Abstract
Objective:
Telehealth in epilepsy care is not new. During the COVID-19 public health emergency, telehealth became more readily used to deliver epilepsy care. However, a summarized guidance of use in caring for people with epilepsy utilizing telehealth is needed.
Methods:
Existing literature was reviewed to provide guidance on various aspects of telehealth. Billing aspects are reviewed. Recommendations and considerations along with benefits and barriers to telehealth are provided.
Results:
Telehealth can be a preferred delivery route of care for people with epilepsy in specific situations. Examples include psychiatric complaints, medication management, and follow-up visits for noncomplicated epilepsy care. In addition, telehealth is useful for patients who need postoperative visits, are not able to travel, or live in residential facilities. In-person care may be more suitable for patients who are medically complex, have language barriers or difficulty with resource access, hearing impaired, or have neurostimulation devices where remote monitoring or programming options are infeasible.
Discussion:
Telehealth care for people with epilepsy can be a useful and important method of care delivery. It should remain an option for providers to use in epilepsy clinical care. It is important for the neurology provider to understand the benefits, billing, and barriers to providing telehealth.
Introduction
It has long been recognized that persons with epilepsy (PWE) may face numerous barriers to specialty care. 1 Reasons for this are multifactorial but certainly include transportation difficulties, geographic barriers, and economic challenges.
Specialty care delivered via telehealth is not new. Chua and colleagues reported in 2001 2 that video telehealth was well accepted by patients during new-patient visits. A retrospective report by Rasmusson and Hartshorn published in 2005 3 demonstrated that video telehealth, using registered nurses at off-site distant clinics as presenters along with medical provider, could deliver care comparable to in-person epilepsy clinic visits. The technology for delivering high-quality video interactions with patients has advanced in the intervening years, with several United States and global investigators suggesting comparable clinical outcomes using telehealth technology. 4,5 Most early evaluations of structured remote clinic appointments were delivered using video-conferencing technologies that required patients to travel to a site other than their home.
In addition to video-based care, telephonic care is an option in certain circumstances. Bahrani et al conducted a prospective, randomized study comparing telephone-based care with traditional in-person care in a large (n = 429) group of medically stable PWE. 6 Using the clinical outcome of occurrence of breakthrough seizures during the evaluation period, these investigators found no differences in outcome between groups.
More recently, increased adoption to telehealth with technological advances were necessitated during the COVID-19 public health emergency (PHE), thus, allowing for delivery of video-telehealth using devices such as smartphones, tablets, or laptops. 7 -11 These reports suggest patient care is not compromised, and patients are satisfied with this modality of care.
In the contemporary era, video and/or telephonic health care offer opportunities to improve outcomes when used as an adjunct to in-person care in PWE. Specifically, these modalities may increase accessibility of providers in specific disciplines and facilitate interprofessional provider consultations (epileptologists, general neurologists, primary care providers, advanced practice providers [APPs], clinical pharmacists, dieticians, psychosocial, and psychiatric care providers) that might not otherwise be possible. From a clinical perspective, opportunities include improving outcomes. An ability to leverage providers in specific disciplines and facilitate interprofessional provider consultations (epileptologists, general neurologists, primary care providers, APPs, clinical pharmacists, dieticians, psychosocial, and psychiatric care providers), exist where otherwise such consultations might not otherwise be possible.
On the other hand, an inability to perform detailed neurological examinations or reduced access to timely laboratory or neurodiagnostic evaluations (eg, EEG) may be obstacles to quality care. In this review, we will address these opportunities, barriers, and suggest approaches that clinicians should consider in advancing telehealth in epilepsy care.
Performing Telehealth in Epilepsy Care
In general, telehealth visits should never be considered a replacement to in-person visits in a traditional setting, but rather as a complementary method. The rate of needing to convert a telehealth to an in-person visit has been reported to be less than or equal to 5%. 9,12 When further analyzing by entry symptoms in neurology, a complaint of epilepsy was overall less likely to need follow-up in-person visits compared to that of back pain and global developmental delay.
