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Introduction

Telemedicine has been used in many areas of health care. A Medline search for telemedicine papers found 911 articles concerning its use in radiology, 931 in surgery and 735 in pathology (Figure 24.1). There were 69 articles concerning telemedicine in neurology and 19 concerning epilepsy.

The term ‘imaging’ was found in 710 articles, ‘video’ in 969 and ‘electrocardiography’ in 250. ‘Electroencephalography’, the typical investigation of epilepsy, was found in 27 articles only. The most commonly mentioned aim of telemedicine was consultation (3022), followed by diagnosis (3654) and education (1718). Other indications were instrumentation (1729), treatment (2984), cost (2015) and payment (45).

Figure 24.1 The number of telemedicine articles published in different specialities (PubMed search, April 2008)

Clinical telemedicine applications can be considered on two axes: a vertical axis representing the level of maturity and a horizontal axis representing the extent of the application. The maturity is based on several factors, including quantity and quality of research pertaining to the application, the degree to which the application has been accepted by the profession, and the development of standards or protocols for its use. The evidence of the application refers to attributes such as technical feasibility, diagnostic accuracy, sensitivity, specificity, clinical outcome and cost-effectiveness. Tele-radiology, telesurgery and telepathology rank high on the maturity scale. Psychiatry, dermatology and ophthalmology are regarded as maturing areas of telemedicine, whereas paediatrics and emergency medicine, for example, are emerging specialties with respect to the use of telemedicine (Figure 24.2).1

In neurology, real-time telemedicine has the greatest potential in the management of neurological emergencies such as status epilepticus, stroke and movement disorders and in neurophysiology. Status epilepticus and stroke require urgent treatment within the window period for better outcome. Transporting these patients to a specialist centre might take several hours, resulting in high mortality and morbidity. Live demonstration or video recordings of patients with movement disorders and neuro-physiological tracings (electroencephalography, nerve conduction studies and evoked potentials) can be transmitted to a specialist centre for expert opinion without physical referral of the patient.

Figure 24.2 Categorization of medical specialties according to their maturity in telemedicine

Epilepsy

Epileptic seizures can be infrequent and difficult to diagnose. The best method of diagnosis is by observation of the seizure episode, and in its absence one has to rely on the description of a bystander. The data concerning seizures are so important that full information should be made available to the physician so as to make or revise the diagnosis. Patients with epilepsy often have travel limitations placed on them, which may cause difficulties with the different centres involved in treatment of multiple handicap. Communication between different hospitals and physicians in difficult-to-diagnose epilepsies can be greatly helped by telecommunication.² This can not only avoid frequent and sometimes arduous visits to experts in different hospitals and repeated investigations, but also allow the simultaneous opinion of different physicians to be obtained.

Status epilepticus is an emergency in which seizures recur without the patient regaining consciousness between two discrete seizures, or individual seizures continue for at least 30 minutes. Often, a patient is admitted to a primary centre and is referred to another more specialized centre when the seizure is not controlled. Finally, when the patient reaches an advanced specialized centre, he or she may be have been undergoing status epilepticus for several hours or even longer. This is likely to result in various complications and a poor prognosis. Early diagnosis and prompt treatment would assist with controlling the attack and improving the prognosis. According to a recent study, a telemedicine-based epilepsy service was as safe and effective as conventional face-to-face consultation.³ In this study, a neurologist was based at a centre and managed epilepsy patients at a rural hospital by video link. Patients were usually accompanied by a family member and always by a trained nurse, who acted as care manager, coordinated medication and ensured compliance, and was able to reinforce what the neurologist said. A comparison was made of patients managed by this method and those managed by a conventional urban clinic. Seizure frequency, emergency room visits and hospital admissions were used as measures of efficacy and safety. No difference was found in these outcome measures between telemedicine and conventionally treated patients.³

Acute stroke

Recombinant tissue-type plasminogen activator (rtPA) represents a major breakthrough in the treatment of ischaemic stroke. If it is administered within 3 hours of onset of stroke, it results in improved survival and outcome.4 Many institutions lack the specialized personnel and resources necessary to provide the response for acute stroke patients. These institutions depend on the rapid transfer of patients to regional stroke centres for therapy. In practice, the main reason for patients not receiving this therapy is their late arrival after the critical time window of 3 hours. Telemedicine is emerging as an efficient means of making early decisions about therapy.

