key: cord-0720794-x2ov8s2r authors: Sharma, Akshay; Winkelman, Robert D.; Schlenk, Richard P.; Rasmussen, Peter A.; Angelov, Lilyana; Benzil, Deborah L. title: The Utility of Remote Video Technology in Continuing Neurosurgical Care in the COVID-19 Era: Reflections from the Past Year date: 2021-09-09 journal: World Neurosurg DOI: 10.1016/j.wneu.2021.08.145 sha: 705bffcc0ca38b42276b15ca64e023b75c309be4 doc_id: 720794 cord_uid: x2ov8s2r Objectives The 2020 COVID-19 pandemic exposed existing stressors in the neurosurgical care infrastructure in the United States. We detail innovative technologic solutions inspired by the pandemic-related restrictions that augmented neurosurgical education and care delivery. Methods Several digital-health and audio-visual innovations were implemented, including use of remote video technology to facilitate inpatient consultations and outpatient ambulatory virtual visits, optimize our regional hospital neurosurgical coverage, expand our interdisciplinary patient management conferences (i.e. Tumor Board), and further enhance our neurosurgical resident education program. Enterprise patient-experience data was queried to evaluate patient satisfaction following the switch to virtual visits. Results Between January 2020 and April 2021 utilization of virtual visits more than doubled in the department of Neurosurgery. A survey of 10,772 patients following ambulatory visits showed that virtual visitation was equal if not better in providing satisfactory patient care than in-person visitation. After switching our interdisciplinary spine tumor board to virtual, we increased surgeon participation and attendance by 49.29%. Integration of remote audio-visual technology in resident didactics and clinical training improved ability to provide comprehensive and personalized educational experiences for our trainees. Conclusion Digital health technology has improved neurosurgical care and comprehensive training at our institution. Investment in the technologic infrastructure required for these remote audio-visual services during the pandemic will facilitate the expansion of neurosurgical care provision for patients across the United States in the future. Governing bodies within organized neurosurgery should advocate for the continued financial and licensing support of theses service on a national fiscal and policy level. Between January 2020 and April 2021 utilization of virtual visits more than doubled in the department of 13 Neurosurgery. A survey of 10,772 patients following ambulatory visits showed that virtual visitation was 14 equal if not better in providing satisfactory patient care than in-person visitation. After switching our 15 interdisciplinary spine tumor board to virtual, we increased surgeon participation and attendance by 16 49.29%. Integration of remote audio-visual technology in resident didactics and clinical training improved 17 ability to provide comprehensive and personalized educational experiences for our trainees. 18 Digital health technology has improved neurosurgical care and comprehensive training at our institution. 20 Investment in the technologic infrastructure required for these remote audio-visual services during the 21 pandemic will facilitate the expansion of neurosurgical care provision for patients across the United States 22 in the future. Governing bodies within organized neurosurgery should advocate for the continued 23 financial and licensing support of theses service on a national fiscal and policy level. minutes of set-up time prior to neurosurgical evaluation. In the setting of emergent neurosurgical need, or 12 even in the context of an already long and over-burdened day, this amount of time investment for setup 13 could be impractical. Another ongoing challenge was that the robot system has not been optimized to 14 include any surrogate participation, particularly problematic during the height of this pandemic when 15 family visitation was extremely limited. As neurosurgeons, delivering bad news is a frequent part of our 16 work made even harder if the patient is isolated. As remote technology expands in health care, wider 17 availability of access to machines and applications, by both providers and patients, will likely minimize 18 both the logistical time burden of and surrogate access to the inpatient virtual encounter. 19 At our affiliated regional hospitals, tele-neurosurgery was rapidly deployed primarily to cover the 21 multitude of inpatient and emergency consultations with limited neurosurgical staff. Prior to the pandemic 22 due to the rising demand of regional neurosurgical care, our affiliated staff found themselves spread thin 23 as they provided enterprise-wide call responsibilities for two Level-2 trauma centers as well as for all 24 neurosurgical services at 3 different regional hospitals. With limited staff at each hospital, frequent call 25 J o u r n a l P r e -p r o o f Sharma 6 burden for each hospitals' separate staff created a perfect environment for dissatisfaction and burnout. As 1 the hospital scaled back elective services at the beginning of the pandemic, our regional departments were 2 forced to re-evaluate and redistribute personnel for remaining urgent neurosurgical care. 3 The first stage of this plan involved merging the regional hospital staffs, who immediately provided call-4 coverage for all hospitals simultaneously using digital-health support with a team of APPs at each facility. 