While telemedicine is in expanding use in acute stroke care, little is known about its use in general neurology, especially in acute care. We sought to investigate the feasibility and possible effects of a telemedicine device within the neurological back-up service of an acute care hospital.
In a 450 bed academic teaching hospital an experienced neurologist (EN) is on call to support the junior doctor at the hospital. Support was possible whether by standard telephone advice (TA) or by audiovisual consultations (AVC). In AVC the expert used a mobile telemedicine device and so he could establish audiovisual contact from his home to the emergency room and examine newly admitted patients. Technical and patient details including timing and diagnosis were recorded. Video and audio quality as well as impact of AVC on diagnosis was rated by the EN.
Out of about 1200 cases in off peak times, during the study period, 164 AVC including remote video examination were done (13.6%). Also 48 cases were documented by pure TA. Video quality was rated to a medium of 1.7, audio quality to 2.1. In 36 cases the audiovisual consultation was influenced by technical issues leading to cessation of AVC in 8 cases. Duration of teleconsultation was 17.3 min in AVC compared to 8.7 min for TA. The consultation diagnosis in AVC was confirmed in 74.4% of all cases compared to 57.7% in TA. AVC was rated as a valuable contribution to the diagnostic workup in 74.3% of all cases seen. In about 40% of all cases AVC was not possible due to technical or organizational reasons.
Audiovisual consultation seems to be a feasible and useful support in routine neurology back-up service of an acute care hospital. Better mobility of devices and flexibility of service is needed to improve availability and quality of this valuable tool.
Telemedicine is in expanding use in acute neurological care as well as in rehabilitation service. Telemedical support in neurological care was studied in the first place for treatment of Parkinson’s disease  25 years ago. Other studies were focused on patients with epileptic seizures  or a general neurological outpatient service . However, most extensive use of telemedicine in clinical neurosciences is for acute stroke care, where feasibility and reliability in guiding therapy, after remote examination of stroke patients by audiovisual connection is well established [4,5,6], especially for facilitating administration of thrombolysis [7, 8]. Since then large networks had been established where specialists are on duty for telemedical assistance 24 h per day 7 days a week . Despite a 25 year history of teleneurology and first attempts to develop even training for teleneurology,  only few original scientific studies are published exploring telemedical care in general neurology [3, 11,12,13]. Most of this work used audiovisual communication to guide clinical examination and provide advice from a remote place. Additionally all of these studies reported on a specialized telemedicine service mainly focussing only on specific neurological diseases. Using audiovisual connection in standard acute care for neurological disease in a general hospital was never reported.
We sought to investigate whether audiovisual telemedicine is also possible and helpful in the routine care of a neurological department in an acute care teaching hospital.
Neumarkt General Hospital (NMGH, Klinikum Neumarkt) is a 450-bed acute care teaching hospital serving for a population of about 150,000 people in central Bavaria, offering the service of 11 medical departments. Since 2008 NMGH is part of the Stroke Care Network using Telemedicine in Northern Bavaria (STENO), one of the world’s largest telemedical stroke care networks including Neumarkt as a spoke in a network of 3 hubs and actually 17 spoke hospitals. Therefore, a telemedicine unit of STENO (EVITA L1, ORI GmbH, Erlangen) was already placed in one room of the emergency department providing full audiovisual communication between NMGH and one of the hubs for acute stroke cases. Technical details of the EVITA-system and organisation of STENO are described elsewhere in detail [14, 15].
In 2010 a neurological department was established providing 24/7 service for all acute neurological diseases. The neurological department cares for about 2000 patients per year, about 80% of them are admitted and first seen via the emergency room, half of them during off peak times (from 5:00 p.m. to 8:00 a.m on weekdays and all time weekend). Continuing service in off-peak times is secured by a junior physician (JP) located at the hospital while an experienced neurologist (EN) is on call at home. The junior physician is primarily responsible for all admissions to the department and all emergencies in patients on the neurological ward. If there is an incident that he cannot handle on his own he is able to call the neurologist at home to receive advice and support. The neurologist at home will be told the history and clinical findings taken by the junior physician via telephone. From his home computer the EN can also log into the information system of NGH via virtual private network (VPN) and could see results of diagnostic imaging or laboratory results as well as written statements on the actual or prior cases of the patients. A direct contact to the patient via video or audio connections was not possible before this study. If the EN would have to see the patient himself he had to drive to the hospital that means about 30 min ride. All five consultants of the department were involved as remote examiners during their normal on call duty, all five are board certified neurologists with long experience in clinical neurology.
