The clinical professor in pediatric neurology and director of regional neurology services at Children's Hospital Colorado shared her thoughts on why epilepsy is the perfect paradigm to implement telemedicine.
Charuta Joshi, MBBS
As technology has continued to advance the abilities of those practicing medicine, the time to grasp the opportunities it can offer comes closer and closer. One of these avenues opened by technological progress has been the advent of telemedicine.
Although telemedicine has, in the eyes of some, been long-viewed as a method utilized only for those unable to come to the physician's office, such as with patients in extremely rural areas, recent data has suggested otherwise—with almost half of the millennial generation noting that they would welcome insurers to cover telemedicine. Additionally, more than 200,000 patients in the United States utilized the method in 2013, with that number growing exponentially since.
Charuta Joshi, MBBS, a clinical professor in pediatric neurology and the director of regional neurology services at the Children's Hospital Colorado and the University of Colorado-Denver, has been an advocate and practitioner of the craft since the early millennia. As such, she spoke with NeurologyLive in an interview at the Child Neurology Society's 2018 annual meeting to discuss her experience with telemedicine, as well as to provide insight into how it can impact patients with epilepsy.
Charuta Joshi, MD: I think the first thing I realized at the conference is that there is more interest in telemedicine than I had realized. I’ve been doing telemedicine since 2001 and I thought this was old news, but it is actually happening news right now in the United States.
The other thing to consider is that there are multiple centers across the states that want to implement it and people have some real questions about how to implement it and what is needed, and sometimes even some misconceptions about it.
The thing to know is that in a survey 40% of millennials would want telemedicine to be covered by their insurance or would want telemedicine as an option for them. The second thing to know is that 250,000 Americans were using telemedicine in 2013 and by 2018 that number will have crossed 3 million. This is really an exponential increase and we, as physicians, need to be aware of it and need to understand that we need to bring medicine to patients instead of traditionally, where the patients keep coming back to us.
I talked about epilepsy being a paradigm in the implementation of telemedicine in general, because the majority of what I do is medically intractable epilepsy. There are only a handful of patients that actually have the glamorous epilepsy surgery outcome, they are definitely there, but medical intractability is the majority of what I see, and these patients need chronic repetitive care, and so telemedicine becomes really an important platform to get it to them.
CJ: Let’s assume I’m taking 45 minutes to see a patient in my in-person clinic, I feel that 35 minutes are in respect to gathering the history, counseling, choosing the correct drug, and maybe 5—7 minutes are spent really examining that patient. In attendance in an epilepsy patient, saltation of the liver does not change my management, even if somebody’s liver might be large, or testing a patient’s reflex using a reflex hammer which I might do at an in-person clinic, doesn’t change my management.
Therefore, epilepsy is the perfect paradigm of disorder, because its chronic, which can sometimes be acute and life-threatening, which is complex because people want care immediately. I’m able to say that I can make myself accessible across the barrier of time and geography using telemedicine, and therefore epilepsy is the perfect paradigm I feel in implementing telemedicine.
CJ: It is important to know that if I’m going to practice medicine then my license has to be in the state or the geographic location of the patient. If I live in Colorado and have a license in Colorado but I want to see a patient in Utah then I need to have a license in Utah, if the patient is situated in Utah—and some people don’t realize that. Now if I’m doing an educational conference then it doesn’t matter, but if it’s going to be a live audio-visual consultation then it has to be where the patient is.
The other question people frequently have is about payer and who will pay. It’s important to know that there is something called the Telemedicine Parity Act, parity means equality, and it means that the patient will be seen the same way as an in-person visit, which also means that the payment will be the same had it been an in-person visit, but it’s really state dependent. The state decides whether Medicaid or Medicare patients for that state get the parity or not and so it’s important to check with your state and it’s very easily found on the American Telemedicine Association (ATA) guidelines website.
CJ: I think from my perspective in terms of research it’s a very murky area because there’s no precedent and so I don’t know if I could do a blinded study using telemedicine, because once I use telemedicine its pretty obvious. Sometimes it’s also difficult within our individual hospital reach to say I’ve seen a million patients and I’ve only seen a tumor one time. I will not be able to see a million patients, so I think it’s critical to do monthly center research in terms of outcome. I have been involved in telemedicine research since early 2010/2011 and we all know patients love it, it is economical, they’re almost always satisfied, the no-show rate is almost non-existent, and so both things have already been done.
Now the question is in terms of cost utilization, the cost you put into the infrastructure, is it really paid back? You wouldn’t know that unless you have a high volume of patients and that’s yet to be seen.
CJ: I think to know that typically the barriers are mostly personal and personnel. Start with one cell and if you feel you are able to care for a patient that might have a neurological illness comfortably with telemedicine then it is something you need to be doing now. I would say that it is possible to do it very safely and in no way different than in-person. I think mostly the barriers are personal, if I can’t convince myself that it is not second-rate medicine, it is indeed second-rate medicine, it is the same quality of care as in-person visit and it is just as important to realize that.