Telemedicine and neurosciences by Dr Ganapathy Krishnan, @ApolloTeleMed

It is well documented that there is an acute shortage of neurologists and neurosurgeons in India and globally. Despite all efforts, it will be impossible to make available neurospecialists in all suburban and rural areas.

Simultaneously, there has been an exponential increase in the growth and development of Information and Communication Technology (ICT). Plummeting costs and unbelievable sophistication in the availability of user-friendly mobile video conferencing devices is making distance meaningless. Geography has become History! Worldwide, the ultraconservative health care industry, in particular, the medical community, has been uniformly slow to adopt and embrace the use of ICT to extend their clinical reach. In the last decade, however, specialists in all branches of neurosciences are slowly accepting the inevitable that telemedicine must and will have to be incorporated into the core of the healthcare delivery system. This literature review summarizes the current use of telemedicine in different subspecialties of neurosciences. The author defines the growth and development of clinical telemedicine in India with special reference to Neurosciences and attempts to show the stellar role telemedicine has to play in enhancing the services provided by doctors. As clinicians regularly using technology, it should not be difficult for us to convince our patients that today a virtual remote consult and management can indeed effectively substitute for a physical face-to-face encounter.

Key Message:

The acute shortage of neurologists and neurosurgeons in emerging economies, particularly in suburban and rural areas, can only be addressed by extending their reach, using Information and Communication Technology (ICT). Pilots and Proof of Concept validation studies have now confirmed that deploying ICT in providing neurological services is mandatory to address the urban-rural health divide.

The term “telemedicine” encompasses the entire spectrum of technology, armamentarium, and processes required to enable history taking, conduct a clinical examination, perform investigations, and manage a patient, with the consultant and the patient at physically different locations. It presupposes the availability of a personal computer (PC)/laptop/tablet/smart phone, a good video conferencing (VC) system/digital camera, adequate connectivity, and software to capture, store, transfer, visualize data, and enable the teleconsultant at the remote end to view reports and digitally manipulate images.[1],[2],[3] An internet connected ophthalmoscope facilitates remote fundus examination. Telemedicine makes the concept of “distance” and “terrain” redundant. The fact that telemedicine in developing countries is different from that in developed countries has been highlighted.[4],[5] Eight hundred million Indians have no direct access to secondary and tertiary care, having to travel 40 to 100 km for medical facilities. It is easier to set up a telecommunication infrastructure in suburban and rural areas than to make neurologists and neurosurgeons available there. Once the “virtual” presence of a specialist is acknowledged, a patient can access resources existing in a tertiary referral centre without constraints imposed by distance.

Gourie Devi [6] pointed out that there would be a higher prevalence of neurological disorders in rural areas in the over 30 million patients afflicted. The author [Figure 1][7] demonstrated that 935 million Indians lived in areas where there was not a single neurospecialist. Telemedicine is the only answer to bridge this urban–rural health divide. Digital information is also easy to disseminate, is widely available, relatively inexpensive, and can level the playing field. The World Health Organization (WHO) initiated the “Global Burden of Disease Study” in 2013,[8] has confirmed that, worldwide, neurological disorders are priority health problems. Neurological expertise is deficient worldwide. Twenty percent of the US population does not have physical access to immediate neurological services. Patients are sent to far off places at considerable expense, even though treatment could have been carried out locally with teleadvice from a specialist. Unnecessary transfers result in overwork at tertiary centers. In 1959, the University of Nebraska College of Medicine used video communications to accomplish a telemedical consultation. Subsequently, the Telemedical Emergency Neurosurgical Network (TENNS) in northern California was created to facilitate neurosurgical decision making before patient transport. While telemedicine has been developing in the last three decades, in the last five years, the growth has indeed been exponential.[9] Smartphone apps in neurosurgery are increasingly being used. Zaki in 2013 reviewed 111 such apps.[10] The author, in the last 17 years, conducted remote clinical examinations in about 1500 patients [Figure 2]. Patients were seen at peripheral telemedicine centers and at their homes. Commercial VC systems were used. Laboratory reports and images (which could be digitally manipulated) were uploaded. For complex arteriovenous malformations (AVMs), the author held virtual joint meetings with other specialists, with the patient physically located in another state or country.
Figure 1: Distribution of Neurologists and Neurosurgeons in India. Reprinted with permission from:Ganapathy K. Distribution of neurologists and neurosurgeons in India and its relevance to the adoption of telemedicine. Neurol India 2015;63:142-54


