AANS Neurosurgeon | Volume 28, Number 4, 2019


Virtual Neurosurgery: The Future is Here

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Imagine practicing neurosurgery in a time and place where patients come in person only to see you at the time of their surgery. Sound far-fetched? Impossible? Not really, as that world exists today. Through the collision of personal smart phones, high-speed internet and digital health delivery tools, that imaginary world is now a reality.

eMedicine Has Arrived

Over the last 5-10 years, the world has seen an explosion in growth of the technologies that support and deliver the above vision. Here is an example of current state capabilities:   

A patient from southern Ohio (more than 2 hours away) is referred for second opinion, calls to schedule as an in-person consultation in Cleveland. Instead, a virtual visit is offered to the patient and family. Prior to the virtual appointment, the patient electronically sends the MRI and angiogram from their home to our hospital PACS system, and the records from her local PCP and neurosurgeon are electronically shared via common EHR. At the time of the virtual appointment, a meaningful review of the patient’s history, prior records, and imaging is done. A limited cranial nerve and motor exam is conducted through video, and a recommendation is made for Gamma Knife Radiosurgery to treat the deep-seated, non-ruptured AVM. Informed consent (IC) discussion occurs at the same time, both parties sign the IC electronically via the Internet, and the patient arrives in Cleveland days later for her procedure.  All follow-ups are then done via virtual visit with imaging obtained at her local hospital and transmitted electronically. 

This vignette illustrates only a few of the myriad of digital technologies that exist that allow for high-quality, complex care at a distance. Generally speaking, digital health technology is grouped into two buckets:  Synchronous and asynchronous. Synchronous almost always means live audio with or without accompanying video. Asynchronous involves the storage of medical data in some form which is then transmitted to a provider for action and response in the future. Asynchronous digital health encompasses:

  • Transmission of medical records and images such as X-ray, CT, MRI or photographs for review;
  • Transmission of physiologic data such as HR, heart rhythm, blood pressure, temperature, activity, glucose level, postural stability, tremor, etc.;
  • Request for an eConsult from another provider; or
  • Request for an eVisit from a patient.

eConsults and eVisits

These later two are well-recognized digital delivery mechanisms that are increasingly popular with patients, providers, and payors.  To understand eConsults, think of a traditional, curbside consult from a colleague.  Instead of “Hey, Mary/Mike, do you think you can do a vertebroplasty on Mrs. Smith?”   An eConsult would involve submission of a request through the Electronic Health Record (EHR) to a colleague (Dr. Mike Steinmetz, Chair Department of Neurosurgery, Cleveland Clinic) who would then review the relevant EHR records, associated images, and then write a response that is documented in, and routed back to, the requesting provider via the EHR.  eConsults have been shown to dramatically decrease the time to specialty consultation and improve access to specialty care.  From a specialist viewpoint, this allows for greater access to their expertise and allows for more appropriate triage of patients.   In contrast, an eVisit is initiated by a patient through the EHR to a provider who then reviews the request (often with directed history prompted by branching logic algorithms) and responds to the patient back through the EHR.  For routine concerns and follow-up, eVisits score high marks from a patient experience and satisfaction perspective.

What About the Personal Touch?

Perhaps is will come as a surprise that  all aspects of digital health score as high or higher than in-person visits from a patient experience or consumerism standpoint.  Often the combination of the convenience along with access to physicians from their home, delights patients well beyond an office visit.  And let’s be real about this…  who would really want to travel and wait to talk with us even in the nicest of waiting rooms? Currently, insurance companies limit payment for this yet many patients are more than willing to pay out of pocket because of the advantages and appeal.  No doubt, insurers will soon recognize this and policy will follow.

eMedicine and Neurosurgery’s Future

Notably, it’s now possible to “see” many neurosurgical patients without literally seeing them. Take just a moment to ponder that…  This concept has profound implications in many regards, including the need for office space, office personnel, and overall clinical efficiency.  Now think about how this impacts your ability to access new patient markets or for others to access your patient market.  And that doesn’t even begin to contemplate the non-traditional health care providers disrupting traditional health care space.  Major changes to health care delivery secondary to growth of digital tools will change health care delivery dramatically.  Ten years from now, it is easy to imagine neurosurgery with 30-50% virtual care while improving patient satisfaction and quality of care.  Bring it on!

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