Medication Management—Role of Interprofessional Care
It has become increasingly recognized that optimal care of PWE should include a multidisciplinary approach, which can be particularly challenging for patients who do not have access to specialized epilepsy centers. Management of complex, pharmacoresistant epilepsy may further benefit from health care professionals with specific pharmacological expertise or access to clinical pharmacists in the traditional epilepsy clinic setting. 13 -16 For example, the National Association of Epilepsy Centers designation for a level 3 or level 4 center includes access to consultation with a clinical pharmacist with expertise in epilepsy. 17 Recently, studies demonstrating positive clinical outcomes including improved medication adherence, medication utilization, adverse effect assessment, and patient education in patients with neurological disorders have been reported in those models where interprofessional care involving either a pharmacist or nurse was available. 18 It has been well established that nurses can provide an important bridge for patients with a variety of disorders via telehealth. During the COVID-19 PHE, nurse-led telehealth was crucial in providing continuity of care for patients with limited in-person access. 19,20 Epilepsy specialty nurses may be valuable in identifying medication adverse effects, and adherence issues. 19,21 Further, the inclusion of pharmacist-led telehealth can improve medication adherence, and overall clinical outcomes in patients with complex medical conditions such as cardiovascular disease, diabetes, and depression. 22 -28 Clinics without access to on-site expertise may be able to leverage pharmacists practicing using a telehealth approach.
Benefits for Telehealth Visits
Methods in which care improved via telehealth visit have been elucidated previously in Neurology. 9,12,29,30 The telehealth group of the American Academy of Neurology (AAN) published an overview of the state of telehealth in late 2019; indicating ample support for “new” patients with epilepsy; with benefits to both patient and practitioner. 31 Large scale studies (n > 2000) 9 assessing overall short term safety of pediatric telehealth were later published early in the PHE. 9 Specific analysis of safety in telehealth visits did not indicate any features that might lead to cause admissions within 8 weeks of a telehealth visit at a single center. 32 No study has compared if a particular type of epilepsy is amenable or not for telehealth. However, a study that looked at a comparison of new telehealth consults versus in-person consults demonstrated that patients with headaches and seizures were less likely to need to be seen in-person after a telehealth visit in comparison with patients diagnosed with multiple sclerosis, demyelinating disorders or spinal cord disorders. 33 In another study evaluating 7130 audiovisual telehealth visits at a single center 34 ; visits that required patients to be seen in person after an initial telehealth visit were noted in 5% and comprised visits that had associated technological challenges, younger or minority patients, patients who had a lower median household income, and patients who presented with developmental delay or neuromuscular entry complaints. 34
Barriers to Telehealth Visits
Broadband internet access and digital literacy have now become a social determinant of health. 35 Patient perspectives on how to narrow the digital divide should be considered. 36 Situations where video visits are a challenge, audio visits are still better than no access to care. These situations ideally should be preidentified. Regulatory/legal barriers may exist. Licensing, providing telehealth care to a state or even a country outside of where providers reside, and work represent a few examples. The following table indicates which patients might be best suited for an in-person versus telehealth visit, although post-pandemic data has not been rigorously studied (Table 1). 37
Telehealth Versus In-Person Advantages. 1
Telehealth Visit Process
Sinksy et al suggest that a successful telehealth visit requires a workflow that mirrors what outpatient clinics do for in-person visits. 38 In their article, Katyal et al provide detailed instructions on how to perform the neurological exam remotely. 39 The below table offers considerations for a successful telehealth visit (Table 2).
Collection of Quality Measures
Quality measures are typically collected during in-person visits and adoption with telehealth has been slower. The American College of Physicians (ACP) position paper 43 identifies important aspects about quality measures in the telehealth setting. It is important that measures do not discriminate against patients who have poor digital connectivity. The ACP recommends that measures used in both telehealth and in-person visits have similar criteria, that both clinicians and health care systems have access to telehealth information, and that quality measures should undergo analysis to make sure that telehealth data qualifies for inclusion in measures. 43 Sattar and Kuperman provide a roadmap to capturing the 2017 AAN epilepsy quality measures in a telehealth visit. 41 Screening instruments can be emailed, mailed, or sent via a patient portal prior to the visit or completed during the virtual rooming period. Seizure frequency data may be captured using electronic diaries that can be sent to the provider or via link to the electronic health record (EHR) and incorporated into the visit note.
Counseling via telehealth is as important as is during in-person care. American Academy of Neurology quality measures require education on safety issues and counseling regarding issues such as reproductive health issues where applicable and completion should be documented during the visit. 44 The ILAE recommends discussing occupational and safety issues with patients and educating their families during the telehealth visit. 1 Lua et al created a text-based counseling service and such a service could also be utilized regarding education for topics. 39,45 Samia et al caution that delivering bad news can be more challenging with telehealth and suggests training staff with specific techniques with regard to conveying negative information virtually. 1 In this situation, an in-person visit may be better and advance preparation would be needed to convert if already scheduled as a telehealth visit.
