Neil Busis, New York University, introduced the workshop’s third session, which explored telehealth experiences and considerations in specific clinical contexts. The speakers were Ray Dorsey, University of Rochester; Jeffrey Hine, Vanderbilt University and TRIAD Primary Care; Ileana M. Howard, Veterans Health Administration and University of Washington; Melissa Ko, Indiana University; Ellen Cohn, University of Pittsburgh; Chad Gladden, Veterans Administration Audiology and Speech Pathology National Program Office;
Saleem Chowdhry, Cleveland Clinic; Betsy Cyr, University of New England; and Joseph C. English III, University of Pittsburgh.
REMOTE NEUROLOGICAL EVALUATIONS
Ray Dorsey, University of Rochester
Ray Dorsey, professor of neurology at the University of Rochester Medical Center, discussed challenges people face in accessing neurological care and explored how telehealth can help address these challenges. Dorsey said that many people with disabilities have inadequate access to health care and are underdiagnosed both within neurology and in other medical specialties. He noted that for many, the alternative to telehealth is not in-person care, but no care at all.
As an example, Dorsey highlighted gaps in care for people with Parkinson’s disease. More than 40 percent of Medicare beneficiaries with Parkinson’s disease do not see a neurologist within 4 years of diagnosis (Dorsey et al., 2013). He said that older individuals, those living in rural areas, and those from historically marginalized groups are less likely to receive care from a neurologist. He added that these groups are also more likely to have adverse health outcomes, including death.
Dorsey outlined how telehealth can help more people receive the care they need. A key strength of telehealth is that it can bring greater access to specialists, especially for the large number of people who live in areas that lack neurologists or other specialists. He said:
If you think about it, it is kind of odd that we generally ask sick patients to come see generally healthy clinicians on our terms. We should be bringing care to patients instead of patients to care.
He explained that research has found that physicians can garner most of the information they need to make a diagnosis from a patient’s medical history alone—before they even undertake a physical examination or diagnostic testing—suggesting that a great deal can be learned from a simple conversation and review of the medical record, which is easily done virtually (Keifenheim et al., 2015).
Dorsey said telehealth has already dramatically altered neurology care. He outlined the five Cs that have driven a shift to teleneurology during the COVID-19 pandemic:
- reduced contagion, which is important for people with disabilities, who are at higher risk;
- expanded care, which is important for patients with disabilities who experience barriers to care;
- increased convenience, which is needed for those with mobility or cognitive impairments;
- enhanced comfort, as telehealth allows patients to be in their natural environment and with trusted caregivers; and
- greater confidentiality, as telehealth from home protects patient privacy (Dorsey et al., 2020).
Dorsey said now that teleneurology is available for many subspecialties, it is feasible to diagnose most conditions via telehealth, and this modality is also suitable for disability evaluations (Hatcher-Martin et al., 2020). However, there are limitations. Dorsey noted that a remote neurological exam is often more difficult to perform than an in-person exam and requires clinicians to be more attentive and observant; in some cases, it is necessary to follow up with an in-person visit (Al Hussona et al., 2020).
ASSESSMENT OF AUTISM SPECTRUM DISORDERS (ASDs) IN CHILDREN VIA TELEMEDICINE: FEASIBILITY, LESSONS LEARNED, AND FUTURE DIRECTIONS
Jeffrey Hine, Vanderbilt University and TRIAD Primary Care
Jeffrey Hine is an assistant professor of pediatrics at Vanderbilt University Medical Center and director of primary care outreach in the Vanderbilt Kennedy Center Treatment and Research Institute for Autism Spectrum Disorders. He discussed ASD assessment before and during the pandemic.
Hine explained that telehealth assessment tools have the potential to (1) eliminate barriers to care, especially for those in underserved communities; (2) rapidly identify ASD; and (3) streamline care and services. However, while multiple diagnostic assessments for ASD exist, there has been very little research on ASD assessment via telehealth. He noted that there is a slightly stronger literature base for telehealth behavioral interventions, but most ASD assessment tools were designed for use in in-person settings with standardized materials.
Hine said two models were typically used for remote assessment before the COVID-19 pandemic: store-and-forward video screening and synchronous video screening (Berger et al., 2022). Store-and-forward video screening, a model in which clinicians analyze videos made by parents, is convenient but not interactive and may require specialized software. Synchronous video screening requires an appointment with a provider, but is more likely to rely on simple, low-cost, flexible software. He noted new tools to complement these approaches were rapidly developed and deployed during the pandemic.
