Inpatient Telemedicine for Neurology Consultation at Satellite Hospitals: Patient and Provider Perspectives

Abstract

Background and Purpose: Describe an inpatient teleneurology consultation service novel to our hospital system, and capture feedback from patients, ordering providers, and consulting neurologists. Methods: A single cohort of teleneurology consult patients was surveyed via telephone. Ordering and consulting providers completed online surveys. Quantitative survey data was reported using descriptive statistics and free-response survey data was summarized. Patient demographics and consult data were gathered via retrospective chart review. Results: Telephone survey was obtained from 25 of 53 patients receiving teleneurology consults from June 1–September 30, 2020. Patient-reported benefits included better understanding of condition (72%) and ability to remain close to home. Online surveys were completed by 11 ordering providers and by consulting neurologists on 20 telemedicine encounters. Ordering providers reported they were likely to use the service again (98.7%), agreed it added value to patient care (91%) and was valued by patients (82%), with concern for missed diagnosis (46%) and potential patient transfer (36%) without the service. In contrast, fewer consulting neurologists predicted need for transfer (5%) or missed diagnosis (10%) in the absence of teleneurology, though 20% indicated that length of stay may increase without the service. Conclusion: We confirm feasibility of an inpatient teleneurology service run by an academic medical center. Satisfaction was high among all key stakeholders, with few transfers to a tertiary care center. This service is valuable to patients, ordering providers, and potentially the hospital network, as a community based care model of neurological care, centered on the needs of the patient and hospitalist.

Introduction

Telestroke has been standard of care since the mid 2000s, bringing physicians to the patient for acute care decisions when time is brain and minutes matter. ¹ The implementation of telestroke and teleneurology offers a solution to the persistent gap between a short supply of neurologists and a high demand of patients with neurologic disease, a mismatch of provider availability and patient need that is exacerbated in many rural areas.^2,3 Hub-and-spoke models traditionally used in telestroke have the most comprehensive evidence to guide practice, with studies demonstrating improved access to care, improved quality of care, and more timely administration of tPA without reduced diagnostic accuracy.^4,5

Following success in “drip-and-ship” models, with remote administration of thrombolytics guided by telemedicine followed by transfer to the telestroke hub, systems of care have expanded to include “drip-and-keep” models. ⁵ This permits regional centers to keep patients with non-acute and minor strokes under the virtual guidance of vascular neurologists. However, this is still relatively limited in scope. Similarly, e- ICU models have been developed to provide high acuity care in hospitals without critical care specialists. ⁶ Adjunctive inpatient teleneurology systems or interfacility tele-stroke programs can provide the necessary inpatient care to prevent unnecessary transfers of stroke patients from regional to tertiary centers.^7,8

Wake Forest Baptist Health is comprised of a tertiary referral center (Baptist Medical Center) in Winston Salem, North Carolina with four satellite hospitals in surrounding counties, three of which do not have inpatient neurologists. While we have utilized a telestroke network since 2009 for acute treatment decisions across a statewide network, prior to June 2020, neurologists were available for general neurology questions and non-acute stroke questions by phone only, with transfer to WFBMC available if additional neurological evaluation and management was needed. In June 2020, we implemented a telemedicine service for inpatient neurology consults at three satellite locations.

Inpatient teleneurology lacks rigorous study in the literature. Two separate systematic reviews (2013 and 2020) found a combined total of 4 papers that investigate the role of telemedicine in general inpatient neurology.^4,9 There is limited study of patient and physician acceptance and satisfaction with inpatient teleneurology systems, with data from 20 patients, 22 consulting neurologists, and 21 spoke providers at one site in Northern Ireland reported in 1999. ¹⁰ The COVID-19 pandemic, with social distancing requirements and expansion of reimbursement for remote services, has undoubtedly facilitated and accelerated the growth of telemedicine in all fields of medicine, including neurology. In considering the role of telemedicine post-pandemic, additional data is needed to direct resources to evidence-based virtual solutions. We sought to describe an inpatient teleneurology consultation service novel to our hospital system, and capture feedback from three key stakeholders: patients, ordering providers, and consulting neurologists in the current environment of telemedicine expansion.