5 On the weekend, virtual rounds (via FaceTime®, Duo®, or InTouch Inc.) would be made at each hospital 6 seeing all critically ill patients, any patients with changes in their status, and any new consults seen 7 previously by the APP staff in-person. On an average day, a staff would complete 8-10 urgent or 8 emergent consultations, see multiple post-op patients and respond to the wide spectrum of patient-related 9 queries at all 3 hospitals. Second call, which was required because of trauma center designations and the 10 rare but potential requirement to have emergent surgical needs at both hospitals simultaneously, was 11 provided by Board-Eligible neurosurgical fellows who had little educational activity during the state-12 mandated moratorium on elective procedures. Initially, the program had to be approved by hospital 13 administration and the neurosurgical staff themselves. Within the context of uncertainty surrounding the 14 pandemic and necessary precautions, approval was expedited as a means to ensure the continuity of 15 emergent neurosurgical services at all hospitals. 16 The success of the endeavor during the height of the pandemic led the regional neurosurgeons to elect to 17 continue with this system upon hospital re-opening with slight modification. The transition required a 18 size increase in the APP team in order to supply sufficient full-time equivalents to provide first call 19 coverage all weekend and for 12 hours/day during the week. This total cost was ultimately less than the 20 salary support needed to compensate 3 separate staff to cover all 3 hospitals. Evaluation of the program 21 initially showed a reduction in satisfaction by the APP team, as they took on significantly more 22 responsibility and had new scheduling concerns; however, this was short lived as the staffing numbers 23 were increased. Staff satisfaction was also dramatically improved with the reduction in weekend call 24 requirements. Assessment by the emergency department, trauma team, and hospital leadership rated the 25 J o u r n a l P r e -p r o o f Sharma 7 quality and access to neurosurgical services as excellent. After 12 months, few, if any, patient safety 1 issues or quality issues have been raised. 2 From the onset of the precautionary lockdowns and even following the full-service reopening of the 4 hospital system for routine care, our institution placed significant emphasis on shifting a majority 5 outpatient clinical visits from in-person to virtual appointments. With the relaxation of HIPAA-6 regulations to allow patient evaluation with consumer applications such as FaceTime®, Duo® or Zoom® 7 (Zoom Video Communications Inc.), as well as certified virtual patient platforms such as AmWell 8 (AmWell Corp., Boston, MA), our department has found the transition to virtual patient visits to be 9 relatively seamless. Cleveland Clinic has had significant experience with the development of digital-10 health platforms over the last decade; however, utilization within the department of Neurosurgery was 11 limited until the pandemic. For reference, within the Center for Spine Health, utilization of virtual visits 12 increased from 3% to 40% of overall visit volume between 2019 and 2020 (with only a 13% decrease in 13 overall visit volume). Overall, the department of Neurosurgery doubled its utilization of virtual visits 14 following March 2020 in comparison to the previous year, with virtual visits accounting for a majority of 15 outpatient visits overall between March 2020 and May 2020, and at least half of all outpatient visits from 16 June 2020 and further ( Figure 2 ). 17 Patient satisfaction improved with virtual visitation (Table 1) . A total of 10,772 total visits were assessed 18 (5541 In-person office-visits and 5171 virtual appointments). Patient's were more likely to answer 19 satisfied or higher on a Likert scale from 1 to 5 in the virtual setting when considering the availability of 20 appointments (69.7% vs 63.3%, P<0.0001), degree to which they felt cared for by the provider (87.9% vs 21 85.8%, P=0.001), and the likelihood of recommending services to others (88.4% vs 86.7%, p=0.007). 22 When considering ease of scheduling, inclusion in decision making, and understanding the explanation 23 the provider gave, there was no significant difference in satisfaction between the virtual and in-person Our status as a quaternary-level referral center increases the likelihood that patients who seek care at our 1 institution live outside our conventional geographic catchment area. Decreased travel time and cost as 2 well as simpler logistical planning improved satisfaction, decreased tardiness, and improved coordination 3 with other provider visits that may have been scheduled on the same day. Patients could participate from 4 their own home or an acute care facility, and interested parties such as family or friends could join the 5 visit despite at many times strict in-person visitor limitations. When the visit started, the electronic 6 medical record was already open, allowing for ease of access to the electronic patient-provider interface. 