Telemedicine in Movement Disorders: Leçons du COVID‐19

The coronavirus disease 2019 (COVID-19) pandemic and enforced lockdown in many regions of the world has obligated a fundamental restructuring of the way in which care is delivered to patients with movement disorders. Most clinicians have faced a common dilemma—trying to care for their vulnerable and often elderly patients, with comorbidities, while minimizing the risk of viral transmission. Equally, social distancing norms have led to great upheavals in the research sphere. Clinical trial recruitment has often been suspended, with difficult questions raised about how best to structure follow-up assessments for those already enrolled. These extraordinary circumstances have, in most instances, necessitated the use of telemedicine as a proxy for traditional "face-to-face" encounters. Synchronous communication modalities such as videoconferencing, phone interviews, and occasionally instant messaging have enabled remote assessment and monitoring to continue, while innovative technologies such as wearable devices have been proposed as potential substitutes for gathering data that in normal circumstances would be obtained through history and physical examination. As the number of COVID-19 cases drops, social restrictions will eventually be eased and "normal life" will resume. What is less clear is what lasting impact the change in working practices that have been required during the past few months will have on movement disorder practice going forward. Some argue that this global pandemic should act as a "catalyst" for increasing the use of telemedicine in neurological care.1, 2 Although remote consultation may be appropriate for a subset of patients, for example, some follow-up appointments for stable individuals or those living in remote areas, applying this strategy more broadly could have a number of important negative consequences. Technological innovation will increasingly be incorporated into our practice in years to come. Indeed, if nothing else, the COVID-19 pandemic has exemplified how well technology can respond to a specific set of demands within healthcare systems. However, a number of questions need to be addressed regarding its impact on the doctor–patient relationship, medical education, accuracy of diagnosis, and treatment. Moreover, important caveats remain related to the use of remote monitoring devices. Just as Charcot, in his "Leçons du Mardi," stressed the importance of critically observing each patient, we too in our "Leçons du COVID-19" observe what this pandemic can teach us about telemedicine in movement disorders. We highlight that telemedicine is not a substitute for face-to-face encounters but, rather, a useful adjunct to the clinical consultation in response to specific healthcare demands. We also hope that this discussion spurs further debate as to its optimal deployment within our field. Despite technological progress, the doctor–patient relationship remains the cornerstone of clinical medicine. It is a privileged medium through which information is gathered, questions answered, therapeutic plans formulated, and alliances constructed.3 Any breakdown in this compromises adherence to therapies and promotes negative health outcomes.4, 5 In the field of movement disorders, doctor–patient relationships arguably assume even greater importance. Many of the diseases that we treat span decades and often lack curative therapies. In such instances, the cooperative camaraderie that develops between doctor and patient may be of great solace. Maintaining this connection is therefore paramount. Face-to-face interactions have been recognized for centuries as critical to the development of trust and alliance, and there is concern that the filtered interactions of telemedicine may impede patient–physician entente. Bonding is strongest for in-person interactions and declines stepwise through the adoption of video-chat, audio-chat, and, finally, instant messaging mediums.6 The nuances of humor, "personal touch," and tacit knowledge often get lost via telemedicine, and the least favorite aspect for patients is often the difficulty in establishing personal connections with the physician.7, 8 In a cohort study involving 258 patients receiving remote videoconferencing follow-up for Parkinson's disease, only roughly 30% agreed that teleconferencing was "better overall," whereas even less felt that they had received "better care."9 As one patient stated, "I found that the visit was not hands-on. It should not replace in-person totally."7 Such communication issues assume particular relevance for "difficult conversations" such as palliative care and brain donation, which are frequent in movement disorder practice. Therapeutic equivalence between face-to-face and telemedicine consultations remains to be conclusively proven. It is well established that patients with neurological diseases, particularly Parkinson's disease, experience significant placebo responses, at times approximating the benefit of medications,10 and that these are the product of complex, multifaceted psychosocial circumstances and attribution of significance to therapeutic rituals that have at their