Methods

Study Design: A single cohort of teleneurology consult encounters was investigated. Patients, ordering providers, and consulting neurologists were surveyed about completed inpatient telemedicine consults during the pilot implementation phase of our inpatient teleneurology consult service (June 1-September 30, 2020). Quantitative and qualitative data was gathered to characterize both patient and provider feedback regarding their experience using the service.

Setting: Consults were ordered by hospitalist providers (physicians and APPs) with non-urgent questions at satellite hospitals through Epic, our shared electronic medical record. Urgent questions including immediate transfer requests continued to be handled by phone. When a consult was received, the on-call consulting neurologist at WFBMC connected with the primary team and bedside nurse to schedule the video consult during regular business hours (Monday through Friday, 8am–5pm). Staffing physicians were 11 attending level neurologists that volunteered to participate in the pilot service. Multiple subspecialties were represented; all volunteers had experience with inpatient service time on either the general neurology (9) or stroke (2) service. Satellite hospitals were equipped with laptops with video capability and virtual consults were completed through video capability in Epic. Bedside nurses assisted with video connection and physical exam maneuvers. Consulting neurologists documented the visit in the EMR and billed the patient for inpatient consult codes, using GT modifiers to indicate utilization of telemedicine at a distant facility.

Patient Demographics and Consult Characteristics: Patient demographic information including age range and sex, and consult characteristics including satellite location, clinical question, length of stay, clinical outcome, discharge location, consultant contribution to management plan, and post-consultation follow-up was collected by retrospective chart review.

Patient Survey: The patient population was comprised of admitted patients at three satellite hospital campuses who required neurology consults during their hospitalization. Survey participants were obtained via convenience sampling of all patients for whom teleneurology consult was completed during the pilot implementation phase (June 1-September 30, 2020) and had subsequently been discharged. Patient survey was conducted via telephone within 3 months of the completed inpatient teleneurology consult after the patients had been discharged (all phone surveys were completed in August-September, 2020). Non-English speaking patients were excluded. Patients were contacted via telephone call using the numbers listed in their medical record, with a minimum of two calls if not initially reached. Patient-reported reasons for not participating in or completing the survey included did not recall the visit, or a disconnection of the call by the patient. Assenting patients or proxy family members were asked if they recalled the virtual visit. If they recalled the visit, they were asked three subsequent survey questions about their experience with the teleneurology consult service. Questions were read from a standardized script. Answers to free-response questions were recorded verbatim. Survey questions and response data is summarized in Table 1.

Table 1.

Patient Feedback.

Interview Question	Percent Agreement, %	Free Responses
1. Did this computer or video visit help you better understand your condition and treatment? (% yes)	72
2. What was the benefit of being able to see a neurologist for your brain or nervous system condition?		Commonly identified themes
		Improved understanding It helped me understand a little bit better since I wasn’t sure what happened to me It helped me to understand how I would be treated It gave me a better understanding of what was going on in my body
		Communication with a specialist He really helped us by explaining what went on when he had a stroke Good to be able to see a specialist We talked a lot about my symptoms Reassured me that I didn’t have a severe stroke
		Preference for in-person visits It was helpful to be able to follow-up in clinic later Would have been better in-person
3. Please share with me any general feedback about your experience with the telemedicine video		Commonly identified themes
		Technological barriers It took quite a while to log on You can see more and know more about the patient at the bedside
		Convenience of remote services I prefer virtual visits, because I hate going anywhere It was nice that we didn’t have to go anywhere It’s a good thing when you don’t have a doctor available in person

Provider Surveys: Provider surveys were disseminated by email to ordering providers and consulting neurologists who utilized this service in July-August 2020 to assess satisfaction with the first two months of implementation (June 1-July 31, 2020). Responses were anonymous. Ordering providers and consulting neurologists were sent separate surveys via email consisting of questions regarding their experience with the teleneurology consult service. Survey data were collected and managed using REDCap electronic data capture tools hosted at Wake Forest School of Medicine. Consulting Neurologists were asked to complete a survey for each consult encounter. Ordering providers were allowed one unique survey response evaluating their overall experience. Provider survey questions and response data is summarized in Tables 2 and 3 of our results.