Billing, Coding, and Documentation Tips
Many of the barriers to effective telehealth are operational limitations, rather than concerns about inferiority of telehealth visit quality (Table 3). During the PHE, most of the regulations regarding telehealth practice were relaxed. In 2024 and beyond, it remains uncertain which regulations have been or will be reinstated. Payment policies are widely variable and ever-changing across payers and states. Telehealth raises new security, privacy, and malpractice concerns, which must be adequately addressed to limit risk.
Factors Governing Patient and Provider Acceptance of Telehealth. 58
Telehealth policies for Medicare, Medicaid, and private payers are provided yearly by The National Telehealth Policy Resource Center of the Center for Connected Health Policy (CCHP) 46 and updated most recently in fall 2023. Information by state is provided in a user-friendly format. Medicare and Medicaid rules can also be found on the Centers for Medicare and Medicaid Services (CMS) and Department of Health and Human Services (HHS) websites 47,48 and in the Consolidated Appropriations Act of 2023, H.R. 2617. 49 Major factors to consider in the performance of telehealth are described below.
Types of Activities Allowed via Telehealth
Many evaluation and management (E/M) and procedural services, as described in the Current Procedural Terminology (CPT®) can be provided via telehealth. 50 Centers for Medicare and Medicaid Services publishes an annual list of CPT codes allowed via telehealth, as well as whether the payment decision is temporary or permanent and if the service can be provided as audio-only. Allowed codes include most outpatient and inpatient E/M visits, nursing facility and home visits, behavioral and mental health services, analysis and programming of brain and cranial nerve devices, some rehabilitation services, some health and well-being coaching services, social determinants of health risk assessment and the new complexity add-on Healthcare Common Procedure Coding System (HCPCS) code G2211. Billing provider types have also been temporarily expanded until the end of 2024 and include all eligible Medicare providers such as marriage and family therapists, mental health counselors, occupational and physical therapists, audiologists, and speech-language pathologists. In addition, activities requiring direct supervision can be provided by audio and video communication rather than solely in-person. State Medicaid and private payers may or may not follow the CMS guidelines, so requirements should be verified with the CCHP, state, or individual payer.
Location
For Medicare, several location policies have been made permanent. These allow Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) as eligible distant site providers for behavioral/mental health telehealth services, and Referral Emergency Hospitals as eligible originating sites for telehealth. In addition, Medicare patients can receive behavioral or mental health services in their home and geographic restrictions for the originating site of behavioral or mental telehealth services have been eliminated permanently. For some services, the policy changes are only temporary, until the end of 2024. These include allowance of FQHC and RHCs as distant site providers for nonmental health telehealth, the ability of Medicare patients to receive telehealth services in their home and deferral of geographic restrictions for originating site of nonmental telehealth. Teaching physicians may use audio/video telehealth (but not audio only) to supervise residents in a 3-way telehealth visit with the residents and teaching physicians in different locations. Finally, there has been a deferral of a requirement for providers to register their homes as practice locations; for 2024, providers can continue to do telehealth from home and bill from their currently enrolled practice location. Patients used to have to travel to a certain location to access telehealth. The providers location also used to be significant, and doing telehealth from home was not possible previously which has now changed.
Medication and Controlled Medication Prescribing
Most states consider a telehealth visit to be sufficient for establishing a patient–provider relationship and for the prescription of medications. The Drug Enforcement Agency (DEA) and HHS have extended pandemic telehealth flexibilities for controlled medications through the end of 2024, in a policy entitled “Second Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications.” 51 Pre-COVID regulations required at least one in-person visit before prescription of controlled medications. The 2024 extension allows providers to prescribe schedule II-V controlled medications via audio-video telehealth, even when the prescribing provider has not performed an in-person evaluation, allowing for uninterrupted epilepsy care and pharmacy support. Final DEA regulations will be forthcoming over the next year.
Telehealth Practice Across State Lines
State licensing requirements for telehealth vary by state. Because the originating site for telehealth is the physical location of the patient, if the patient resides in another state, the provider typically must be licensed in that state. There are some state-by-state exceptions for telehealth practice in contiguous states or provision of temporary services. In general, practitioners who provide frequent services outside of their state of practice should be licensed in these other state(s). Some states have an expedited pathway for full or new telehealth-only licensure. The Interstate Medical Licensure Compact 52 intends to streamline the licensing process and currently includes 37 states, the District of Columbia, and the Territory of Guam. It allows practitioners to file only one application to receive separate licenses (all still requiring licensing fees) from each state of intended practice. For the Veterans Affairs (VA) care, it is possible to have access to specialists across state lines that VA providers in other states.
