What is telehealth?
Telehealth is the delivery of health care services over digital and telecommunication platforms. It is used to provide healthcare to patients who may be in a different location than their healthcare provider1.
There are two different formats of telehealth as defined by the U.S. Department of Health and Human Services (HHS). The first is synchronous telehealth which happens in a real-time setting where the patient interacts with a provider directly often via video or phone. The second is asynchronous telehealth in which patients and providers exchange information over a digital platform but which is not a real-time interaction. For example this might include sending of electronic messages, releasing test results, remote health monitoring, and others2.
What formats of telehealth do we use in care at the Mellen Center?
For telehealth visits we use an encrypted synchronous audio-visual platform which allows the provider, patient, and the patient’s care partners to interact in the visit in real-time.
We also utilize asynchronous telehealth services to supplement the visits via our MyChart online platform. We use this platform to have patients respond to pre-visit questionnaires on a variety of quality-of-life domains. Additionally, we use the MyChart platform to allow communication between the patient and provider beyond the visit for follow-up questions, review of testing results, and other non-urgent concerns.
In this Mellen Center Approach we will focus predominantly on synchronous telehealth for virtual visits.
What is the evidence for use of telehealth in Multiple Sclerosis (MS) care?
The use of telehealth is increasing in MS clinical practice3,4. Several studies have evaluated the use of telehealth in the care of persons with MS (pwMS). In a randomized control trial of single virtual visits were found to be equally feasible as in-person clinic visits for pwMS5. In an observational study evaluating telehealth visits for MS and other neuroimmunological conditions, clinicians reported that virtual visits achieved their goals in 98% of the visits and 83% of patients felt that the virtual visit was as effective as an in-person visit for their care6. Additionally, there has been clinician report that the use of virtual visits has been able to avoid sending an MS patient to the emergency room in several instances6. Patients report equal satisfaction with virtual visits as compared with in-person visits including across assessments of provider empathy, explanations of planned medical evaluation, and engagement in shared decision-making7. In one study 97% of pwMS who had completed a virtual visit reported that they would recommend it to others5. From the provider standpoint at one large academic center 96% of MS clinicians utilizing virtual visits reported that the overall experience was the same or better than in-persons visits during the COVID-19 pandemic8.
However, studies evaluating potential implications of use of telehealth in MS care on diagnostic accuracy, disease-specific outcomes, treatment adherence, hospitalizations, use of ancillary testing, cost of care, and rates of adverse events are limited at this time. Additionally, the studies to date have predominately focused on care at academic medical centers and single visits. There is less evidence for the use of telehealth in other neuroimmunological conditions.
What are the advantages to telehealth use in MS/ Neuroimmunology care?
For persons with MS and/or neuroimmunological conditions disease-related symptoms including fatigue, bowel and bladder dysfunction, weakness, cognitive dysfunction, and others can make coming to traditional in-person office visit a challenge. Utilizing a virtual visit allows them to engage with their provider from a location that is convenient for them. Additional benefits have been described as follows:
- eliminates the need to travel and cost of travel4,6
- reduces time off work for patients and their care partners6
- helps avoid arranging childcare6
- improves access to specialized care9
- allows for the assessment of a patient’s local environment (eg., home, work)10
Benefits to providers have also been noted with the use of telehealth. In AMA telehealth survey 54.2% of respondents reported that telehealth improved the satisfaction of their work. Use of telehealth allows flexibility for providers allowing them to conduct visits from locations other than their office11.
What are the disadvantages to telehealth use in MS/ Neuroimmunology care?
The drawbacks that have been reported in telehealth care for our patients include limitations to performing the neurological exam and possible widening of health disparities. Specifically, widening of gaps in care for Black or Hispanic individuals, persons with disabilities, persons receiving Medicaid, those whose highest level of education was high school or lower12, and rural communities13 have been described. Additionally, ancillary testing and other multidisciplinary providers are not readily available to patients receiving telehealth care as they are for our in-person office visits.
Also, the regulations surrounding licensing, credentialing, patient insurance coverage, and malpractice insurance coverage continue to evolve which can be a challenge for both patients and providers in planning telehealth visits. These regulations are unique for each type of provider (e.g. neurologist, psychologists, physical therapist). Regulations surrounding use of virtual visits for diagnosis and treatment may differ from those for education and triage purposes.
Some other disadvantages noted from the provider perspective are lack of staffing resources to support telehealth workflows, lack of interoperability between telehealth platforms and the electronic medical record, and limited telehealth-specific training for their team-members11.