Figure 2: Remote shunt assessment on preoperative CT scan
Body language is vital in interpersonal relationships. Today's VC systems are so sophisticated that body language of several groups of people can be viewed simultaneously. Minute facial expressions can be discerned. Participants remain in view at all times making it essentially a face-to-face meeting. Spontaneity, naturalness, and interactivity of a person-to-person meeting is present – except the fact that the patient and doctor are hundreds of miles away. Acquiring a high-quality video and transferring it with minimal data loss is crucial in the assessment of gait and movement disorders. Low-cost cameras and email/chat are sufficient for management of many neurological disorders. Remotely, elicited reflexes can be viewed. Replaying the video of a teleneurological examination enables one to study clinical signs in greater detail.

Neurological teleconsultations benefit family physicians. Unnecessary investigations and transfers are avoided, providing much needed family support at home. Telemedicine is doable, safe, and cost effective. Telemedicine hinges on transfer of text, reports, voice, images, and videos between geographically separated locations. Success relates to the efficiency and effectiveness of information transfer. In the past, telemedicine was primarily teleradiology – transfer of high-resolution medical images. Today, even a detailed clinical examination can be conducted remotely. Telemedicine has been used in various subspecialties of neurosciences.[11] The doctor–doctor teleconsultation allows rapid resolution of queries which otherwise causes stress to patients and increases the cost and complexity of care.[12] Maulden [13] stressed that the internet is changing the neurologists' relationships with other professionals in the health care industry. The advantages and disadvantages of e-mail in teleneurology have been discussed.[14] The attitudes of general practitioners towards teleneurology have also been documented in several reports.[15]

Tele-emergency services

Telecommunications have been found to be useful in rural emergencies. An article with a provocative title, “Brain surgery by fax,”[16] illustrates this point. Video assessments reduced referrals from 73% to 52% for mental health emergencies. Patients and providers found the service to be very helpful. Most patients (81%) stated that they would recommend or use the service again. Specialists On Call (SOC) launched additional telemedicine service lines that addressed the specialty physician shortage. An emergency telepsychiatry service line for hospitals hard pressed to provide 24/7/365 psychiatric on-call coverage in their emergency rooms is now available. The telepsychiatry service has already produced six times the consult volume that the SOC teleneurology service generated during the first nine months after its launch.[17] The author and his team [18] in an innovative public–private partnership (PPP) with the Government of Himachal Pradesh ensured the provision of tele-emergency services at 14,000 ft. height in the Himalayas where people used to commute 20–50 km for primary healthcare services and even up to 250 km for secondary healthcare services. Over a 28-month period, 550 emergencies were attended to, remotely. Thirty-six patients with neurological problems including seizures, severe migraine, head injuries, stroke, high altitude cerebral edema, meningitis, and possible subarachnoid hemorrhage were treated.

Technical issues in telemedicine

N-ISDN (Narrowband Integrated Services/Digital Network) was compared to an emerging technology, ATM (Asynchronous Transfer Mode), while transferring images in neurosurgical emergencies from a general hospital to a 100-km distant university hospital. Internet allows the re-distribution of medical resources between advanced countries and developing countries. Telemedicine in neurosurgery between Japan and Malaysia using international digital telephone services has been reported. An inexpensive, digital camera/mobile phone can be used to send images through compressed jpeg files through e-mail from small community-based hospitals. Several publications deal with technical aspects involved in image transfers.[19] In a study involving 100 emergency cranial CTs, Ludwig discussed whether image selection is a useful strategy to decrease transmission time.[20] Internet and World Wide Web (WWW) play a major role in extending the reach of neurospecialists. Publications dealing with applications of WWW to neurosurgical practice [21] and use of electronic forums reiterate this. An exponential increase in the image processing power and data transmission speeds are resulting in remote medical visits, surgical simulation, and even remote virtual surgery.[22] Virtual reality is being increasingly used in neurosurgery.[23] Neurosurgical resources on the net are also steadily increasing.