core doctor–patient interactions in specific environmental milieus.11 The effect of telemedicine on this remains unknown. Furthermore, patients' understanding of management plans, which are essential in ensuring good compliance, may be affected by telemedicine. Patients frequently misunderstand the advice given to them by phone,12 even more so when other factors such as deafness are at play.13 The impact on telemedicine on this component of communication needs to be ascertained. The ability of telemedicine to produce comparable rates of new correct movement disorder diagnoses as compared to traditional interactions has not been established. To date, most studies in this field have either evaluated its feasibility in the provision of follow-up services to patients with known diagnoses or examined its usefulness in the administration of standardized rating scales.7-9, 14-17 Telemedicine studies on new referrals to general neurology clinics report possible reduced diagnostic certainty and increased diagnostic testing.18, 19 Telemedicine could compromise diagnostic abilities on many levels. First, it impacts on clinical history taking, which is the most powerful diagnostic tool at our disposal, potentially restricting both the quality and quantity of information transferred. Telemedicine particularly affects nonverbal communication. These behaviors of the face, body, or voice (which make up more than 50% of all communication) act synergistically with verbal language and are essential to understanding conveyed meaning.20 Indeed, how something is said can often be more important than what is said. Any alteration in synchronous verbal and nonverbal information flow (as inevitably occurs even with the most sophisticated of videoconferencing interfaces) not only impairs coding of information by the sender but also decoding by the receiver.19, 20 In clinical telemedicine trials, one of the more common complaints is of the physician not obtaining all the necessary information.7 Requests for repetition are also greater when using telemedicine than during classic face-to-face interactions,21 and these are not related to speech becoming unintelligible or scrambled over the media interface; rather, they appear to reflect an intrinsic defect in the communication process.21 In addition, telemedicine might alter the type of information transferred: on one side, patients may become less talkative and more passive,21 whereas on the other side, physicians tend to focus narrowly on the specific medical problem rather than exploring its physical, social, and emotional impacts in a holistic manner.21, 22 The factors underpinning this are uncertain but may relate to a degree of depersonalization on behalf of physicians. Second, telemedicine limits our ability to perform a thorough neurological examination, especially so in cognitively impaired people. Certain signs (rigidity, reflexes) are unobtainable, whereas the identification of subtle abnormalities, often key to diagnosis (eye movement abnormalities, stimulus sensitivity, Kayser–Fleischer rings), may be hampered by incomplete patient visualization, pixelation, inadequate lighting, poor video-streaming capabilities, and technical issues. It might be argued that these are less important issues in routine follow-up visits, however, the presence of new comorbid conditions (eg, cervical spinal cord compression as an explanation for a patient with long-standing Parkinson's disease to "go off their feet") may be missed in this situation. Medical education relies heavily on practical bedside learning to form the next generation of physicians (the apprenticeship model).23 This practice is beneficial not only for students but also for patients, who often enjoy participating, feeling involved in educating the next generation of medical professionals, and gaining a better understanding of their disease.23, 24 Our outpatient clinics are usually attended by at least half a dozen medical students, residents, and fellows bound by the common purpose of social learning and optimizing patient care. Telemedicine may lead to the loss of these hands-on teaching practices. However, in an appropriate setting, telemedicine may also promote education. It could, for example, be used to support primary care colleagues in the provision of specialist services, transferring some specialist knowledge to the primary care community.25 This dichotomy exemplifies the need for a tailored rather than a blanket implementation of telemedicine in education and the need to concomitantly explore alternative teaching approaches to maintain competence. The COVID-19 pandemic has exposed the frequent lack of training of currently practicing movement disorder physicians in the use of telehealth resources. Just as one would not require a surgeon to operate without the necessary skill, specific instruction is critical to the appropriate use of telemedicine in movement disorders—a "telemedicine manner" so to speak, akin to the traditional bedside manner.26-28 Alas, there exists little standardization of teaching curricula or learning objectives,29 and even when telemedicine education forms part of formal medical training, physicians