Implementation and Patient Experience with Outpatient Subspecialty Teleneurology

Podcast Transcript

Alex Rae-Grant: Neuro Pathways, a Cleveland Clinic Podcast for medical professionals exploring the latest research discoveries and clinical advances in the fields of neurology and neurosurgery. Welcome to another episode of Neuro Pathways. I'm your host, Alex Rae-Grant, Neurologist in Cleveland Clinic's Neurological Institute. In an effort to explore the latest advances in neurological practice, today we're talking about the use of teleneurology in the outpatient subspecialty setting. Today's conversation is based on published data from Cleveland Clinic's experience implementing teleneurology technology over the last four years.  I'm very pleased to have Dr. Marisa McGinley join us for today's conversation. Dr. McGinley is a neurologist in the Mellen Center for Multiple Sclerosis in Cleveland Clinic's Neurological Institute. Marisa, welcome to Neuro Pathways.

Marisa McGinley: Thanks for having me.

Alex Rae-Grant:  I'd like our listeners to get to know you a little better, Marisa. Tell us a bit about yourself - where are you from, where did you train and when did you begin your career at the Cleveland Clinic?

Marisa McGinley:  Absolutely. So, I'm from Ohio originally, from Toledo. And I went to undergrad just south of Cleveland at the College of Western and then did my medical school training at Ohio University down in Athens. I left the state briefly and did my residency over at Loyola in Chicago where I did my neurology residency. And then I came to the Cleveland Clinic in 2016 to do a neuroimmunology MS fellowship, which I completed in 2017, and then stayed on staff at the Mellen Center.

Alex Rae-Grant: And we're very happy to have you.

Marisa McGinley:  Thank you.

Alex Rae-Grant: So, let's start off. Can you begin by telling us how the Cleveland Clinic uses digital platforms to engage with patients and family? Just give us a general overview.

Marisa McGinley:  Yeah. So, I think when we think about teleneurology, a lot of the times we think about telestroke. I think that was kind of the first place in the neurology field that kind of the digital platform was implemented, the idea being that you could bring that subspecialty stroke knowledge to hospitals that didn't even necessarily have a neurologist 24/7. And so, I think that's the first place that teleneurology really grew both at the Cleveland Clinic and kind of all over the nation and what we realized is that there's a great use for it in the inpatient setting and those kind of emergency situations. But there's also a use for it in the outpatient setting. So, about four, almost five years ago, Cleveland Clinic started using teleneurology to bring subspecialty teleneurology care to outpatient visits. And it was all follow-up visits. So, the idea being if someone came to the Cleveland Clinic to see a neurologist, either a general neurologist or a subspecialist, but wanted to have some continuity, they would have the option of doing these teleneurology visits in addition to in person visits.

Alex Rae-Grant: Could I do a visit with someone from another state? Would that be a possibility?

Marisa McGinley:  Yeah, absolutely. So, right now, like I said, we're doing all follow-up patients. So, any time a patient is seen at the Cleveland Clinic, they kind of establish themselves as one of our patients here. And then we're able to provide continued follow-up care on the digital platform. And so, that's where all of the visits that I looked at with my team were based on these follow-up visits, and any patient could ask to do a virtual visit. We are looking at doing new patient visits to out of state patients that have never been seen at the Cleveland Clinic. Those are a little bit more education based, just kind of providing knowledge around a disease state. We don't necessarily diagnose and treat in those situations. But we can kind of offer this platform to anyone across the country.

Alex Rae-Grant: You guys looked more formally into what's been done in the last four years. Do you want to talk a bit more about the details of this work?