Cost effectiveness in telemedicine

Teleconsults avoid unnecessary transportation. Boarding and lodging expenses of attenders increase cost. Cost effectiveness of teleneurology, teleneuroradiology, and telepsychiatry consults have been worked out in western countries.[24] Reviewing 100 consecutive telemedicine neurosurgical consultations from 20 western Pennsylvania community hospitals, the authors documented savings of $500,000.[25] In the USA, financial viability is linked to dynamic changes in reimbursement policy and legislation at the national and state levels. Keeping abreast of the latest changes in state policy and legislation is critical. Khalid et al., while conceding that reducing language barriers, credentialing, providing 24/7 tele-emergency services, making available resources in remote areas, and ensuring protection of patient's privacy are important hurdles to be overcome, stress that reimbursement issues are also critical.[26]

Clinical studies in neurological conditions deploying telemedicine

Clinical trials [27],[28] have shown that teleneurological evaluation is as effective as face-to-face evaluations. Hospital stay was significantly shorter with teleconsults in hospitals without specialists.[29] Childhood migraine, headache, and cervical spinal cord compression [30] have been assessed with interactive videos. Remote video surveillance (RVS) has been used to assess relationship between lip position and drooling in cerebral palsy.[31] Telemedicine enables effective community-based research by narrowing the gap between the patient population and the researcher. The gap may have occurred due to the distance, limited access, and lack of resources.[32]

Telemedicine in neurotraumatology

Universally, the number of neurosurgeons available to manage head trauma is suboptimal.[33] Telemedicine helps to institute therapeutic measures before transfer of patients to major centers, thus reducing unnecessary transfers and work load.[34],[35] Use of telemedicine in remote management of head trauma in India has been reported.[36],[37] The author in 17 years has remotely evaluated 335 patients. Several serious head injuries were managed. Telediscussions of treatment options preceded transfers. Teleconsultation was used for follow-up.[38] A general surgeon telementored by the author remotely operated upon three cases of depressed skull fractures. With immediate virtual access to specialists, the family physician can manage simple head injuries. Interestingly, there was a drop in subsequent neurosurgical telereferrals. Goh, from Hong Kong, discussed whether or not teleradiology would improve interhospital management of head-injuries.[39] Poca also addressed similar issues.[40] The US military uses teleneurology to facilitate and prevent patient evacuations. Five hundred and eight teleconsults for neurology, and 131 teleconsults for traumatic brain injury were studied. Overseas providers in remote locations received expert recommendations for a range of neurologic conditions.[41]

Telestroke

Neurologists are increasingly using telemedicine in emergency stroke care as time is critical.[42],[43] Response time for acute stroke assessment has significantly reduced with a multidisciplinary collaboration. Telestroke and neurointerventional therapy have been become the “mainstays” of therapy. Identifying and triaging patients safely and efficiently is done remotely. Weschler [44] reported that the outcomes obtained after intravenous tissue plasminogen activator treatment via telemedicine were similar to those with in-person evaluations. A regional telemedicine network for the management of acute ischemic stroke is effective and safe. Nardeto [45] from Italy compared acute and monitoring phase of stroke care in 25 telethrombolysis and 106 thrombolysis patients. There was no differences in door-to-scan, door-to-needle (DTN), and onset-to-treatment times (OTT). Costs of telestroke services have also been studied.[46] A web-based telestroke system facilitates rapid treatment. Neurointerventional therapy and poststroke telerehabilitation are now a reality. Telestroke is now recognized for reimbursement. Whether or not thrombolysis was initiated attracts malpractice claims. Cost effectiveness of the “hub-and-spoke” telestroke networks, where the “stroke therapist” at the hub hospital interacts with the patient, and bedside physician performing the National Institutes of Health (NIH) Stroke Scale assessment and reviewing images, has been established. Studies have shown that a stroke center “Vascular Neurology Nurse Practitioner” (VNNP) may administer an intravenous tissue plasminogen activator for stroke-in-evolution even if the patient is far away from a neurologist, provided telemedicine facilities are available. VNNP, in partnership with a vascular neurologist, could deliver timely telemedicine consultations, accurate diagnoses, and correct treatment in patients suffering from acute stroke who present to remotely located rural emergency departments within a “hub and spoke” network.[47]

