Dr. Geppert. I have the pleasure of interviewing Dr. Larry Davis, Distinguished Professor of Neurology at the University of New Mexico School of Medicine in Albuquerque and chief of the NMVAHCS Neurology Service. Welcome, Dr. Davis. Can you describe a teleneurology visit?
Dr. Davis. The NMVAHCS is the only VA located in a large rural state. Location is a real challenge because we treat a lot of veterans who live rurally, and they often have to travel 5 to 6 hours to Albuquerque. When the VA set up its telehealth systems, it was obvious to the NMVAHCS Neurology Service that this was a gold mine. We have many patients who are unable to drive because of their neurologic condition, and they need a caregiver—sometimes a spouse—to drive them to NMVAHCS to see a neurologist, usually in an outpatient setting, often for 30 to 45 minutes, and then drive back 5 hours.
When I get a consult from a rural CBOC, I invite the patient to come to NMVAHCS for the first visit. First, I examine the patient face-to-face so the patient can get to know me. Second, I order special tests or imaging, which are not available in rural areas. Sometimes, for complicated cases, the patient stays overnight.
We discuss the diagnosis with the patient, and make the decision whether the patient is a good candidate for telehealth. If the patient consents and wants to be seen at a local community VA center, we set it up. On a given day, the patient travels—often 15, 20 minutes at most—to the VA facility and goes into a modified examination room. The patient sits in front of a TV screen with a camera focused on him or her. The patient can see me on the screen. In my office I have 2 screens, one has the patient record; the other allows me to see the patient.
Over the years, I have discovered that once I know the patient, it’s just like talking across the table. I can get a history of what has changed either with medications or chronic illness since the last follow-up.
Dr. Geppert. What are the issues and challenges in treating patients with epilepsy, multiple sclerosis, and other neurologic conditions?
Dr. Davis. We have the most difficultly with sensory examinations. I can perform a good motor examination via telehealth, but it is more difficult if I need to look carefully at the patient’s reflexes. We follow individuals with headaches, seizures, multiple sclerosis, Parkinson disease, and a variety of other illnesses. There are not too many we cannot follow that way. If patients have questions, I can look at their medical record and laboratory data while they are on the screen.
The caregiver or spouse can sit next to the patient, so they can be part of the conversation. If the patient is having trouble describing what is going on, the caregiver can offer comments.
Dr. Geppert. If I’m the patient and I’ve had a previous stroke and it looks as though I might have had another, wouldn’t you like to do a neurologic exam but can’t via telehealth?
Dr. Davis. That’s a very good point. When I talk to a patient and I don’t like what I see, I have the ability to ask the patient to come to NMVAHCS. I had one patient who suddenly started getting chest pains during the exam, so we called the CBOC primary care doctor to immediately move the patient to the local hospital. I had another patient who started talking about suicide. I kept the patient on the phone, but we got the primary care doctor in the room. We do have backup.
Dr. Geppert. You mentioned that you often involve family and that you work with local CBOC registered nurses (RNs). Can you tell us how you extend the reach of teleneurology through self-care and family education?
Dr. Davis. We have 2 qualified RN patient educators. One is an expert in Parkinson disease; the other follows up with the patient who has had a stroke, to reduce risk factors for a second stroke.
When I see a patient for a limited time, I deal with the drugs and things like that. I am less focused on what type of chair the patient should sit on, whether the patient might fall, how to safely get up, etc. So I set up a separate appointment with the nurse educator, who goes through all the day-to-day activities that the patient has to be able to do. Patients with Parkinson disease do not like to sit on low sofas, for example. What are the tricks for constipation? If a patient falls, how do you safely get up? The nurse will have the patient get down right in front of the camera and walk them through how to get up.
Dr. Geppert. I know that in many rural areas, especially in our state, there are real shortages of neurologists and psychiatrists. Can you talk about how this helps multiply your ability to care for patients?