What factors do we weigh in considering use of telehealth visits for persons with MS or neuroimmnuological conditions?
In deciding if a virtual visit is reasonable, we consider factors including disease stability, use and type of disease modifying therapy, time since last in-person evaluation, reason for the visit, need for multidisciplinary care and/or testing in conjunction with the visit, availability of local medical resources, and the level of burden that would be required to come to the clinic in-person. We use virtual visits both to replace traditional office visits and as an option to expand care touch points with patients. Due to the wide range of factors considered we do not have one ideal schedule for telehealth vs in-person visits for MS/neuroimmunology care.
When do we prefer a traditional in-person office visit?
There are several instances where we prefer to have an in-person clinic evaluation. The first is for evaluation of a new patient in order to complete a full neurological examination for diagnostic purposes and to establish a baseline. Evaluating new patients in person also allows us to give more informed and detailed medical recommendations, whereas virtual visits presently have regulatory restrictions and limit the scope of advice. Next is in the setting of a possible relapse to compare the current neurological exam to prior baseline. Finally, in the setting of concern for severe infection such as PML, cryptococcal meningitis, herpes encephalitis, or others an in-person evaluation is helpful to update the exam and evaluate need for acute care services.
What logistics need to be in place for neuroimmunology providers to conduct virtual visits?
The primary logistical need is for an institution to provide a HIPAA compliant platform to conduct synchronous video visits. These compliant platforms have specifications for encryption to avoid privacy breeches along with audit trails that allow institutions to ensure health information is protected. Providers also need to be aware of the physical environment that they and the patient are conducting the virtual visit to ensure privacy.
Additionally, providers should consider adjusting communication strategies to effectively engage across the virtual platform. Our Cleveland Clinic Center for Excellence in Healthcare Communication has a list of best practices for virtual visit communication.
What logistics need to be considered for a person with MS or neuroimmunological condition considering a virtual visit?
The patient must be able to access and use the telehealth platform. They must have reliable access to a broadband wired or wireless internet connection. Typically, connection speeds around 600kbps (up/down) or 3G or later are best to facilitate video conferencing15. The patient must also have access to device capable of audio/visual transmission (e.g., computer with a webcam, smartphone, tablet, etc.). Some telehealth platforms may also require download and/use of various of software or applications or have browser restrictions (e.g., may only work over Google Chrome or Firefox and not Internet Explorer). Additionally, the patient must be able to utilize the device with their current physical and cognitive ability status and actively participate in the visit and/or have a care partner who can assist.
What settings do we use telehealth in MS/neuroimmunology care at the Mellen Center?
We offer telehealth services across our multidisciplinary care team. These services differ in accordance with the type of care being provided as below:
-Neurology: Our neurology team offers two types of virtual visits for new MS/ neuroimmunology patients: visits focused on disease education and triage visits to plan for in-person visit to our center with consideration for coordinating testing and other specialty appointments. We also offer an educational virtual second opinion program to answer questions about neuroimmunological diagnoses and treatment options. At present we do not offer new patient visits or consults for making a new diagnosis or treatment plan. We offer virtual visits for individual follow-up for our established patients to replace in-person visits and/or to supplement in-person visits. Finally, we offer telehealth visits for several of our shared medical appointments which include those focused on education around a new diagnosis of MS, wellness topics, and preparing to start infusion disease-modifying therapies.
-Health psychology: Our psychologists are essential practitioners in managing the array of emotions that people with MS experience as well as the high prevalence of mood disorders in MS. Our psychologists offer several types of telehealth appointments which include: individual evaluation, individual and family therapy, shared medical appointments, and group therapy. Currently these telehealth services are available to those patients who are in the state of Ohio.
-Spasticity: Our spasticity team is comprised of physical medicine and rehabilitation specialists and advanced practice providers who provide expertise on non-medical, medical, and procedural treatments for spasticity for MS patients. They offer telehealth visits as an option for some follow-up appointments including visits focused on discussion of risks and benefits of procedures for spasticity and symptom evaluation after procedures.
-Social work: Our social work team provides resources for patients and caregivers with social, emotional, financial, and environmental challenges and update other members of the health care team about these components. They offer telehealth visits for follow-up appointments for MS patients.
-Research: The use of telehealth applications and visits for MS care is an active area of research at the Mellen Center. These and other opportunities to engage with our research efforts via telehealth change rapidly. For the latest information please contact our research team at 216.445.9855.
How can a physician or other provider refer a patient for a virtual visit with the Mellen Center?
