General TeleneurologyA solution for limited neurology access in SC

Sujai ‘Ron’ Nath, MD

October 15, 2015

Disclosures• None

Objectives• Review the types of care

provided by a general neurologist

• Review the current status and needs of neurology care in SC

• Discuss the how general teleneurology is a solution to provide expert neurological care

Overview• Background

• Current status

• The Need

• Challenges

• Solutions

• Future

Background:Teleneurology

• Neurology care through remote means (real-time or delayed)

• Inpatient – Neurohospitalist care

• Outpatient – clinic only

• Neurodiagnostics

• Intraoperative Monitoring (IOM)

Background: Inpatient• Neurohospitalist care: Neurology

in the hospital setting (incl ER)

• Provided by board-certified neurologists, fellowship trained

• Same premise as “Hospitalists” in the field of general internal medicine

Background: Outpatient• Traditional office based practice

with scheduled visits

• Chronic disorders

• Often subspecialty clinics• MS, dementia, headache,

movement disorder, epilepsy

Background: Diagnostics

• Lumbar punctures

• EMG/NCS

• Evoked potentials

• EEG

Background: IOM• Remote visual review of signals

• Mostly spine cases, some brain

• SSEP, TceMEP, EMG, EMG, BAER, VEP, mapping

• Interact with technician and surgeon

Background: Disorders• Inpatient and Outpatient settings

• Determined by severity and acuity – dementia vs. delirium

• CNS: stroke, MS, tumor, seizure, coma, headaches

• PNS: GBS, MG, myositis, radiculopathy

Current Status: Overall• ~70 hospitals in SC serving a

populace of 4.8 million

• Ranges: 25 beds to 800 beds with a total of 12,300 beds

• Neurological disease burden affects 15% of the population (800,000 people in SC)

Status: Inpatient• Estimated 500k overall admits

per year (about 1300/d)

• At least 20% involve a significant neurological disorder (260/d)

• Almost completely consultative

• Number of consults increases based on availability

Status: Outpatient• Estimated 1 million neurology-

related outpatient visits per year

• Estimated 160 neurologists in SC but nearly half in Charleston

• Estimated wait is 4-5 weeks

• Not clear how many hours per week in clinic

Status: Diagnostics&IOM

• Hard to gauge numbers in SC since there is no single source

• EEG: 250,000 per year

• EMG/NCS: 130,000 per year

• About 8000 spine cases per year

Need: Inpatient• Typical load is about 1 neurology

patient per 20-30 beds (5%)

• A single full-time neurohospitalist needs a census of about 15-20

• This does not include ED consults or phone consults

• So a hospital needs 300-500 beds to support one full-time neurohosp

Need: Outpatient• Nationally there is 1 neurologist

for every 19,000 people

• In SC there is 1 neurologist for every 30,000 people

• Goal is 1 for every 18,000

• SC is short 100 neurologist!

Need: Diagnostics&IOM

• At least 20% increase across the board in testing but they cant get access

• Nearly all 8000 spine cases should be monitored but no access to IOM trained neuro

Challenges: the shortfall

• Increasing neurological disease burden as population ages

• Less students choosing neurology

• Significant reduction in hours and insurance-based access

• Uneven distribution

Ideal Solutions• More neurologists overall

• Better distribution

• Better hours

• Better access

Real Solution: Teleneuro

• Allows neurologist to stay in desirable geographic locations

• Allows smaller hospitals and communities access

• Allows larger hospitals to fill-in gaps of coverage

MUSC Teleneurology• Complements and builds on

success in telestroke

• 2 full-time neurohospitalists covering 5 hospitals

• Provide daily scheduled consults and urgent consults

Goals• Expand services and inpatient

coverage to all hospitals that need it in SC

• Begin to provide outpatient, IOM and diagnostic neurology service

Future• Teleneurology will become part of

residency training

• Additional competition from non-profits such as Cleveland Clinic and for-profit companies such as Specialists on Call

References• Neurological Disorders: Public Health Challenges

(ISBN9789241563369)

• An analysis of avoidable admissions to a neurology service (Rev Neurol 2006 Dec)

• Supply and demand analysis of the current and future US neurology workforce (Neurology 2013 Jul)

• How can teleneurology improve patient care (Nature Clin Prac Neuro (2006:vol 2, no.7)

• Teleneurology applications: Report of the telemedicine workgroup of the AAN (Neurol 2013 Feb)

• Advantages and limitations of teleneurology (JAMA Neurol 2015 Mar)