Teleneurological Services Unbound: Bringing Virtual Subspecialty Care to Providers and Patients

Podcast Transcript

Intro: Neuro Pathways, a Cleveland Clinic podcast, exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD: Well reports abound about how COVID-19 pandemic fueled a surge in virtual outpatient visits. Providers in the acute care setting, like stroke, have spent the last decade perfecting the technology for diagnosis and treatment of patients from miles away. In today's episode of Neuro Pathways, we'll discuss the storied and evolving use of telemedicine in sub-specialty neurological care.

I'm your host, Glen Stevens, neurologist neuro-oncologist in the Cleveland Clinic's Neurological Institute. I am very pleased to have Dr. Khawaja join me for today's conversation. Dr. Khawaja is medical director of the Telestroke Program and a stroke neurologist in Cleveland Clinic's Neurological Institute. Dr. Khawaja welcome to Neuro Pathways.

Zeshaun Khawaja, MD: Thank you for having me. It's a pleasure to be here.

Glen Stevens, DO, PhD: So Dr. Khawaja, I'm a baby boomer and sadly, the number of people with Alzheimer's disease is expected to triple by 2050. A study published in neurology in 2013, predicted that we'll need almost 20% more neurologist to meet demand by 2025. I guess we'll find out in your conversation today how telemedicine may help us with this problem of a lack of number of neurologists that are out there.

So with the first question, as an early adopter, your team recognized that telemedicine technology would be valuable to your practice. Can you brief me on your telestroke practice, how it began and what you've achieved to date.

Zeshaun Khawaja, MD: Yeah, absolutely. But before I do that, you're not that old you're heading up a podcast, aren't you?

Glen Stevens, DO, PhD: I'm that old.

Zeshaun Khawaja, MD: Yeah, that's got to count for something. But yeah, we started providing telestroke almost 10 years ago. And interestingly enough, we started at non Cleveland Clinic hospitals. We were fortunate to have a consistent neuro coverage at our Cleveland clinic hospitals, but there were other community hospitals that didn't really have consistent stroke coverage. And this can actually play a big toll on the communities and also the hospitals. On one hand, those patients don't get the treatment they need or they're bypassed or sent to hospitals outside their community.

So telestroke really helped us care for patients in their communities and helped ensure that they received a thorough acute stroke assessment. And so we learned a lot as we experimented with different aspects of the Telstra program. As you might imagine, telestroke is a really complex service, especially when you're first starting out. There are tons of variables and choices.

What equipment should I be using? How many doctors do I need? How do I document? How do we review images? How do I communicate my findings back? And how many layers of backup do I actually need? And the backup thing was really surprising because, one of the things that we don't immediately think about is how emergent or how stroke isn't necessarily a scheduled disease. And the calls could be really, really sporadic. Sometimes we have nothing and sometimes we get three or four at a time and we can't necessarily have patients just to wait for us until we're done with our existing patients.

So we needed to design a layered backup system that helps us push cases to the next available physician without any significant delay. And then after a few years of experience, we actually started to cover more Cleveland Clinic hospitals and found that our ED colleagues, hospital leadership, and none-stroke neurologist like the service so much that we rolled the service out to almost every Cleveland Clinic Regional hospital, including the site and floor. And despite this massive expansion, we've been able to improve upon our treatment times, maintain safety and also create efficiencies that have enabled us to increase our capacity. So, we're still in growth phase right now and we're really excited to grow.

Glen Stevens, DO, PhD: Well, I think you're the person to answer this question. From telestroke your group has transitioned to the neurologic intensive care setting. Tell us about that and what needs have been addressed in this model.

Zeshaun Khawaja, MD: Yeah, this is really interesting because our neuro ICU docs actually participate in our Telestroke pool. So they came with tons of experience. And so they were very comfortable with the technology and they themselves realize that this could be really useful in the neuro ICU. They became very comfortable assessing critically ill patients using the video conferencing tools that we had. And basically used it to supplement overnight neuro ICU coverage. Traditional neuro ICU models where basically, the docs would spend the whole night in the hospital there rounding. But when they do that, it kind of limits, or it puts a bit of a strain on the system and you tend to need a lot more doctors.

Using EICU they were able to provide more coverage with less staff, and that resulted in a pretty significant cost savings and allowed expansion. And the most interesting part was is that there was no compromise to patient care. Our neurointensivist basically studied the outcomes and found no increase in mortality or changes in length of stay or ventilator days. So this was a real value add for our neuro intensive program.

