Building Telemedicine into the Post-COVID-19 U.S. Health Care Delivery System
Stephanie J. Zawada, M.S.
Affiliations: Mayo Clinic School of Medicine and Science, Yale University Sherwin B. Nuland Institute, American Medical Students Association
During the COVID-19 public health emergency, interest in telehealth soared to an all-time high. Specifically, telemedicine, the delivery of clinical health care services to remote patients using telecommunications tools, is seen as the most promising mode of health care delivery in the near future, with investor capital flowing into telemedicine platforms.
Regulatory waivers provided by the Centers for Medicare & Medicaid Services (CMS), executive orders issued by state governors, and mandatory social distancing measures fueled the widespread use of telemedicine during the pandemic. Healthcare stakeholders should keep the following telemedicine issues in mind as we prepare for the 2020-21 flu season:
- Defining the services offered. The distinction between telemedicine and telehealth is critical. The Oxford dictionary defines telemedicine as “[t]he remote diagnosis and treatment of patients by means of telecommunications technology”; telehealth as “[t]he provision of healthcare remotely by means of telecommunications technology”. Telemedicine is the offering of established health care services, appropriate in scope and frequency, to remote patients - this can include remote monitoring. Telehealth describes “the wider range of ancillary health-related services and less-than-comprehensive virtual health options”.
Today, the methodological frameworks for the clinical validation of digital health technologies are still being developed. Separately defining telemedicine and telehealth services is critical to ensuring patient safety and promoting innovation. If telehealth is regulated like telemedicine, innovation will be limited. (Think about the potential of requiring artificial intelligence to pass licensure exams to deliver care.) If telemedicine is regulated like telehealth, patient safety could be compromised. (Think about online surveys where you can fill out questions to get a lifestyle drug without a doctor’s prescription. A heart attack patient in the ER who does not have this prescription in his EHR might then be prescribed drugs that lead to harmful drug interactions.)
- Using consistent documentation. Providers should select a documentation process for telemedicine services and consistently adhere to it. One example of such an approach is in Massachusetts, where providers “include a notation in the medical record that indicates that the service was provided via telehealth [and] the technology used”. Not only will consistent documentation practices streamline the reimbursement process, but they also provide a baseline for data generated by telemedicine for research purposes.
- Tracking drugs prescribed. The Drug Supply Chain Security Act (DSCSA) calls for an “electronic, interoperable system to identify and trace certain prescription drugs as they are distributed in the United States...to enhance FDA’s ability to help protect consumers from exposure to drugs that may be counterfeit, stolen, contaminated, or otherwise harmful”. Spurred by telehealth deregulation during the pandemic, new supply chain models for pharmaceutical compounds have emerged, such as the remote prescribing across state lines with same-day delivery. With the expansion of telemedicine, an interoperable drug tracking system, particularly for opioid prescription tracking in state prescription drug monitoring programs (PDMPs), is needed. Blockchain, a peer-to-peer (PRP) public ledger software maintained across a distributed network of computers, is one application that demonstrates potential in addressing this need.
- Reforming policies restricting patient access. State and federal policymakers should eliminate patient location requirements, freeing patients to access telemedicine care from home. CMS’s temporary waiver allowing Medicare patients to access telemedicine care at home for the duration of the pandemic should be made permanent. In addition to removing location-based restrictions for patients seeking telemedicine care, states should follow the American Medical Association’s guideline for removing pre-existing patient-physician relationship requirements by defining the formation of said relationship when “a physician affirmatively acts in a patient’s case by examining, diagnosing, treating, or agreeing to do so”, whether in person or online.
States should address licensure reform that allows out-of-state physicians to practice telemedicine with in-state residents. Many states temporarily implemented this approach for the duration of the pandemic. This would allow patients in rural areas with a physician shortage to access doctors in near-by states and enable patients in states without a world-renowned medical center to access telemedicine care rendered by top-ranked specialists.