7 For example, sharing virtual resources or reviewing patient radiographic studies was simple using screen-8 share functions, and prescriptions could be written or orders placed with only a few simple steps. A large 9 portion of the outpatient visit is composed of history taking, counseling and answering questions, refilling 10 prescriptions, planning and setting expectationsall essential components of relationship building with 11 patients. These tenets of the physician-patient relationship are easily met and strengthened in the virtual 12 visit (Table 1) . Finally, limiting the number of people that needed to come out of their home environment 13 to the institution was advantageous in infection control for both patients and staff. 14 Conducting outpatient virtual visits was initially thought to be limited mainly by the inability to perform 15 an in-person physical exam; however, with time and some imagination, we found that the critical 16 components of the neurologic exam were accessible through the virtual platform. For example, the use of 17 lifting common household objects and observing simple tasks done by the patient could be used to assess 18 motor function and symmetry. Including a family member in the exam who could provide direct tactile 19 stimulation allowed for directed sensation-grading, or if they could operate the mobile-camera, a more 20 thorough inspection of a wound or drainage. Enough information could be elicited to make reliable This would either allow us to provide immediate recommendations and care planning, recommend they 1 come into the office for an in-person visit, or confirm the need for presentation immediately to the 2 emergency department. This limited unnecessary emergency resource utilization, cost, and exposure for 3 our patients. 4 One of the strengths of virtual visits has been its utility in providing an optimal learning environment for 6 neurosurgical trainees. Using a group chat model of conferencing, the video visit allows residents and 7 other trainees to interact with a patient with the attending physician present, observing more naturally in 8 the virtual setting than would be feasible in the in-person setting. Our use of virtual visits has allowed a 9 rare opportunity for our trainees to obtain specific and direct feedback on communication skills, physical 10 exam techniques, and history-taking abilities. The ability for attending physicians to be present in the 11 virtual chat rooms allows for these interactions to take place in a time-efficient manner that is usually lost 12 on a normal busy in-person clinic day. This is especially valuable as increasing inpatient clinical demands 13 pull residents away from outpatient experiences, and increasing outpatient clinic volumes limit the 14 amount of teaching trainees can receive during a normal clinic-day. 15 Growing digital clinical services required a bolstering of our electronic imaging infrastructure and the 17 ability to easily transfer images from outside centers or facilities for review during virtual visits. 18 Neurosurgery is heavily dependent on diagnostic imaging findings for treatment planning 12 , and many 19 neurosurgeons prefer to review the hard images as opposed to only reading imaging reports from 20 radiology. With patients no longer coming to in-person clinic appointments with imaging in-hand, 21 development of a patient-accessible system was necessary to allow for efficient image-sharing from 22 outside institutions with our clinical staff. Our institution had previously implemented a secure online 23 patient portal, through Ambra® Health, that allows patients to easily upload DICOM images directly 24 J o u r n a l P r e -p r o o f Sharma 10 from a CD-ROM via a website. This then directly imports into our EHR and imaging library. This process 1 negates the need for a physical disc to be mailed or couriered to our facility, and shortens a 1-week 2 process to less than 48-hours. In some cases, with provider facilitation, staff can request upload of images 3 into EHR within a few minutes of entry into the portal. Similar infrastructure has been implemented for 4 digital media and clinical photos collected from patients, such as wound photos, which can be directly 5 emailed to a secure central server for upload and documentation in the electronic patient chart. 