Telemedicine Effectively Treats Parkinson’s Patients

For Parkinson’s patients with limited access to specialists, telemedicine offers an opportunity for neurologists to evaluate and treat patients in their homes.

Telemedicine continues to gain in popularity. With the use of videoconferencing software similar to Skype, patients can have a virtual visit with a physician, saving the time and expense of travel associated with in-person visits.

While telemedicine generally has been used to provide care to patients in hospitals or clinics, it also can deliver care directly to patients in their own homes. “The visits are analogous to the traditional in-person visit in every way except that the physician and the patient are in different geographic regions,” explain E. Ray Dorsey, MD, MBA, and Kevin Biglan, MD, MPH, neurologists at University of Rochester Medical Center in New York. “The physician takes a history, performs an examination—modified for the virtual encounter—and makes recommendations about care to the patient and the patient’s other physicians.”

Dorsey and Biglan coauthored the study “Virtual Visits for Parkinson’s Disease,” published in Neurology: Clinical Practice, which provided telemedicine consultations with specialists to patients with Parkinson’s disease at their homes or local facilities.

Focus on Parkinson’s Disease
Access to specialized neurological care improves outcomes, and while there are enough neurologists to care for patients with Parkinson’s disease, distance can prevent many patients from seeing specialists. Fortunately, Parkinson’s disease is well suited for telemedicine because physicians can observe how these patients are doing without physically touching them.

“We have previously demonstrated that the vast majority of the standard Parkinson’s disease examination, which includes visual assessments of tremor and gait, can be performed remotely and closely correlates with in-person assessments,” Dorsey and Biglan say. The physicians can follow patients remotely over time much like they do in a clinical setting, assessing treatment response and complications by asking patients how they feel and by conducting a remote focused neurological exam.

Treatment approaches for Parkinson’s disease include medication, surgical therapy, and general lifestyle modifications. Through the virtual visits in the study, the neurologist could make treatment recommendations such as increasing exercise, prescribing new medications or changing current dosages, and discussing surgical options.

The majority of patients were satisfied with the telemedicine care, and many said they prefer it because they feel more comfortable in their own homes. They also appreciated receiving expert care from a specialist who was knowledgeable about Parkinson’s disease.

“Primary care physicians, geriatricians, and other physicians generally provide the best care they can for individuals with Parkinson’s disease and other conditions,” Dorsey and Biglan explain. “Neurologists, especially those who specialize in the care of individuals with movement disorders such as Parkinson’s disease, are more familiar with the condition, its associated conditions—everything from constipation to depression—and the treatment approaches ranging from exercise to surgery. An important study by Allison Willis, MD, found that more than 40% of Medicare beneficiaries with Parkinson’s disease do not see a neurologist, and those who don’t are 20% more likely to fracture a hip, be placed in a skilled nursing facility, and to die. She says, ‘We are trying to use technology to enable anyone anywhere to receive the care that they need.’”

How It Works
Patients can download secure HIPAA-compliant Web-based videoconferencing software that requires only an Internet-connected computer and a webcam. Elder patients already may be familiar with this type of technology from using Skype to communicate with their grandchildren.

For the project, the patients were provided with the software via an e-mail link. Dorsey and Biglan used software from Vidyo and SBR Health, which provides additional functionality such as enabling a virtual waiting room. Assistants provided technological support over the phone, instructing the patients on how to install the software, use the webcam, and test the connection before the appointment. Additionally, the patients provided a medication list and contact information for local physicians monitoring their Parkinson’s disease.

While the majority of visits occurred in the patient’s home, the remainder took place in local facilities, enabling the participation of patients who didn’t have a computer or didn’t understand how to use the technology. According to Dorsey and Biglan, the technology is commercially available and generally costs much less than office space.

Spreading the Word
The study’s telemedicine program was promoted via website, community outreach, national meetings, social media, and media coverage. Dorsey and Biglan, who have had patients come to them in several ways, offer the opportunity for virtual visits to patients they see in clinics and nursing homes.

“We, especially Dr Biglan, see patients in nursing homes in upstate New York... Not only do patients residing in these nursing homes have the opportunity for subspecialty telemedicine visits, these homes open their space for patients with Parkinson’s disease residing in their communities to see us virtually,” Dorsey says.

Later this year, Dorsey and Biglan plan to launch a program that will enable anyone in the state of New York who has Parkinson’s disease to virtually see a Parkinson’s disease specialist from home at least once, regardless of the ability to pay. “Our vision is that anyone anywhere can receive care. To fulfill that vision, we need to develop the internal processes and secure external resources,” they say.

Medicare coverage is a significant barrier to wider adoption since Medicare doesn’t pay for telemedicine care provided to people in their homes. According to the neurologists, “While Medicare will pay for telemedicine encounters originating where the patient is at the time of the visit—in hospitals, physicians’ offices, and nursing homes—this is limited to specific geographic regions. And while many of our patients do not have access to subspecialty care, Medicare will not reimburse for telemedicine visits originating in any of the nursing homes we serve. Political will from older Americans who want to receive care for their conditions independent of where they live will be required to change Medicare’s reimbursement policies. Currently, Medicare pays $200 for a follow-up visit for Parkinson’s disease if done in a hospital-based clinic; $100 if done in a community-based clinic; and $0 if done virtually in the home. To change these policies, older—and all—Americans will have to let Medicare know how they want their tax dollars spent.”

In addition to reimbursement, another challenge is providing care across state lines, as many states prohibit out-of-state physicians from providing remote care.

While there still are barriers to be overcome and policies to be changed to enable widespread adoption, in-home telemedicine care has been demonstrated to be feasible, effective, and just as good as care received at an academic medical center.

— Heather Hogstrom is an editorial assistant for Today’s Geriatric Medicine.