General TeleneurologyA 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)
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)