The coronavirus disease 2019 (COVID-19) heralded an unprecedented increase in telemedicine utilization.

Telemedicine has many patient-centered benefits, demonstrating that for certain elective subspecialty clinics, telemedicine may be utilized as the preferred method for surgical consultations. However, to ensure the equitable adoption and advancement of telemedicine services, healthcare providers will need to focus on mitigating the socioeconomic barriers to telemedicine participation 1).

Kitov BD, Davarski AN, Kitova TT, Kilova KP. Letter: Telemedicine in Neurosurgery: Lessons Learned From a Systematic Review of the Literature for the COVID-19 Era and Beyond. Neurosurgery. 2021 Jun 16:nyab215. doi: 10.1093/neuros/nyab215. Epub ahead of print. PMID: 34133745.

The use of telemedicine drastically increased across all 4 divisions within the Neurosurgery Department, Thomas Jefferson University, and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, with a significant increase in online-first encounters in order to meet the needs of our patients once the shelter-in-place measures were implemented. Mouchtouris provided a detailed account of the lessons learned and discuss the anticipated role of telemedicine in surgical practices once the shelter-in-place measures are lifted 2)

The objective of Rodrigues et al. from Stanford was to assess patient satisfaction with telemedicine during the COVID-19 era.

Telemedicine visit data were gathered from Stanford Health Care (Stanford) and the Hospital for Special Surgery (HSS). Patient satisfaction data from HSS were captured from a Press-Ganey questionnaire between April 19, 2020, and December 12, 2020, whereas Stanford data were taken from a novel survey instrument that was distributed to all patients between June 22, 2020, and November 1, 2020. Participants: There were 60,550 telemedicine visits at Stanford, each linked with a post-visit survey. At HSS, there were 66,349 total telemedicine visits with 7,348 randomly linked with a post-visit survey. Main Outcomes and Measures: Two measures of patient satisfaction were used for this study: (1) a patient's “overall visit score” and (2) whether the patient indicated the highest possible “likelihood to recommend” (LTR) score (LTR top box score). Results: The LTR top box percentage at Stanford increased from 69.6% to 74.0% (p = 0.0002), and HSS showed no significant change (p = 0.7067). In the multivariable model, the use of a cell phone (adjusted odds ratio [aOR]: 1.18; 95% confidence interval [CI]: 1.12-1.23) and tablet (aOR: 1.15; 95% CI: 1.07-1.23) was associated with higher overall scores, whereas visits with interrupted connections (aOR: 0.49; 95% CI: 0.42-0.57) or help required to connect (aOR: 0.49; 95% CI: 0.42-0.56) predicted lower patient satisfaction.

They presented the largest published description of the patient satisfaction with telemedicine, and they identify important telemedicine-specific factors that predict increased overall visit score. These include the use of cell phones or tablets, phone reminders, and connecting before the visit was scheduled to begin. Visits with poor connectivity, extended wait times, or difficulty being seen, examined, or understood by the provider were linked with reduced odds of high scores. The results suggest that attention to connectivity and audio/visual definition will help optimize patient satisfaction with future telemedicine encounters 3).

Telemedical Deep Brain Stimulation: Merits and Limitations 4).

Jackson et al. performed a retrospective chart review of children with intracranial hemorrhage transferred for emergent neurosurgical intervention between January 1, 2011 and December 31, 2016. We identified those patients whose neuroimaging was transmitted via telemedicine to the neurosurgical team prior to arrival at our center and then compared the telemedicine and nontelemedicine groups. Mann-Whitney U and Fisher exact tests were used to compare interval variables and categorical data.

SETTING: Single-center study performed at Johns Hopkins Hospital.

PATIENTS: Patients less than or equal to 18 years old transferred for operative intracranial hemorrhage.

INTERVENTIONS: Pediatric transport implemented routine telemedicine use via departmental smart phones to facilitate transfer of information and imaging and reduce time to definitive care by having surgical services available when needed.