At the medical centre of the University of Maryland, the tele-stroke service uses videoconferencing and CT image transfer. Between 1999 and 2001, 50 stroke consultations were reviewed. Of these, 23 were managed by telemedicine and 27 by traditional telephone conversation followed by transfer. Two of the 23 telemedicine consultations were aborted because of technical difficulties. Of the patients evaluated by the traditional method, 1 (4%) received rtPA, whereas 5 patients from the telemedicine group (24%) received rtPA and there were no complications due to this therapy. Telemedicine provided a treatment option that was not previously available at the remote hospital. For administration of rtPA, telemedicine was safe, feasible and well received.^5,6

Assessing the stroke patients and their CT scan by using videoconferencing offers an opportunity to improve stroke care in remote and rural areas. In a study from Swabia, seven rural hospitals were connected to the stroke unit via videoconferencing. One hundred and fifty-three patients were examined by teleconsultation, and a relevant contribution could be made in more than 75% of cases regarding diagnostic work-up, CT assessment and therapeutic recommendations.⁷

Although the number of emergencies is increasing, there is growing anxiety about medical errors and an increasing number of medical negligence cases. Pre-hospital use of telemedicine for stroke is already being piloted, linking patients in an ambulance to the emergency department.⁶

Movement disorders

Telemedicine has been found to be useful for diagnosis, treatment and follow-up of patients with various movement disorders. Live video or prerecorded video clips can be used for these purposes. In a recent study, video clips of normal and abnormal gait disorders were used by a geriatrician for diagnosis and were compared with the diagnosis of the treating clinicians, i.e. the latter was considered the gold standard. The agreement of the video clip examination with the gold standard in identifying abnormal gait ranged from substantial to excellent among assessors, although there was only a low agreement with the gold standard in the detection of specific gait diagnosis. This technique appears to be a valid screening procedure for detecting gait abnormalities, with a sensitivity of 100% and a specificity of 70%.⁸

Telemedicine has also been used to follow up patients with Parkinson’s disease in remote areas. Over a 3-year period, 100 teleconsultations were carried out on 34 patients with Parkinson’s disease. Each teleconsultation lasted for 30–60 minutes. Patients and providers were satisfied with the consultations, and they reduced the time and cost of travelling.⁹

Neurophysiology

Digital technology for clinical neurophysiology allows teleneurophysiology to be developed. Such a service may improve patient care in remote areas, since the clinician can obtain a second opinion from other centres. The process may even help in education and the creation of a national data bank. A telemedicine facility of this kind has been established in Scandinavian countries.¹⁰

Neurological outpatients

In remote areas where neurologists are not available, telemedicine has been used for providing outpatient consultations to neurological patients. In a randomized controlled trial, the efficacy of telemedicine consultation was compared with face-to-face consultation, the groups comprising 82 and 86 patients, respectively.¹¹ The diagnostic categories were similar in the two groups. The patients in the telemedicine group had more investigations, but there was no difference in the number of drugs prescribed. The patients were generally satisfied with both processes, although they were concerned about confidentiality and embarrassment in the telemedicine consultation.

Teleneurology, although feasible in the outpatient setting, is less well accepted than face-to-face consultation, and can lead to over-investigation.¹¹ However, in a remote area where there are too few neurologists, telemedicine may become a viable option, especially in developing countries.

Mobile phones

The telephone has always been used for consultation between doctors, especially for fixing appointments, calling for home visits or obtaining immediate advice. Following the mobile phone revolution, most urban and even rural people have access to a telephone. This has opened up opportunities for using mobile phones for health care delivery. In developing countries, the doctor:patient ratio is far too low. Specialized and even primary hospitals are overcrowded. The use of a mobile phone can help in obtaining appointments and monitoring therapy, especially in chronic disorders such as epilepsy, migraine, headaches and stroke. Such patients often have to travel long distances, and it may take several hours or even days to obtain a consultation. In such a situation, adjusting the dose of drugs, checking compliance, monitoring side effects and defining the patients who need an early appointment may be done by telephone or mobile phone. The difference between a mobile phone and the ordinary telephone service is not only the former’s mobility, but also that mobile phones have additional capabilities, including text messaging, video and Internet facilities.