Hine described TELE-ASD-PEDS, a process for synchronous remote ASD evaluation that Vanderbilt released in 2020 after years of development
and fine-tuning as an example of a recent advance in remote ASD assessment. He said the program supports ASD assessment with high levels of diagnostic clarity and certainty without requiring trained clinicians to be onsite with the child being assessed (Corona et al., 2020; Juárez et al., 2018). Researchers developing the tool first used a machine learning algorithm to review more than 700 comprehensive ASD evaluations to identify key social communication behaviors and repetitive behavioral observations that are most predictive of an ASD diagnosis (Corona et al., 2020). Then, clinical experts created behavioral descriptors, a ratings system, and a set of simple tasks that caregivers or family members could initiate while clinicians observe via video (Corona et al., 2021).
Hine said many families strongly prefer remote assessment, and TELEASD-PEDS has been helpful in reducing barriers to care, lowering costs and wait times, and starting interventions more quickly (Stainbrook et al., 2019). Initial data showed high-level agreement with in-person assessment and increased access and comfort for families (Wagner et al., 2020). He explained that challenges with TELE-ASD-PEDS include the need for training and coaching, eliminating distractions for the children under study, and coordinating care (Wagner et al., 2022).
TELEHEALTH IN REHABILITATION MEDICINE
Ileana M. Howard, VA Puget Sound Health Care System and University of Washington
Ileana Howard is outpatient medical director for rehabilitation care at VA Puget Sound Health Care System in Seattle, Washington, and assistant professor of rehabilitation medicine at the University of Washington. She discussed the practice of psychiatry and the use of telehealth in rehabilitative medicine.
Howard explained that physiatrists are specialists in physical medicine and rehabilitation who treat the fast-growing group of patients with chronic disabling conditions. These specialists focus on holistic evaluation of how patients function in their own environment and nonoperative evaluation and rehabilitative management of musculoskeletal and neurological conditions such as spinal cord injuries, neuromuscular disease, and amputation care.
Howard said incorporating remote and virtual care models into rehabilitative medicine provides clear benefits. She noted that telehealth can substantially improve access to care, allow clinicians to observe how a patient functions at home, and reduce infection risk for vulnerable groups during the COVID-19 pandemic (Hatcher-Martin et al., 2020). She explained that many patients who work with physiatrists have complex medical conditions, and she described how telehealth can also help to facilitate comprehensive,
interdisciplinary virtual consultations that involve multiple medical specialists at once. This can save time on the part of both patients and clinicians, reduce the need for patients to repeat themselves, help to avoid confusion or conflicting advice, and create a more unified care plan and comprehensive electronic health record (EHR) documentation on par with in-clinic reporting.
Howard noted the rapid pivot to telehealth during the pandemic did pose some challenges. Clinicians learned they needed to clarify where patients should be during the visit; what to wear; how much space would be needed; and whether any peripheral health devices, props, or caregivers should be present. Physiatrists learned that telehealth works well for initial and follow-up care. However, she said successful deployment requires patient training with regard to accessing emergency services, staying within the practice area, and getting assistance when needed. Howard added that group exercise programs were also adapted to telehealth during the pandemic, which allowed for ongoing social connection and offered particular benefits for those at risk of social isolation or physical deconditioning.
Howard expressed her view that telehealth has proved immensely valuable for physical and rehabilitative medicine, with pandemic-related changes bringing a variety of new resources, models, and training (Laskowski et al., 2020; Verduzco-Gutierrez et al., 2020). She pointed to a need for improved devices that provide objective data to augment clinical evaluation; more research on specific issues, such as lumbar assessments; and policies that address the medical, legal, administrative, and technological barriers to care.
THE DOCTOR WILL “SEE” YOU: VISUAL ASSESSMENT VIA TELEHEALTH
Melissa Ko, Indiana University
Melissa Ko, professor of neurology and ophthalmology at the Indiana University School of Medicine, discussed telehealth use in ophthalmology. Telehealth has been rare in ophthalmology, both before and during the COVID-19 pandemic (Lai et al., 2020). Ko said despite technological advancements, it is still very difficult to assess the eye’s inner workings for purposes such as medical diagnostics and disability assessments using telehealth modalities. Teleconferencing software does not have a high enough frames-per-second rate to detect subtle eye movements, though high-quality lighting and cameras can detect some slower eye movements. She noted that for some aspects of the visual exam, digital visual testing apps can help bridge gaps, but very few of these apps have been clinically validated, and most are neither easy for patients to self-administer nor suitable for assessing visual acuity, visual field, or eye motility (Mena-Guevara et al., 2021; Prea et al., 2018; Steren et al., 2021).
