General Teleneurology A 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) 25 beds (Allendale and Williamsburg) 800 beds (Greenville)

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)