Less than 1.5% of acute stroke victims are treated with thrombolytics and few benefit from the expertise and experience of stroke teams. “Telestroke” management using state-of-the-art video telecommunications can address this. The Bavarian Stroke Registry [48] demonstrated that, compared to 10 patients in the preceding year, 86 received systemic thrombolysis when there was a 24/7 “stroke therapist.” The impact of telemedicine in routine stroke management has been analyzed, including the diagnostic workup, computed tomographic (CT) assessment, and therapeutic recommendations.[49] Health-care providers gain experience and expertise through telementoring. Stroke patients in ambulances are video linked to the emergency department. In ischemic stroke, recombinant tissue plasminogen activator (rtPA), if administered within 3 hours of stroke onset, improves survival and outcome. Safe rtPA administration for ischemic stroke during telemedicine consultation has been documented.[50] Many organizations lack resources and specialized teams for managing acute stroke patients. Rapid transfer to nearby regional stroke centers is crucial. In the University of Maryland Medical center, employing a pan, tilt and a zoom camera with remote site control, and CT image transfer, 50 stroke consultations between 1999 and 2001 were reviewed. Twenty-three patients were remotely managed and 27 transferred. One patient among the 27 in the transferred group received rtPA compared to five patients among the 21 in the telemedicine group. For the administration of rtPA, telemedicine was safe, feasible, and was well received. Barber [51] has reviewed the validity of the telephone interview for assessing cognitive status (TICS) in poststroke patients.

International teleneuroradiology services

In 1998, a teleradiology system was established in Croatia [52] connecting 34 CT and magnetic resonance imaging (MRI), as well as digital subtraction angiogram (DSA) scanners in 29 hospitals, to a referral neurosurgery center in Zagreb. In the first 3 years, the network saved 400,000 km of patient transportation (i.e. the distance patients would have been transported without a teleconsultation). In 1997, the national neurosurgical teleradiology system in Ireland connected six major referring hospitals to the only two neurosurgical departments present that were serving a population of 3.5 million individuals.[53] Of the 750 emergency CT scans transmitted, transmission failures occurred in 6% cases. As the CT and MRI scanners were not digital imaging and communications in medicine (DICOM) compatible then, films were scanned. Poon [54] from Hong Kong has discussed the possibility of teleradiology improving the interhospital management of head-injury. Apollo Telehealth Services, Telerad Solutions, and other health consortiums now provide teleneuroradiology services in India. Teleneuroradiology is the most developed branch of teleneurology. Several publications discuss in depth the pros and cons of different methods of data transfer, as well as maintaining cost effectiveness without compromising on quality.[55],[56]

Parkinson's disease and dementia

Studies have confirmed that valid motor assessments of Parkinsonian patients can be made via Interactive Video Conferencing (IVC). In a study involving 9 patients, the unified Parkinson's disease rating scale (UPDRS) score was determined by two movement disorder specialists – in-person and via IVC 350 miles away by a teleconsultant. Individual patient scores did not differ.[57] IVC provides information and support to caregivers of demented individuals. Computer-mediated information and support systems are viable complements to Alzheimer's disease support centers. Telephone and e-mail have been used by specially trained nurse/counselors who record the caller's query and provide emotional support, as well as practical advice for demented patients.[58] A telephone interview, although not a substitute for a face-to-face diagnostic evaluation, is a reliable procedure for evaluating cognitive, functional, and behavioral functioning in an elderly population with normal aging and dementia.

Telerehabilitation

Virtual reality (VR) techniques through telemedicine have been used in the rehabilitation of patients afflicted with cognitive impairment. VR has been used in stroke rehabilitation. A platform for home rehabilitation controlled telemedically has been evaluated. Telerehabilitation has also been achieved using web-based telecommunication.[59] Providing psychiatric backup to family physicians by telephone has also been reported.

Epileptology

The wide spectrum of clinical manifestations makes clinical observation by a specialist desirable. Ideally, this should be accompanied by a simultaneous video electroencephalographic (EEG) analysis. Experts to interpret the readings are available only in tertiary centers. Current technology can transmit EEG signals remotely,[60] enabling epileptologists to extend their reach. Clinicians in Finland obtain a second opinion on digital EEG recordings from a centre of excellence using interactive data and video consultations. Studies comparing epilepsy patients in a traditional ambulatory clinic and a telemedicine clinic have been reported.[61] Cost-effective epilepsy follow-up care through telemedicine has been reported. A face-to-face consultation in western Canada costs Canadian $466.00, including traveling, lodging, and lost productivity, whereas the expense was Canadian $35.85 for a teleconsult.[62]