Ko explained that greater adoption of telehealth approaches in ophthalmology will require validated, easy-to-use, and affordable at-home visual testing apps for patients. She added that protocol revisions would also be needed to accommodate the use of validated technologies in disability evaluations requested by the Social Security Administration (SSA). Looking toward the future, Ko said that virtual reality goggles and AI approaches hold promise for applications in visual field testing and diagnostics for glaucoma, papilledema, and atypical optic neuritis subtypes (Milea, 2020; Razeghinejad et al., 2021). She highlighted that while further research and development is needed, continued innovation and adoption of such technologies could increase patient access to needed ophthalmological care.
THE USE OF TELEPRACTICE TO ASSESS ADULT SPEECH, LANGUAGE, AND SWALLOWING DISORDERS
Ellen Cohn, University of Pittsburgh
Ellen Cohn, a certified speech-language pathologist and fellow of the American Speech-Language-Hearing Association, gave an overview of telepractice in the context of speech-language pathology. She explained that speech-language pathologists examine every aspect of speech, including hearing, cognition, communication, and swallowing. Practitioners focus on functional patient goals that encompass prevention, diagnosis, habilitation, rehabilitation, and enhancement, and they work collaboratively with other health professionals such as audiologists.
Cohn said speech-language pathologists use synchronous and asynchronous methods for in-person, remote, or hybrid telepractice visits. She noted telepractice is the preferred term in the field, signaling the fact that this work often takes place in nonmedical settings such as schools. However, she also indicated that this preference can be problematic when collaborating with other disciplines or advocating for reimbursements. The field’s telepractice strategies are influenced by environmental factors including insurance companies, state and federal licensing requirements, and professional societies.
Cohn noted that like other specialties, the COVID-19 pandemic significantly advanced telepractice in speech-language pathology. There is growing evidence that these methods have equivalent or superior results, save time and money, and are applicable to most speech-language pathology subfields (Carotenuto et al., 2021; Reverberi et al., 2021; Weidner and Lowman, 2020). Cohn speculated that technological innovation and changes in state licensure requirements will further advance telepractice in the field. However, she noted that technology often moves faster than policy, payers, and consumer trust. Looking ahead, she said that adequate funding, sustainable faculty positions,
and interdisciplinary research institutes will be needed to support randomized clinical trials, multicenter studies, consumer-driven research, and evidence-based translational research in order to advance practices, standards, and professional guidelines.
TELEAUDIOLOGY EVALUATIONS AT THE VETERANS HEALTH ADMINISTRATION
Chad Gladden, Veterans Health Administration Audiology and Speech Pathology National Program Office
Chad Gladden, audiology telehealth coordinator for the Veterans Health Administration Audiology and Speech Pathology National Program Office, discussed telehealth and teleaudiology in the Veterans Affairs (VA) health system. Gladden said that VA has been a leader in telehealth, breaking down barriers to bring enhanced accessibility, capacity, and quality to veterans, families, and caregivers. In these efforts, accessibility means that care is delivered conveniently; capacity means VA will match clinical supply to patient demands; and quality means providing the right care, at the right time, in the right place.
Gladden explained that VA telehealth modalities encompass synchronous and asynchronous visits as well as remote patient monitoring. He said the 2018 Anywhere-to-Anywhere legislation greatly expanded the reach of VA’s VideoConnect platform, a free, mobile, Health Insurance Portability and Accountability Act (HIPAA)-compliant system used for many services, including mental health and rehabilitation. He said the VA system saw more than 100,000 teleaudiology interactions in 2020, including synchronous video-based visits for diagnostics, fittings, and follow-ups; asynchronous tablet-based hearing tests; online rehabilitation and tinnitus education; and remote programming and fine-tuning of hearing aids and cochlear implants.