To establish audiovisual connection there was a portable telemedicine system (EVITA Z1 mobil, ORI GmbH, Erlangen) bought for this study that was taken by the EN at home (Fig. 1) and handed over to the other colleagues on a rotation scheme. Connections were established via asymmetrical digital subscriber line (A-DSL) with a median data transmission rate from 6 to 100 MB/s. At the patient’s site in the emergency room the EVITA unit of the telestroke network had been used, data safety technology and regulations, therefore, were equal to the STENO network . Mobile telemedicine was already proven to be feasible in a telestroke setting .
Over the study period in each call to the EN he could decide to perform an audiovisual consultation (AVC). In AVC the Neurologist on call can see and examine the patient at the emergency room from his workplace at home, using the telemedicine system. He is also able to hear and talk to the patient. Assistance at site was provided by the junior doctor on duty that was with the patient in the emergency room. The JP was also able to hear and talk to the EN at home simultaneously to the patient via the central microphone and loudspeaker of the telemedicine unit.
Alternatively the EN could give advice via telephone in the traditional way such Telephone advice (TA) was structured prior to the study and a documentation record was implemented. There were also periods defined when each call had to be answered by AVC whenever possible. The EN had to note a diagnosis after the first call and after the AVC or TA. Diagnoses recorded before and after AVC as well as the admission diagnosis confirmed after personal examination at bedside the next day were compared for evaluation of diagnostic stability. All timelines, technical and organizational problems in the examination were recorded as well as demographic data of the patient. Quality of audio and video signal was rated by the remote examiner on a scale of 1–6 (1 = very good–6 = insufficient, similar to German school grades) as well his overall impression on the additional benefit of the AVC to the workup of the case (helpful—not helpful—undefined). All patients gave informed consent, the study was approved by the local ethics committee of the University of Erlangen.
Over the study period from May 2015 to November 2016 a total of 164 Patients were seen by AVC out of about 1200 patients admitted during the study period’s off-peak times, 86 were female, mean age was 64.3 years (18–93 years). In the initial phase of the study 48 cases were discussed by telephone advice (TA) only and documented by a structured record, mean age of these patients was 68.3 years, 26 patients were female. Mean duration of one AVC was 17.3 min including taking the history, in direct talk to the patient and a short talk to the JP in hospital while duration of one TA including documentation was 8.7 min (3–16 min). However, examination times differed according to the neurological disease or problem presented. Table 1 lists examination times for various diagnostic groups.
Video quality was rated by the ENs to a medium of 1.7 (min grade 1–max grade 3) with time delays in camera control, reduced dynamic contrast and interruption of images as main problems reported. Audio quality was rated to a medium of 2.1 (min grade 1–max grade 4), echo loudness control, and sound distortions were the main problems reported here. In 36 AVC cases there were technical issues influencing the course of AVC. In eight of these cases, the neurologist had to stop AVC and switch to telephone. In another six cases, the audiovisual communication could not get started due to technical reasons. The reasons of technical problems were handling errors in 10 cases, trouble in data transmission in 13 cases, in another 6 cases there were problems with the telemedicine unit at the emergency room and in another 7 cases with that at the examiner’s side. Details of all technical problems reported are listed in Table 2.
There were no substantial differences in examination time or frequency of technical issues between examiners with very low and high data transmission rates.
In 74.3% of all AVC performed the examiner rated the audiovisual communication as a valuable contribution to the diagnostic workup. Especially movement disturbances and paresis, differentiation of speech problems and vertigo a useful hint was experienced. Another benefit experienced was the direct talk to the patient completing the history that in some cases gave unexpected hints.
In 51.8% of all cases the initial diagnosis by the EN before consultation was changed after AVC. In 42 patients (25.6%) the diagnosis stated in AVC was also different to the admission diagnosis confirmed next day after personal examination. However, after pure telephone advice admission diagnosis differed in 42.3% of all documented cases to the consultation diagnosis. Therefore, the diagnosis stated in AVC was finally confirmed in 74.4% of all cases in contrast to 57.7% after TA.