Table 2.

Ordering Provider Feedback.

Survey Questions		Percent Agreement, %	Free Responses
Do you think the service adds value to the care of your patients? (% yes)		91	Extremely valuable and allows us to keep patients that we normally wouldn’t
			More personalized and in depth discussions than we were previously able to do via patient access line
			Better patient-centered care, prevents transfer, gives hospitalist back up when there are questions
			Tremendously helpful getting specialist opinions and the added support beyond just peer to peer
Do you think the patient valued the availability of teleneurology? (% yes)		82
Availability of teleneurology consults is essential to keeping patients in their community and preventing unnecessary transfers to WFBMC. (% agreement)		100
If the teleconsult option was not available what would happen? (may choose more than one)	Transfer to tertiary care	36
	Phone advice would have been sufficient	18
	Potential missed diagnosis	46
	Potential harm	18
	Increased length of stay	27

Table 3.

Consulting Neurologist Feedback.

Survey Question		Free Responses
Was consult able to be completed? (% yes)	85%	The initial consult had been completed; I reached the physician who did not require further guidance
		Initial consult had been completed and primary team did not require further advice
		MD discontinued consult- had called [a different hospital] due to delay in getting consult completed/miscommunication
Ease of coordination with the primary team (mean +/− standard deviation, Likert scale0 – 100)	65.3 +/− 21.6	The physician with whom I spoke said this was his first experience with teleneurology consults and he was very pleased
		Without speaking to the MD, it’s hard to know exactly what the consult question was
Briefly describe any challenges/other comments (% described challenge with technology)	60%	We could not connect initially; finally, we used a nurses cell. The patient was hard of hearing an had dementia so much assistance was needed from the nurse, who did a great job
		The nurse had never used the tele-consult laptop, so she had to get help from another nurse in ICU. Then, the laptop could not connect, so we ended up using an Android to iPhone Doximity call
Connectivity was adequate (% true)	65%
If the teleconsult option was not available what would happen? (may choose more than one)	Transfer	5%
	Phone advice would have been sufficient	50%
	Potential missed diagnosis	10%
	Potential harm	0%
	Increased length of stay	20%

IRB Approval: This study was approved by the Institutional Review Board (IRB) of Wake Forest School of Medicine

Data Analysis & Synthesis: Descriptive statistics were performed to analyze quantitative answers to multiple choice questions. Free-text provider survey responses and recorded quotes from patients were analyzed qualitatively. The data supporting these findings are available upon request.

Results

Background Characteristics

The inpatient teleneurology service performed consults on 53 patients between June 1–September 30, 2020. Patient demographics and consult outcomes are recorded in Table 4. There was no notable difference between in age, sex, length of stay, and transfer to tertiary care between all completed consults and the subgroup of those patients who completed surveys.

Table 4.

Patient Characteristics.

Clinical Characteristics	Completed Consults (n=53)	Completed Surveys (n=25)
Age (mean +/− standard deviation, years)	63.2 +/− 13.7	68.2 +/− 11.11
Sex (% male)	58%	52%
Length of stay (mean +/− standard deviation, days)	5.6 +/− 7.4	3.24 +/− 1.75
Transfers to tertiary care (% of patients)	8%	0%

Monthly consult requests increased from 15 in June to 34 in September (Figure 1). Of those, a portion were discontinued due to incorrect ordering or lack of availability of on call neurologist prior to discharge (eg. consult ordered on weekend). The percentage of completed consults increased from 47% in June to 85% in September.

Figure 1.

Consult volumes during pilot phase.

Reasons for consultation included focal neurological deficit (47%), altered mental status (23%), confirmed stroke (17%), and “other” (13%; seizure, weakness, headache, sensory changes). The most common discharge diagnosis following consultation was Stroke/TIA (58%), followed by delirium/encephalopathy (19%), with the remaining 23% comprised of the following: epilepsy, Parkinson disease complication, neuropathy, syncope, dementia, and unclear etiology.