Gladden described an example of the tools used: specialized workstations for synchronous patient interactions that are equipped with multiple cameras for full diagnostic evaluations within permissible noise standards. All data integrate into a patient’s EHR. He said several other service delivery models and tools, such as an asynchronous hub-and-spokes model and self-administered audiograms, are being pilot tested to further improve services. The Booth-less Audiometry Networking Group, a collaboration between VA and the U.S. Department of Defense (DoD), gathers information from audiologists, researchers, and industry to increase awareness, capabilities, and access to telehealth services and diagnostic tools. Gladden noted that DoD, the Federal Bureau of Prisons, and others have also been using teleaudiology technology. He indicated that VA has a strong working relationship with industry partners
to help translate tools to other settings and increase their adoption outside the VA system.
Saleem Chowdhry, Cleveland Clinic
Saleem Chowdhry, a gastroenterologist and telemedicine lead for the Digestive Disease and Surgery Institute at Cleveland Clinic, discussed telehealth approaches to gastrointestinal (GI) disorders. Chowdhry noted that GI diagnoses, such as chronic liver disease and inflammatory bowel disease, make up a very small proportion of the SSA disability claims overall, but they can lead to a range of debilitating effects and require treatments such as surgery, blood transfusions, and liver transplantation.
Chowdhry explained that endoscopies play a major role in the diagnosis of many GI disorders and cannot be performed remotely. However, some follow-up and continuing care services can be delivered through various telehealth modalities. Chowdhry said before the COVID-19 pandemic, few Cleveland Clinic gastroenterologists offered telehealth visits, and typically only for patients who were out of the state or out of the country. Many diagnostic endoscopies were postponed when in-person care was sharply reduced in response to the pandemic. Chowdhry said after a few weeks, patients with chronic conditions began to experience suboptimal care as a result of the restrictions on clinic visits. However, within a few months, the clinic was able to transition more than half of its visits to telehealth. He noted that proportion has decreased, but it has stabilized at a larger portion of visits than prepandemic levels over the past 2 years. He said the GI group at Cleveland Clinic currently offers a hybrid model of in-person endoscopies and telehealth follow-ups or new patient visits, supporting patients with technology training as needed.
Patient feedback on GI telehealth interactions has been positive overall, Chowdhry said. Patients especially appreciate being able to access experts in particular GI subspecialties, such as inflammatory bowel disease, bariatric medicine, or nutrition. He noted that common drawbacks include unfamiliarity with the technology required, especially among older users; limited Internet access; and the fact that most diagnoses rely on blood work or endoscopies, which still require a hospital visit. Chowdhry said as technologies improve, it will be important to continue to fund and support telehealth options to give patients with GI conditions a seamless, affordable, and accessible hybrid model for improved care.
PHYSICAL THERAPY EVALUATION THROUGH THE TELEHEALTH PLATFORM
Betsy Cyr, University of New England
Betsy Cyr is a professor at the University of New England, a board-certified clinical specialist in pediatric physical therapy, and a founding member of the Academy of Pediatric Physical Therapy’s Telehealth Committee. She discussed research and best practices for physical therapy (PT) via telehealth.
Cyr noted that prior to the pandemic, telehealth comprised less than 2 percent of PT consultations (APTA, 2020), but, as in other areas of health care, that percentage rose quickly during the pandemic. Many organizations provided practice-based telehealth guidelines, education, and toolkits that smoothed the transition.
Cyr outlined seven core competencies for quality PT telehealth care: compliance, privacy, safety, technology skills, telehealth delivery skills, assessment and diagnosis, and care planning and management (see Figure 4-1) (Davies et al.,
2021). She explained that in practice this framework means that telehealth visits encompass a diverse array of activities including not only care delivery activities but also safety assessments and cognitive screenings, technology training, guidance on effective lighting and video angles, and more. Clear instructions are critical to success, Cyr said, adding that it is also important to be aware of limitations and change course if a safe and effective setup cannot be achieved.
Cyr explained that research conducted prior to the pandemic offers strong evidence that validated telehealth modalities can support accurate diagnoses with close agreement with in-person assessments and reliability across impairments (with some exceptions for lower back pain) (Boonzaaijer et al., 2017; Cottrell et al., 2018; Peterson et al., 2019). She noted recent research has also demonstrated that telehealth for PT is feasible and convenient for patients and therapists for functional assessments, developmental assessments, and musculoskeletal assessments across age and patient groups (Kronberg et al., 2021; Maitre et al., 2021; Tanner et al., 2021; Wilroy et al., 2021). Cyr said further research is needed to validate more outcome measures, use telehealth more broadly, and incorporate telehealth more fully in clinician training.
