Expert Tips for Implementing Telemedicine in Parkinson's Disease: Myths and Tips

Who is Jill Farmer DO?

Dr. Farmer is an Assistant Professor of neurology and the Director of the Parkinson’s Disease and Movement Disorder Program at Drexel Neuroscience Institute. Her clinical and research interests include non motor symptoms of Parkinson’s disease and Functional Movement Disorders. She developed the Delaware Valley Regional Movement Disorder Meeting, a quarterly educational event for movement disorder specialists and their teams. She currently serves on the editorial board of Practical Neurology for their movement disorder section. Dr. Farmer is one of the lead administrators for the Women Neurologist Group which she has helped grow to over 2700 international members. She has a particular interest in telehealth and Dr. Subramanian and I picked her brain for the parkinsonsecrets.com blog.

Myth #1: Parkinson Disease patients require an in person visit for every visit.

Not always; and this was known even before the pandemic. Dr. Ray Dorsey, a world-renowned expert in telemedicine has published numerous articles on the topic. In one of his most recent papers, “Patient Views on Telemedicine for Parkinson Disease,” published in the Journal of Parkinson’s Disease in 2019, he conducted a national survey of close to 800 Parkinson’s patients. His research has shown that over 75% of the respondents had a high interest in telemedicine but less than a third used the service. Top advantages were access to specialists, convenience and time savings. Common concerns were lack of hands-on care and intimacy of the visit as well as technical difficulties; these are the concerns we will address in this blog. For patient with Parkinson’s Disease, since their exams are visual and observable, this particular specialty lends itself to utilizing telemedicine to diagnose, manage symptoms and to develop a plan of care. It may be necessary that a doctor be able to examine you in person for the first visit, since it is often crucial to test for increased tone in person with a physical examination, however subsequent visits can lend themselves to tele-health. Followup visits are often for medication adjustments, checking in on side effects and checking compliance; which can all be done through telehealth. Some experts have found that they can in most cases see new diagnoses or initial evaluations by telehealth.

Myth #2: Most patients with PD will not be able to use the technology since they are too old to be tech savvy.

Multiple nonprofits and academic institutions have conducted real time survey studies and the vast majority of responses have been positive including those with elderly populations. Research conducted by the Alliance for Connected Care (http://connectwithcare.org/) and Children’s Hospital of Philadelphia has shown:

• A March survey found that 59% of the 500 U.S. consumers surveyed said they are more likely to use telehealth services now than previously, and 36% said they would switch their physician in order to have access to virtual care.

• A new poll of more than 1,000 seniors found 52% are comfortable using telehealth to receive health care. Of those who have used telehealth during the coronavirus, 91% reported a favorable experience, and 78% were likely to complete a medical appointment via telehealth again in the future

. • The latest Modern Healthcare CEO Survey finds that health system CEOs see a wave of innovation in telehealth over the next year. In addition, 92.9% of CEOs cited telehealth as a technology with the most potential to support response to the COVID-19 pandemic.

• A survey of more than 1,300 physicians found that more than 90% are treating some or all of their patients via telehealth. Additionally, roughly 60% of physicians currently using telemedicine tools during the public health emergency said they plan to use telemedicine more often than they were pre-COVID.

• Research conducted by the Children’s Hospital of Philadelphia analyzed 2,589 people during the Covid-19 pandemic and results suggested telemedicine was feasible and effective for a large proportion of child neurology care. Patients appreciated the safety of a telemedicine visit offered during the pandemic as well as the convenience, even outside of the current public health crisis, many patients have mobility issues and transportation issues that make going to the doctor quite cumbersome. One of the arguments against adopting telemedicine sooner was that patients across ages and disease states would have difficulty using the tele-med platforms. That myth has been dispelled since many patients have smart phones and tablets and are already familiar with video chat capabilities. Technical glitches are an annoyance but can often be easily overcome with a little patience.

Myth #3: I tried to do a tele-health visit and it did not work; there is no hope that I can be successful in the future.

• You can access the telemedicine platform your doctor uses from your phone, tablet or computer, but your computer needs a webcam to perform the video. If you wish to only use a phone for a phone call, you can request this since your doctor will still be reimbursed for the phone call (this is new thanks to the CARES-ACT waiver), but this will be a more limited encounter.

• Whatever type of device you are using make sure you are connected to the internet and you have good connection with almost all the access bars highlighted – the worse the connection the worse the video and audio will be. To ensure a good connection hook up as close as you can to the router in your house.

• To make sure the telemedicine platform will run as fast as possible, make sure that it is the only application or webpage open on your device – close everything else on your phone, tablet and computer.