- Addressing reimbursement policies. At the start of the pandemic, many states and the federal government established temporary reimbursement parity for clinical health services delivered via telemedicine  . Reimbursement parity for health care services levels the playing field for telemedicine as an alternative mode of health care delivery. For health care services established to be safe, appropriate in scope and frequency, and equally as effective as in-person visits, telemedicine reimbursement parity is vital to allowing physicians to offer more patient-centered care, enabling patients to choose either an in-person or telemedicine visit. Otherwise, providers will need to encourage patients to schedule in-person visits to meet revenue targets, even if a telemedicine visit would be more appropriate.
Additionally, as rural hospitals face ever-increasing financial challenges, telemedicine reimbursement parity offers them an opportunity to restructure their services. Mercy Virtual Hospital is a blueprint for adapting the delivery of health care services to meet the needs of the digital age.
- Preparing for tax reporting. The Internal Revenue Service (IRS) has yet to update its definition of “patient”, which currently does not consider services rendered by providers at non-profit hospitals to remote patients as medical expenses. For these patients who are not admitted to the non-profit hospital, telemedicine payments may be classified as unrelated business income (UBI). When providers render telemedicine services to patients across state lines, other UBI-related rules could apply. To address these issues, the IRS definition of patient should be updated to include telemedicine-only patients and state departments of revenue should issue guidance on telemedicine-relevant UBI rules.
Business expensing for telemedicine is possible. For instance, technology investments for telemedicine practice, such as “software, hardware, or hosting fees”, may be deductible. Even 3D-printed medical devices may qualify for R&D tax credits. For telemedicine doctors using a home office, the “space and the equipment that [they] use to work from home are all part of [their] tax deduction…[as well as] part of [their] home’s utility costs, internet costs, and even mortgage” .
Telemedicine use amid COVID-19 outbreak: A global perspective
Affiliations: Md Azharuddin1, PhD, Mohammad Adil2, PhD, Prem Kapur3, MD, Pinaki Ghosh4, PhD, Manju Sharma2, PhD
1Department of Pharmaceutical Medicine, Division of Pharmacology, School of
Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
2Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia
Hamdard, New Delhi, India
3Department of Medicine, Hamdard Institute of Medical Sciences and Research, Jamia
Hamdard, New Delhi, India
4Department of Pharmacology, Poona College of Pharmacy, Bharati Vidyapeeth, Pune, India
In December 2019, several unidentified pneumonia cases were reported in Wuhan, China, caused by β-coronavirus, a novel strain of coronavirus (2019-nCoV). On 11 February 2020, WHO officially announced “COVID-19” as the name of this new disease.1 It is steadily rising by human-to-human transmission and has confirmed 26,31839 cases worldwide, till April 24, 2020.2 The WHO declared the outbreak a global public health emergency on January 30, 2020.2 COVID-19 pandemic has put most of the countries under public health as well as economic strain.3 Several measures have taken by different countries to cope with COVID-19 outbreak. Now the global health crisis continues to escalate, telemedicine critically stepped into the spotlight in health care system to slowing the COVID-19 outbreak.
Telemedicine is the use of electronic information and telecommunications technologies including, videoconferencing, internet, store-and-forward imaging, streaming media, telephone calls and wireless communications. It promotes and improve the vast distances patient and clinical health care by the means of interactions between patients and clinicians or between two or more consulting practitioners.4 Additionally, interactions of telemedicine have a different role in patient care. Synchronous interaction, where patients and consulting practitioners interacted in real-time. It is a two-way communication using audio-visual technology (e.g., video call). It may use to diagnose a disease, and provide treatment. Asynchronous telemedicine not providing the direct patient care, the shared information can be reviewed and answered in a delay of time between patients and consulting practitioners (e.g., e-mail).4 It may use to provide a patient care and healthcare opinion.
