Increases in patient demand can strain any neurology practice, leaving those with neurologic problems traveling within a large catchment area to find care and neurologists struggling to find space and time to provide evaluations and care. This is especially true in epilepsy care, for which a significant shortage of neurologists or epilepsy specialists limits the number of patients who can be seen.1 This burden becomes even larger globally with fewer health care resources in general and even fewer neurologists (eg, 3 neurologists within Tanzania).
The health care system is in an era of continuous change with a drive toward quality measures and evidence-based practice, while at the same time trying to meet increased patient demand and increased complexity of care. In this context, telemedicine, has been embraced by patients and providers alike across multiple medical disciplines.
Telemedicine is the practice of medicine using technology when physician and patient are not in the same location.2 The option of telemedicine enables providers to connect with patients and consultants across challenging geographic distances in a cost-effective, convenient manner.3 In the area of cerebrovascular medicine and stroke, telemedicine has been used with excellent outcomes and management strategy, greatly improving health care access, especially for acute or hyperacute stroke through the use of remote imaging, or teleradiology.
Similar interventions have been performed for persons with epilepsy to improve management, clinical care, and coordination. Individuals followed with telemedicine had a similar number of seizures, hospitalizations, and emergency room visits compared with those who received epilepsy care by physically visiting their providers in a clinic.4 Telemedicine for people with epilepsy has also been used for outpatient management, counseling regarding videoEEG evaluation, and surgery for individuals in the community including women with epilepsy who are pregnant or individuals who are incarcerated, for whom the logistics of clinic visits can be especially challenging.5
Telemedicine Clinic Visits
Successful epilepsy clinics or centers have several requirements nursing support, administrative support, credentialing, and sustainability. Developing a protocol for epilepsy care that can be individualized to each patient is important. In addition to these factors, telemedicine requires specialized technology and information technology (IT) support. Basic technologic requirements include tablet devices, computers, laptops with web cameras, smartphones, and access to internet-based services. Integration of the electronic health record (EHR) system is also considered the best method to document and record telemedicine encounters. Transfer of data (eg, seizure logs, seizure action plans, and reports from investigations across web-based services) can then be seamless and well supported. With technological advances, issue related to privacy and health information protection arisen. Internet-based services can provide data encryption, providing some support in this area.
With the addition of complex technologic service required by telemedicine, specialized staff training and knowledge to help troubleshoot as needed arises. Although telemedicine is becoming more mainstream and increasingly covered by insurance companies, restrictions on reimbursement can be an obstacle. Determining if mainstream and commonly used insurance companies will cover services is very significant for the continuation of a telemedicine program.6
A telemedicine session should approximate all key components of an on-site visit. The same attention to both processes and personal rapport building should be given in telemedicine appointments as in on-site appointments.6
Involving family members, caregivers, and other support personnel is important to obtain a good medical history and medical care plan for people with epilepsy. Many times, the person with epilepsy may not be completely aware of their symptoms, and corroboration of events that may help with differential diagnosis may be required. Having family members available and able to participate in the visit using their own devices can make a telemedicine visit more productive. This can reduce dependency for a person with epilepsy who may need significant help to arrange their care, especially for those who cannot drive, and in turn, reduce societal costs of care.
We performed a prospective pilot study using the Zoom video-conferencing application, which is a secure internet-based HIPAA-compliant software application. In this study, we used a clinic and patient preparation checklist (Checklist) before scheduling the telemedicine appointment. Patient satisfaction was measured and most patients and their caregivers indicated they would prefer telemedicine visits in the future if it were easy to do because these appointments did not require missing work or family time or other engagements and were also significantly less expensive. Most people had traveled 3 hours or more, round trip, to their neurology appointments before telemedicine was available. The average person traveled 180 miles round trip and would pay an average of $60.00 for gas and parking (Figure 1). Providers were as satisfied with the telemedicine visits. They could see a patient from their office or their home at any time they were available (Figure 2). This also allowed the providers to stay on schedule because they were not waiting for patient to be checked in and have their vital signs measured. The health system saved $28.00 per appointment by not having to check people in or take their vital signs.
Quality of Life
Managing epilepsy is dependent on controlling seizures and improving quality of life. Many people with epilepsy have neuropsychologic comorbidities that limit their independence and ability to function. People with epilepsy are also susceptible to medication-related cognitive side effects and behavioral complications, including nonepileptic seizures, which have significant negative effects on quality of life. Office visits usually address these issues with educational tools and resources developed or available at the center. In a study on the use of telemedicine to track quality of life improvement for people with epilepsy using a a mobile texting short messaging system (SMS) tool, a positive effect on quality of life was seen, although the intervention did not improve disease control or other neurocognitive assessments.7 In another study, mobile telephone-delivered messages generally generated better outcomes than tailored print materials.8 Whether the combination of both tailored interventions together could be improve efficacy remains to be studied.
Epilepsy diagnosis remains a clinical art—one that is supported by clinical studies such as EEG and videoEEG, particularly for differential diagnosis, including nonepileptic seizures, status epilepticus, and surgical evaluation. EEG and videoEEG services are available to many centers, although implementation of such a service lags behind available expertise. TeleEEG presents an opportunity for centers to collaborate in diagnosing epilepsy and managing the care of people with epilepsy in in acute or chronic settings. Use of teleEEG for for over a period of 1 year has been shown effective.9
The development of mobile health and wearable technologies has invigorated the field of seizure detection, particularly generalized tonic–clonic seizures (GTCS) with nonEEG measures.10,11 These devices have potential to be used as seizure alarms for caregiver alerts that may eventually help reduce the risk of sudden unexplained death in epilepsy (SUDEP).12 Several seizure tracking and seizure log applications are available on mobile platforms for health care providers and people with epilepsy to choose among. Some provide an interface for obtaining photos for evaluation of ictal episodes that are crucial to the differential diagnosis of epilepsy and nonepileptic seizures. These applications are still in their infancy, although many are available commercially and in use by people with epilepsy. Research remains to be done to further understand and validate possible clinical uses.
Advances in technology are driving innovations to engage people with epilepsy and their health care providers that may improve clinical care. From easing patient and caregiver burdens to alerting mechanisms that might help prevent SUDEP, telemedicine is an advance that is shaping the future of care for people with epilepsy.
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10. Beniczky S, Polster T, Kjaer TW, Hjalgrim H. Detection of generalized tonic-clonic seizures by a wireless wrist accelerometer: a prospective, multicenter study. Epilepsia. 2013;54(4):e58-61.
11. Onorati F, Regalia G, Caborni C, et al. Multicenter clinical assessment of improved wearable multimodal convulsive seizure detectors. Epilepsia. 2017;58(11):1870-1879.
12. Ryvlin P, Beniczky S. Seizure detection and mobile health devices in epilepsy: update and future developments. Epilepsia. 2018;59(S1):7-8.
MR-D and VS report no disclosures.