6 Our health-system also participates in a national image exchange program, in which our picture archiving 7 and communications system (PACS) allows for electronic image exchange with complementary servers at 8 over 200 health systems around the country. This allows for seamless transfer of high data-volume images 9 across systems within minutes, and without the need to burn the images to a physical disc, or the need for 10 transport services for hard copies from hospital to hospital. In October 2020, our Neurologic Institute 11 partnered with our Central Transfer Center to coordinate and facilitate electronic image export at the 12 initiation of an inpatient transfer request. This allows images to be available to our on-call staff in many 13 cases at the time of the initial transfer request and discussion. Our surgeons can then more accurately 14 triage remote patients, counsel the consulting physicians, and prepare for care once patients arrive at our 15 hospital, sometimes from great distance and in many cases in critical condition.. 16 The transition of our interdisciplinary patient management conferences was one of the more intuitive The benefits of the transition to a virtual platform are best exemplified by our Spine tumor board. As one 1 of our newer interdisciplinary meetings, we struggled with coordination of schedules and location as our 2 Center for Spine Health resides in a separate building on campus, multiple blocks away from offices of 3 the collaborating staff from radiology, radiation oncology, and medical oncology. In contrast, our cranial 4 and neuro-oncology staff share office space with these colleagues within the Brain Tumor Institute, 5 which makes it easier to coordinate schedules in a way that would accommodate attendance and 6 participation in the conference while also balancing busy clinic or inpatient schedules, surgical cases and 7 start times, and other clinical duties. Inconsistent attendance limited the discussion of patient cases and 8 further coordination amongst services. While significant accommodation had been made prior to the 9 pandemic to provide a virtual platform for the spine tumor board, it wasn't until pandemic lockdowns 10 forced the shift to the virtual platform, as well as the major market introduction of the Zoom® 11 application, that virtual attendance became a reality. The reduction of elective cases early in 2020 likely 12 facilitated improved spine surgeon participation in the conference; however, even with the restart of 13 elective procedures, improved attendance was sustained and engagement maintained through remote 14 technology. For surgeons, there is no longer a need to travel to a different building for the conference 15 prior to or during OR cases; a surgeon can simply participate in discussion from their office or while 16 waiting for anesthesia induction and preparation prior to cases starting. Supporting staff joining the 17 meeting virtually (scheduling, nursing, and case managers) can also follow along and facilitate further 18 enhanced care-coordination simultaneously. With increased attendance, we have noted an improved 19 robustness in the discussion and significantly increased ease in coordinated and integrated care amongst 20 our collaborating services (Figure 3) . 21 As we have expanded our membership, we have found places for extra-institutional involvement as well. 22 Cases from the surrounding region or even internationally, presented by physicians looking for a second 23 opinion or more nuanced recommendations for patients not affiliated with our institution have been 24 presented at our Brain and Spine tumor boards in few instances. Though we have not made arrangements 25 J o u r n a l P r e -p r o o f Sharma 12 for formal inclusion of guest presenters, we recognize the promise this program imparts in expanding our 1 ability as a highly specialized neurosurgical center to deliver high quality neurosurgical care around the 2 world. 3 In the days following a state-wide mandated canceling of elective surgeries in Ohio, our neurosurgical 5 service found itself slowing to almost a standstill as residents and faculty limited in-hospital activities to 6 those only deemed emergent or essential. Daily in-person educational conferences, a departmental point 7 of pride for faculty and residents, were cancelled and residents were left without structured sessions that 8 formed the backbone of the resident-led education program. Capitalizing on available remote 9 conferencing technology, and the open schedules of many of the department faculty, six days following 10 the hospital shutdown our department shifted to daily 1-2 hour "grand-rounds"-style virtual lectures that 11 focused on a range of neurosurgical topics ( Figure 4A ). These included time for resident and faculty 12 discussion and debate, and continuing medical education credit was granted to faculty who attended as 13 presenters or in the audience. 