits. NP testing requires an in-depth clinical interview and face-to-face administration of both paper-and-pencil and computerized tests. The CARES Act allowed for broad use of telehealth technology, including in-home NP testing. However, very few neuropsychologists were prepared for tele-neuropsychology (tele-NP).
Telehealth refers to all aspects of health and health care using telecommunication technology such as emails, faxes, telephone, computers data/information, electronic equipment, and wearable devices, and most commonly, at least for today’s purpose, video interaction. Telemedicine specifically delivers health care to patients via telecommunication, and is defined as “the remote diagnosis and treatment of patients by means of telecommunication technology.” State law defines what constitutes telemedicine and telemedicine practice.
There are always advantages and disadvantages with the advent of any new technology, and telemedicine is no different. Use and adaptation of technology was the most common roadblock to adopting tele-technology in a health care setting (11%), while resistance to change and cost (8% each) and age or ability of the patient to use tele-technology (5% each) were also hindrances. Table 9.1 highlights many of the advantages and disadvantages that we currently have in using tele-technology to deliver health care services. As the technology evolves and improves, advantages to using the technology will increase while the disadvantages decrease.
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Our expertise as neuropsychologists brings more to the clinical evaluation than simply psychometric assessments. In addition to (and sometimes in place of) psychometric assessments, we can use our multispecialty training to diagnose, educate, and treat or to create treatment plans through clinical interviews, record reviews, and qualitative aspects of neuropsychological assessments. Such skills are particularly relevant and useful during the COVID-19 pandemic or when the clinical situation or population does not allow for formal neuropsychological test administration.
This chapter will review how tele-NP has evolved over time, with the critical research showing its reliability, feasibility, effectiveness and limitations; it will also address practical issues, billing, and ethical considerations, and offer tips for developing and improving your own tele-NP practice.
Patient satisfaction
Patient satisfaction is a key component for a successful telehealth program. Patients need to be confident in the delivery methods, technology, and perceived effectiveness. A 2017 meta-analysis showed that acceptance of change in health care delivery (in person vs. teleconferencing) is generational-based with older patients less likely to accept change, but there is a growing trend of older patients being more accepting of technology incorporated into health care. However, what was striking was the resistance that health care providers initially experienced in using/accepting teleconferencing, with some doctors not wanting to adopt it. However, during a 5-year period in the mid-2010s, patients’ expectations were met when using teleconferencing or a telephone. It also improved access for patients (from remote or far-away areas), communication with the provider, and outcomes for chronic illness. Similar findings were noted for tele-psychology (clinical) with good efficacy, outcome, and clinical response. There does not appear to be any concerns for patient satisfaction in Spanish-speaking populations or Native American Indians. It is highly likely that our current COVID-19 pandemic will only serve to increase patients’ acceptance of the technology and improve patient satisfaction.
Issues such as reimbursement, regulatory limitations, technology, and ease of platform use prevented many doctors from using telemedicine pre-COVID-19 despite the known economic and access benefits to lower-income patients. However, it has been conducive to certain areas of medicine such as radiology, psychiatry, and tele-stroke. As of 2016, health care providers’ use of telehealth technology in the United States was very limited with only 15% of physicians used interactive teleconferencing (ranging from just under 10% to about 40%—emergency medicine). Interestingly, that same survey showed that patients were more likely to use telehealth (about 20% more than doctors). It appeared that the size of the physician practice was a major factor in using teleconferencing, with only 8% of doctors doing so in practices with four or fewer physicians, compared to 25% of doctors in larger practices with more than 50 doctors. This changed after the Coronavirus Aid, Relief, and Economic Security Act (CARES) was passed, which allowed for ease of billing and reimbursement (and practicing across state jurisdiction) and likely acted as an incentive for doctors to use telehealth.
Research in tele-neuropsychology
Given the scope of this chapter, this section will be limited to videoconference-based tele-NP research. The use of the telephone to deliver focused auditory, verbal-based NP tests has been available since the 1980s—much longer than video-based tests—and has shown good applicability, reliability, validity, and ease of use. Its obvious limitation is that only auditory, verbal-based tests (in terms of both administration and response) can be used.