Documentation
Documentation of the visit is required for reimbursement and should follow guidelines for the comparable in-person service. Most federal and state payers require that informed consent for telehealth, either written or verbal, be obtained from patients, and documented in the medical record. Consent details may be determined by state law and may include a description of telehealth services; disclosure of fees and permission to bill; technology, privacy, and security risks; information about refusal and alternatives; and procedures for emergency and follow-up care. Providers should also document verification of the identity of the patient, confirmation of his/her physical location, and introduction of all other personnel involved in the telehealth session with their credentials.
Reimbursement
Through the end of 2024, CMS will continue covering telehealth at payment rates matching those of traditional E/M visits. Services provided to patients in their home will be reported with place of service (POS) 10, providing a higher nonfacility payment rate. In 2025 and beyond, new telehealth CPT codes will likely be created and valued by the American Medical Association (AMA). Medicaid and private payer coverage varies and can be found at the CCHP website and in payer coverage policies. Some states have now adopted pay parity telehealth laws for Medicaid and private payers. “Payment parity” requires equal payment for in-person and telehealth services. The equally important “coverage parity” requires that in-person services also be covered when delivered via telehealth. Given the rapidly changing environment for reimbursement, it is essential that billing and reimbursement teams be involved in designing and monitoring telehealth program revenues.
Access to Technology
Not all patients are able to engage with telehealth services. While 77% of US adults have home high-speed broadband internet connections, and 85% own a smart phone with cellular service, rates are lower among those with lower income and levels of education. 53 In 2021, 37% of US adults reported utilizing telehealth in the last 12 months, with higher use among female, college-educated, white (as compared to black, Hispanic, or Asian), higher income, and urban patients. 54 Social determinants of health remain an important factor in accessibility and acceptance of telehealth.
Security and Privacy
Telehealth services are vulnerable to a range of security risks, including virus or malware software infections, session access by unauthorized third parties and cyber-criminals, and data breaches. All services provided by telehealth must be compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) rules 55 protected health information. Providers should ensure that their telehealth systems/vendors comply with HIPAA and are covered by appropriate business associate agreements. The Office of Civil Rights will likely soon begin enforcing compliance and imposing penalties for telehealth noncompliance with HIPAA rules. Health care providers should perform initial and periodic security and privacy audits ensuring compliance with best practices.
Other Legal and Malpractice Concerns
Telehealth law has lagged. To date, there are few case law examples of telehealth malpractice. Visits by telehealth are considered sufficient to establish a patient–provider relationship and subject to all the malpractice risks of traditional visits including missed diagnosis, failure to diagnose, medication errors, and negligence. 56 Unreliable or unstable telehealth platforms may increase risk by preventing adequate communication between patient and provider. Inability to physically examine the patient may also create gaps in care that increase risk. During the PHE, multiple liability protections were utilized for health care providers; most of these are now expired or expiring. Providers should ensure that the malpractice carrier covers telehealth, and in all states where the provider intends to practice. Some insurance liability policies require a supplemental policy. States may have different minimal coverage limits. Individual state interpretations of telehealth may also affect insurance coverage decisions. Providers should review the state laws and Board of Medicine and other relevant Board regulations for telehealth in intended practice states. Finally, providers should consider whether liability insurance covers technology errors and omissions and cyber liability.
A full set of policies and procedures should be developed for telehealth, addressing the same areas as would be covered for in-person visits. All providers and staff who participate in telehealth should receive comprehensive initial and periodic training. Providers should be credentialed and have clinical privileges to perform telehealth, including at the distant-site hospital (the location of the provider) for hospital-to-hospital activities. A CMS rule indicates that originating-site hospitals (the location of the patient) may rely on credentialing and privilege decisions of the distant-site hospital, but this does not apply to all forms of telehealth.
Providers should also be aware of any state definitions of standard of care for telehealth and should document all histories, exams, and medical decision making fully. The Centers for Medicare & Medicaid Services has good online resources. Such guidelines include defining the patient–provider relationship, obtaining consent, verifying patient identity, and describing prescription medication use. Providers should consider whether some documentation of the telehealth visit needs to be maintained at both originating-site and distant-site hospitals. Finally, telehealth visits are subject to the same rules regarding health care fraud and abuse as in-person visits.