• Make sure you are using the recommended internet browser – your doctors office will tell you if you should be using internet explorer, google chrome, safari or mozilla firefox (as web browsers). If you do not have the browser installed on your device, your doctor’s office can give you instructions or a family member/friend can help.

• If all of that seems too confusing, FaceTime is always a back up if you have an iPhone/iPad and you can request this option.

• Make sure your computer volume is turned all the way up

• Do not sit in front of a window, your doctor will have a hard time seeing you since you will be in a shadow the whole time.

Myth #4: Everyone loves telemedicine and it will replace all care moving forward.

Some patients and providers are worried that this push toward telemedicine will dissolve the sanctity of the doctor patient relationship. It is a valid concern and those that are advocates for telemedicine have a responsibility to make sure it doesn’t. Most advocates, both physician and patient, do not want to have telemedicine become the norm, but want it to simply be included as a practical option for some who may choose it over in-person visits. Even those that raise concerns about its widespread adoption cannot argue it has a practical place in the new landscape of medical care. The doctor patient relationship is already being chipped away in many respects – the rise of minute clinics, allied health professionals increasing their scope of practice without requiring direct physician supervision – each of these scenarios started out as a way to enhance access to medical services – so as with telemedicine, there needs to be checks and balance. It can be argued, utilizing telemedicine can help you to regain some of the doctor patient relationship if you are able to see YOUR physician more easily through a quick telemedicine visit, you will have to rely of minute clinics or am alternate provider less. Telemedicine can increase access, but not just access in general but access to YOUR doctor. It can be personalized and if a doctor has a good bedside manner, more often than not they will have a good screen side manner too.

Myth #5: Insurance companies have reimbursed for tele-health visits the same as they have reimbursed for in-person visits.

Since the start of the global pandemic (with orders of social distancing set in place for public health safety), the CARES-ACT (https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers ) waiver allowed telemedicine to be quickly adopted as a platform to allow for continued continuity of care and it was incorporated across all specialties. Why did it take a global pandemic to use technology that has been around for decades? Insurance reimbursement and site location restrictions explain the delay. Many states and commercial payers can boast that they have telemedicine policies in place, but most of these policies only state that the service provided through telemedicine can be considered equal to a face to face visit. This is called service parity and is a first step, but not an impactful one because it does not require payment parity – which means that insurance, which recognizing the services are comparable, are not required to pay them comparably or even at all. Medicare was the biggest hurdle with did not recognize telemedicine at all. The CARES-ACT waiver removed all reimbursement restrictions as well as site location restrictions which meant that even if telemedicine was a reimbursable option, it often had to be completed with a patient at a designated office that was declared an approved site for telemedicine – so not entirely in keeping with the intention of telemedicine’s potential.

Myth #6: As a patient there is nothing I can do to advocate for keeping tele-health around in the future even though I do like it and I do hope that my doctor will continue to use it:

Patients are POWERFUL advocates and you can join the many neurologists and movement disorder specialists who have been working with their state medical and neurological societies, as well as national organizations like the American Academy of Neurology and patient advocacy groups like the Parkinson’s Foundation and MJFox Foundation; to stress the importance of continued access to this service. These provider’s efforts are amplified by your testimonials and support. In fact, many patients have taken to writing emails to share their stories of how telemedicine has positively impacted them. Most recently this advocacy has helped to set the stage for securing ongoing access with a recent decision by Centers for Medicare Services announcing that for the 2021 fee schedule it has proposed adding several new services to the Medicare tele-health coverage list permanently. What wasn’t included and still needs to be advocated for is removing arbitrary geographic restrictions on where a patient must be located in order to use tele-health services. Meaning you can still access telemedicine from your home and not a different doctor’s office. If you feel strongly about telemedicine and want to share your experiences and express support please look at the initiatives through the following organizations. These pages will allow you to get in touch with your local and state representatives where you can simply email a form letter to them. To make sure the letter is going to the correct representative you will be asked to provide your address, but this is not stored on the sites. Also, you do not need to be a member or supporter of any of these groups to send the letter.

The American Academy of Neurology: https://aan.quorum.us/issue/16377/

Michael J Fox Foundation: https://www.michaeljfox.org/advocacy-campaign/tell-congress-people-parkinsons-need-telehealth

This blog is brought to you by Michael S. Okun and Indu Subramanian.

To read more books and articles by Michael S. Okun MD check Twitter @MichaelOkun and these websites with blogs and information on his books and http://parkinsonsecrets.com/ #EndingPD #ParkinsonPACT #Parkinsonsecrets and https://www.tourettetreatment.com/

He also serves as the Medical Director for the Parkinson’s Foundation.

To see more on Dr. Indu Subramanian she does live interviews of experts in Parkinson’s for the PMD Alliance