As the COVID-19 contributing higher fatalities among immunocompromised people like chronic diseases and comorbidities, it can be used to avoid virus exposure by the means of reducing hospital visits.5 In addition to, it can reduce the risk of COVID-19 transmission among health care professionals those working tirelessly in the frontlines by keeping all the significant infected patients out of hospital. 5 Televisiting and teleconsultation can be used to triage more patients, screen and diagnose remotely.5
According to Infectious Diseases Society of America (IDSA), it also supports cost effective care by keeping patients to unlikely visit to emergency department and face to face consultations.6
In recent, due to wreaks havoc of COVID-19 virus, the Centers for Disease Control and Prevention (CDC) a Federal agency urging the public and healthcare professional to use telehealth programs for communication in an effort to reduce the burden of unnecessary emergency rooms and clinics visits.
The World Health Organization (WHO), CDC, as well as several state public health agencies have suggested that telemedicine service must considered as an essential part of healthcare provider in “strengthening the Health Systems Response to COVID-19” policy. In addition, according to a new WHO policy, within the adequate service delivery action, it should be considered as one of the alternative models for clinical services and clinical decision support.
A survey carried out among U.S. patients have shown that 84% are more likely to choose those providers who offers telemedicine. In Israel, a TytoCare’s telehealth solution has launched a TytoHomeTM kit to examine COVID-19 patients in quarantine wards, as well as to monitor patients in isolation stays and home quarantine.5
TytoCare’s partners is all set to emerged the solution and expanded their use in the US and Europe. In recent March 25, 2020, the American Medical Association (AMA) launches telemedicine during COVID-19 outbreak, where physicians and experts can discuss the several issues and share the experiences over the ongoing pandemics. Also, the Government agencies are associated with industry leaders in virtual care. Ro is a patient-driven virtual telehealth company launched a digital health clinic, now it became a part of the White House’s Tech Task Force for coronavirus, aims to be the patient's first call for all of their healthcare needs.7
On March 25, 2020, the Indian Ministry of Health and Family Welfare (MoHFW) with NITI Aayog and Board of Governors (BoG) Medical Council of India (MCI) launched the official guidelines for telemedicine practices to prevent transmission of virus.8 Advised all the registered medical practitioners and doctors to provide and support healthcare services remotely via phone or online communication consultation where citizen go on nationwide lockdown for 21 days. Under this consideration, doctors can write prescriptions based on receiving telephonic, textual or video conversations-chat, images, messaging, emails, fax and others.8
This is a crucial step for digital health, and the decision has been lauded by current digital healthcare solutions, who believed that this is the need of the hour especially when the world is facing unprecedented challenges with the coronavirus pandemic.
Furthermore, there are several online health services such as Practo, 1mg, Medlife, mFine, significantly stepped in online consultations during the COVID-19 pandemics, where 1mg claimed a 300% rise in e-consultations for flu and fever-related illnesses since the beginning of March 2020. The telecommunication received from across the country, nearly 600 cities and towns. In addition, Practo, an online doctor-consultation service reported that, it sharply increases in telemedicine calls after a week since the first confirmed case of COVID-19 in India.9 Additionally, the USA, Israel, UK, Nordics and France are amongst the leading countries with established telehealth providers, and their cumulative experience is helping to respond to the current situation.10
This study briefly addressed the global perspectives towards use of telemedicine, in order to deliver and ensure the patient health and safety of health care professionals. Therefore, all countries are suggested to use telemedicine during this pandemic and set up an infrastructure for the next inevitable, infectious disease, if emerge.
Sun Pharmaceuticals, India, for providing assistantship for this project under the joint collaboration for the Ph.D. programme with Jamia Hamdard, New Delhi, India.
- World Health Organization website. Novel Coronavirus (2019-nCoV) Situation Report-1 https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200121-sitrep-1-2019-ncov.pdf. Accessed April 12, 2020.