Telehealth Program Assessment
Telehealth platforms differ significantly in their features, integration with the electronic medical record, security, and ease of use. Evaluation of a telehealth platform may be best performed using a structured questionnaire, which can include assessment of feasibility, usefulness, service reliability, technological features, user satisfaction, quality, and cost-benefit. 57 Key performance indicators to assess telehealth program success could include patient and provider satisfaction scores, percentage of successfully completed visits, revenue generation, safety and quality measures, and health outcomes.
Conclusion, Summary, Future Directions, and Gaps
The recent rapid increase in telehealth to provide epilepsy care emerged during the PHE from concerns about spreading infection from the COVID-19 virus during a time following the era that introduced broad availability of internet-based audio-video communication. This historical confluence truly was less significant than it seems because technological changes have always influenced the delivery of health care, and the emergence of telehealth was arguably inevitable. Nevertheless, the rapid change has introduced a need for deliberation on telehealth through the lenses of health care quality, equity, and economics. As discussed in this review, the understanding and implementation of telehealth is continuing to evolve.
Epilepsy care is appropriate for telehealth based on the reliance of ongoing care for interactive communication that includes the patient, the patient’s family or companions, and the provider with lesser reliance on detailed physical and neurological examination. This does not mean that telehealth care can adequately serve all epilepsy care because remote interactions miss elements of communication that in-person interactions can provide. In-person communication affords a connection and a clarity that cannot be matched when the individuals are remote, and this degree of communication can be critically important during some clinical conversations. Knowing in advance of an encounter whether a higher level of communication will be needed is confounding, so telehealth carries an intrinsic risk of suboptimal care during some clinical encounters.
Epilepsy care depends upon communication of details that emerge more readily when the provider is experienced or subspecialized in epilepsy, and such providers are not local to many communities, thus further benefiting use of telehealth for epilepsy by allowing convenient access to expert providers without inordinate financial and time costs from travel. Telehealth narrows the epilepsy access practice gap. Nevertheless, telehealth increases the care delivery gap that relates to the digital divide. Individuals without ready access to reliable, high-speed internet and appropriate computer or smartphone devices do not benefit from telehealth, and these are often the individuals who were not receiving equivalent access to care before telehealth’s expansion. As overall health care evolves to depend more on telehealth, the gap for such individuals may unfortunately widen.
Ultimately, the polishing of implementation will bring telehealth into a utilization that is more convenient and efficient, but considerable concerns and obstacles remain. The rapid introduction of EHRs provides an analogous health care advancement that can yield perspectives on telehealth. Electronic health records promised easy, reliable, and widespread access of individual patient’s medical records with the expectation that would improve health care outcomes. The access to medical records has undoubtably improved many aspects of clinical decision-making, but EHRs are well recognized to also introduce problems to provider workload, provider–patient interaction, and cost. As such, technological advancements can address one problem without as much benefit as expected while also introducing new problems. Moreover, the introduction of many technologies that increase efficiency with greater consistency, such as in manufacturing, typically come with increasing homogenization and output motivations that often do not serve providers or patients. Just as keystroke fatigue is a factor in physician burnout, the non-stop progression through telehealth visits can lead to an assembly line mindset that in-person, office interactions do not produce.
Telehealth will remain an important component of health care delivery regardless of the regulatory or financial changes that are certain to occur. Attention to telehealth’s delivery limitations alongside the fundamental elements of ethical and quality health care delivery also will remain critical. As was expressed during the emerging technology era of the 20th century, continual progress necessitates an intelligent and daily exercise of judgment. The substitution of some personnel with AI may increase the use of telehealth.
Supplemental Material
Supplemental Material, sj-pdf-1-epi-10.1177_15357597241255274 - The Tell on Telehealth
Supplemental Material, sj-pdf-1-epi-10.1177_15357597241255274 for The Tell on Telehealth by Anup D. Patel, Charuta Joshi, Rohit Das, John M. Stern, Susan T. Herman and Barry E. Gidal in Epilepsy Currents
Footnotes
Acknowledgments
The authors undertook this effort as representatives of the Treatments and Practice Management Committees of the American Epilepsy Society. This publication underscores the commitment of the American Epilepsy Society, the Council on Clinical Activities, and its committees to advancing patient care, promoting education, and fostering innovation within the epilepsy community. They also thank Lauren Orciuoli for her major assistance in the process of this manuscript completion and for her dedication to the American Epilepsy Society.
Author Contributions
Conceptualization, all authors; writing—original draft preparation, all authors; writing—review and editing, all authors. All authors have read and agreed to the published version of the manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
References
Supplementary Material
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