MEASUREMENTS AND MAIN RESULTS: Fifteen children (eight in telemedicine group; seven in nontelemedicine group) met inclusion criteria. Most had extraaxial hemorrhage (87.5% telemedicine group; 85.7% nontelemedicine group; p = 1.0), were intubated pre transport (62.5% telemedicine group; 71.4% nontelemedicine group; p = 1.0), and arrived at our center's trauma bay during night shift or weekend (87.5% telemedicine group; 57.1% nontelemedicine group; p = 0.28). Median trauma bay Glasgow Coma Scale scores did not differ (eight in telemedicine group; seven in nontelemedicine group; p = 0.24). Although nonsignificant, when compared with the nontelemedicine group, the telemedicine group had decreased rates of repeat preoperative neuroimaging (37.5% vs 57%; p = 0.62), shorter median times from trauma bay arrival to surgery (33 min vs 47 min; p = 0.22) and from diagnosis to surgery (146.5 min vs 157 min; p = 0.45), shorter intensive care stay (2.5 vs 5 d) and hospitalization (4 vs 5 d), and higher home discharge rates (87.5% vs 57.1%; p = 0.28).

Telemedicine use during interhospital transport appears to expedite definitive care for children with intracranial hemorrhage requiring emergent neurosurgical intervention, which could contribute to improved patient outcomes 5).

Existing literature suggests that use of telemedicine during postoperative appointments can increase access to care and is valued by patients and providers alike.

Selected patients with head trauma who have a pathological CT scan may be safely managed in level II trauma centres following neurosurgical consultation using teleradiology 6).

Telemedicine avoids unnecessary travel time and was welcomed by the majority of patients without compromising clinical or functional outcomes. 7).

Pediatric patients in areas of the continental US and its territories with limited access to pediatric neurosurgery services could benefit from this model, if other pediatric neurosurgery centers provide telehealth services 8).

The pooled data presents compelling evidence that the WhatsApp Messenger app is a promising system, whether used as a communication tool between health care professionals, as a means of communication between health care professionals and the general public, or as a learning tool for providing health care information to professionals or to the general population. However, high-quality and properly evaluated research is needed, as are improvements in descriptions of the methodology and the study processes. These improvements will allow WhatsApp Messenger to be categorically defined as an effective telemedicine tool in many different fields of health care 9).

Telemedicine in general provides clinical healthcare at a distance by using videotelephony and teleradiology and is used particularly in acute stroke care medicine (TeleStroke).

see Telestroke.

see smartphone

James describes the creation, structuring, and development of a pediatric neurosurgery telemedicine clinic (TMC) to provide telehealth across geographical, time, social, and cultural barriers.

In July 2009 the University of Florida (UF) Division of Pediatric Neurosurgery received a request from the Southeast Georgia Health District (Area 9-2) to provide a TMC to meet regional needs. The Children's Medical Services (CMS) of the State of Georgia installed telemedicine equipment and site-to-site connectivity. Audiovisual connectivity was performed in the UF Pediatric Neurosurgery office, maintaining privacy and HIPAA (Health Insurance Portability and Accountability Act) requirements. Administrative steps were taken with documentation of onsite training of the secretarial and nursing personnel of the CMS clinic. Patient preregistration and documentation were performed as required by the UF College of Medicine-Jacksonville. Monthly clinics are held with the CMS nursing personnel presenting the pertinent clinical history and findings to the pediatric neurosurgeon in the presence of the patient/parents. Physical findings and diagnostic studies are discussed, and management decisions are made. RESULTS The first TMC was held in August 2011. A total of 40 TMC sessions have been held through January 2016, with a total of 43 patients seen: 13 patients once; 13 patients twice; 8 patients for 3 visits; 2 for 4 visits; 2 for 6 visits; 2 for 5 visits; 2 for 7 visits; and 1 patient has been seen 8 times. CONCLUSIONS Pediatric patients in areas of the continental US and its territories with limited access to pediatric neurosurgery services could benefit from this model, if other pediatric neurosurgery centers provide telehealth services 10).

There is still much uncertainty as to whether it will have a permanent role in treating spine patients. Some of the ongoing legal challenges include patient confidentiality, liability coverage for treating healthcare workers, and financial reimbursements by insurance companies. One of the impediments of telemedicine is its lack of a standard legal framework. Telehealth is currently regulated through a state-based system with each state having its own policy regarding this practice. In addition, each of the components of a virtual visit represents a potential area for legal concerns. Nonetheless, telemedicine has the ability to provide convenient and effective health care to patients. However, the spine surgeon, as well as other physicians, must consider the legal issues along with some socioeconomic factors identified herein. Moreover, without parity and uniformity, the incentive to offer telehealth services decreases. There may be a need for modifications in the law, insurance policies, and medical malpractice coverage to strengthen their support for telemedicine usage. As spine surgeons become more familiarized with the telemedicine framework, its role in patient care will likely expand 11).

