By Marcello Cherchi, MD PhD
Introduction
Although “telemedicine” and “telehealth” may strike some people as new words for new concepts, the idea of providing medical care over a distance is hardly novel. Every time a clinician speaks with a patient by telephone, telemedicine is happening.
Background
Some aspects of remote provision of healthcare are relatively new, or at least the public is more aware of them. The features that tend to catch people’s attention include:
- The ability to have an interaction by video for medical purposes. In the United States this was very seldom used prior to the COVID‑19 pandemic.
- The ability to perform certain procedures remotely. In this regard, the media seems to enjoy covering high-stakes, high-tech endeavors such as remote robotic surgery.
Since the COVID‑19 pandemic accelerated the adoption of telemedicine practice, it is reasonable to wonder what took it so long. In the United States there had been at least three significant barriers.
- Privacy concerns, which became paramount since the passage of the Health Insurance Portability and Accountability Act (HIPAA) in 1996.
- Medical licensure, which varies state-by-state and has little reciprocity. From the perspective of the law and of insurance companies, medicine is practiced wherever the patient is. When an out-of-state patient would come into the state where a physician was practicing for an evaluation, this was straightforward. But when a patient from out-of-state remains in their home state, a physician who takes a history by video, or “performs” a video-assisted procedure, would be practicing medicine in the patient’s state — where the physician probably does not hold a medical license.
- Reimbursement issues. Prior to the COVID‑19 pandemic, public and commercial insurers would rarely reimburse for medical care that was not provided at a face-to-face encounter.
The COVID‑19 pandemic obliged regulatory authorities to relax some HIPAA restrictions and relax restrictions on practicing medicine across state lines, and it obliged insurers to cover some types of telehealth encounters. When the COVID‑19 pandemic began to fade, insurers began to restrict reimbursements again, but the public’s appetite — indeed, expectation — for telehealth, had irreversibly shifted. Patients demanded remote healthcare because it was more convenient, and entire industries emerged to serve as intermediaries providing support for (and profiting from) this newly prevalent kind of remote doctor-patient relationship.
Telehealth is a tool
If one sets aside the many non-medical factors (political, legal, regulatory, financial, bureaucratic) that unduly influence the practice of medicine in the United States, probably the most crucial point about telemedicine is that made by Dr. Eric R. Anderson (Anderson 2015a, b; Anderson et al. 2013; Govindarajan et al. 2017; Hatcher-Martin et al. 2020; Hatcher-Martin et al. 2021; Murphey and Anderson 2022), who has often emphasized that telemedicine is just a tool, and like any other tool, there are some tasks for which telemedicine is appropriate, and other tasks for which it is inappropriate. To make this point, Dr. Anderson sometimes states at his lectures, “If I gave you a stethoscope and said, ‘Please use this stethoscope to figure out if my arm is broken,’ you would say that the stethoscope is the wrong tool for that task.”
There are probably many medical purposes — perhaps many that are yet undiscovered — for which telemedical delivery of care is appropriate, and there are surely other purposes in which telehealth should play no role. It is also possible that the judgment of “appropriateness” for telehealth will change over time as technology evolves.
There are likely going to be some “gray areas” as well, some of which depend on attitudinal shifts. A good example might be telehealth evaluation of brain death (Girkar et al. 2020). The idea of withdrawing medical care from a brain-dead individual is already very difficult for a family to absorb. Letting the medical assessment of brain death take place remotely is a step that many families will not accept, even though there is good medical evidence that this can be done properly.
Telehealth for general neurology
Telehealth has become a fairly mature care modality in some areas of general neurology, as well as some specialties, particularly acute stroke care.
There have been substantial discussions regarding the feasibility and implementation of telehealth for general neurology (Agarwal and Warburton 2011; Anderson et al. 2013; Boes et al. 2021; Craig et al. 2000; Dorsey et al. 2018; Larner 2011; Patterson 2005; Roy et al. 2020; Rubin et al. 2013; Tarolli et al. 2021; Tsao and Demaerschalk 2015; Wechsler 2015) and the feasibility of conducting a general neurological examination (Al Hussona et al. 2020; Awadallah et al. 2018; Boes et al. 2021; Craig et al. 1999). Reviews of this evolving literature have led to the development of guidelines and position statements (Bagot et al. 2018; Hatcher-Martin et al. 2020; Hatcher-Martin et al. 2021; Wechsler et al. 2013).