often feel inadequately prepared.30 What impact this lack of training has on the standard of care being provided is unclear. In addition, seamless integration of telemedicine consultations with the patient's medical record in a safe and secure manner must also be ensured. Telemedicine is often suggested as a means of promoting equitable access to healthcare for a greater number of patients.2 This, however, assumes that either (1) movement disorder physicians have ample amounts of "down time" in their current schedules, which could be filled with extra telehealth consultations, or (2) that telemedicine approaches allow assessments to be conducted in a more expedient manner, thereby allowing increased volumes of consultations per physician. Given the huge increases in demands on medical systems in recent years, the first assumption seems untenable. What of the second? Well, most studies do not convincingly prove that telemedicine approaches reduce consultation times, physician workload, or healthcare costs.31, 32 Furthermore, given that the quality of doctor–patient interactions correlate positively with the duration of consultations,22 whether one should be advocating shorter consultation times is a matter for debate in itself. According to a recent study collecting experts' predictions about the attainment of major research milestone in Parkinson's disease, body-worn sensors are forecasted as the most likely milestone to be reached in the coming years.33 Symptom fluctuations make the validity of our current intermittent assessment model questionable and may limit the detection of clinically significant improvements. Wearable devices will address this issue by enabling prolonged objective measurements of motor and nonmotor function. However, it is worth remembering that (1) many of these methods have not been validated against in-person assessments and (2) patient confidentiality and data protection issues arise from the use of such technological platforms.1, 34, 35 From the clinical perspective, as well as considering the points raised previously, one must ensure that health technology devices are adopted in response to a clinical need rather than being employed simply because they are novel.35 Moreover, practical implications are likely to limit their use. Above all, lack of motivation is a significant factor—around 50% of patients stop using wearable devices after roughly 1 year, and 74% of smartphone apps are used no more than 10 times.36, 37 This evidence must be taken into account in the design of new technologies. This is a critical time when, as physicians, we are charged with shaping our future clinical practice. This will affect our patients, future generations of health professionals, and our perception in society. Telemedicine and novel health technologies will rise to meet a number of challenges in current healthcare models, including time and cost-savings for our patients. However, we doubt that telemedicine can, in its current form, replace in-person interactions, especially first consultations. Just like other interventions, telemedicine and health technologies should be critically evaluated and validated before becoming part of routine practice. (1) Research Project: A. Conception, B. Organization, C. Execution; (2) Manuscript: A. Writing of the First Draft, B. Review and Critique. Eoin Mulroy: 1A, 1B, 1C, 2A, 2B Elisa Menozzi: 1A, 1B, 1C, 2A, 2B A.J.L.: 1A, 1B, 1C, 2B T.L.: 1A, 1B, 1C, 2B A.E.L.: 1A, 1B, 1C, 2B K.P.B.: 1A, 1B, 1C, 2B Eoin Mulroy is supported by the Edmond J. Safra Philanthropic Foundation. Elisa Menozzi reports no disclosures. A.J.L. is funded by the Reta Lila Weston Institute of Neurological Studies, University College London, Institute of Neurology, and reports consultancies from Britannia Pharmaceuticals and BIAL Portela. He also reports grants and/or research support from the Frances and Renee Hock Fund, and honoraria from Britannia Pharmaceuticals, BIAL, STADA, UCB, and Nordiclnfu Care. T.L. has received a health research grant from the Michael J. Fox Foundation. A.E.L. reports consultancy support from Abbvie, Acorda, AFFiRis, Biogen, Denali, Janssen, Intracellular, Kallyope, Lundbeck, Paladin, Retrophin, Roche, Sun Pharma, Theravance, and Corticobasal Degeneration Solutions; advisory board support form Jazz Pharma, PhotoPharmics, Sunovion; other honoraria from Sun Pharma, AbbVie, Sunovion, American Academy of Neurology, and the International Parkinson and Movement Disorder Society; grants from Brain Canada, Canadian Institutes of Health Research, Corticobasal Degeneration Solutions, Edmond J Safra Philanthropic Foundation, Michael J. Fox Foundation, the Ontario Brain Institute, Parkinson Foundation, Parkinson Canada, and W. Garfield Weston Foundation; and royalties from Elsevier, Saunders, Wiley-Blackwell, Johns Hopkins Press, and Cambridge University Press. K.P.B. holds research grants from EU Horizon 2020 and has received honoraria to speak at meetings or to attend advisory boards from Ipsen, Cavion, Allergan, Teva Lundbeck, and Bial pharmaceutical companies. He also receives royalties from Oxford University Press and a stipend for Movement Disorders Clinical Practice editorship.