"Virtual house calls" over consumer-grade webcams and mobile devices have great potential to improve the care of patients with Parkinson's disease and other neurological disorders, new research has shown, but the lingering issues of reimbursement and physician licensure continue to hinder growth of remote consultations.
In a study published this month as an open-access article in the journal Neurology: Clinical Practice, 100 percent of the 55 patients who participated in a virtual house call with a neurologist said they were likely to recommend telemedicine to a friend. The researchers, from Johns Hopkins University in Baltimore and the University of Rochester (N.Y.), found patient satisfaction levels topping 90 percent for most aspects of remote consultations.
Nearly all remote sessions led to neurologists recommending specific treatments or activities. According to the paper, 86 percent of patients were instructed to exercise more, 63 percent had their medications changed, 53 percent were prescribed new meds and 10 percent had discussions with the doctor about possibly having surgery to address their condition.
One patient who had previously been diagnosed with Parkinson's was instead found to be likely to have progressive supranuclear palsy, and four patients with previously unknown diagnoses were diagnosed with other serious neurological conditions. Four more likely had an impulse control disorder, according to the study, and received appropriate counseling.
"As demonstrated by more than 50 remote consultations, providing neurologic care to new patients with PD and related disorders directly in their home is feasible, results in recommended changes to care, and is largely well-received. Such an approach has the potential to transform care and increase access for patients not only with PD, but also other chronic neurologic conditions from autism to Alzheimer disease," the study said.
This research is important because telemedicine helps neurologists connect with patients they might otherwise never see, according to corresponding author Dr. Ray Dorsey, co-director of the Center for Human Experimental Therapeutics (CHET) at the University of Rochester. He told MobiHealthNews that more than 40 percent of Medicare beneficiaries with Parkinson's don't have a neurologist caring for them – "and those are the people who have insurance and a [Parkinson's] diagnosis."
Dorsey said the U.S. has more than enough neurologists to treat those with Parkinson's and associated movement disorders. But many do not see a specialist because of the hassle associated with visiting the doctor while fighting a disabling condition, distance from care sites and the geographic distribution of physicians, according to the study.
"The care you receive has largely been determined by who you are and where you reside," Dorsey said.
He noted that physicians routinely use telemedicine to see and monitor patients in intensive care, those recovering from strokes and even those with skin conditions. "It's done every day in prisons," Dorsey said.
"The problem isn't technology," Dorsey said. "The issues are licensure and reimbursement."
"Patients who see a neurologist more frequently cost less," Dorsey said.
"We pay $70 for a visit to prevent a fall and $70,000 for the consequences of a fall," Dorsey said, illustrating the power of preventive care.
For many patients, the cost of a tablet computer to conduct telehealth from home is not much more than the expense of commuting from a remote area for one office visit, according to Dorsey.
The researchers employed Vidyo videoconferencing technology, which just requires an Internet connection and a webcam – standard equipment on laptops, tablets and smartphones or an inexpensive accessory for desktop PCs.
Networking site PatientsLikeMe helped the Rochester and Hopkins researchers identify patients to take part in the study. (PatientsLikeMe, the Verizon Foundation and medical device manufacturer Medtronic funded the study.) Researchers also promoted the study through a Johns Hopkins Medicine website, social and traditional media, national neurology meetings and community outreach.
Patients ranged from 35 to 90 years old, with a mean age of 67.8, and 80 percent of "visits" were conducted remotely. Not all patients were too far from a neurologist, with the mean distance being less than 9 miles. Still, two-thirds said the telemedicine consultation gave the same level of connection with the neurologist as a traditional, face-to-face encounter.
Respondents, particularly older ones with limited computer skills, did express concern with the technology. Others complained that the specialists did not have access to patient vital signs and other information, and some said the connection quality was lacking.
All patients selected for the study lived in California, Delaware, Florida, Maryland and New York, the five states in which Dorsey is licensed to practice medicine. Of course, cross-state licensure has been a longstanding obstacle for telemedicine advocates.
Insurance reimbursement remains a major stumbling block as well. "Medicare pays me $200 if I see them in a hospital-based clinic, $100 if I see them in a community-based clinic and no dollars if I see them virtually in their homes," Dorsey said. With the median age of the study population above the Medicare threshold of 65, this is a serious concern.
Indeed, patients were not all that interested in paying a lot of money out of their own pockets for remote consultations. The majority, 55 percent, said they would spend less than $50 a month for the service. Another 21 percent would pay $50 to $99 monthly, but only 24 percent expressed a willingness to shell out $100 or more per month.
Dorsey said that this research is expanding now with the help of the Patient-Centered Outcomes Research Institute (PCORI). That organization is about to start a study to randomize 200 patients throughout the U.S., half with standard, in-person care and the other half with normal care as well as virtual visits, according to Dorsey.
"This is technologically feasible … and it's extremely well-received by patients," Dorsey said of treating Parkinson's patients remotely. "It can be combined with in-person care."