Telehealth for otoneurology
The idea of tele-otoneurology is not new. Wolf and colleagues (Wolf et al. 1991; Wolf et al. 1995) proposed the idea of tele-electronystagmography in the early 1990’s. Viirre suggested video-mediated diagnosis and vestibular rehabilitation therapy (Viirre 1996). Viirre and colleagues (Viirre et al. 1997) even presciently proposed tele-videonystagmography, complete with two-way video capabilities, as shown in the Figure below.
Interest in tele-neurotology was further spurred by the Hurricane Katrina catastrophe in Louisiana in 2005. In the wake of this natural disaster, both “real-time” and “store-and-forward” tele-neurotology modalities were employed, and proved serviceable. Circumstances forced this “proof-of-concept” experiment and brought this type of telehealth evaluation out of the realm of theoretical feasibility, into actual practice.
Telemedicine is potentially very appropriate in the field of otoneurology for two main reasons:
- There are few practitioners. Otoneurology expertise is not widely available.
- Some of the diagnostic “tools” can be easily mediated by video. For a substantial proportion of otoneurological conditions, the diagnosis relies heavily on observation of digitized video of eye movements, which can be sent as easily as any other video material.
Some lines of research explored whether smartphone capabilities can be leveraged for remote examination. For example:
- Some investigators have tried to leverage the video capabilities of ubiquitous smartphones in the emergency room (Shah et al. 2019) or at home (Barreto et al. 2021a; Barreto et al. 2021b; Green et al. 2021; Kiroglu and Dagkiran 2020; Young et al. 2019b).
- There has been an attempt to use the video capability of a smartphone to evaluate head impulse testing (Parker et al. 2021).
- Some investigators have leveraged the gyroscope capabilities of smartphones (Dijkstra et al. 2010a; Dijkstra et al. 2010b; Fortune et al. 2014a; Fortune et al. 2015; Fortune et al. 2014b; Galan-Mercant and Cuesta-Vargas 2014; Gefen et al. 2015; Lemoyne et al. 2010a, b; Lugade et al. 2014; Manohar et al. 2011; Mizuike et al. 2009; Parker et al. 2022; Schindler 2015; Sun et al. 2014; Umek and Kos 2016).
Some investigators have cobbled together existing technologies, such as the combination of videoconferencing and video head impulse testing (Gold et al. 2019; Muller-Barna et al. 2019; von Martial et al. 2021; Zee et al. 2020).
Other investigators have developed new technologies. For example:
- Some investigators have focused on technological aspect of tele-otoneurology by developing specific devices (Kong et al. 2018; Young et al. 2019a).
- Some investigators have focused on developing software algorithms to generate tracings of eye movements captured on a smartphone (Friedrich et al. 2022).
A consensus statement has been issued regarding telehealth evaluation of patients with disequilibrium (Shaikh et al. 2021).
Regarding treatment, several teams have shown that once benign paroxysmal positional vertigo is properly diagnosed, it is possible and effective to train patients remotely in the execution of canalith repositioning maneuvers (Kim et al. 2023; Tahtis et al. 2021).
Regarding audiologic and otologic evaluations:
- Some steps have also been made in mobile audiometry (Kohlert and Bromwich 2017) and remote audiology evaluation and treatment (Beukes et al. 2018).
- One paper has cleverly suggested using smartphone’s vibration function as a substitute for tuning fork tests (Yang et al. 2021).
- There is preliminary literature regarding remote video otoscopy (Biagio et al. 2013; Don et al. 2021; Ezzibdeh et al. 2022; Moshtaghi et al. 2017; Patricoski et al. 2003; Shah et al. 2018).
Finally, there is an emerging literature regarding the application of telehealth in the related discipline of neuro-ophthalmology (Conway et al. 2021; Ko and Busis 2020; Lai and Ko 2023; Lai et al. 2020; Liu et al. 2021; Moss et al. 2023; Ramakrishnan and Gilbert 2021).
All of these steps are promising, but it is probably fair to characterize tele-otoneurology as a nascent field.
It may be that smartphone technology will prove sufficient for diagnosing and managing benign paroxysmal positional vertigo, which would be fortunate since the condition is so common and eminently treatable.
However, for many otoneurological conditions, most practitioners would probably be hesitant to try to secure a diagnosis without infrared video oculography, and this will require technology beyond what smartphones offer. This problem may need to be addressed by having satellite facilities with trained examiners who forward infrared oculography videos to a central examiner — in other words, the hub-and-spoke model that has proven successful in stroke care. For non-urgent conditions this could be processed by a store-and-forward approach. Acute care (such as for vestibular neuritis) would more likely be managed by real-time remote video examination. The technology for these things already exists; the logistical hurdle will be the implementation.
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