Adults
In order to determine if tele-NP administration is equivalent to in-office face-to-face (FTF) administration, one needs to assess the same patients under both conditions relatively close together in time. Munro Cullum has led this research, which dates back to the early 2000s. Brearly et al. performed a systematic review and meta-analysis addressing the effectiveness of tele-NP videoconferencing test administration compared to in-office FTF test scores. A total of 12 studies were included in the meta-analysis ( n = 497) looking at a wide range of healthy adults (aged between their 30s and their 80s) and those with diagnosed psychiatric and neurocognitive disorders. Results of the meta-analysis showed that untimed tele-NP tests allowing for repetition were only about 0.01 standard deviation (SD) different than the same tests administered FTF. Moreover, performance on verbally mediated tests such as Digit Span (DS) and list-learning paradigms were unaffected by videoconferencing administration. The sole exception was the Boston Naming Test, which typically showed − 0.1 SD. The authors opined that the standardized normative data for the verbally mediated tasks were applicable when the same tasks are administered via videoconferencing. They noted the challenges of administering motor tasks and found too much variability to interpret that data. The authors noted methodological variability between studies and recommended the establishment of tele-NP administration and service delivery standards.
In a more recent update, Marra et al. had similar findings to Brearly et al. but were able to look across ethnicity and countries. They found “strong support” for tele-NP administration of screening measures (Montreal Cognitive Assessment and Mini-Mental State Examination) and verbal-based tests such as language, list-learning, and attention/working memory tests (Boston Naming Test, Letter Fluency, Hopkins Verbal Learning Test, and Digit Span). Other measures were “promising” but lacked adequate research evidence. Table 9.2 provides a list of videoconferencing administered NP tests showing good feasibility, reliability, and validity compared to in-office testing.
Adults
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A critical distinction between the above research and real-world tele-NP assessments is that the tele-NP research was done under controlled conditions: the subjects were brought into an exam room and completed the tele-NP assessment after it was set up by a technician in a controlled environment using high-quality, standardized equipment. The control of the environment and standardization of computer equipment (monitor, speakers, and mouse) and standardized presentation are factors under less control in a true home-based tele-NP assessment and can impact test scores that can lower scores based upon environmental factors and thus lead to misinterpretation of test scores (and invalidate the use of normative data based upon in-person administration). Few studies considered at-home tele-NP administration. This latter point is especially important and a critical weak link in the clinical utility and readily adopting home-based tele-NP at present.
The impact of cultural and language-related issues on tele-NP has not been systematically studied. However, two studies indicated that tele-NP can be successfully used in a Spanish-speaking population or in Native Americans living on a tribal reservation.
Pediatrics
One can easily see the added difficulties of administrating neuropsychological tests remotely to a younger population with limited attentional spans, ability to follow instructions, comprehension, and behavioral problems. Two studies performed remote language, reading, and intellectual assessments with good success and interrater reliability between the remote and the on-the-ground clinician. However, only one study systematically looked at the comparability of scores between videoconference and FTF administration. Using a pediatric multietiologic demyelinating clinical group, Harder et al. administered the same battery of verbal-auditory, visual, and visuo-motor-based neuropsychological tests via videoconference technology with the patient at home (the patient’s parent helped with computer setup but was not in the room during formal videoconference testing) and FTF, counterbalanced across patients. Consistent with the adult literature, scores across the two settings were highly consistent with high patient and parent satisfaction (≥ 90%).
In the Hader et al. study, subjects were likely less impaired than other neurodevelopmentally compromised patients, thus allowing the patients to take the tests without any assistance. To that end, Pritchard et al. described the considerations and specific challenges of rapidly adopting to pediatric tele-NP models, while Pederson et al. presented a three-tier model for tele-NP evaluations with neurodevelopmentally complex patients with specific case examples and recommendations. The model consists of a clinical interview with a comprehensive neurobehavioral status examination. This was used to determine if the model was enough to provide recommendations or if the patient was best suited for a “tele-screen” (additional standardized parent- or self-rating scales and abbreviated intellectual measures), tele-testing, or required FTF testing.
Tele-NP models
There are three tele-NP models being used today: (1) at-home without an examiner; (2) in-office with an examiner outside of the testing room; and (3) remote testing with an examiner in the room. The at-home without an examiner is the model that is of most interest to us in today’s pandemic as well as for future use, but also the one with the least amount of environmental control and poorer comparability to FTF testing and normative data interpretation. The at-home model requires the patient to have adequate computer hardware and connectivity, and a quiet environment. There are risks of test and data security, and concerns about nonstandard test administration and the use of normative data collected in a standardized fashion. The in-office tele-NP is a “hybrid” model attempting to have better environmental control to ensure a more accurate and as close to standardized neuropsychological assessment as possible while maintaining physical distance. In this model, the patient physically comes into the office and into an exam room where a computer is set up for a tele-NP assessment while the examiner is in another room. The connection can be via internet or a closed-circuit television, which has better security. The neuropsychologist or psychometrician administering the tests has control over the testing environment (noise, distraction, test security, and prevention of any recording). Tests can be preorganized and placed in folders that the patient is instructed to use. This allows for using many visual-based and computerized tasks that are not readily available with an in-home assessment. Please note that in order to use computerized tests, the examiner will likely have to enter the room to set up the computer, adding a very minimal health risk. Under this model, at least during a health emergency, there is still increased risk of exposure to the patient. The third model uses a psychometrist “on the ground” administering neuropsychological tests to the patient in person. Obviously the psychometrist is well trained and has complete control over the environment, and a full standardized neuropsychological evaluation is possible. However, it is not suitable in an emergency such as the SARS-CoV-2 pandemic as it places the examiner (and even the patient) at a higher risk for contamination.
