By Ashley S. Westerman
Capital News Service
CHARLOTTESVILLE, Va. – Picture this: You are the parent of a football player who plays at a high school in a rural, farming community in the foothills of the Appalachian Mountains. One Friday night your son, the quarterback, is sacked on the field on a fourth down. The school’s athletic trainer races to your son’s side and helps him off the field, suspecting he may have a concussion.
The nearest health facility is a small, primary care clinic in town, but you know the nearest neurological specialist is at a hospital hours away. You know it could take many long drives, a lot of gas and time to get your son’s brain injury assessed and cared for.
Doctors and scientists at the University of Virginia’s Center for Telehealth are hoping in the not-too-distant-future such worries will weigh less heavily on families who live in rural areas. The center is exploring what it hopes will lead to the use of telehealth — audio-video links connecting a patient in one location to a physician in another — to assess concussions and other sports-related injuries in rural areas.
This is new territory. The Mayo Clinic in 2013 teamed up with Northern Arizona University to study how to assess concussions on the athletic field in real-time. But this has not yet been attempted on any kind of large scale.
Rooted in Neuroscience
David Gordon, director of the UVa. Office of Telemedicine, said telehealth has widespread use across medical specialties today, and neuroscience has helped to lead the way. He said stroke patients were among the first to be assessed through the use of telehealth; later, its use spread to assessing and diagnosing post-traumatic stress disorder and traumatic brain injury in veterans.
“One day the light goes on and everybody understands that this is the way to provide care,” he said.
And although the marriage between telehealth and sports concussion diagnoses is just now being explored, the assessments of all traumatic brain injuries are similar, said Dr. Katherine Wibberly, director of the Mid-Atlantic Telehealth Resource Center, located at UVa.’s Telehealth Center.
“So there’s an effort right now to think through, ‘How much of this [sports concussion] assessment can be done by telemedicine, and how much of it can’t?’ ” Wibberly asked.
Jason Freeman, a neuropsychologist at UVa., said a concussion assessment could be done remotely over an audio-video link. On one end would be the specialist, and on the other would be the patient and either another doctor or a nurse practitioner helping with assessment. The doctor on the remote end could easily observe the physical challenges used to diagnose a concussion “such as heel-to-toe walking, opening and closing of the eyes and extending hands to either side,” he said.
Testing response and comprehension to auditory commands could also be done orally through an audio-video connection, Freeman said, and “there may be some measures that can be done remotely that involve pencil-paper and timed decision making.”
On the patient’s end, Freeman said there doesn’t seem to be a preference, at least in older populations, when it comes to having a face-to-face cognitive assessment vs. a telemedicine assessment. “So at least there’s some preliminary research out there that is showing patients, and in this case, student athletes, would be open to that concept.”
Wibberly said studies have shown the patient no-show rate decreases significantly when a tele-assessment is an option.
“If you’re sending someone 45 minutes to an hour for a consult, the no-show rate is very high,” she said. “You send someone to their local community center via telemedicine, and the no-show rate drops considerably. ”
Wibberly said recent studies have found patients get more face-time with a doctor on a telehealth monitor than in-person.
“Patients are saying I don’t even get eye contact in those 30 seconds in the room with my physician,” she said. “Whereas on that computer screen, it’s completely 100 percent attention to the patient, and so that makes a difference.”
Over the years studies have shown patients are satisfied with examinations via telehealth. A 2000 study published in Telemedicine Journal that looked at almost 500 real-time interactive telemedicine clinical consultations found an overall patient satisfaction rate of 98.3 percent. Study participants reported care was easier to obtain when they didn’t have to deal with factors such as travel time.
In a 2013 study by the Commonwealth Fund that examined data from large telehealth programs run by the U.S. Department of Veterans Affairs, Partners HealthCare in Boston and Centura Health, researchers found that patient satisfaction was up 85 percent when monitoring via telehealth.
As with all new technologies, there are concerns about how telehealth is applied as it becomes more prevalent. Issues such as the costs of telemedicine technology and workforce training, insurance coverage for assessments and security of patient records are just a few examples of concerns over its implementation.
Greg Billings, executive director of the Robert J. Waters Telehealth and eHealth Law in Washington, D.C., said one of the biggest issues is that different states and regulatory bodies define telemedicine differently.
“From a legal and regulatory aspect, there is not a single, uniform definition,” he said, which makes it difficult when trying to understand different states’ requirements.
Billings said this can get in the way of something as seemingly simple as what it means to establish a physician-patient relationship. He said all states say something to the effect that before a doctor can diagnose and/or treat a patient, there has to be a physician-patient relationship established through a face-to-face examination.
“Then the question becomes: Can you conduct a face-to-face examination through a telemedicine encounter, if you’re using two-way video, peripherals, diagnostic tests and a presenter – can those meet the requirements of a face-to-face examination?” he asked.
Billings said 20 states, including Maryland and Virginia, allow a physician-patient relationship to be established via a remote assessment. But some states, such as Texas, require the patient to be in a medical facility for the initial assessment.
Additionally, Billings said states differ in their laws about licensing requirements for consultations with doctors in other states via telehealth. He said most states – including Maryland and Virginia – allow for consultations with out-of-state doctors to take place, without the remote doctor needing a medical license in the patient’s state.
But when these statutes were put into place, “informal consultations or ‘curbside consults’ were in mind,” he said.
Billings said while his group is urging states to adopt clarifying language on these and other matters, he doubts there will ever be nationwide regulations for telemedicine.
“States are going to be very resistant, governors would be very resistant to the federal government usurping their rights to protect the health and welfare of their citizens,” he said.
Realistic Application Moving Forward
Dr. Donna Broshek, associate director of the Brain Injury and Sport Concussion Institute at the University of Virginia, sees telemedicine’s potential for reaching injured athletes in some of the more remote areas. “But we don’t have that capability at this time,” she said.
For now, Broshek said, the institute is concentrating on providing outreach and education on sports concussions all over the state. She said state legislation passed in 2011 that mandated concussion education for coaches, parents and students has been well-received.
“Now people have seen some of the, thankfully very rare, but devastating outcomes, now people are more concerned, and they’re very receptive,” Broshek said.
Gordon said it’s becoming cheaper to set up telemedicine hookups in doctors’ offices and clinics: The average cost to set up a unit is around $2,500 today. That’s compared to the $120,000 price tag of about 20 years ago, he said. Broadband access will be critical to the connections, Gordon said.
Although the UVa. Telehealth Center does not yet have a timeline for when assessments of concussions via telehealth will begin, Gordon said it’s important that the light bulb is coming on.
“There’s much that can be done by using telemedicine where we can support small communities,” he said.