Pediatric neurology

Members of the Child Neurology Society reported that the mean waiting period for a new patient clinic visit in the United States is 49 days, and 12% of patients must wait 3 or more months to be seen. The Hospital for Sick Children in Toronto is using a telephone nursing line to expand its services. To respond to calls, a nurse is trained in effective telephone triage. Long telephone calls (>10 minutes) were strongly associated with a diagnosis of epilepsy.[63] Dedicated, planned telephonic consultations in child neurology practice were available as early as 1999. One thousand and sixty-five patients used the 1-800-NOCLOTS pediatric stroke telephone consultation service. Sixty percent of the callers had not initiated antithrombotic therapy. For acute ischemic stroke, questions concerned the selection and interpretation of etiological investigations. Telemedicine has been used in the diagnosis of Duchenne's muscular dystrophy, profound mental retardation, peripheral neuropathy, spastic diplegia, autism, Tourette syndrome, Rett's syndrome, and myotonia.[64] Communication intervention for young children with severe neurodevelopmental disabilities using telemedicine has been implemented.

Teleneuropathology

Neuropathology consultation via digitized images was reported as early as 1992.[65] Due to an increased subspecialization and a demand for precise diagnosis, teleneuropathology will become increasingly available.[66] Some are afraid of sampling errors in remote diagnosis. Viewing digitized images of histological slides on a video monitor is now commonplace. Different technologies used include ordinary telephone lines, broadband telecommunications channels, and the internet. Transmitted images may be utilized for primary neuropathological diagnosis, teleconsultation, quality assurance, proficiency testing, and distance learning. Static-imaging systems are insufficient for diagnostic neuropathology. Viewing video images in real time ensures high levels of diagnostic accuracy. A robotized telemicroscope enables the remote teleneuropathologist to manipulate and examine the entire histological specimen. In some European countries, pathology laboratories are linked and telediagnosis of frozen section histology specimens are made by experts from hundreds of miles away.[67] Teleneuropathology has been described as “Telemedicine of the future.” Correlation of histology, cytogenetics, and proliferation fraction in meningiomas through image analysis done remotely has been reported.[68] Remote frozen section diagnosis is now available. Concordance was established in 45 out of 52 frozen sections between the transmitted video image diagnosis and diagnosis on direct evaluation. Remote evaluation took 2 minutes less though the referring pathologist spent 16 minutes more to select a slide for transmission.[69] A new concept of a microscope system for telepathology, named the World-Wide Microscope (WWM) has been thought of;[70] the prototype is being implemented. WWM is constructed with three units – microscope, control, and internet unit. The microscope unit is a conventional light microscope equipped with a motor drive and a charge-coupled device (CCD) camera. The internet unit is a WWW homepage with a Java applet and a communication server. The control unit relays request commands from the applet to the microscope unit, capturing the microscopic images. The WWM may become the all-round telepathology tool of the next generation. Legal issues have been raised. Some consider telepathology “a breach of registrational barriers.” The G8 states in Europe have recommended that location of the remote health-care professional defines licensure and liability site. Jurisdiction uncertainties add to complexities. Data protection and data security require attention. The principles of minimum data exchange, anonymity, pseudonymity (disguised identity of the patient), and cryptography must be established as a basis for all telepathology procedures.

Teleneurophysiology

Digitized neurophysiological waveforms, textual annotations and interpretive reports facilitating data interchange between instruments and computer systems, and other information systems in the hospital and outside healthcare facilities have been developed.[71],[72] This has resulted in remote access, through the WWW, to physiological data in the neurosurgical intensive care unit (ICU).[73] The University of California at Los Angeles (UCLA) neurosurgery ICU has developed a distributed computer system that provides access over the WWW to current and previously acquired physiological data, such as intracranial pressure, cerebral perfusion pressure, and heart rate from critical care patients. Physicians and clinical researchers can access these data through personal computers from their offices, homes, and in their vehicles even when they are travelling. A limited, predefined set of clinically relevant questions can be posed.[74] PC-based multimedia telemedicine systems have been designed to receive and transmit neurophysiological parameters, aiding in remote assessment of brain function. Quality assurance in clinical neurophysiology has been ensured through telematics. The acquisition, storage, interpretation, and telecommunication of electromyographic (EMG) findings between different clinical centers has been carried out in Europe. Telemanipulation of intelligent systems enable EMG-based joint angle estimation and even remote continuous physiological monitoring at home.[75]