Consultants’ contribution to the management plan included diagnostic recommendations (51%) and treatment recommendations (72%). Only 8% of management plans had no additional recommendations added by the consultant (Figure 2). Outpatient follow-up was recommended in 66% of consults.

Figure 2.

Consultant contribution to management plan.

Patient Feedback

Feedback was obtained by telephone survey of 25 of the 53 patients receiving teleneurology consults (48%). Of the patients interviewed, 72% reported that the teleneurology consult helped them to better understand their treatment or condition. Common themes found in qualitative responses describing patient-reported benefits included better understanding of their conditions and ability to remain closer to home. Commonly reported barriers included technological issues (8%).

Ordering Provider Feedback

Surveys were sent to 26 ordering providers and satellite hospital leaders, with 11 surveys returned (42%). Ordering providers included physicians (64%), 27% advanced practice providers (27%), and system leaders (18%), with one provider selecting two roles. Two respondents did not have direct clinical roles at the time of survey. Providers delivering clinical care rated themselves 96-100% likely to use the service again (mean 98.7%).When asked which clinical questions were likely to warrant future use of the consult service, providers chose TIA/Stroke (100%), Other Neurologic condition (78%), headache (44%), AMS (33%), and dizziness and syncope (22%). Feedback was generally positive, with all ordering providers in agreement that the availability of teleconsults kept patients in their community. Most agreed that this service added value to patient care (91%) and was valued by patients (82%). Survey respondents indicated that without the availability of teleneurology consults, missed diagnosis (46%) and need for patient transfer (36%) would increase (Table 2, Figure 3). Common themes found in qualitative statements regarding the benefit of the teleconsult service included preventing transfer, improving patient-centered care, and additional support for hospitalist providers.

Figure 3.

Anticipated outcomes without teleconsult availability.

Consulting Neurologist Feedback

Neurologists were asked to complete surveys for each encounter from June 1, 2020-July 31, 2020. There were 17 consults completed and 20 surveys returned. Survey respondents indicated that without the availability of teleneurology consults, length of stay may increase (20%). Compared to ordering providers, fewer neurologists predicted the need for patient transfer (5%) and missed diagnosis (10%) in the absence of available teleneurology (Table 3, Figure 3). Neurologists indicated that telephone call would be sufficient in 50% of cases and did not believe that the absence of the teleconsult service would result in potential harm. Common suggestions for improvement included clarifying consult questions and fixing connectivity issues.

Discussion

While integration of technology into subspecialty care via telestroke has been established evidence-based practice for over 10 years, inpatient teleneurology lacks rigorous study in the literature. ¹ With a shortage of specialists in many regions, telemedicine has the potential to address unequal access to neurological care within many health systems.^2,3

Here we confirm feasibility of an inpatient teleneurology service run by an academic medical center for 3 satellite hospitals. Furthermore, we show satisfaction was high among all key stakeholders: patients, ordering providers, and consulting neurologists. Lastly, we provide evidence of the value of this service to patients, ordering providers, and potentially the hospital network.

This model is feasible. Over the 3 month pilot phase studied here, consult volumes and percent of completed consults increased as communication and workflows were optimized. Notably, this has continued to increase as the service was extended beyond the pilot phase. Connectivity was adequate per consulting neurologists and technical complications were rare after the initial startup, with few patients reporting technology challenges that impacted their visit. This is notable in comparison to our outpatient teleneurology experience at Wake Forest Health. In our patient population, 46% of patients scheduled for outpatient telemedicine visits required audio only visits due to technology limitations. ¹¹ Unlike outpatient teleneurology, inpatient telemedicine has built in infrastructure such as broadband access, and technological support including staff to assist patients with disability, cognitive limitations, or low technologic literacy impacting their ability to connect to a visit and participate in the physical exam. These resources can successfully resolve technological issues and minimize the patients’ and providers’ perception of technological barriers to care.