13 These lectures continued daily for almost 2 months until an institution-14 wide reopening for normal hospital services was approved ( Figure 4B ). The conferences still continue 15 daily, however have been abridged to 30 minutes prior to first round surgical cases, and now resemble a 16 virtual version of our previous resident-driven morning conference program. We have found the virtual 17 platform allows residents to participate in lectures more efficiently while balancing early morning patient-18 care responsibility. Furthermore, it allows faculty to join in with much more ease to supplement resident 19 education with their practical experience. Faculty attendance was more cumbersome and limited prior to 20 moving to the virtual system. Even further, department interdisciplinary conferences (morbidity and 21 mortality conferences, tumor boards, spine surgical indications conference, cerebrovascular case 22 conference, etc.) have adopted virtual platforms, as detailed previously, increasing the accessibility of 23 these learning opportunities to residents. In the context of a busy clinical day including rounding, 24 J o u r n a l P r e -p r o o f Sharma 13 documentation, consults, operative cases, and sign-out rounds, virtual access to educational conferences 1 allows residents to supplement their education more efficiently and completely than in the past. 2 There is a paucity of literature demonstrating the effective utilization of modern digital-health strategies 4 within neurosurgical care, either in the inpatient and outpatient setting, outside of the realm of acute 5 endovascular stroke intervention. 5 A new study of ambulatory neurosurgery consultation services over 6 the last year has shown positive provider and patient experiences, similar to our own. 14 For our institution, 7 provider and patient experience have both been positive, with virtual clinics allowing for more efficient 8 yet equally medically valuable visits with patients. Our analysis of satisfaction surveys allowed for review 9 of a large sample of patients (n=10,772). While significant differences were noted in the satisfaction 10 among patients attending in-person and virtual visits, it is important to note that the raw difference in 11 percentages was no more than 7% for any category. With our data we can conclude at the very least that 12 virtual visitation matched and, in some cases, may have slightly exceeded in-person visitation to further 13 support validated use of the technology for ambulatory neurosurgical care. importantly, imaging findings to guide clinical decision making. 12, 19 The majority of the time, information 1 provided amply in a virtual visit or consult is more than adequate to proceed with safe surgical decision 2 making, especially as immediate and shared access to the EHR in a virtual context, allows for 3 simultaneous review of relevant imaging and lab work while collecting the clinical history during the 4 visit. For our institution, adoption of digital-health technology in multiple realms of patient care has 5 served as a practical supplement and substitute to classical neurosurgical services. Our adoption of these 6 remote technologies has allowed us to leverage our workforce and expand our traditional services to 7 include a broader patient population in a cost-effective manner. 8 Our experience over the last year utilizing digital neurosurgical resources has allowed us to expand the 9 delivery of neurosurgical care and augment resident education. Evidence exists to suggest that the 10 regionalization of neurosurgical care and the development of "Centers of Excellence" --single centers in 11 which highly subspecialized neurosurgical care is provided in high volume--decreases the rate of adverse 12 events while improving patient safety and outcomes. [20] [21] [22] These new technologic modalities as described, 13 present an opportunity to extend specialty neurosurgical evaluation and intervention to areas of the 14 country that previously had poor access, and as such broadly improve the quality of that care when 15 delivered. Remote technologies allow for the expansion of care networks. This counteracts the impact of 16 workforce shortages, resource poor environments, and geographic and distance-base limitations, as it has 17 in fields such as acute stroke care. 4, 7, 8, 23 18 As we have demonstrated, the possibilities for use of this technology in patient care include but are not 19 limited to direct neurosurgical consultation for evaluation, inpatient rounds, and formalized inclusion of 20 patient cases in multidisciplinary treatment panels. New opportunity to expand digital neurosurgery 21 services exists in the development of new technology. 11 For example, the addition of wearable or remote 22 monitoring devices (smart watches, phones, surgical implants, etc.) to neurosurgical care to provide 23 "home" data could add a layer of personalization to care plans that has not previously existed 24 . Further, 24 "store-and-forward" monitoring utilizing digital databases, in which patients proactively collect and 25 J o u r n a l P r e -p r o o f Sharma 15 report data in a continuous fashion could allow providers access to insight not seen in the typical episodic 1 patient-provider interaction (e.g in seizure frequency recording in the treatment of medically-refractory 2 epilepsy). 