Introduction
Since its branching from internal medicine few decades ago, of which neurology once was a subspecialty itself, subspecialization of neurology has been marching forward at a great pace. As a result, today there are more than two dozen neurology subspecialties and up to three-quarters of graduating neurology residents continue to complete a clinical fellowship program in one of those subspecialties. One of those subspecialties is movement disorders. The term “movement disorders” in general use pertains to “Parkinson’s disease, related neurodegenerative and neurodevelopmental disorders, hyperkinetic movement disorders, and abnormalities in muscle tone and motor control”, and includes diseases such as dystonia, chorea, ataxia, Tourette syndrome, essential tremor, myoclonus, restless legs syndrome, and many others. While its subspecialty training curriculum is not currently stipulated by the Accreditation Council for Graduate Medical Education and thus movement disorder fellowship programs are not accredited like many others, the several dozen available clinical fellowship programs are usually formal and curriculum-based.
Parkinson’s disease (PD), arguably the most important movement disorder, is historically recognized via its four cardinal motor features (resting tremor, bradykinesia, rigidity, and postural instability) and played a pivotal role in the birth of “movement” disorder as a subspecialty field, due to its most recognized features related to impaired movements and motor control. Considering the importance of phenomenology of movement abnormalities, visual observation plays a fundamental role in diagnosing and managing patients with PD and other movement disorders. Therefore, videotaping and video evaluations have become an inevitable part of movement disorder care. It naturally follows that video or “virtual” visits, a pinnacle of telehealth, which allow such visual observation and examination of motor symptoms in movement disorders, represent a care delivery particularly relevant and appropriate in the care of movement disorder patients. Care in PD, relying on the use of virtual visits, was found to be noninferior in comparison to traditional care, including patient and provider satisfaction. Besides PD, telemedicine has been also used for hyperkinetic movement disorders and a wide range of other movement disorders including atypical parkinsonian syndromes, Huntington’s disease, and essential tremor.
In addition to the importance of video assessments (which can be technically done via virtual visits), objective measurements in PD and movement disorders, many of which technically and feasibly doable remotely, have been increasingly introduced in PD and movement disorder care. More recently, a new term, “digital phenotyping,” has been proposed to describe this novel domain of objective assessment of symptoms and findings in PD and movement disorders. Digital phenotyping represents a novel, critically important direction in the assessment and management of PD and movement disorders, considering its many advantages over traditional care: objectivity, lack of intra- and interrater variability, high reproducibility, feasibility of remote application, ecological validity, higher accuracy and finer grading compared to scales forcing scores into fewer, cruder, arbitrarily defined categories, and often a greater degree of automation.
The year 2020 witnessed unprecedented changes in Parkinson’s and movement disorder telehealth practices around the world due to the profound impact of the COVID-19 pandemic. Thanks to the many regulatory adjustments and easing, telehealth access have improved considerably since the start of the pandemic, with many of the financial and regulatory burdens having been eased significantly in no small part due to the CARES Act in the United States.
Deep brain stimulation (DBS) implants have been critical in the management of many movement disorder patients, most notably those with advanced and/or intractable PD, dystonia, and essential tremor (ET). The COVID-19 pandemic profoundly impacted DBS care. In addition, a recent survey (2020) has been conducted by the Motor Working Group of the Parkinson Study Group (PSG) in the United States on the impact of COVID-19 on clinical care, clinical research, and advanced therapy (such as DBS) practice adjustments among movement disorder specialists, and this work has been submitted as an abstract for the 2021 AAN Annual Meeting.
Telemedicine in your movement disorder practice
Due to the profound impact of the COVID-19 pandemic on PD and movement disorder care around the globe, movement disorder clinics have witnessed unforeseen, dramatic adjustments in their practices. A number of high-quality editorials have been authored in recent months on the topic. While many advantages of telemedicine in PD and movement disorders were established well before the pandemic, including but not limited to feasibility in the age of the internet, cost effectivity (saving travel cost and time, especially when traveling a distance, parking), convenience (especially for those challenged physically in their mobility), high favorability ratings by providers, and satisfaction by patients, the pandemic directed our attention to another major advantage of telehealth delivery of care: eliminating physical contact and thereby risk of viral spread.
