Welcome to ReachMD. This medical industry feature, titled “Applying Telemedicine to Multiple Sclerosis Care Amid COVID-19”, is sponsored by Novartis Pharmaceuticals Corporation. This program is intended for health care professionals. Here’s your host, Amanda Montague from the Multiple Sclerosis Association of America.
The cornerstone of constructive medicine is in the concept of a complete medical examination.
Amanda Montague: Hi, I’m Amanda Montague from the Multiple Sclerosis Association of America, the MSAA. Today, my colleagues, Amy Sullivan, Jennifer Hartman, and Mary Rensel from the Cleveland Clinic, and I, will talk to you about the role and evolution of telemedicine in multiple sclerosis, particularly during the COVID-19 pandemic but also in times to come. Telemedicine is an underused resource for MS treatment .
Currently, more patients with neurological disorders are seeking specialist care than there are neurologists to meet the demand . One large epidemiological study found that nearly 30% of people with MS did not receive care from a neurologist . People were significantly less likely to see a neurologist if they lacked health insurance, were poor, or lived in rural areas, and if they had mobility issues, such as requiring a wheelchair or scooter . Teleneurology has a potential to increase access to quality specialized care while reducing overall costs for patients and caregivers .
Amy Sullivan: There is research that suggests that when individuals are quarantined, the psychological impact can be wide ranging, substantial, and long lasting . Social isolation and loneliness are linked to physical comorbidities , worsening of depression and anxiety , and substantially increased risk of hospitalization and mortality . Thus, it is vital that providers learn to use telemedicine as a way to stay connected with patients.
Guidelines for psychologists on practicing telepsychology are outlined by the Joint Task Force for the Development of Telepsychology Guidelines for Psychologists .
Jennifer Hartman: First, the practice needs to choose a telemedicine communication platform that complies with the Health Insurance Portability and Accountability Act of 1996 . At the Cleveland Clinic, American Well is the main platform used for virtual visits. FaceTime, Google Duo, Skype, Zoom, and Doximity are also available options. Facebook and other social media platforms are not secure networks and should be avoided.
Physicians or administrators may need to contact private payers to determine telemedicine coverage limitations . Typically, televideo visits are offered for routine follow-up care . However, the Mellen Center has recently begun to offer telemedicine for new patient evaluations. We offer neurology; neurology extenders; wellness, physical, occupational, and speech therapy; as well as social work services and health psychology.
Mary Rensel: Although telemedicine somewhat limits our ability to perform a thorough neurologic examination, it can provide the patient with access to medical history, medication, results review, symptom discussion, and partial neurologic examination.
During the telehealth visit itself, we can begin with a mental status examination ; it is even possible to perform a Montreal Cognitive Assessment (or the MoCA) . To complete the vital sign assessment, many patients have the ability to take their own blood pressure at home; height and weight can also be collected, but it should be documented as estimated or from the patient or family scales. Affect can be observed and noted for the exam. Language can be assessed through repeating, reading, writing, and comprehension. At times, upper-extremity motor function can be observed through pronator drift, forearm rolling, and finger taps. Lower-extremity strength can be inferred through the get up and go (the patient independently rising from their chair), and the hip flexors while sitting, as well as balancing on one leg while standing, and the heel to toe walking.
Once the diagnosis of MS is confirmed, the discussion of short- and long-term management of MS symptoms and disease process can be performed through telemedicine, which also allows for comprehensive review of disease-modifying therapies (or DMTs), and ordering tests and medications. Family or support members can be present to enhance the discussions. Established patients currently on DMTs with ongoing clinical or radiographic MS disease activity can use a telemedicine appointment to review alternative DMT options, and the required pretesting can be ordered at the time of the telemedicine visit.
Using telemedicine to continue pediatric chronic care during the pandemic has been encouraged by the American Academy of Pediatrics . Pediatric patients’ telemedicine visits will require the presence of a parent or adult caregiver. It is important to collect and document a child’s height and weight at each visit as they are actively growing, and so medications may need to be adjusted. Pediatric MS has a high rate of mood disorders, similar to adult-onset MS, so there should be directed questions to screen for mood disorders, as would be done during an in-person office visit.
Amy Sullivan: Mental health practitioners are essential medical personnel, and therefore, mental health services have been incorporated to address concerns for both patients and healthcare providers affected by COVID-19. There are a number of barriers to implementing virtual care, including insurance policies, state and federal regulations, and willingness to participate [11, 12]. Specifically, in the practice of psychology, until recently, few insurance companies were covering psychology appointments conducted virtually. Additionally, it was decided that all initial evaluations would need to be conducted in person. This approach to virtual visits drastically shifted with the need to respond to the COVID-19 crisis.