11,25 Telesurgery and use of robotic technology to perform neurosurgical procedures remains of 3 frontier in innovation that would revolutionize the ability to provide distance-based neurosurgical care in 4 the future, however the field remains in its infancy though show some promise in the realm of 5 endovascular stroke intervention. 11,26 6 Neurosurgical education has also experienced a true evolution in the last year. 27,28 Beyond the changes 7 made at our institution 13 , nearly all Neurosurgery-related national conferences adopted a virtual platform 8 for the 2020 annual meetings, and many will be extending virtual options in addition to the standard in-9 person forums for 2021. New online resource forums, such as the Neurosurgical Atlas® (Neurosurgical 10 Atlas, Inc.) have expanded significantly, and the Congress of Neurological Surgeons (CNS), and the 11 professorships, lecture series and online resources to replace previously held in-person CME. This 13 transition has allowed for an exponential increase in the availability of such neurosurgical education 14 resources, as attendees may have been previously limited from access due to time constraints or travel 15 cost. 27 Our institutional interdisciplinary meetings have been enhanced by the digital platform, with 16 improved attendance and participation among surgeons. This easy transition can serve as a simple 17 solution to decrease the logistical and fiscal burden for future academic meetings, medicolegal 18 proceedings, and other events in which neurosurgeons must make large sacrifices to appear and provide 19 their expertise. At our institution, daily conferences have now transitioned to a virtual platform, and have 20 enhanced access to these resources for residents and staff throughout a busy clinical work-week. Our 21 ability to integrate residents into our virtual clinics has provided a new layer of observed clinical 22 experience that allows for feedback and education not previously available to our program in its history. around the country. 10, 14, 19 At this time, save for a few handful of states and territories, there appears to be 1 no plan to provide waivers of the regulatory burden past the period of the public health emergency. This 2 may stifle the unexpected progress made over the last year using virtual technologies to improve 3 neurosurgical care deliveries at specialized centers around the country. As policies lapse or expire, much 4 of the capital investment made into digital infrastructure during the pandemic may become useless or too 5 burdensome to use for neurosurgeons transitioning back to typical practice in the United States. As the 6 country prepares to enter a post-pandemic era, organized neurosurgery societies within the United States 7 should develop formal guidelines on digital neurosurgical care, advocate for the expansion of interstate 8 medical licensure and support the current Interstate Medical Licensure Compact (IMLC) now adopted by 9 34 states, encourage the sharing of medical information and imaging across institutions, and continue to 10 work with CMS to continue reimbursement for digital neurosurgical services. Further these bodies should 11 continue to support neurosurgical innovation in digital health including investing in broadband 12 infrastructure in the United States, development of remote monitoring devices for neurosurgical disease. 13 Our experience using remote health technology previously and over the last year at the Cleveland Clinic 14 has allowed us to develop an infrastructure to balance ongoing pandemic-related healthcare stressors 15 while also building a platform to expand our delivery of neurosurgical services to patients in-need across 16 the country. Our discussion is focused on neurosurgical practice in the United States, a resource-rich 17 environment in which we are privileged to practice, and as such, may lack insight into infrastructural 18 gaps, policy nuances, and cultural differences that may affect care in other countries, particularly low-and 19 middle-income countries around the world. Nevertheless, the lessons learned in the past year reflect a new 20 model for neurosurgical care delivery that can be leveraged world-wide to expand delivery of essential 21 neurosurgical services worldwide. 22 Remote video technology and the implementation of neurosurgical digital-health has proven to be a useful 24 adjunct for the provision of neurosurgical care and continuation of resident education at our institution 25 J o u r n a l P r e -p r o o f Figure 1 -Inpatient Technology. The InTouch Health mobile televideo unit could be mobilized from a 11 central docking station to patient rooms around the hospital for remote patient exams or video team 12 rounds. 13 The Next Generation of Office Communication Tech Access to neurosurgical care: A critical component of the manpower 10 equation Neurosurgical coverage: Essential, desired, or irrelevant 12 for good patient care and trauma center status Telestroke: The promise and the challenge. 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