Teleradiosurgery

Telemedicine has been used to provide connectivity and access to specialized high-performance computing and advanced software resources, as those used in radiosurgery. This requires volume visualization of projected treatment data and imaging anatomy via photo realistic rendering and virtual scenario simulation techniques – all manipulated remotely.[76]

Mobile telemedicine

Wireless telemedicine, enabling a clinician to receive images, text, and voice messages on a hand held device, is now routine practice.[77] Preliminary literature on viewing CT images were reported as early as 1995 in a portable telemedicine unit comprising a PC linked to an Inmarsat B earth station through a modem allowing videoconferencing at 64 kbit/s! Portable telemedicine units have been a major asset during the war. Clinical examinations and a review of all investigations are now routinely done on a smartphone.[78]

Advantages of deploying telemedicine in neurology

Advantages and limitations of teleneurology have been documented.[79] Seizures have been managed in rural communities remotely with no difference in the frequency of consultation, hospitalization or emergency room visits. Email triages by neurologists[23] of new referrals have reduced physical visits by half. Wound infections were monitored via cell phone images in a pediatric neurosurgery teleconsulting centre.[80] Unfamiliarity with email, video conferencing, or nonavailability of connectivity at the consultant's end are no longer constraining issues. Occasionally, unfamiliarity at the patient/peripheral hospital end could contribute to the reduced usage of telemedicine services. The relative unwillingness of specialists to dispense with face-to-face consultation is still a limiting factor. The insistence on always conducting a hands-on neurological examination is essentially a belief and is not based on evidence. The author has carried out even detailed sensory examination remotely with the patient touching different dermatomes. Medicolegal implications (more conjectural and hypothetical) are another concern. Neurohospitalists are site-specific subspecialty neurologists who care for patients in the emergency department, general ward, and intensive care unit setting, Through telemedicine, a neurohospitalist extends expertise to centers without specialists.[81] Eighty-five percent of leading US neurology departments currently used or planned to implement telemedicine by the year 2016.[82]

The US military has a limited number of neurologists – a store-and-forward consultation system has enabled military neurologists to deliver far-forward battlefield care for service members deployed overseas. Telemedicine provided follow-up care to veterans in rural southwest United States. Veterans are offered follow-up teleneurology care at 11 rural community-based outpatient clinics following their initial evaluation at Albuquerque. Ninety-five percent of 310 respondents reported that they wanted to continue remote neurologic care. Teleneurology to rural veterans provided quality neurologic care and overwhelming patient satisfaction, saving considerable time and money.[83]

Telementoring

Robotic telepresence (RTP) in the supervision of neurology trainees is now a reality and is being used for reacquisition of patient's history, data synthesis, and direct observation of the trainees' clinical skills.[84] Teaching teleneurology has been advocated in contemporary graduate medical education to keep the next generation future ready.[85] Long-distance robotic-assisted telementoring indicates that telementoring is feasible, reliable, and safe. Although still in its infancy, telementoring has the potential to improve surgical care, to enhance neurosurgical training, and to have a major impact on the delivery of neurosurgical services throughout the world.[86]

Telemedicine in neurosciences in India

A teleneurological demonstration in February 2002 by the author convinced the then chairman of ISRO (Indian Space Research Organization) to set up very small aperture terminals (VSATs) in superspecialty and peripheral hospitals. Published reports of the formal usage of telemedicine in neurosciences in India are available.[87],[88],[89],[90],[91],[92],[93],[94] Of the 400 virtual grand rounds carried out between the various tertiary Apollo Hospitals, using multipoint video conferencing, 95 were in neurosciences; 18.92% of teleconsultations (13043 out of 68929) at Apollo Hospitals, Chennai, till Aug 31st 2017 were in neurology and neurosurgery [Table 1].