Marisa McGinley:  Again, the novel thing that was done at the Cleveland Clinic was that we were using teleneurology in the outpatient setting. So, there had been a couple of published studies about the use of teleneurology, but they were pretty small scale disease specific, so kind of only one disorder. And they were on very outdated platforms. And by that, I mean it would be just audio sometimes, or it would be in situations where a patient would still have to travel to a local physician's office, and then at that physician's office, they would teleconference with a provider. And so, that still provides a lot of barriers. Audio is not as good as a video audio platform. And then, with patients still having to travel to a physician's office, obviously that travel anywhere may be difficult for some patients, especially some neurologic diseases that are pretty disabling.  So, the thing about the Cleveland Clinic platform that we use is that it's a video audio conferencing that is done on a personal device. And so, this was kind of the first real explanation of a platform like that that had been used. So, again, there had been a couple of small things, but nothing on a very large scale like this. And so, what we did is we summarized kind of the last four years of the use of teleneurology in the outpatient setting at Cleveland Clinic. And it ended up being over 5,000 visits that we looked at. And it spread a lot of disciplines. So, when we were looking at this, we kind of wanted to know what kind of fields within neurology are using this platform? And we found that it was used in a large variety of platforms, although obviously some fields used it a little bit more. So, what we found was headache, epilepsy and spine subspecialties tend to use it a lot. But really, we saw the use of it in all subspecialties, which I think was one of the most interesting things that we found. So, really within all of our different clinics, clinicians were finding a way to make this useful with their patients, and patients of a large range of disorders were interested in using it. And I think the other big question we had when we wanted to look at this data is where are patients coming from that are using this? So, I think the bias that I had going into this was that it was going to be patients from a long distance that wanted to use this. So, it was just my patients coming to me from California or Florida that didn't want to take a plane ride to come talk to me again. But really, when we broke down the data of where patients were that were coming from, it was a big range. So, actually almost 30% of patients were considered local. So, less than 50 miles from the Cleveland Clinic main campus were electing to do these virtual visits. So, it wasn't just these patients at a far remote range. So, about 23% were greater than the 270 miles, so those really faraway patients that were probably almost taking a plane ride to get us. But it was pretty well distributed among the distances. So, that kind of said to me that really this is something that patients want to do, and it doesn't necessarily mean they have to live a great distance to think that it's valuable for them.

Alex Rae-Grant: I guess it's a lot of travel that patients didn't have to do. Do you have some sort of numbers on how much travel was saved in this program?

Marisa McGinley:  Yeah, so it was really an interesting analysis that we used kind of an algorithm using Google Maps actually, to kind of estimate the distance that people would have had to drive or fly to get to us. And so, of these 5,646 visits, we estimated that we saved 1.4 million miles of travel. So, that's a huge number. And again, when you start to think about that from a cost time perspective, it's not only the driving or the travel, it's also the gas or the flights that these people had to buy in addition to hotels. There's a lot of significant savings in that regard.

Alex Rae-Grant:So, how did the patients perceive this program? I mean, what was their assessment of how well this went?

Marisa McGinley:  So, for each of the visits, we asked kind of just a simple satisfaction of, "How satisfied were you with the visit and with the provider?" And on average, the patients were rating them on a scale of five, they were rating their experience as a 4.7 or 4.9. So, overall, patients were very satisfied with their experience. Again, to me just saying that it's something that a lot of patients are eager to do and would add to their kind of medical care.

Alex Rae-Grant: Results of your study were over four years. How did the program change during that time? And did it expand? Did it grow?

Marisa McGinley:  Yeah. It was a huge growth. So, you can definitely see in our first year, we really only had I think 30 visits in our first year. And it was kind of in those fields of headache and epilepsy initially. And then by the fourth year, that's when we really saw our largest growth. And that was where we had over 4,000 virtual visits. I think that speaks a little bit to providers just kind of getting trained on how to use this, when to offer it, patients becoming more comfortable with the idea of not sitting across from their doctor in the office. But there was an exponential growth over those four years. And not only did we see just a growth in the number, also in the subspecialties. So, again, like I said in the first year it was only like one or two subspecialties that seemed to be utilizing it. By the fourth year, really every single subspecialty here was using it in some capacity.

Alex Rae-Grant:So, I know everything is cellphones these days. So, can doctors do this on their cellphone? Is that part of the technology?

Marisa McGinley:  Yeah, absolutely. So, when I do these visits personally, there's sort of two ways that you can do it. You can do it on your cellphone or you can do it on your desktop. It's just a matter of what is more convenient to you. Both of them work just as well. Same for patients, they can do it both on cellphones or on desktops, iPads, pretty much any kind of personal device they can use it. It gives both patients and providers a lot of flexibility, I think, because you wouldn't necessarily have to be in your typical clinic setting to be able to do these visits.

Alex Rae-Grant: So, Marisa, where do you think this kind of technology approach is going in neurology? I mean, where do you see teleneurology going to?