- World Health Organization website. Coronavirus disease (COVID-19) Pandemic. https://www.who.int/emergencies/diseases/novel-coronavirus-2019. Accessed April 25, 2020
- McKibbin WJ, Fernando R. The global macroeconomic impacts of COVID-19: Seven scenarios. SSRN Elec J. 2020.
- American Telemedicine Association. Telemedicine glossary. Available at: https://thesource.americantelemed.org/resources/telemedicine-glossary. Accessed April 12, 2020.
- Telemedicine during COVID-19: Benefits, limitations, burdens, adaptation. HealthcareITNews. Bill Siwicki. March 19, 2020. https://www.healthcareitnews.com/news/telemedicine-during-covid-19-benefits-limitations-burdens-adaptation. Accessed April 12, 2020.
- Young JD, Abdel-Massih R, Herchline T, McCurdy L, Moyer KJ, Scott JD, Wood BR, Siddiqui J. Infectious Diseases Society of America position statement on telehealth and telemedicine as applied to the practice of infectious diseases. Clinical Infectious Diseases. 2019 Apr 24;68(9):1437-43.
- Apple releases COVID-19 screening tool, resource guide. Mobihealthnews. Laura Lovett. March 27, 2020. https://www.mobihealthnews.com/news/apple-releases-covid-19-screening-tool-resource-guide. Accessed April 12, 2020.
- Telemedicine Practice Guidelines. Board of Governors in supersession of the Medical Council of India. https://www.mohfw.gov.in/pdf/Telemedicine.pdf. Accessed April 12, 2020.
- Telemedicine takes spotlight in season of flu. The Economic Times; Healthcare. Alnoor Peermohamed. Mar 16, 2020. https://economictimes.indiatimes.com/industry/healthcare/biotech/healthcare/telemedicine-takes-spotlight-in-season-of-flu/articleshow/74642448.cms?from=mdr. Accessed April 12, 2020.
- Telehealth in the time of COVID-19. Mobihealthnews. Marianna Imenokhoeva. March 31, 2020. https://www.mobihealthnews.com/news/europe/telehealth-time-covid-19. Accessed April 12, 2020.
Why Veterinary TeleHealth is Critical to Keeping Our Pets (And Ourselves) Healthy During - And After - the COVID-19 Crisis
Hannah Cheng Lau, DVM
I have been very lucky to work almost exclusively in the field of veterinary telemedicine for over a year. I see patients over video and phone consults for a myriad of issues that can be managed at home. Planning, implementing, and troubleshooting a well-rounded telemedicine program in our large 30-veterinarian hospital has been exciting, new, and intimidating for everyone involved. A year ago we had no idea how extensively the program would be put to the test with the public health crisis that is COVID-19. Telehealth has a whole new purpose in this new reality. We have realized that while trying to ride the wave of current events, many of our colleagues are just dusting off their surfboards - or even more concerning, are still sitting on the beach.
I believe strongly that telehealth is an essential organ in the veterinary beast - and it has been for years. Telehealth has always been a part of any veterinary business, and it happens every day in every practice around the world. Like any untrained muscle, it can be challenging and uncomfortable to intentionally strengthen it - but it has always been there. When I speak to my colleagues about telehealth, the first thing I remind them of is that they are already doing it. Granted, a big portion of this is done by paraprofessional staff: mainly client service representatives, veterinary nurses, and assistants. Teletriage and teleadvice is being regularly performed over the phone, either when the client first contacts the clinic, or as veterinary nurse consults. Continuing care is also done daily on the phone, through email, or with voicemail tag. All of these communications, when done well, take hours of employee time and require years of professional and on-the-job training. Although the medium of multiple phone calls and voicemails feels familiar and therefore comforting, they are inefficient to document, confusing for a third party to interpret, and difficult to monetize.
