General Teleneurology A solution for limited neurology access in SC Sujai ‘Ron’ Nath, MD October 15, 2015
Jan 20, 2016
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)