Before a detailed practical review of the steps to set up a movement disorder telemedicine practice, it is necessary to review the various modalities and types of telemedicine care. The word “telemedicine” is commonly used in reference to remote synchronous video visits, sometimes also referred to as “virtual visits,” during which the patient and the provider are video conferencing in real time. However, there are many other types and options that are included under “telemedicine” in addition to just virtual visits, although undoubtedly this is the most frequent and most widely recognized form of telemedicine. During virtual visits, it is possible to take history, involve a care partner, and a limited motor exam is also usually possible. Some movement disorder scales have been validated for remote use, including a modified version of the Unified Parkinson’s Disease Rating Scale and the Unified Huntington’s Disease Rating Scale.
While “synchronous” virtual visits are the norm when broadband internet connection is available at both the provider’s and the patient’s end, so-called “asynchronous” video visits may be considered under certain circumstances, especially in technologically less advanced regions with lack of high-speed internet access. In asynchronous video visits, the patient’s examination is recorded—for example, following instructions to include specific tasks or views; it is then uploaded over a low-speed internet connection to a dedicated secure server, from where the provider can access the video recording and evaluate or rate it according to a predetermined protocol.
In addition to synchronous and asynchronous video visits, “telemedicine” in movement disorders may refer to visits involving interdisciplinary care, the use of objective devices such as wearables or “telemetry,” tele-psychiatry and tele-therapy, management of advanced therapies such as DBS 17 , and screening for advanced therapies and research eligibility.
The international Movement Disorders Society (MDS), through its Telemedicine Study Group, has developed a step-by-step guide for providers to set up or optimize their telemedicine practice specifically for Parkinson’s disease and movement disorders. A webinar, with a similar goal and also granting continuing medical education credits, was published by the same Telemedicine Study Group.
Before beginning to set up a telemedicine practice and delve into any telemedicine technical steps and guidance to any depth, it is important to review and fully understand the specific national, regional, local, and (if applicable) institutional regulatory environment of one’s practice, as it pertains to providing telehealth care. Specific regulations across countries and regions may vary widely. The MDS Telemedicine Study Group has compiled an extensive database that is available online and is updated regularly to aid movement disorder providers with their review of regional regulatory information. A detailed review of telemedicine regulatory status was also included in a peer-reviewed publication by the same group.
In addition to regulatory requirements, it is critical to address the financial aspects and feasibility of a telemedicine practice. Naturally, this varies greatly by regions and countries. In the United States the most comprehensive review of nonface-to-face evaluation and management codes have been prepared by the American Academy of Neurology. It is believed that telehealth may become part of an integrated and patient-centered management model in PD, where tangible, validated, and relevant health outcomes, as opposed to fee-for-service incentives, will primarily determine health care practices, as is predominantly the case currently in the United States.
After applicable regulatory requirements and billing/coding information have been reviewed and complied with, the next challenge in telemedicine setup is securing the necessary hardware and software. Fortunately, most modern medical offices nowadays either are already equipped or can easily be furnished with the basic hardware needed for a telemedicine setup, including a computer or other device that is outfitted with audio and video capabilities and a broadband internet connection. Typical devices may include a desktop or laptop computer, a tablet or cell phone, with camera, microphone, and speakers. A somewhat more complex question is the choice of software. Increasingly, some electronic medical record (EMR) systems include built-in video visit capability. It is necessary to confirm if such an option is available or another preferred platform is otherwise offered at the practice location, where a provider seeks to begin virtual visits. Fig. 7.1 provides an overview of the relevant decision points usually applicable to most practice environments.
When reviewing software options, especially in cases when these are not already available institutionally or embedded in EMR, privacy is an utmost consideration. While some regulatory agencies and institutions have relaxed the rigor of privacy enforcements in response to the COVID-19 pandemic, the prolongation of the pandemic and widespread adoption and integration of telemedicine led to its normalization, where the rigor of enforcing privacy policies gradually return to their prepandemic baseline.
Once the regulatory and hardware/software matters have been addressed, the next important aspect of setting up a telemedicine practice or, if we want to stay narrow in our definitions as discussed above, virtual visits, will be the proper way of preparing the video and room setup. Tables 7.1A and 7.1B review some steps that can help, for both the provider’s ( Table 7.1A ) and the patient’s ( Table 7.1B ) side. Review the steps outlined in Table 7.2 on how to conduct a teleneurology visit.
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