With the continuing effects of COVID-19 stretching out with unknown horizons into the future, likely resulting in a society that is forever changed, it is naive and perhaps negligent to assume life will return to “normal” and telemedicine will become a dying fad. COVID-19 has underlined the importance of telemedicine to the general populace by helping clients and providers socially distance and reduce unnecessary travel. However, this has always been and will continue to be a concern for many of our clients even without a worldwide health crisis. COVID-19 has opened all of our eyes to the dangers and anxieties of navigating the world as someone who is immunocompromised. However, those concerns will continue to exist for our community members who are battling illness, differently abled, do not have access to transportation, or are away from home. Human medicine has trailblazed this space already, and offering virtual doctor’s visits has become more and more accepted with readily observed advantages in convenience and patient access. Deeming telemedicine as unnecessary or too risky for practitioners is the coward’s way out of developing better care for the marginalized.
In addition to providing better care for clients, I have seen patients benefit greatly from well-utilized telemedicine. I am the first to agree that the physical exam is the cornerstone of good veterinary medicine, and telehealth must be used shrewdly and with careful judgement (just like every other tool in the veterinary arsenal). However, there are many common consults that fit beautifully into the virtual space. Very anxious pets can experience stress-free vet consults in their comfort zone, with no danger of canine scuffles in the lobby or losing an escape artist cat in the parking lot. Exposure to infectious illness in the hospital can be reduced. Without the adrenaline of the hospital and white coat syndrome, I can often get a more accurate picture of what the client is seeing at home. Behavioral issues, good husbandry techniques, new puppy education, mild/moderate skin issues, acute lameness, diarrhea, and many other common issues can be discussed at length and often successfully treated. To be abundantly clear - telemedicine is not the space for the lethargic or very painful pet, the intractably vomiting pet, or the nonambulatory pet, just as these cases are not to be handled solely over the phone. There are still issues that must be seen in the hospital. There is no escaping using good judgement, and there is never a one size fits all for every situation. Luckily, this is nothing new to the experienced veterinary practitioner.
I too am clinging to the hope that soon things will be “back to normal.” However, COVID-19 has opened our collective eyes to the many advantages of conducting telemedicine in a purposeful and intentional way - in which an effective medium is used, efficient and thorough documentation is maintained, and the client is charged at a fair rate for a practitioner’s undivided time and attention. Clients will expect us to continue to provide this service even when social distancing becomes less critical for the average community member. Many veterinary practices have realized that a well-established telehealth program increases efficiency, revenue, and client satisfaction. Necessity being the mother of invention, this era of unprecedented challenges is also the birthplace of triumphant problem-solving. A sure way to add to this pandemic’s staggering losses to humanity would be to emerge on the other side refusing to embrace new technologies and ideas in order to grow, both as a profession and as a community. That said, this is neither the first nor the last challenge we will face together as a field, and small-minded fear is not a new enemy. I have abundant faith that we will not allow it to guide us going forward, and instead choose to explore exciting new ways to relieve animal suffering and protect global health.
Telemedicine: From Green Eggs and Ham to Bread and Butter
Richard B. Sanders
Affiliations: American College of Healthcare Executives, Society of Hospital Medicine – (Former Section Leader for the Rural Hospitalist Section), American Telemedicine Association
As the COVID-19 pandemic presses upon the world, it has acutely changed our concept of social engagement, as well as the practice of medicine. The pillars of policy and regulation that have previously restricted the otherwise bright future of telemedicine and virtual health are cracking.
Penned by a self-proclaimed early adopter and advocate for telemedicine, this opinion piece offers four (4) considerations for turning telemedicine from “Green Eggs and Ham” into “bread and butter” in post-COVID-19 responses.
In “Green Eggs and Ham,” the popular children’s book by Dr. Seuss, a persistent yet unpersuasive Sam attempts to convince the reluctant Guy to try his favorite delicacy. But no matter whether on a boat or a train, in a house, or even in the company of his favorite animal, Guy is uninterested in sampling such a visibly unappealing meal. Yet Sam’s persistence pays off when Guy, in an attempt to get Sam to leave him alone, finally agrees to try the green eggs and ham. At that point, Guy realizes what he had been missing all along!