Cyr posited that telehealth visits generate enough data for International Classification of Functioning assessments. She emphasized evidence-based best practices should reflect the best available research along with clinical expertise, clinician and patient training, technology testing and usability, administrative support, effective resource allocation, and patient choice. She noted it is important to consider the goal of the evaluation and potential outcomes, especially when working with patients with disabilities, who may require assistive technologies. She noted that providers should also consider concerns related to cultural, familial, or privacy needs.
Joseph C. English III, University of Pittsburgh
Joseph English, professor of dermatology and director of teledermatology at the University of Pittsburgh, discussed telehealth practice and research in the field of dermatology. He explained that teledermatology encompasses a wide range of applications, including physician-to-physician and physician-to-patient interactions; outpatient and inpatient settings; and synchronous, asynchronous, and hybrid approaches. Asynchronous methods, widely used before the pandemic, can be used to store and forward high-resolution images (standard with most smartphone cameras). He highlighted the benefits of
asynchronous methods, including decreased time constraints and low cost. He noted the use of both asynchronous and synchronous modalities increased dramatically during the pandemic. The American Telemedicine Association and the American Academy of Dermatology have developed teledermatology guidelines that address state licensing requirements, security, safety, malpractice insurance, and HIPAA compliance (McCoy et al., 2016).
English said that evidence-based telehealth approaches can be effective for triaging and diagnosing patients, improve care access and reduce costs and wait times for patients, and aid SSA-requested examination of a wide range of skin disorders (SSA, n.d.). He explained that while quality can vary depending on the clinician, the methods used, and the particular health condition involved, teledermatology has been shown to be on par with in-person care delivery in many cases, achieving interobserver agreement between virtual and in-person dermatologists of up to 90 percent (Lee and English, 2018; Resneck et al., 2016). English noted that video quality during synchronous virtual appointments must be quite high in order to diagnose and recommend treatment options, and success often depends on the skin condition involved (Kazi et al., 2021). He suggested that in the future, artificial intelligence (AI) approaches may help to further improve teledermatology interactions for improved accuracy (Majidian et al., 2022).
In a moderated discussion, participants expanded on particular telehealth considerations and limitations along with clinician experience and oversight needs.
Devices and Technology for Telehealth
Georgia Malandraki, Purdue University, asked how peripheral devices were purchased for home assessments or treatments. Cohn answered that because of the quick pivot to telehealth during the pandemic, many clinicians ended up using their own money to purchase the needed equipment. Howard noted that VA has a specific program to address patients’ device needs, while many private patients had to self-finance such purchases, which can be very expensive and of varying quality.
Gladden said that VA conducts a national vetting process for audiology equipment before committing to a new technology. Busis added that the U.S. Food and Drug Administration must approve new technology, but there is a backlog for new and potentially useful devices for neurology.
Cheryl Hann, SSA, asked if there was a consistent model to measure mobility and range of motion via telehealth. Howard answered that gait assessments are more qualitative than quantitative. Cyr added that there is no consistent model for PT, but some platforms include validated measurement methods, and there are also wearable devices that provide valid, reliable assessments.
Dorsey added that for certain teleneurology applications, such as stroke care, it is helpful to have a nurse or trained assistant present with the patient. He reiterated that patient history is a very important diagnostic factor, especially for virtual visits where testing reflexes or capturing lower extremities on camera is difficult. Busis agreed, noting that it is important that clinicians recognize when in-person assessment or onsite assistance is needed.
Experience and Oversight Needs
Busis noted that while one may assume that younger clinicians would be more adept with telehealth technology, it is actually those who have more experience performing in-person diagnoses and assessments who tend to adapt more easily to using telehealth. Dorsey added that skills and bedside manner are critical:
If you are not a good clinician, telemedicine is not going to help you become a better one; if you do not have a good bedside manner, that is going to get worse with telemedicine.
English added that experience is very important in teledermatology, where practitioners learn from hours of image analysis.
Denise Lopez-Majano, a caregiver advocate, asked about quality evaluation and oversight for telehealth platforms. Cyr replied that many of the platforms were created before the pandemic and tailored to different HIPAA and documentation standards than those that emerged during the pandemic. Cyr said she is not aware of any specific oversight requirements, though she noted that the companies that develop telehealth platforms are open to feedback.