Dr. Davis. With the exception of 3 different communities, there are no neurologists within 50 to 100 miles.
Dr. Geppert. Or neuropsychiatrists.
Dr. Davis. Or neuropsychiatrists or even a psychiatry office. So patients are very limited. We have an extremely loyal population of VA patients because it isn’t easy to say, “I’m just going to go down the street and get another doc.”
Dr. Geppert. What type of feedback do you get from patients and family about doing this virtually?
Dr. Davis. We sent a carefully worded satisfaction survey and received 700 responses. We found the following responses: 90% agreed that they received good care during their visit. Ninety-one percent reported that they were able to communicate and 87% would continue their care via teleneurology. Was the teleneurology more convenient than driving here? Yes, 90% said that it was. And did they have overall satisfaction with the visit? Literally 90% reported that they did. It’s a very high satisfaction rate.
We know that patients will say, “Oh, you can see me every 3 months, but I want to come down to see you face-to-face from time-to-time.” When I ask why, the most common answers are either “I live so rurally, there are no stores.” Or “I have family, and I want to come down.” So we then try to set up that face-to-face visit on a Friday.
If they’re traveling, they get their travel pay, but then they get to spend the weekend with a friend or family. There are often secondary reasons. Occasionally, they have to come back for another specialist; we make great efforts to put both those visits on the same day so they don’t have to go back and forth.
Dr. Geppert. So Dr. Davis, you’re a world-famous neurologist, but do you have to have special training or expertise to do teleneurology?
Dr. Davis. It helps to be a good clinician; I’ve been doing this for many years. Because we see patients on a sequence by television, I have to keep track of the time, whereas in the face-to-face clinic if something is really going wrong, I have the ability to shift things around right away and spend more time with that patient. I try to set up longer times for telehealth. I work with a clinical nurse practitioner colleague who takes care of headache patients, and she has a shorter time between visits. I never quite know what’s going to happen, and I want to leave a lot of time for the patient or the spouse to ask questions.
Dr. Geppert. We are both, certainly, senior clinicians and technology is a little different and new. Did you have problems learning to use the teleneurology?
Dr. Davis. Believe it or not, no. The television system is very similar to Skype. It is called Jabber and is encrypted, so it’s safe to transmit. You have to feel comfortable talking to somebody on a TV screen. And the first time I did it, I felt a little awkward. Within a day or two, I was fine.
Dr. Geppert. Federal Practitioner readers may want to start teleneurology or get more involved in it. Are you in touch with other VA and DoD providers?
Dr. Davis. Practitioners can contact me if they want to talk about how we do patient education. We’ve also spent a fair amount of effort developing a handbook that we send out on the ABCs of how to do it.
Dr. Geppert. Do you involve residents in this?
Dr. Davis. No, not at this point. My goal is to do it, but ironically enough, I’m trying to get students who rotate out here to get a feel for what telehealth could be. They don’t do the exam and everything else, but they get a chance to see what telehealth can be. If they want to live in a rural state, they may be involved in it.
Dr. Geppert. If the primary care provider was seeing a patient with multiple sclerosis, which we both know can have symptom flare ups, would they be able to contact you and say, “Hey, Dr. Davis, I’m seeing so and so, and she looks like she’s having some visual problems today.”
Dr. Davis. That’s harder to do because we’re not the only ones using the telehealth system. Telemental health, dietitians, and others are using it all the time, so I have to have a scheduled time to be able to see patients. I’m surprised that more rural states aren’t using it because it really is very enjoyable.
Dr. Geppert. What has the VA learned about telehealth from this program?
Dr. Davis. We know that it actually saves NMVAHCS a lot of money because we don’t pay as much travel pay. The patients like it. The CBOC physicians like it because if I have to, I can type the note right away, and they can read it if the patient is staying there.
Author disclosures
Dr. Hixson has received a collaborative grant from UCB Inc. for research on online epilepsy resources.
Disclaimer
The opinions expressed herein do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.