As an early evangelizer of telemedicine, I felt much like Seuss’ character, Sam. I started to point my healthcare career toward telemedicine and virtual health in 2007 when a visionary CEO looked to create new value for patients and caregivers. I immediately bought into his mission of technologically enabling the hospitalist workforce. This work propelled me into the world of innovation and advanced educational pursuits where I spoke to national and international audiences, obtained a doctoral degree, and published articles in the journal of Telemedicine and e-Health.
Over the years and after many odd hours and late nights of pioneering new territory in the heavily entrenched healthcare industry, I got the impression that those who had yet to see the efficacy of telemedicine viewed my physician friends, administrative colleagues, and me as dreamers. Like Sam, I persistently recommended solutions that if the hospital or physician would just simply try, they would find appealing and perhaps even transformational. I know others’ collective experience in being early adopters of telemedicine have been the same. Although initial resistance was the norm, once a telemedicine solution was deployed the organization was never the same.
As the COVID-19 pandemic presses upon the world, it has acutely changed our concept of social engagement, as well as the practice of medicine. The pillars of policy and regulation that have previously restricted the otherwise bright future of telemedicine and virtual health are cracking. Our fee-for-service system is buckling under the pressure of dramatic reductions in patient visits across the entirety of the healthcare industry, so much so that the opportunities for technology-enabled physician services are finally being realized.
Telemedicine stalwarts and newcomers alike are realizing in a matter of weeks what before now would have been an impossibility at worst, or taken years for adoption at best. To be clear, while I am an ardent supporter of telemedicine services, I readily acknowledge that it isn’t ideal for all health conditions, nor for every patient. If it were possible to have an in-person visit and personalized physician-patient relationship for all patients, that would be preferred. However, that isn’t practical, and we have new and exciting technological advances that help us provide modern medicine and deliver care in ways that wouldn’t be possible otherwise given the complexity of disease and the relative centrality of medical expertise.
So, in true carpe-diem fashion, we must collaborate now to ensure that we can reasonably and responsibly “hardwire” current gains for the ongoing success of such technology-enabled physician services. Below is a list, though certainly not exhaustive, as there are many unique aspects to consider for each medical specialty in order to enable a telemedicine post-COVID-19 response:
1. Make interstate medical licensing a permanent fixture and expand to all 50 states
The pandemic has further exposed the longstanding issue of maldistribution of healthcare provider resources across the nation. We need broader adoption of the existing Interstate Medical Licensure Compact. By making it easier for our medical professionals to practice across state borders, we would not only be better prepared for the next crisis, but also bring more healthcare options to patients now.
2. Establish professional billing parity
By establishing a consistent framework for billing parity, barriers to entry would be lowered and ultimately patients will win, as their own local doctors will have further incentive to digitally engage rather than be replaced by the well-funded national aggregators that lack a true sense of the provider/patient relationship.
3. Mandate standards for Electronic Medical Records (EMR)
A standard for EMR interoperability has long eluded our medical record system and would create further synergy between caregivers across the care continuum, allowing for improved coordination of care and workflow efficiencies between and among providers. This would ultimately keep a patient “connected” and safe from the harmful effects of communication gaps.
4. Payor and provider value-based care contracting
While this may seem contradictory to the second point above, payors and providers alike need to reach greater and broader alignment for value-based care across the spectrum. Doing so can lead to greater clinical and technological innovation that will benefit patients individually and as a population. It could potentially insulate healthcare providers from the downward economic impacts of fee-for-service reimbursement during a pandemic, or in other states of emergency that discourage or prevent the direct contact and volume-based touchpoints demanded by the fee-for-service model.