There is a paucity of randomized controlled trials evaluating the efficacy and satisfaction level of mobile phone consultations in comparison with conventional face-to-face consultations. Psychotherapy delivered by telephone revealed a significant improvement in depression. In telephone-administered cognitive–behavioural therapy, there was an improvement compared with usual care.¹² Patients can often capture an event such as a seizure or movement disorder and present it to a physician for evaluation during consultation.

Medical education

Telemedicine has great potential to transform medical education at undergraduate, postgraduate and professional levels. The educator has to select the appropriate context, content and delivery method to suit the needs of the largest number of the learners. In medicine, education has to continue throughout the professional’s career. Learning is greatest when adults act as self-directed, motivated learners, perusing the topics of their interest in the appropriate context, i.e. interactive, practical and self-paced.¹³ These principles can be incorporated into a distance education programme.¹⁴ Online continuing medical education (CME) and web-based CME have also provided CME credits for the practising physician. The Internet also has the ability to support the presentation of complex multimedia presentations to augment learning. The Internet has created learning communities.

A survey was conducted regarding the motivation and choice of topics for a journal club and the websites accessed in two institutions. The institutions were the Sanjay Gandhi Post Graduate Institute of Medical Sciences in Lucknow and the King George Medical University in Lucknow. The views of specialty (n = 58) and subspecialty (n = 97) residents were compared.¹⁵ Most of the residents used Medline and PubMed for choosing their journal club topics. The choice of Google, the Oxford database, Science Direct and the Cochrane Review did not differ between the residents of the two institutions. At the Post Graduate Institute, the choice of articles was based on the availability of good articles, whereas in the Medical College, it was faculty driven. The choice of articles related to patient management and examination were not different between the two institutions. Female residents more frequently selected articles related to patient management or examination, although the difference was not significant.

Internet use by residents and faculty members of the Medical College and the Post Graduate Institute was surveyed by us, and we found that 89% of individuals performed a computer literature search at least once a month. The reason for a computer-based literature search was for presentation in 90% of cases, research in 65% and patient care in 60%. The benefit of literature searching was acknowledged in learning and teaching by 80% of respondents, in research by 65% and in patient care by 54%. Formal training in computer-based literature searching was received by 41%, of whom 80% were residents. Of the participants in this survey, 64% had a home Internet connection and the remainder used the Internet at their workplace or at a cyber café, suggesting widespread use of computers and the Internet by medical personnel.¹⁶

We have used videoconferencing for neurology teaching in India. We have conducted a neurology educational conference between the Post Graduate Institute and the Medical College. These locations are 1500 km apart. Faculty members and residents of the two departments participated. Desktop videoconferencing systems were connected by an ISDN line at 128 kbit/s. During 2001–2004, there were 30 sessions, 22 of which were successful and 8 partly successful (owing to power and communication failure). In each session, two to four cases were discussed, with clinical pictures, neurophysiological and radiological data as illustrations. Discussions provided inputs for both learning and patient management (Figure 24.3).¹⁷

Figure 24.3 A videoconferencing session between the Sanjay Gandhi Post Graduate Medical Institute and a remote centre in India

Telemedicine in India

There are few reports in the literature of the successful use of telemedicine in India. Mahakumbh Mela is a religious congregation that occurs every six years and in which millions of Hindus gather for religious ceremonies and discussions. Such a large gathering of people is associated with inherent health problems, such as infections and accidents, so that health care for the attendees is a major public health problem. The Post Graduate Institute used telehealth to avoid an outbreak of cholera at the Mahakumbh Mela in Allahabad, Uttar Pradesh.¹⁸ Ganapathy¹⁹ took the initiative of providing consultations to distant areas in India in Aragonda and Sriharikota. Desai et al²⁰ used teleconsultation between a tertiary cancer centre and a rural cancer hospital. Ninety-three cases were analyzed in which static pathology and telepathology were used to obtain a consultation between the Tata Memorial Hospital, Mumbai and the Nargis Dutt Memorial Cancer Hospital at Barshi. A diagnosis was offered in 92 (98%) cases.