C. Munro Cullum has advocated using a “staging approach” for at-home tele-NP evaluations. This staging approach requires you to determine if in-home tele-NP assessment will be viable before actually attempting it. The first stage requires a record review and sometimes a call to the patient and their family to determine if there is any evidence that at-home testing would not be possible. Examples include patients who do not have adequate computer hardware, do not have internet access, have difficulties seeing, or are older without a family member to assist in computer setup. Next, doing a videoconference clinical interview will help you determine the feasibility of having a successful tele-NP assessment. Look for how the patient interacts with the computer—do they have adequate cognitive abilities to follow directions? Does the patient have the correct computer setup (laptop or desktop computer, not tablet or cell phone)? Sufficient bandwidth, lighting, sound, and potential for distractions are all factors to consider. If you feel that the patient can successfully complete at-home test administration, then a date is arranged for the at-home tele-NP evaluation. Feedback is performed separately on a later date.
I have used the staged at-home model since the COVID-19 emergency was declared and a “psychometrist on the ground” model for the past 4 years remotely when caring for sports-related concussions. In a program sponsored by the Houston Texans and General Electric Corporation, I have evaluated and treated more than 200 high school student-athletes who sustained sports-related concussions, covering a 350-mile radius from Houston. I trained several certified athletic trainers in test administration and clinical examinations as I instruct and observe remotely. This often entails at least two or three visits and allows me to have detailed FTF feedback sessions with the student-athlete and parents.
“Connecting” with the patient
Establishing a therapeutic connection with the patient is critical in psychology. Nothing fully replaces being FTF with your patient and being able to read body language and other nonverbal cues. However, research shows that good patient rapport and clinical intervention are successful with virtual video visits in psychotherapy, and that the majority of cognitively intact or impaired adults find tele-NP testing acceptable, with more than 90% being satisfied with tele-NP testing and almost 66% having no preference between traditional in-office or FTF testing. Context often shapes a patient’s satisfaction. In the current pandemic environment, consumer satisfaction with, and preference for, tele-NP should be higher than that reported 7 years ago, as more and more patients are trying to avoid excessive community contact. One can only anticipate better acceptance of tele-technology as it becomes more integrated into health care delivery.
Improving clinical outcomes
Tele-NP testing can improve diagnosis and clinical outcomes for patients who otherwise would not have access to clinical services because of travel/distance or transportation, for example. Harrell et al. showed that tele-NP assessments for elderly individuals living in remote areas (mean age 75; range 55–90 years old and living 100–180 miles from the clinic) improved clinical care by clarifying or correcting the clinical diagnosis in 87% of the elderly patients referred. Moreover, additional comorbid psychological and psychiatric diagnosis were made in 62% of the patients seen for a tele-NP evaluation, allowing for additional treatment recommendations and improved outcomes. Barton et al. performed neurologic and neuropsychological testing with elderly veterans referred for memory complaints who lived far from the San Francisco Veteran’s Administration Hospital. The researchers were able to help with clinical diagnoses and treatment recommendations for the primary care doctors at another VA hospital who referred the patients. It appears that diagnoses and treatment recommendations made via tele-NP are valid and consistent with those made in FTF settings, at least for dementia in a geriatric setting.
Improving tele-NP visits
Performing tele-NP visits is challenging under the best of circumstances. However, there are several things one can do to improve the quality of these visits. Table 9.3 provides a list of practical suggestions designed to improve the quality of your tele-NP visits. Always remember that it will take practice, and that you will run into glitches along the way. One cannot expect that tele-NP visits will go as smoothly as your in-office visits, and you need to accept that they will fail on occasion. Having an alternative plan will help in the long run. It is hoped that the visits will improve with technological advancements. There are a few published guidelines for conducting tele-NP visits. Two of them are older and pre-COVID, while two were written specific for tele-NP evaluations during COVID-19.
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