Over the years, I have increasingly appreciated this Niccolò Machiavelli quote: “The innovator has for enemies those who have done well under the old, and lukewarm defenders in those who may do well under the new.” I believe the new system is upon us and, if handled carefully, will reward all those who will embrace it.
And so, I invite all former telemedicine “enemies” to become friends, and “lukewarm defenders” to become champions, as what was once “green eggs and ham” to many caregivers may now be “bread and butter” necessary in our current times.
New York: Beginner Books. Seuss, Dr. Green Eggs and Ham. New York: Beginner Books, 1960.
Drake C, Zhang Y, Chaiyachati KH, Polsky D. The limitations of poor broadband internet access for telemedicine use in rural America: an observational study [published online May 21, 2019]. Ann Intern Med. doi:10.7326/M19-0283
Struminger BB, Arora S. Leveraging telehealth to improve health care access in rural America: it takes more than bandwidth [published online May 21, 2019]. Ann Intern Med. doi:10.7326/M19-1200
Whatsapp Neurology: Meeting the Challenges of Teleneurology in India during the COVID-19 Pandemic
Prahlad K Sethi 1, MD and Nitin K Sethi2, MD
1 Department of Neurology, Sir Ganga Ram Hospital, New Delhi (India)
2 Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)
In the space of a few weeks the COVID-19 pandemic has changed the way neurology is practiced around the world. In order to control the spread of COVID-19, the World Health Organization and Centers for Disease Control and Prevention (CDC) recommended isolation of sick persons, quarantine for those who may been exposed to the virus and social distancing. 1 Social distancing also referred to as physical distancing meant keeping space between people outside of their homes. A distance of at least 6 feet (2 meters) was recommended and people were asked not to gather in large groups, avoid crowded places and mass gatherings. 2 All non-essential staff were advised to stay home and work remotely if the facility to do so was available to them. Hospitals in different countries around the world were forced to make some drastic changes in order to prepare for the expected surge of COVID-19 patients.
On March 24th, 2020, Indian Prime Minister Narendra Modi announced the world’s largest lockdown asking 1.3 billion Indians to stay home for 21 days to slow the spread of COVID-19. 3 The lockdown has now been extended till May 3rd.4 All international and national flights were suspended and so was train and vehicular services in the cities and across state lines. In New Delhi, hospitals canceled all elective surgeries, closed in-patient epilepsy and stroke units and canceled all outpatient clinics. Patients were discharged from the hospitals. Beds especially ICU beds and other resources such as ventilators were reserved for COVID-19 patients. Physicians working in these hospitals were advised to adopt telemedicine in order to primarily maintain continuity of care for their existing patients. A developing country like India did not have existing infrastructure to support telemedicine. Unlike hospitals in the United States, most physician neurologists in India do not have electronic health record (EHR) software. After seeing the patient, the neurologist documents the history, clinical findings, assessment and plan including prescriptions on paper (letterhead) which is then handed over to the patient. Most neurologists do not maintain copies of this letterhead for their own records. When patients come for a follow up visit, they brings the original letterhead with the doctor so that continuity of care can be maintained.
In the wake of the COVID-19 pandemic some hospitals in India tried to roll out vendor supported platforms through which telemedicine could be practiced. India has the largest population of illiterate adults and many patients experienced difficulty in downloading the software and logging on to the patient portal. India leads the world in accessing the Internet by mobile phones and for the people in semi-urban and rural India, mobile phones are an easy and more economical way to stay connected than devices like laptops. India’s mobile (cellular) subscriber base including active and inactive users has reached 1,176 million in 2018 as per TRAI report. 5
Mobile customers in urban areas reached 647.52 million. India has 528.48 million mobile users in rural areas. WhatsApp was founded in 2009 by Brian Acton and Jan Koum, former employees of Yahoo.6 On February 19th, 2014, Facebook, Inc. acquired WhatsApp. 7 Most Indians even those residing in villages are quite savvy in use of mobiles phones and apps such as WhatsApp and it is estimated that there are more than 400 million WhatsApp users in India.