Zhu J, Lois AW, Gitonga B, Chen-Meekin JY, Williams EJ, Khandelwal S, Carrera Ceron R, Oelschlager BK, Wright AS. The impact of socioeconomic status on telemedicine utilization during the COVID-19 pandemic among surgical clinics at an academic tertiary care center. Surg Endosc. 2022 Mar 24. doi: 10.1007/s00464-022-09186-x. Epub ahead of print. PMID: 35332387.
Mouchtouris N, Lavergne P, Montenegro TS, Gonzalez G, Baldassari M, Sharan A, Jabbour P, Harrop J, Rosenwasser R, Evans JJ. Telemedicine in Neurosurgery: Lessons Learned and Transformation of Care During the COVID-19 Pandemic. World Neurosurg. 2020 Aug;140:e387-e394. doi: 10.1016/j.wneu.2020.05.251. Epub 2020 Jun 5. PMID: 32512241; PMCID: PMC7274123.
Rodrigues A, Yu JS, Bhambhvani H, Uppstrom T, Ricci WM, Dines JS, Hayden-Gephart M. Patient Experience and Satisfaction with Telemedicine During Coronavirus Disease 2019: A Multi-Institution Experience. Telemed J E Health. 2021 May 7. doi: 10.1089/tmj.2021.0060. Epub ahead of print. PMID: 33961522.
Zhang C, Zhang Y, Zhan S, Li D, Jin H, Denys D, Sun B. Telemedical Deep Brain Stimulation: Merits and Limitations. Stereotact Funct Neurosurg. 2018 Sep 5:1-2. doi: 10.1159/000491603. [Epub ahead of print] PubMed PMID: 30184552.
Jackson EM, Costabile PM, Tekes A, Steffen KM, Ahn ES, Scafidi S, Noje C. Use of Telemedicine During Interhospital Transport of Children With Operative Intracranial Hemorrhage. Pediatr Crit Care Med. 2018 Aug 21. doi: 10.1097/PCC.0000000000001706. [Epub ahead of print] PubMed PMID: 30134361.
Ashkenazi I, Zeina AR, Kessel B, Peleg K, Givon A, Khashan T, Dudkiewicz M, Oren M, Alfici R, Olsha O. Effect of teleradiology upon pattern of transfer of head injured patients from a rural general hospital to a neurosurgical referral centre: follow-up study. Emerg Med J. 2015 Dec;32(12):946-50. doi: 10.1136/emermed-2014-203930. Epub 2015 Oct 7. PubMed PMID: 26446312.
Reider-Demer M, Raja P, Martin N, Schwinger M, Babayan D. Prospective and retrospective study of videoconference telemedicine follow-up after elective neurosurgery: results of a pilot program. Neurosurg Rev. 2017 Jul 22. doi: 10.1007/s10143-017-0878-0. [Epub ahead of print] PubMed PMID: 28735437.
James HE. Pediatric neurosurgery telemedicine clinics: a model to provide care to geographically underserved areas of the United States and its territories. J Neurosurg Pediatr. 2016 Dec;25(6):753-757. Epub 2016 Sep 2. PubMed PMID: 27589599.
Giordano V, Koch H, Godoy-Santos A, Dias Belangero W, Esteves Santos Pires R, Labronici P. WhatsApp Messenger as an Adjunctive Tool for Telemedicine: An Overview. Interact J Med Res. 2017 Jul 21;6(2):e11. doi: 10.2196/ijmr.6214. PubMed PMID: 28733273.
James HE. Pediatric neurosurgery telemedicine clinics: a model to provide care to geographically underserved areas of the United States and its territories. J Neurosurg Pediatr. 2016 Dec;25(6):753-757. PubMed PMID: 27589599.
Perez-Roman RJ, Trenchfield DR, Perez-Roman NI, Wang MY. The Legal and Socioeconomic Considerations in Spine Telemedicine. Neurosurgery. 2022 Apr 1;90(4):365-371. doi: 10.1227/NEU.0000000000001856. PMID: 35086979.
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