Telemedicine is essential to supporting community based care and allowing patients to be treated locally, often far from the specialty providers. This model supports system based care, addressing the needs of all key stakeholders and is a win-win-win for patients, hospital providers, and consulting neurologists. Patients expressed appreciation for the specialty care and added education about their condition. A portion explicitly preferred the virtual format recognizing that although they were not able to see the provider in person, it allowed them to stay close to home, indicating that this program is centering the needs of the patient. Ordering providers appreciated the service as well, and plan to continue using it for a wide variety of neurologic conditions. Consulting neurologists were overall satisfied with the ease of coordination with the primary team, were able to complete the majority of consults, and described few concerns with the service beyond initial technological concerns. These findings support a “Evaluate and Keep” model of care similar to the “Drip and Keep” model of stroke care. ⁵ Patients can be initially evaluated and triaged via telemedicine- in that case for emergent tPA administration- and stay locally if appropriate. The specialty consultation ensures best practices are followed and supports the local hospitalists or other providers, and maintenance of local care supports the patient and allows network hospitals to retain higher acuity diagnoses, potentially leading to a higher reimbursement rate. The participation of the consulting neurologist, though virtual, had notable value in patient care. Neurologists provided diagnostic and management recommendations in the majority of cases, and few ordering providers felt that phone advice would have been sufficient. Virtual diagnostic and management support is similar to, or higher than, previous studies of in-person Neurology consults, which lead to a change in diagnosis in 21-63% of evaluations, and management recommendations in 21-88% of consults. ¹² In this population, nearly half of ordering providers were concerned about missed diagnosis without telemedicine, and a portion noted the potential for patient harm without the service. This is interesting in comparison to the perception of the consulting neurologists, half of whom felt phone advice would have been sufficient with very few concerned about missed diagnosis or harm without telemedicine. Notably, this is different from previously reported data. A similar small study in Northern Ireland had concordance between consulting providers and ordering providers, with only 5% of each group agreeing that a telephone call would be sufficient. ¹⁰ In both studies, providers indicated that the addition of video was important to the consultation. In our system this service is hospitalist-centric; while the clinical questions may seem simple to the consulting neurologist, perhaps representing a consensus bias, there is great value in this specialty consultation to the community provider.

While not explicitly studied, there is potential value to the hospital system as well. A portion of ordering providers and neurologists felt that this service decreased length of stay. This aligns with data demonstrating decreased length of stay for inpatients seen by teleneurology consultation in other small cohorts.^13,14 In person neurohospitalist services have shown decreases in length of stay as well as cost of care; it will be important to further evaluate these metrics in a virtual or “teleneurohospitalist” consult model going forward. ¹⁵ Ordering providers in our cohort reported prevention of transfers as well, and only 8% of consulted patients were transferred, similar to previous studies with small transfer rates in systems with teleneurology availability.^16-18 Additionally, all of the ordering providers and system leadership surveyed agreed that availability of teleneurology consults is essential to keeping patients in their community and preventing unnecessary transfers to our tertiary care center. These potential benefits to the hospital network require further study and are critical to consider as we adjust to a post pandemic world. During COVID surge planning in many regions, steps were required to reserve tertiary care beds for the sickest patients, requiring community hospitals to care for patients that may have traditionally been transferred to a higher level of care. In times of crisis or bed shortage, telemedicine may allow a local standard of care to continue, bringing the specialists to the patients instead of transferring and filling much needed tertiary beds.

It is important to note that a majority of consults were placed for patients with stroke, with altered mental status comprising an additional quarter of cases. This may limit the generalizability of findings to other neurological conditions. While the acquisition of both quantitative and qualitative feedback obtained soon after the tele-consults from all three stakeholders is a novel contribution to the literature, the use of survey data and potential for recall bias with retrospective data collection are important limitations to note. Only half of patients were reached by telephone, and provider survey response was voluntary, introducing the potential for selection bias. Finally, clinical outcomes and financial data were not collected.

With this study we show that inpatient teleneurology consultation is not only a feasible way to expand the reach of neurologic care, but an acceptable service to patients, ordering providers, and consulting neurologists. The model is patient centric, and of great value to ordering providers, thus supporting the health care network and community based care. Through teleneurology, we can improve access to care and provide patients the specialty expertise they need where they are.

ORCID iDs

Juneja PJ https://orcid.org/0000-0002-1995-9823

Strowd RE https://orcid.org/0000-0001-6651-5267

Guzik AK https://orcid.org/0000-0003-3282-7611