Table 1: Neurology teleconsultation details January 2015 to August 2017

Two hundred of the 2500 CME lectures delivered for doctors in 45 countries under the Government of India Pan African e-Network project have been in neurosciences [Figure 3].[95] More than 500 tele-neuroconsultations were given between 2000 and 2002 to villagers in Aragonda. Video clippings of pseudoseizures, involuntary movements,  Parkinsonism More Details, myopathy, etc., assisted the local doctor. The quality of CT images received even then were adequate to give an expert opinion. Misra has pointed out that the use of telemedicine in the treatment of status epilepticus and strokes has a high potential for improving patient management.[91] The impact of telemedicine in the postoperative care of 3000 neurosurgery patients in a virtual outpatient clinic has been reported from Bengaluru.[92]


Figure 3: Tele-lecture from Chennai to doctors in African Countries

Patient empowerment in rural India: Relevance to neurosciences

Promoting health literacy is critical in improving health outcomes. By deploying multipoint videoconferencing, the author has initiated a knowledge empowerment programme at the internet enabled Village Resource Centers of the MS Swaminathan Research Foundation in rural Tamilnadu.[96] Over a 4-year period, consultants spoke on 94 topics and interacted with 21,800 villagers in 18 villages. The lectures [Figure 4] included “Recognising the dangerous headache,” “Management of head injuries,” “Management of brain tumours,” etc., Many neurological conditions are eminently preventable and e-lectures by specialists go a long way in providing necessary awareness quickly and cost effectively.

Educational videoconferencing – Global and National

Videoconferencing is an inexpensive way of interacting with colleagues worldwide. In August 2001, the author organized a two-hour teleconference with Professor Tetsuo Kanno of the Department of Neurosurgery, Fujita Health University, Nagoya Japan. A similar meeting followed with the Department of Neurosurgery, University of Dentistry and Medicine of New Jersey (UDMNJ), New Jersey in December 2001. In 2002, a multipoint intercontinental neurosurgery/trauma-emergency medicine and disaster management conference was conducted in Tunisia, Chennai, Geneva, and Paris. Fifteen global teleconferences have taken place subsequently including a postgraduate course organized by the World Federation of Neurosurgical Societies (WFNS). The paediatrics department of Apollo hospitals has been conducting weekly tele-continuing medical education programmes where specialist neurologists and neurosurgeons often participate. Tele Grand Rounds were held in neurosurgery where Diplomate of National Board (DNB) candidates and consultants from Apollo Hospitals in various cities participated [Figure 5].

Figure 5: Grand Rounds for DNB candidates through video conferencing

A WFNS educational programme conducted in Bhubaneshwar in 2012 was transmitted live to several neurosurgical centers through multipoint videoconferencing enabling a large number of virtual participants.

Legal questions

Application of telemedicine has raised legal questions. The legalities and legislation to date relevant to teleneurology practice are complex, outdated, or absent, representing a barrier to the use of teleneurology.[97],[98] Data security is crucial. Accidental loss of data must be avoided. Artefacts must be recognized. Special encryption mechanisms that secure data against unauthorized access and even modifications are, therefore, necessary. Patients' rights to confidentiality are paramount. Unless regulations for special situations have been agreed to by both sides, the liability is on the side of the consulting rather than the advising physician. Procedures for reimbursement of professional charges is in the process of being fine-tuned. Indians primarily are not litigatious. However, they are becoming conscious of their rights and claims for medical malpractice are increasing. Obtaining an informed consent before providing a teleconsult is advisable.

Conclusion

iThe author ventured into the then unknown discipline of telemedicine in 1998. As Walter Hugo had once remarked “nothing can stop an idea whose time has come.” We are slowly reaching the critical mass of interested people in telemedicine essential for a successful take-off. The Government of India and many state governments have recently started and are encouraging the deployment of telemedicine. The Telemedicine Society of India is contributing to creating the much-needed awareness. The exponential increase in the deployment of ICT, particularly in the mobile wireless area, the phenomenal increase in computing power, and the significant drop in costs is providing the necessary conducive milieu to embrace telemedicine and to make it an integral part of the health care delivery system. All that is required now is a change in our mind set and the realization that a solution is a solution only if it is available to anyone, anywhere, anytime. We, the neurospecialists, will be doing a disservice to our fellow brethren if we do not use telemedicine to extend our presently limited reach. It is the author's dream that in his lifetime, all neurospecialists will deploy telemedicine. 


After all, today, distance is meaningless and Geography has become History!

The article was first published here: Ganapathy K. Telemedicine and neurosciences. Neurol India [serial online] 2018 [cited 2019 Apr 11];66:642-51. For the references, please visit the original article, Available from: 
http://www.neurologyindia.com/text.asp?2018/66/3/642/232346
its been republished on the blog with the Author's permission

Author
Dr Ganapathy Krishnan
President at Apollo Telemedicine Networking Foundation
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