As stated above, based on the decision of the EN on call 13% of all new admissions were seen by AVC. Within the period of obligatory AVC 61.2% of all new admissions were seen (52 cases). In the remaining cases AVC could not be done because the EN was not at home in 17 cases. In the remaining 15 patients, there were other technical or processual issues, e.g., the telemedicine room in the emergency department was not available.
Additionally there were 46 calls according minor problems of patients already in hospital at the ward. In 10 of these cases the EN rated a AVC to be suitable, however, it was not done as the telemedicine device was located in the emergency department only.
Our pilot study aimed to investigate the feasibility and the use of direct audiovisual communication to support the neurological clerkship service in an academic teaching hospital and to our knowledge this is the first study published to do so.
While telemedicine was already proposed as a solution to overcome an increasing nighttime shortage of hospital specialists  this is the first study published to test telemedicine in an on call back-up service of a neurological department. In our trial, audiovisual telemedicine was found to be helpful for increasing quality and safety of care, especially for emergency cases. It was rated to be valuable by the experienced examiners in most of all cases. Remote contact lead to a change of initial diagnosis in more than half of the cases compared to about 40% after pure telephone advice, consultation diagnoses were correct more often in AVC than in TA cases. So there could be a higher rate of diagnostic accuracy in video consultation. However, in many cases the direct talk to the patient, repeating the history, was as valuable as performing a clinical examination. Examination as well as taking history were of different value in different clinical problems. Variety of examination times may reflect the difficulties in evaluating the diagnosis. Unfortunately our numbers were too small to elicit the value of AVC in certain clinical problems. Additional studies may differentiate the use of telemedicine in various neurological symptoms and syndromes and proof the clinical effect of audiovisual telemedicine.
Technical problems hindering remote audiovisual communication were rare but not absent at all. There is no such study published to compare directly with our results, but telemedicine was already used in general Neurology. Craig et al. found in a cohort study that telemedical neurologic consultation was superior to standard care for inpatient service , standard care was without any routine neurological consultation in this study thus it demonstrates that telemedical consultation is superior to no involvement of neurologists at all. Feasibility was generally good within this study but there was a standard videoconference system used with low data transmission rates . However, there was communication between two hospitals in this study in contrast to a telemedicine service within one hospital or even one department as in our work.
Telemedical support was also tested for treatment of Parkinson’s disease  and in patients with epileptic seizures . Also within these studies technical details and obstacles of feasibility were described only in part. However, most experience of telemedicine in clinical neurology is from acute stroke care within telestroke networks in Europe and North America. In these networks, telemedical support is performed by a special service that is on duty for urgent remote assistance 24 h 7 days a week [6, 15]. Prior studies have indicated that experience from telestroke cannot be directly transferred into General Neurology  because of different features in examination. Additionally the setting is a different one: While in telestroke there is one specialist prepared for a standard stroke scenario and working with various teams in multiple hospitals at the patient’s bedside, the experienced neurologist on call in our study is working with his usual team, that he is familiar with, but is responsible for a variety of clinical problems to cope with. Therefore, telemedicine is not his method at all but one auxiliary technique within his work. This is one possible explanation for the relatively low frequency of telemedicine use on the voluntary basis of our study. However, other reasons are patient’s privacy that should prevent remote audiovisual transmission in every case when it is not really necessary and especially also technical reasons, that is, the availability of the device in one location at the patient’s and also at the examiner’s side. Future technical improvements may overcome these obstacles and lead to a more widespread and simple use of telemedicine in general acute care neurology.
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We are very grateful to Sonia Heinloth for proof-reading the manuscript.
Sources of funding
The project was funded by the Bavarian State Ministry of Health and Care (DE). There are no restrictions by the funders.
Conflicts of interest
None of the authors has any conflict of interest or any financial relationship to companies or products named in this article. All authors contributed substantially to the manuscript.
The study was conducted according to all common ethical standards including the rules given by the Declaration of Helsinki.
The study was approved by the ethics committee of the University of Erlangen.
All patients participating gave their informed consent prior to inclusion in the study.
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Cite this article
Janssen, F., Awadallah, M., Alhalabi, A. et al. Telemedicine in general neurology: use of audiovisual consultation for on call back-up service in an acute care hospital. J Neurol 265, 880–884 (2018). https://doi.org/10.1007/s00415-018-8756-4
- Clinical neurology