On March 17, 2020, the Centers for Medicare and Medicaid Services announced several waivers and changes to policies to expand telehealth services for Medicare beneficiaries during the COVID-19 crisis . This was a vital shift in policy as a means to slow the spread of the virus. A mental health crisis is occurring alongside COVID-19. Uncertainty about health, wellness, and the economy leads to fear and anxiety, and social distancing and isolation can lead to, and exacerbate, existing symptoms of depression. As a result, suicidal ideation, intent, planning, and completion may increase. In our practice we have transitioned 100% to virtual care. Mental health practitioners are in an excellent position to be “front-line”, yet virtual, crisis caregivers to both our patients and fellow healthcare professionals.
Jennifer Hartman: Despite its many advantages, telemedicine has some limitations and barriers, for example [8, 9, 11, 12, 14]:
1. It’s best used for non-urgent visits
2. Equipment and software costs
3. Reimbursement issues
4. Federal regulations that control how disciplines, such as psychology, manage telehealth
5. The technology literacy learning curve for both patients and providers
While some patients have easily embraced the idea of telemedicine, others have been hesitant. One common concern patients have is that they won’t be able to navigate the technology. It’s helpful to reassure patients that they won’t lose the opportunity to speak with their provider, even if they can’t connect virtually. I’ve found it very helpful to reach out to the patient myself to reassure them that I’m confident I can deliver exemplary care virtually, just as I can in the office.
Amy Sullivan: Telemedicine can increase access to quality specialized care while reducing overall costs and burden for patients and caregivers . For people with MS, telemedicine has important advantages extending beyond the current COVID-19 pandemic. We hope you have enjoyed hearing about our experience of transitioning from in-person specialized interdisciplinary medicine to the new horizon of telemedicine.
VO: We realize this situation is changing rapidly and that by the time of this broadcast, some of this information may be outdated. That being said, we hope that we have provided helpful tools and a “playbook” for this new experience of treating our patients virtually. We will change with the evolving situation and we will always do what is best for our patients.
This program was sponsored by Novartis Pharmaceuticals Corporation. If you missed any part of this discussion, visit reach-m-d-dot-com/industry-feature. This is ReachMD. Be part of the knowledge.
- Hatcher-Martin JM, Adams JL, Anderson ER, et al. Telemedicine in neurology: Telemedicine Work Group of the American Academy of Neurology update. Neurology. 2020;94:30-38.
- Minden SL, Hoaglin DC, Hadden L, et al. Access to and utilization of neurologists by people with multiple sclerosis. Neurology. 2008;70:1141-1149.
- Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395:912-920.
- Hämmig O. Health risks associated with social isolation in general and in young, middle and old age. PLoS ONE.2019;14:e0219663.
- Greysen SR, Horwitz LI, Covinsky KE, et al. Does social isolation predict hospitalization and mortality among HIV+ and uninfected older veterans? J Am Geriatr Soc. 2013;61:1456-1463.
- Joint Task Force for the Development of Telepsychology Guidelines for Psychologists. Guidelines for the practice of telepsychology. Am Psychol. 2013;68:791-800.
- American Academy of Neurology. Telemedicine and COVID-19 implementation guide. Accessed May 5, 2020.https://www.aan.com/siteassets/home-page/tools-and-resources/practicing-neurologist--administrators/telemedicine-and-remote-care/20-telemedicine-and-covid19-v103.pdf
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- American Academy of Pediatrics. Critical updates on COVID-19. Accessed May 5, 2020. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/
- Yeroushalmi S, Maloni H, Costello K, Wallin MT. Telemedicine and multiple sclerosis: a comprehensive literature review. J Telemed Telecare. Accessed May 5, 2020. https://doi.org/10.1177/1357633X19840097
- Otto L, Harst L. Investigating barriers for the implementation of telemedicine initiatives: a systematic review of reviews. Computer Science. Accessed May 5, 2020. https://aisel.aisnet.org/cgi/viewcontent.cgi?article=1216&context=amcis2019
- Centers for Medicare and Medicaid Services. Medicare telehealth frequently asked questions (FAQs). Accessed April 29, 2020. https://www.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf
- Hatzakis M Jr, Haselkorn J, Williams R, et al. Telemedicine and the delivery of health services to veterans with multiple sclerosis. J Rehabil Res Dev. 2003;40:265-282.