2,3 We have had success with Zoom, in particular, for patients who were unable to complete setup of the primary telemedicine platform in use at PSH-MSHMC (American Well). The increased access allows use of Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, or Skype. Although it is preferable to use Health Insurance Portability and Accountability Act (HIPAA)-compliant platforms, the Centers for Medicaid & Medicare Services (CMS) relaxed rules and expanded access to telehealth in March and April 2020, in response to and for the duration of the pandemic. Second, it is important to provide adequate technical support to the caregiver for setting up the telemedicine platform, with consideration to having an alternative platform as a backup. A caregiver needs to be present for the visit to provide a distraction-free environment, give collateral information, and assist with use of the telemedicine platform as needed. Furthermore, extra time may need to be scheduled for the evaluation of a new patient with cognitive concerns, both because of technical challenges of telehealth and the inherently time-consuming nature of a thorough cognitive evaluation. Individuals with cognitive impairment are especially vulnerable to being lost to follow up because of miscommunication or misunderstandings during the scheduling process. Clinic schedulers may not be aware of the special needs of a patient with mild cognitive impairment or mild dementia who require greater assistance during scheduling and telehealth set up. First, it is important to give clear instructions to the schedulers that a caregiver is required to be present for the entire teleneurology visit. Adapted Workflow Proceduresĭuring scheduling there are 2 important considerations. Hershey Medical Center (PSH-MSHMC) in learning to adapt the cognitive neurology evaluation to a telemedicine platform. In this article, we share our practical experiences “from the trenches” at Penn State Health Milton S. Although there are unique challenges posed by the telemedicine platform for the cognitive neurology evaluation, as noted, unexpected benefits have also been seen. This sudden change has been both disruptive and illuminating-shedding light on the essential (and nonessential) in-person components of our clinical work. Many of us have quickly transitioned to telemedicine, in an expedited manner out of necessity, because of the havoc wreaked by the COVID-19 pandemic.
An obvious limitation is the inability to perform full neurologic and neuropsychologic examinations, although some adaptations are possible. Telemedicine also allows more convenient follow up for established patients with dementia and limited mobility. In fact, telemedicine offers some unique advantages-including the ability to obtain “collateral information” and evaluate environmental safety concerns by visual inspection of a patient’s home environment. Fortunately, telemedicine largely does not affect the history-taking process.
As DeJong noted in The Neurologic Examination, “A skillfully taken history will frequently indicate the probable diagnosis, even before physical, neurologic, and neurodiagnostic examinations are carried out.” 1 This is perhaps especially true for cognitive neurology. The neurologic evaluation is rooted in history taking.