The virtual care program built by The Ohio State University Wexner Medical Center allows for expanded access to patient care in rural areas, improved decision-making, and hands-on experience for young neurologists.
The application of telemedicine to remotely connect patients with their providers dates back decades; however, the exponential growth in its use has come in recent years, mainly because of the COVID-19 pandemic. With the advances in technology, the ideas that once seemed impossible have become a reality, with access to provider care reaching new heights.
The need for an effective and sustainable teleneurology program becomes even more critical because of the landscape of some parts of the US Midwest. Recently, The Ohio State University Wexner Medical Center implemented a telehealth program focused on neurology care that aims to improve patient outcomes at rural locations across the state, becoming one of the few health systems in Ohio to do so.
The focus is specifically on inpatient care, and the program is in conjunction with its telestroke counterpart, which is a well-established coalition of 29 sites across the state. Alicia Zha, MD, one of the neurologists responsible for the growth of the program, believes inpatient care is an identified need. "We’ve noticed a pattern where sites will ask us, ‘Can we provide neurology coverage,’ or at certain times saying, ‘Look, we don’t have the neurology capabilities, we need to transfer patients over.’ Over the years, we’ve gotten very good at identifying which patients could probably not need to transfer over and which absolutely need to transfer," Zha told NeurologyLive®.
She added, "Right now, our reach is to hit strategic telestroke partners where we know they have demonstrated a pattern of excellence with their stroke patients. We know that other neurology patients can stay locally as a result of that."
The furthest site the teleneurology program reaches is on the border of Indiana, in Coldwater, Ohio, about 100 miles away from the Wexner Medical Center in Columbus, Ohio. Above all, the system is a testament to the change in medicine and the want to expedite access to care and decrease time spent in the hospital. These types of programs have been shown to be effective across the country. One 2021 study from McCormick et al looking at medical records (n = 899) from 3 community hospitals showed that the median length of stay and time from consult order to consult completion decreased by 28% (P <.0001) and 74% (P <.0001), respectively, after teleneurology implementation.1
"We are focused on quality care, and we do not want to unnecessarily transfer a patient just to do so," Craig McMillen, neurology department administrator at the center, told NeurologyLive®. "When the patient at our partner hospital isn’t transferred because they are receiving the appropriate care, it opens up a bed on our inpatient unit here on main campus, and that creates a trickle-down effect. Somebody from the emergency room that’s been waiting for a while to get to a bed gets transferred into our inpatient unit due to the teleneurology services we are providing."
After completing medical school, internship, and her residency at Ohio State, Zha moved on to the University of Texas at Houston Health Science Center for her fellowship. She remained there as part of an extensive Teleneurology program that saw thousands of patients a year throughout Texas. Upon completion, she headed back to Ohio State to create a similar program for Ohio.
"I think the patients know when something’s done well or not,” she said. "So far, the feedback is overwhelmingly positive because we have that experience and we’re bringing it to them now. It’s not this haphazard switch."
Throughout the pandemic, effective teleneurology programs have been a tool to increase patient visit compliance and ultimately improve long-term outcomes. Another 2021 study from Moghaddam and colleagues compared the data between the pre-COVID-19 period (January 2019 to February 2020) to the active COVID-19 period (March 2020 to August 2020) and showed a 260% increase in virtual visits per month during the active period. Additionally, the number of no-show teleneurology visits decreased from 1.18% per month pre-COVID to 0.57% during active-COVID (P = .018).2
Similar to many institutions, the primary technology used at Ohio State Wexner Medical Center is Teladoc Health. This virtual program connects patients to the medical care they need, while providing guidance on next steps. Zha claims the cameras and functionality are 2 of the greatest advantages of the system for providers. Above all, the capabilities and reach of the teleneurology program have been a major benefit to the surrounding institutions, who may be limited with resources.
"It wasn’t before long we were thinking, 'How can we leverage something like Ohio State and the specialists, subspecialists available?' We don’t have [a] neurology [department], we’ve got patients that need neurology [care]. Let’s see if we can put these 2 together," said John Terpstra, DO. "I had been in contact with Ohio State just related to COVID and had been on a monthly call with some of the chief medical officers, and started talking a little bit about virtual care, and that kind of got the wheels turning from there."
Terpstra is a physician with more than 20 years of experience in emergency medicine at Mercer Health, a community connect hospital that has partnered with Ohio State Wexner Medical Center in its teleneurology services. Prior to going back in his normal role, he spent time as chief of staff to oversee the COVID-19 operations during the beginning of the pandemic. He can attest to the rural landscape of Ohio, and the need for programs like these.
"It led me to all sorts of roles less clinical in terms of emergency medicine,” he said. "It was more of an administrative role, which was very new for me. We opened up a testing station—which was pretty impressive for rural western Ohio—in a hog barn, of course, because those are everywhere. It was stuff like that. Just doing all things COVID-related to keep the hospital up to speed and do the best for the community."
As modern medicine continues to trend towards more virtual care, training becomes a key element of the success of teleneurology programs. Zha has created a curriculum for telehealth and teleneurology training at Ohio State, focusing in on the importance of educating residents and advanced practice clinicians in the best ways to administer and use teleneurology. Trainees learn how to apply their knowledge over the camera, and how to foster effective and accurate communication with patients and other medical teams involved in patient care.3
To Zha, the most important aspects of teaching are exposure and accuracy. "The first thing I tell our residents is you have to learn the neurologic exam in person first. Once you’ve mastered that, then you can talk about translating it over the camera. At that point, it’s translating the excellence you’ve already attained," she said.
Residents can also engage in a teleneurology rotation, where they are introduced to the technology, and are able to get hands-on practice through demo stations. Additionally, there are simulation models with standardized patients that help residents translate what they’re learning into real-life situations. "It gives residents more confidence when there is somebody beside them, helping guide them, helping show them,” Zha said.
The bloom of the teleneurology program has been exciting thus far, and those at Ohio State Wexner Medical Center believe there are still several areas for growth. McMillen sees the potential. “I know we have great potential for how many patients can benefit from our Teleneurology services.. It’s a balancing act," he said. "We have the right experts here to see those patients as we continue to grow as a program and we have a vision in mind to at least double the amount of sites that we have now within a 2-year timespan. However, you don’t want to expand too fast and not learn lessons through the first phase of teleneurology sites."
With the virtual nature of up-and-coming teleneurology programs, the ability to capture large-scale data and make patient decisions from afar has become easier; however, some of the capabilities are not equal. “Every hospital has quality metrics. Telestroke has quality metrics. We should also have quality metrics as teleneurology providers. When we don’t measure or we don’t know what we’re measuring, we have a tendency to fall into patterns that we don’t know are good or not," Zha said.
In addition to the advances in technology, the strides made in research to detect early changes of patients who may be more at risk for late stage neurodegenerative, cognitive disorders, has benefitted the center as well. Currently, there is a team of cognitive experts at Ohio State Wexner Medical Center who are working with local providers to help identify patients who may be appropriate for screening and bring them in for an early evaluation.
"For us, we talk about how there’s certain things like institutions in the community that are so important. Sometimes it’s schools, sometimes its churches. But a lot of times its hospitals,” Zha said. "What we’re trying to do is support a community organization and base it out of the hospital, so that the people locally feel like we are buying into them, and that they are buying into their own neurologic health."