Marisa McGinley:  I think it's going to be a big part of teleneurology. I know as neurologists we are very wedded to our exam for a good reason, obviously there's still a lot we can gain from that. So, I don't ever see us completely moving over to a digital only platform. But I think that teleneurology really provides us the ability to give that subspecialized care or even general neurology care to a large majority of patients. We know that there is a shortage of neurologists that's just growing. So, our ability to reach pretty much the entire nation, regardless of where patients are, I think is very important. I think teleneurology provides that opportunity because again, the fact that you're using a personal device, patients just have to have some sort of device, which really used to be a barrier, but I would say nowadays most patients have some type of device they could do these on. So, I think that it's a huge advantage for patients getting access to a neurologist, which is a very important thing because there are such a huge range of neurologic diseases that need care from a neurologist. And so, I think that we will need to adopt and utilize teleneurology more to be able to provide those services. I think it also helps with continuity too, especially if patients move, doctor’s move, you know? Again, teleneurology breaks down those barriers a little bit too of being able to provide care regardless of where those two people are. And there is so much too, as much as exam in person thing is important, there's so much of neurology that is also symptomatic care. And patients don't necessarily want to go six months to a year without talking to their doctor about things that are slightly changing because they don't want to make the huge trek in with the copays and whatever else they have. But being able to just have a quick virtual visit with their provider I think would allow patients to get symptomatic care more regularly, stay on top of their disease, have access to their providers a little bit more consistently.  So, I think it's going to be a huge part of what we do as neurologists, or in my mind, it should be, just to help provide better access to patients. It'll just be a matter of figuring out how frequently you still need to see people in person. When is a good time for a virtual versus an in-person visit? Do you still need to have a neurologist locally for some emergencies? I think there's a lot of kind of logistical things that'll need to be worked out, but I do think it will be a big part of how we practice in the future.

Alex Rae-Grant: Certainly seems to make sense for certain kinds of visits. So, for example, you prescribed a new medicine with somebody, you want to check in with them to make sure they're taking it, that they're not having a lot of side effects or to keep an eye on their disease progression, but they really don't have the ability to get to the clinic. I mean, it seems like there's a number of situations where teleneurology would be applicable.

Marisa McGinley:  Yeah, I can tell you ... And my practice obviously is MS, so obviously a little bit biased, is that when I start a new disease modifying therapy, I typically like to check in with the patient about three months on typically for some blood work, just kind of make sure, "Hey, is it going okay? No side effects?" But if their disease is stable, I don't necessarily need to see them in person. But I don't want to have to just do that over a quick little internet message. I would like to have a 10, 15 minute discussion to make sure they're doing okay, they don't have questions about their really recently new diagnosis. So, I find that a very useful kind of situation, as you said. I also find it a really useful time is when someone comes to me with say the question of, "Do I have MS?" And we want to get some testing, we're not quite sure. And in a month from now, I want to follow-up those results with them and talk to them about all the implications. Again, clinically, they probably haven't changed their exam, but we have a lot to discuss. We have an MRI to go over or we have blood work to go over. That's, I find, a very useful situation again. So, again, some of these kind of more rapid follow-ups where I don't want to spend 30 minutes on the phone with the patient, I'd like to have a reasonable conversation, this video audio platform, I think, gives that kind of, again, personal interaction with the patient so that we can go over things in detail. We really give good time to that, it's not quick little messages, but I don't need to have them dragged all the way into the clinic just to discuss all of that. Another place that I find we're using it is in post-surgical follow-ups. So, a lot of our spine patients or epilepsy post-surgical patients, again, when the provider just wants to check in and make sure post-operatively there's no questions or concerns, these virtual visits are a great platform for that. They don't necessarily need to come in for any physical exam checks, they're just making sure the patient doesn't have any questions or concerns.

Alex Rae-Grant: Any other final take home messages to our audience? Things that they might think about this whole new field of neurology?

Marisa McGinley:  Yeah. I think that the biggest take home for me is that it is widely applicable in neurology. I think that I had a little bit of a bias that maybe it was only useful in certain subspecialties that have less of an exam component, or things like stroke, you know? But I think what our study kind of showed is that there is a wide range of disorders that are utilizing this so that it has a huge applicability. And then, the other thing that I thought was very interesting, obviously we focused on subspecialty care, but the fact that so many local patients were utilizing this says to me that as a general neurologist where you're practicing, it's likely that you have a lot of patients in your area that would be interested in these types of visits. So, I think not only does it have a large range of applicability for subspecialty use, I think just in neurology in general there is a demand from patients to utilize this platform, and I think it really can augment the way we care for our patients.

Alex Rae-Grant: Well, thanks Marisa. That's been very enlightening and a great chance to chat with you about new directions in teleneurology. So, thanks for coming.

Marisa McGinley:  Absolutely. Thanks for having me.

Alex Rae-Grant:This concludes this episode of our Neuro Pathways podcast. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast. Subscribe to the Neuro Pathways podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you get your podcasts. Don't forget, you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our Consult QD website, consultqd.clevelandclinic.org/neuro, or follow us on Twitter at CleClinicMD. All one word. That's at C-L-E Clinic M-D on Twitter. Thank you for listening. Please join us again soon.