Glen Stevens, DO, PhD: Excellent. And it sounds like this snowball is going down the hill and now you're moving it to less acute settings, just the general inpatient consult service. Tell us about that.

Zeshaun Khawaja, MD: Absolutely. Yeah. You know, our neurology colleagues certainly did an excellent job in spearheading this. Dr. Andrey Stojic headed up project. We're a large enterprise and we have lots of regional hospitals and they vary from very large to smaller community hospitals. And with that, we have very differing neurology needs. You know, we have a larger hospitals that have a lot of neurology consults, and then we have our smaller regional hospitals that might not have a lot of neurology needs.

And so the staffing for that also varies. So this teleneurology program was created and fine-tuned over the last year that basically couples a telemedicine presenter with a neurologist and allows the team to perform really good neurological assessment at some of our smaller regional hospitals. And this has really helped us work smarter rather than harder because before our neurologists were trying to juggle clinic and then drive across town to different hospitals.

Now they can just be mid where needed. And it's good for the doctor and good for the patient. A neurologist can screen patients and determine if the evaluation and treatment they need is possible where they are. And if not, they can be easily transferred to one of our larger centers. You know, one of the goals in teleneurology and telestroke is actually, in addition to of course providing excellent patient care is to keep patients in their communities and prevent unnecessary transfers that we tended to do a lot prior to telemedicine. So, one question we should ask ourselves is where else could we use telemedicine? I think right now we've done a good job in using it in the EDs. We've been, we did a good job using it, the outpatient space, even on the inpatient space in terms of kind of pushing a cart around.

And then there's this whole other segment, like our mobile stroke unit. But we've done one innovative thing at Cleveland Clinic, and that's a development of our M80 unit. Which is basically a completely connected and hardwired unit. And the benefit here is that instead of pushing a cart around and connecting with a patient, that patient's room is actually connected. So any provider at any point in time without any geographic limitation can actually be made and connect with the patient and talk to them. And this becomes particularly important for our surgeons. You know, many of our surgeons are quite mobile. They'll operate in one area and then they go to the next hospital and they're operating there. And connected rooms such as M80 allow those surgeons to connect with their patients, to check on them and to ensure the plan of care is going as scheduled.

And so this is something that's really innovative and it becomes even more important in the times of COVID-19. You know, obviously we want to take care of patients, but at the same time, we want to protect our caregivers. We want to ensure that we're not having to go into the room unless it's absolutely necessary to minimize exposure. And so connected rooms like these avoid us pushing robots in bringing robots out, having to clean these robots continuously and help minimize exposure. So, technologies like these, I think of the future. And I think in, as hospitals continue to evolve, I think we're going to see a lot more connected rooms.

Glen Stevens, DO, PhD: So our colleagues in neurophysiology, I understand have also started to adapt this technology. Tell me about that a little bit.

Zeshaun Khawaja, MD: You know, we've learned that virtual health is not just a face-to-face encounter. Dr. Imad Najm and his epileptologist partners are really, they're experts in this. And they've been able to leverage their experience to offer a host of services, including direct patient evaluations, either in the inpatient or outpatient space or running a virtual patient management conferences. These are really in-depth conferences that help determine if patients are candidates for highly specialized epilepsy surgery. And the best thing about these is that it doesn't require any patient travel, and it doesn't even require the patients to come to Cleveland to have the surgery. So these patients can benefit from these conferences and have surgery in their communities. And they've also been able to create, run and manage entire EMU programs, everything from design to training the technicians.

Glen Stevens, DO, PhD: What other areas of neurologic care do you see benefiting from telemedicine enabled care? I think the list would probably be a lot shorter if we said what doesn't require telemedicine, but other areas that you see moving this direction?

Zeshaun Khawaja, MD: Absolutely. I think you kind of hit the nail on the head. There's so much potential, especially within the neurological space. We've just scratched the surface with telestroke, with teleneurology. Now we're seeing teleneurophysiology really doing great things in telemedicine. And now there's so many patients across our nation that don't have access to some specialists. Sometimes they're forced to travel long distances just to see someone. And this is not only disruptive to their normal routines, but it can be very costly. Not just money spent on travel, but income loss being out of work. And as we continue to gain experience and experiment within virtual health, I'm really eager to see what comes next, particularly in the management of movement disorders, such as Parkinson's disease. You know, I think medical management of these patients is very, very complex. When they're hospitalized, sometimes their medications need to be changed.

