LAUSR

The application of telemedicine to remotely connect patients with providers dates back decades. Prior to the COVID-19 pandemic, telestroke and teleneurology were already delivering much needed care to regions of the country without neurological expertise. Large hospital systems such as Kaiser recently reported more than half of all patient interactions were through telehealth. However, until now many barriers for even greater acceptance of telemedicine prevented growth. The Centers for Medicare and Medicaid Services restricted payment to rural areas, specific originating sites (the location of the patient), and certain Current Procedural Terminology codes. Reimbursement from private insurers varied from some to no coverage of telemedicine. There was widespread skepticism among physicians in many areas regarding the effectiveness of telemedicine visits, which were often considered substandard and antithetical to the proper practice of medicine. Due to challenges to health care during the COVID-19 crisis, telemedicine has moved from a technology with limited use to mainstream medicine. Many reimbursement and licensing obstacles that previously constrained telemedicine adoption were suspended in the setting of the COVID-19 public health wemergency. To continue to care for urgent non–COVID-19 neurological disorders, almost all health systems, departments, and practices turned to telemedicine. Hospital consults in many cases were converted to telemedicine using iPads, carts, cameras, tablets, or cell phones in patient rooms. New applications of telemedicine emerged to minimize exposure during the pandemic. At NYU Langone Health at the epicenter of the pandemic, virtual visits grew from a typical 50 visits per day to >7,000 daily visits within 10 days. Between March 16 and June 7 at the University of Pennsylvania Health System (UPHS), there were nearly 400,000 telemedicine encounters across thousands of providers, requiring expansion of videoconferencing availability, rapid training, and development of new workflows for outpatient and inpatient practices. The UPHS Department of Neurology increased from 36 telemedicine encounters on March 16 to >200 daily visits in early June. All of these changes occurred in days or weeks rather than months or years. If widespread use of teleneurology is to continue after the pandemic, the major impediments might be the lack of evidence for the efficacy of teleneurology and understanding the proper place of teleneurology when in-person care is also available. Randomized trials are challenging in telemedicine, but given the high volume of virtual visits during the COVID-19 crisis, it should be possible to compare outcomes in patients with similar characteristics across modalities. Further evaluation of the physical examination, provider–patient interaction, and workflow changes using telemedicine will be necessary to determine its place in our medical armamentarium. In some ways, teleneurology may allow us to improve on in-person visits. Telemedicine supports a team approach by virtually bringing together providers from various disciplines without traveling to a single location and devoting a dedicated block of time. Similarly, family members can be incorporated into telemedicine visits to obtain relevant history and counseling and to participate in shared decisions even if those family members are remote from the patient and provider. For neurological patients in rural areas and those with limited mobility making it difficult to reach medical offices, telemedicine might be favored when an in-person visit is not practical or the alternative is reduced or no care at all. Teleneurology consultations in such situations streamline evaluation and testing, potentially improving outcomes and reducing costs while increasing time efficiency for busy clinicians. Teleneurology in its current form is in its infancy. As evidenced by digital transformation in other industries, the possibilities for change and improvement are considerable. The experience in large networks with analytics and big data should allow exploration of new and useful applications. The addition of artificial intelligence may automate some of the processes now requiring training and proficiency, expediting teleneurology visits and improving diagnosis and outcomes. Integration into the electronic medical record and interoperability will be essential to improving the teleneurology experience. Wearable devices add important new information to augment teleneurology capabilities. The physical examination is limited in teleneurology, but elements of the examination may be enhanced through observational aids or in some cases the assistance of family members on site. The addition of activity monitors and sensors should increase the yield of