Introduction
Epilepsy management encompasses a spectrum of disease acuity and locations. Whether providing chronic disease management in the outpatient setting, acute consults in the hospital for new onset or breakthrough seizures, or critical care management of status epilepticus, there are now opportunities for this care to occur virtually rather than in-person. Technology to facilitate video-enabled communication between provider and patient has been available for some time, but use for epilepsy care was limited and largely restricted to inpatient consultations provided as a component of broader hospital teleneurology services. The ongoing COVID-19 pandemic has fostered the rapid embrace of telemedicine for routine outpatient epilepsy care. While many previous financial and bureaucratic barriers to adoption of virtual care have been removed, providers must still prepare for the unique considerations and challenges of seizure management provided remotely.
Opportunities in virtual epilepsy care
Once the current global pandemic is stabilized, it is likely that the demand for video epilepsy visits will remain high. Convenience has been one obvious benefit described by many telemedicine users. Video visits can offer greater efficiency than in-person visits, minimizing the need to arrange time away from work, home, and other activities. Many adults with epilepsy face specific challenges with travel to doctor visits because of the legal restriction of driving privileges with this diagnosis. In the United States, people with epilepsy are five times more likely to report transportation as a barrier to accessing health care than others. Even those who have access to means of transport in their locale may not have in-person neurologic care within reach. A 2012 Institute of Medicine report found that close to half of people living with epilepsy have limited to no access to specialized epilepsy care from a neurologist or epileptologist. This is particularly true in rural and underserved urban areas. Telemedicine offers a means to expand timely access to providers with expertise in seizure management by removing the barrier of physical access to a clinic or hospital. The pool of individuals who would benefit from virtual epilepsy care is even larger when one considers the international market.
Initial epilepsy history and physical examination
Previsit preparation
Just as with in-person clinic visits, adequate previsit preparation can improve both the efficiency and effectiveness of a video consultation. Electronic forms can also be effective for obtaining basic elements of the history, including current medications. Validated screening instruments for common epilepsy comorbidities such as depression can be completed and submitted electronically in advance of the appointment. Furthermore, if the digital platform allows sharing of video clips, patients may be able to obtain a cell phone video capturing representative spells or seizures, which they can show to the provider at the time of the appointment.
The successful virtual consultation
The concerns of taking a comprehensive history from the patient are not significantly different whether the visit is done in person or by telemedicine. When investigating possible seizures, an eyewitness account can often be crucial, particularly when the event involves alteration of awareness or amnesia. During a face-to-face visit, it can be challenging to obtain these accounts, given the burdens of time and effort for a witness to accompany a patient to the doctor’s office. Telemedicine platforms may facilitate the participation of friends and family, particularly during times of lockdown, when many family members may be present in the home. For those who are remote from the patient’s location, some platforms will allow a unique meeting link to be sent to the eyewitness, allowing them to join the virtual visit for the brief period necessary to provide their account. Some providers may fear that the digital interaction may preclude accurate detection of nonverbal cues to issues ranging from discomfort with the conversation, psychiatric comorbidity, or psychogenic nonepileptic spells. The author’s experience has been that these cues are generally similarly detectable on a video visit as they are in the office. The video visit offers an added intimacy of interacting with the patient in their home environment, which may increase patient comfort during the overall interaction. In addition, the laws on driving after a seizure vary from state to state, but the common bond is that the laws limits the patient’s ability to get around, even to see their doctor. This barrier is now removed via the use of telemedicine. The previously restricted patient can now see their doctor via a video visit and save the time and potential risk of driving.
The comprehensive neurologic examination that is a standard part of the in-person visit cannot be fully completed virtually in the way we are accustomed to performing it. In particular, assessment in the sensory examination of reflexes, tone, and subtle motor deficits is significantly restricted. However, common concerns regarding the person with epilepsy such as cognitive function, nystagmus, tremor, dysmetria, coordination, and gait instability can be reasonably assessed over a video connection. Virtual examination of the patient’s extra-ocular movements by asking the patient to look in each quadrant can be helpful in evaluating for nystagmus. Having the patient extend their arms toward the camera and then point inward toward their nose can assist in evaluating for tremor and dysmetria. Asking the patient to walk in front of the camera will enable you to evaluate for unsteady gait. During the video interview, you can observe for drowsiness, jerky movements, automatisms, or other signs of involuntary motor movements. Examination of the skin can be performed to check for rashes. Asking the patient to show their teeth can be helpful when evaluating patients taking Dilantin, to screen for gingerval hyperplasia. Evidence comparing the effectiveness of in-person versus virtual initial consultations for the evaluation of seizures in epilepsy in regards to accuracy of diagnosis or clinical outcomes is lacking at this time. It is hoped that studies on the effectiveness of virtual consultations for epilepsy will be forthcoming based on rapid widespread adoption of this model in recent months due to COVID-19.
Evaluation and ongoing management
Once patients have an established diagnosis of epilepsy, follow-up care is often focused less on ongoing assessment of changes in physical examination and more on reporting of seizure control and epilepsy comorbidities. For this reason, telemedicine follow-up for this patient population may be particularly appealing. Use of an electronic seizure diary is a simple tool that can be helpful during return visits. In reviewing common testing, radiographic images can be reviewed relatively easily with patients in the virtual environment as long as the platform allows for sharing of digital images. Most providers are already well versed in electronic review of laboratory studies. Considerations for electroencephalography (EEG) in the telemedicine environment are described in a separate chapter. While the results of imaging and EEG can be reviewed virtually, the testing itself requires in-person acquisition. If testing will be performed remotely, consider whether the timeliness and quality will be sufficient for your needs. If not, the patient should be advised in advance of the virtual care visit that they will need to travel to your physical location to complete the comprehensive evaluation. Medication management is much simpler if the system is set up for electronic prescribing, avoiding the need for phone calls to the pharmacy or mailing/faxing paper prescriptions. In-person visits are still needed for programming of epilepsy devices including the vagus nerve stimulator (VNS), responsive neurostimulator (RNS), and deep brain stimulator (DBS).
Although the literature on telemedicine for follow-up epilepsy care is limited, early published experience has been generally positive. A Veterans Administration study of teleneurology services for outpatient management of chronic neurologic conditions including epilepsy in an older, rural patient population found very high patient satisfaction with quality of care and convenience. The office, however, did note some concern of excess emergency department visits compared to what was expected in those receiving virtual care. There was also financial benefit, with 96% of participants reporting that virtual care saved them time and money. Similarly, a small randomized adults with in person ( n = 18) versus virtual ( n = 23) follow-up for epilepsy in Canada found that the avoided loss of productivity, travel, and hotel costs resulted in an average saving of $466 Canadian. The majority of those in the study were dependent on others for transportation to in-person visits. Another pilot study for epilepsy telemedicine showed a 50% reduction in no-show rate compared to face-to-face clinic visits, which should translate to cost savings to the medical practice. Finally, a comparison of 155 patients managed via virtual versus in-person visits for epilepsy over a 3-month period found equivalent outcomes for seizure control, emergency room visits, and hospitalizations.
Summary
The growth of virtual care options for people with epilepsy is a welcome transformation. Teleneurology for seizures should help address long-standing barriers to optimal care from limited access to personal transportation and limited availability of specialized epilepsy services affecting many regions. While there are challenges in obtaining a traditional comprehensive neurologic examination compared to in-person interactions, much of the standard seizure assessment can be similarly completed in the virtual environment. There are also advantages to the provider and the patient in terms of efficiency and potentially cost. Assuming that administrative barriers to the provision of virtual care are not reinstated, it is likely that virtual visits will see expanded use in the care of patients with seizures in the near future.
References
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