And then as they transition to the outpatient space, all of this can severely affect the disease progression. And we've seen that one of the most common uses of telemedicine in the neuro space is actually the management of movement disorders, particularly Parkinson's patients. So I'm really eager to see what we can do there. And I'm also really excited to see what we can do with telepsychiatry. I think there is significant potential. There are a lot of needs, both in the inpatient and also in the outpatient space. And I think we have a lot of potential to take care of a lot of patients in that space.

Glen Stevens, DO, PhD: So what tips would you share with those who are really just beginning to use the technology or are looking to expand beyond the outpatient setting.

Zeshaun Khawaja, MD: I it's really important for hospitals or programs and physicians to ensure that telemedicine is actually right for the patient. We should always keep the patient at the center of these decisions. Telemedicine will never replace a neurologist. It won't replace our reflex hammer, tuning fork, I mean, it, there's just too much in neurology. Instead, telemedicine is a tool that we have at our disposal. But it is a great tool and it allows us to reach more patients at a safe and reliable way. I've always encouraged people to contact me if they have any questions about telemedicine, if it's, if telestroke would be right for them, but teleneurology would be right for them.

And I always enjoy talking to some of our other subspecialty colleagues to see what they might be able to offer it. If there's anything that they think would be good for patients. And the other thing is sometimes it makes sense to start your own program. And sometimes it makes sense to let an experienced program such as Cleveland Clinic participate in the care of their patients. We never take a cookie cutter approach to patient care and always welcome discussions to see what's best for the patient.

Glen Stevens, DO, PhD: So I assume that COVID has accelerated everything and patient buy-in as well. Have you seen that? That patients are much more readily willing to go to do virtual visits?

Zeshaun Khawaja, MD: Absolutely. I think before it was interesting, both for providers and for patients. I think we were well adapted and very experienced at using telestroke. So for us transitioning to almost full-time virtual health was really easy. But for many patients it wasn't and many other providers within Cleveland Clinic. And they were kind of forced into it. But just being forced into it, I think really helped patients and providers both realize what the value of telemedicine is. That it's certainly, and it's not going to replace an office visit. But there are many indications where telemedicine suffices and it helps us take care of the patient.

It helps patients learn what they need to do. It helps them understand what's going on and it really doesn't disrupt their day. I think what we're seeing now is we're seeing that patients are slowly trying to trickle it back into the office, which we expect. I don't think telemedicine necessarily is right for everybody. There's some people who just don't like it. But I think for the vast majority, I think they're seeing the value of it. And I think they, I think they're realizing that there are many cases where it's appropriate for them. Just as a patient will learn, I'm hoping that we're going to continue to learn and have more offerings for our patients.

Glen Stevens, DO, PhD: So they talk about zoom fatigue. Is there a sweet spot for practice wise for telemedicine, for the physician, for the patient. Is it, physicians do well if 50% of their practices, telemedicine and above that, it's an issue or is that data not exist?

Zeshaun Khawaja, MD: Well, I, it's interesting. I think it's dependent on the physician. You know, there are many physicians who do this full-time and there are some physicians who don't do any of it. And then there's everyone in between. So I really, it depends on what you're looking to do. I think zoom and virtual health, it addresses something that's really important within healthcare, that's burnout. I think a lot of physicians they tend to get burnt out because of increasing service responsibilities. Increased patient care responsibilities. And virtual health it's just another way for us to kind of combat that in the sense that we are no longer tied to our offices.

So we save time with commutes. You know, when it comes to childcare, sometimes it becomes very easy because even if you're at home and you're seeing patients, you can have your children maybe in a different room and still feel comfortable that you can get your job done while keeping an eye on them. So I think that there are a lot of benefits here. In terms of fatigue, that's always going to come. I think that if we don't implement telemedicine correctly, if you don't implement anything correctly, it's bound to cause fatigue. It's bound to kind of lose its appeal, both for providers and patients.

Glen Stevens, DO, PhD: So Dr. Khawaja thank you very much for joining me. It's an exciting time in virtual care delivery and I look forward to seeing what your team does next.

Zeshaun Khawaja, MD: Yeah. I appreciate you having me.

Outro: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, ClevelandClinic.org/neuropodcast or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our consult QD website. That's consultqd.clevelandclinic.org/neuro or follow us on Twitter @CleClinicMD, all one word and thank you for listening.