The first author utilized WhatsApp as the portal to provide continuity of care to his existing neurology patients and to see new patients. Before the appointment, patients were requested to send their medical records (including prior letterhead) and neuroimaging records. The first author then would call the patient at the predetermined time on WhatsApp and use either audio-call or video-call feature to discuss the case and treatment plan. He was successful in using WhatsApp to administer and guide care during neurological emergencies such as stroke, transient ischemic attack, status epilepticus, altered mental status, transient loss of consciousness, concussion and traumatic brain injury. A patient with a large subdural hematoma with significant midline shift and subfalcine herniation was advised emergency decompressive surgery. Another patient’s family with a large brainstem hemorrhage was advised against transfer to the author’s hospital and to continue current care at the regional hospital.
The author realized the limitations of teleneurology when he consulted on a 39-year woman with complaint of numbness of both legs for the past 3 days. Numbness had rapidly increased over 3 days to the point that she was barely able to walk. No bladder or bowel symptoms were reported.
Three months ago, she had complaint of pain back of the neck and both shoulders without radiation into the arms. She had been evaluated in a regional government hospital and prescribed pregabalin. On tele video visit, her gait did not appear spastic; her legs, in fact, seemed frail. While lying down she could barely lift her legs off the bed and was unable to hold them against gravity. The author was able to look for a sensory level by asking the patient’s relative to do the sensory testing examination but was significantly hampered by the inability to test for deep tendon reflexes.
The patient was advised to go to the hospital for an MRI of the spine, nerve conduction study and a formal neurological consultation but the family declined citing the fear of contracting COVID-19 in the hospital. Differential diagnoses included demyelinating neuropathy as well demyelinating disease of the central nervous system.
The author decided to prescribe a course of oral methylprednisolone along with oral Vitamin B12 supplementation. On follow up, tele neurology consultation 7 days later, patient reported she was much better and able to walk with assistance. She was advised to follow up in person after the lockdown was over. Patients paid for the consultation through Paytm, a popular and widely used Indian e-commerce platform available in 11 Indian languages. 8
WhatsApp end-to-end encryption ensures that only you and the person you're communicating with can read what's sent, and nobody in between, not even WhatsApp. India’s population is around 1.3 billion and registered trained neurologist are around 1500. The burden of neurological diseases is huge and unmet by the small number of neurologists. In a low to middle income country like India, the author found WhatsApp as the best platform to offer teleneurology services to his patients during the COVID-19 pandemic. While this application offers tremendous opportunities when it comes to administering neurology services, daunting challenges related to patient confidentiality, keeping patients medical information and health records secure and limitations of teleneurology in a clinical examination heavy specialty such as neurology need to be overcome to truly unleash the full potential of WhatsApp Neurology.
- Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html (last accessed April 18th, 2020).
- Maragakis LL. Coronavirus, Social and Physical Distancing and Self-Quarantine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-social-distancing-and-self-quarantine (last accessed April 18th, 2020).
- Chaudhary A, Pradhan B. India Locks Down 1.3 Billion People in Biggest Isolation Effort. https://www.bloomberg.com/news/articles/2020-03-24/india-to-impose-nationwide-lockdown-from-midnight-pm-modi-says (last accessed April 18th, 2020).
- Government of India. No.40-3/2020-DM-I(A). https://www.thehindubusinessline.com/news/fighting-coronavirus-centre-issues-fresh-guidelines-for-lockdown-20/article31344293.ece (last accessed April 18th, 2020).
- Annual Report Telecom Regulatory Authority of India 2019. https://main.trai.gov.in (last accessed on April 18th, 2020).
- https://www.whatsapp.com/ (last accessed on April 18th, 2020).
- WhatsApp messenger. https://en.wikipedia.org/wiki/WhatsApp (last accessed on April 18th, 2020).
- https://paytm.com/ (last accessed on April 18th, 2020).