Resource availability

In developing countries, an increasing population and a very low doctor:patient ratio represent a difficult challenge for health care. A total of some 800 neurologists in a country such as India with a population of 1.3 billion is inadequate. It will take more than 20 years to achieve a ratio of one neurologist for 50 000 population at the rate of 50 neurologists being produced per year. However, it is not only the numbers that are important. Increasing specialization has reduced the number of physicians who are good at managing emergencies. Although the number of emergencies is increasing, there is growing anxiety about medical errors and increasing number of medical negligence cases.

There is no single solution for upgrading the emergency services, but a favoured model has been a large central hospital with associated local hospitals to which patients are discharged. Unfortunately, this may make the services worse rather than better. Medical emergencies usually occur in a patient’s home, and are followed by a journey to the hospital, assessment, admission, treatment and then discharge. A large central hospital means a long journey, which may delay treatment and influence outcome, as in status epilepticus and stroke. In developing countries, roads and transportation are far from satisfactory. Increased distance also causes problems for visiting families, and weakens the link with primary care, which is crucial when discharging patients from hospital. Large numbers of patients in emergency departments lead to long waiting periods. The local hospitals do not share care or staff with large hospitals, and have poor nursing and medical infrastructure. They are uncomfortable about managing seriously ill patients, and thus assume the role of nursing homes, rather than hospitals.

Black et al²¹ have proposed a reverse model in which patients are admitted to a local hospital, which acts as the catchment area of a big hospital. The medical and nursing staff would be part of the team working in the central hospital, and would rotate between the hospitals. The local unit would have imaging (CT scanning) and laboratory support (EEG, ECG and biochemistry), as well as high-quality electronic links with the central hospital that would allow the specialists to know almost as much about the patients as if they were examining them directly. Such a system would result in avoiding delay in treatment. Patients who did not need admission could be quickly discharged, perhaps within a single day, and some patients would never need to go to the central hospital at all. Those who went to the central hospital would not need to be assessed again, so that the transfer and admission would be faster.²¹

The cost-effectiveness of telemedicine has been a concern because, in a study of teleneurology from the UK, a comparison of 65 patients in a conventional group and 76 in a teleconsultation group revealed that the telemedicine group needed more investigations and reviews than the conventional group. The average cost of conventional consultation was £49, compared with £72 for the telemedicine group.²²

Legal questions

The use of telemedicine has raised several legal questions. These include licensing, reimbursement and liability. The question of data security is also a concern in telemedicine. Thus, accidental loss and data corruption must be prevented by providing effective data control management and artefact recognition algorithms. As personal data is involved, the possibility of loss or criminal access must be considered and prevented. Special encryption mechanisms to secure data against unauthorized access or modification are therefore necessary.12 Patients’ right to confidentiality is paramount.

Unless otherwise agreed by both sides, the liability in telemedicine is normally considered to rest with the consulting rather than the advising physician. Procedures for reimbursement of logistical costs in telemedicine need to be developed.

Conclusion

There are concerns that physicians in future may become ‘telecarers’, at least for part of their working time. A telecarer is a health professional who delivers responsive, high-quality information services, and supports remote patients or clients by using the most appropriate communication technology, such as the telephone, email or instant messaging. The advantages of telecare are the possibility of working from home and better continuity of patient care. However, there are concerns about over-investigation, clinical mistakes and confidentiality. There are also worries about commercial pressures.

A wider market for health service information and products should be welcome. However, the danger of commercial suppliers or cyber-physicians undercutting primary health care services is a possibility, although it may ultimately result in healthy competition. The digital divide in society may also be a concern. People with low education and old age may be excluded from telemedicine, and society must ensure that this does not occur. Telemedicine is a powerful tool, but should be used judiciously and in the interests of society at large.