Several options exist for a healthcare professional to place a referral to the Mellen Center as below. If a virtual visit is preferred simply indicate this as part of the referral and our team will assess if a virtual visit is an available option for your patient.
- Call our dedicated physician referral hotline at 216.445.8455.
- Download and complete our physician referral form and fax to 216.636.2596.
- Use DrConnect.
For our educational Virtual Second Opinion Program call 216.444.3223, or direct your patient and/or their care partners to our dedicated website.
How can a person with MS access virtual care from the Mellen Center?
Persons with MS or their care partners may request a visit with a Mellen Center provider directly. If a virtual visit is desired, please indicate this in your request and our team will assess if a virtual visit is an available option.
- Call our appointment line at 216.636.5860.
- Use our MyChart online platform.
- Request an appointment via our webpage.
For our educational Virtual Second Opinion Program call 216.444.3223 or visit our dedicated website.
- Catalyst N. What is telehealth?NEJM Catal. 2018;4(1).
- Best practice guide: Telehealth for direct-to-consumer care. US Department of Health and Human Services. Accessed September 1, 2022. https://telehealth.hhs.gov/providers/direct-to-consumer/
- McGinley MP, Gales S, Rowles W, Wang Z, Hsu WY, Amezcua L, et al. Expanded access to multiple sclerosis teleneurology care following the COVID-19 pandemic.Mult Scler J - Exp Transl Clin. 2021;7(1):2055217321997467. doi:10.1177/2055217321997467
- Ross L, Bena J, Bermel R, McCarter L, Ahmed Z, Goforth H, et al. Implementation and patient experience of outpatient teleneurology.Telemed e-Health. 2021;27(3):323-329.
- Robb JF, Hyland MH, Goodman AD. Comparison of telemedicine versus in-person visits for persons with multiple sclerosis: a randomized crossover study of feasibility, cost, and satisfaction.Mult Scler Relat Disord. 2019;36:101258.
- Bove R, Garcha P, Bevan CJ, Crabtree-Hartman E, Green AJ, Gelfand JM. Clinic to in-home telemedicine reduces barriers to care for patients with MS or other neuroimmunologic conditions.Neurol Neuroinflammation. 2018;5(6).
- Abbatemarco JR, Hartman J, McGinley M, Bermel RA, Boissy A, Chizmadia DT, et al. Providing Person-Centered Care via Telemedicine in the Era of COVID-19 in Multiple Sclerosis.J Patient Exp. 2021;8:2374373520981474. doi:10.1177/2374373520981474
- Spindler M, Jacobs D, Yuan K, Tropea T, Teng CW, Perrone C, et al. A Department Approach to Teleneurology.Telemed J e-health Off J Am Telemed Assoc. 2021;27(9):1078-1084. doi:10.1089/tmj.2020.0323
- Hatcher-Martin JM, Adams JL, Anderson ER, Bove R, Burrus TM, Chehrenama M, et al. Telemedicine in neurology.Neurology. 2020;94(1):30 LP - 38. doi:10.1212/WNL.0000000000008708
- Hatcher-Martin JM, Busis NA, Cohen BH, Wolf RA, Jones EC, Anderson ER, et al. American Academy of Neurology telehealth position statement.Neurology. 2021;97(7):334-339.
- 2021 Telehealth Survey Report.; 2022. https://www.ama-assn.org/system/files/telehealth-survey-report.pdf
- Roberts ET, Mehrotra A. Assessment of Disparities in Digital Access Among Medicare Beneficiaries and Implications for Telemedicine.JAMA Intern Med. 2020;180(10):1386-1389. doi:10.1001/jamainternmed.2020.2666
- Gray J, Tengu D, Ateev M. 3 Surprising Trends in Seniors’ Telemedicine Use During the Pandemic. STAT News. Published 2021. Accessed August 22, 2022. https://www.statnews.com/2021/08/30/three-surprising-trends-seniors-telemedicine-use-pandemic/
- Top 10 Tips for Virtual Visits Clinician Communication. Cleveland Clinic Center for Excellence in Healthcare Communication. Accessed September 27, 2022. https://my.clevelandclinic.org/-/scassets/files/org/landing/preparing-for-coronavirus/covid-response-digital-health-communication-tips.ashx
- Zoom system requirements: Windows, macOS, Linux. Zoom Support. Published 2022. Accessed September 27, 2022. https://support.zoom.us/hc/en-us/articles/201362023-Zoom-system-requirements-Windows-macOS-Linux