Further reading

Bashshur RL, Sanders JH, Shannon GW. Telemedicine, Theory and Practice. Spring-field, IL: CC Thomas, 1997.

Darkins AW, Cary MA. Telemedicine and Telehealth Principles, Policies, Performance and Pitfalls. London: Springer, 2000.

Norris AC. Essentials of Telemedicine and Telecare. New York: Wiley, 2002.

Wootton R, Craig J, Patterson V, eds. Introduction to Telemedicine. 2nd edn. London: Royal Society of Medicine Press, 2006.

References

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² Elger CE, Burr W. Advances in telecommunications concerning epilepsy. Epilepsia 2000; 41(Suppl 5): 9–12.

³ Rasmusson KA, Hartshorn JC. A comparison of epilepsy patients in a traditional ambulatory clinic and telemedicine clinic. Epilepsia 2005; 46:767–70.

⁴ National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995: 333: 1581–7.

⁵ LaMonte MP, Bahouth MN, Hu P et al. Telemedicine for acute stroke: triumphs and pitfalls. Stroke 2003; 34: 725–8.

⁶ LaMonte MP, Xiao Y, Hu PF et al. Shortening time to stroke treatment using ambulance telemedicine: TeleBAT. J Stroke Cerebrovasc Dis 2004; 13: 148–54.

⁷ Wiborg A, Widder B. Teleneurology to improve stroke care in rural areas: the Telemedicine in Stroke in Swabia (TESS) Project. Stroke 2003; 34: 2951–6.

⁸ Salih SA, Wootton R, Beller E, Gray L. The validity of video clips in the diagnosis of gait disorder. J Telemed Telecare 2007; 13: 333–6.

⁹ Samii A, Ryan-Dykes P, Tsukuda RA et al. Telemedicine for delivery of health care in Parkinson’s disease. J Telemed Telecare 2006; 12: 16–18.

¹⁰ Stålberg S. Small bits to big bites. Muscle Nerve 2002; 11 (Suppl): S119–27.

¹¹ Chua R, Craig J, Wootton R, Patterson V. Randomised controlled trial of telemedicine for new neurological outpatient referrals. J Neurol Neurosurg Psychiatry 2001; 71: 63–6.

¹² Ludman EJ, Simon GE, Tutty S, Von Korff M. A randomized trial of telephone psychotherapy and pharmacotherapy for depression: continuation and durability of effects. J Consult Clin Psychol 2007 75: 257–66.

¹³ Knowles MS. Andragogy in Action: Applying Modern Principles of Adult Learning. San Francisco: Jossey-Bass, 1984.

¹⁴ Ward JP, Gordon J, Field MJ, Lehmann HP. Communication and information technology in medical education. Lancet 2001; 357: 792–6.

¹⁵ Misra UK, Kalita J, Nair PP. Traditional journal club: a continuing problem. J Assoc Physicians India 2007; 55: 343–6.

¹⁶ Kalita J, Misra UK, G Kumar. Computer based literature search in medical institutions in India. Ann Indian Acad Neurol 2007; 10: 44–8.

¹⁷ Misra UK, Kalita J, Mishra SK, Yadav RK. Telemedicine for distance education in neurology: preliminary experience in India. J Telemed Telecare 2004; 10: 363–5.

¹⁸ Ayyagari A, Bhargava A, Agarwal R et al. Use of telemedicine in evading cholera outbreak in Mahakumbh Mela, Prayag, UP, India: an encouraging experience. Telemed J E Health 2003; 9: 89–94.

¹⁹ Ganapathy K. Telemedicine and neurosciences in developing countries. Surg Neurol 2002; 58: 388–94.

²⁰ Desai S, Patil R, Chinoy R et al. Experience with telepathology at a tertiary cancer centre and a rural cancer hospital. Natl Med J India 2004; 17: 17–9.

²¹ Black S, Andersen K, Loane MA, Wootton R. The potential of telemedicine for home nursing in Queensland. J Telemed Telecare 2001; 7: 199–205.

²² Chua R, Craig J, Wootton R, Patterson V. Cost implications of outpatient teleneurology. J Telemed Telecare 2001; 7(Suppl 1): 62–4.

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