Telemedicine shows promise in Parkinson’s disease care

Like countless other patients, Ann Johnson, a retired veterinarian, has been willing to travel long distances and devote an entire day to be treated by a specialist at Rush University Medical Center. But a recent appointment lasted less than 30 minutes, and the only travel was to her living room.

Diagnosed nine years ago with Parkinson's disease, Johnson and a family member would drive regularly more than 130 miles from Champaign to be treated by Christopher Goetz, MD, a leading expert on movement disorders and director of the Parkinson's Disease and Movement Disorders Center at Rush. Then earlier this year, she began participating in a telemedicine pilot project that, if fully developed, would allow about every other of her visits to be conducted via secure, live-streaming video from her home.

"As a medical professional, I know the importance of developing innovative approaches," Johnson says. "When you see your vital signs right on the screen, it's really quite neat."

The potential of telemedicine — the delivery of health services using communication technologies such as telephone or the Internet — has been discussed for years, but improved technology and lower broadband costs are making that promise very real for patients like Johnson.

Being seen from far away

Diagnosing and monitoring the progression of Parkinson's disease and other movement disorders is based almost entirely on visual observation, because there are no blood tests or brain scans to confirm the diagnosis. Rush helped establish and test the visual criteria used to diagnose Parkinson's and similar movement disorders decades ago and has been using video technology for many years during patient visits to track progression of the disease.

Likewise, treatment choices and decisions are largely based on visual information about the patient's function. Goetz was eager to try to demonstrate that the same subtle clues of Parkinson's disease progression or improvement that he assesses in the office — a distinct tremor, a specific change in gait, a change in fine finger movements —also can be assessed by video communication from a patient's home in real time.

Since the project began last October, more than 20 patients in the pilot program have used their own computers to link to Rush for virtual face-to-face meetings with their neurologist. So far, Goetz and neurologist Katie Kompoliti, MD, have been using this approach. Other Rush neurologists will soon adopt it as well.

To date, patients have provided consistently positive feedback. Instead of signing in when they arrive at the neurology department lobby, they log into MyChart, Rush's online health record system, and use it to open a secure video feed using a standard webcam. Goetz or Kompoliti then asks them to perform the same movements and answer the same questions they would have in a typical appointment

'It's not like they are here, they are here'

"Ninety-five percent of the information I gather is visual. Thus, with telemedicine visits where I can see and hear my patient right in front of me on the computer screen, there is no decline in the quality of information I gather," Goetz says.

Goetz discourages the term "virtual visit", often used in the reference to telemedicine. When he examines patients via video and has a full conversation with them "it's not like they are here, they are here — just in two dimensions," he says. "We have our interaction right here in my office, but they have not had to travel."

That latter consideration is receiving increasing attention. Some policy experts are pointing out that the true costs of health care need to include patient's time, not just what is paid to doctors in hospitals. In a 2015 American Journal of Managed Care article, researchers reported that the time expended on a visit is worth more than the financial amount patients spend on a visit.

The average total visit time for a person seeking care (for themselves, a child or another adult) was 121 minutes, the researchers found. By comparison, they wrote, "people spent only 20 minutes with physicians; they spent the rest of the time waiting, interacting with non-physician staff, or completing paperwork or billing." While the average out-of-pocket cost per patient visit is $32, economists cited in the study calculate that the value of those 121 minutes — known as opportunity costs — was $43.

Because patients with advanced movement disorders typically cannot drive, the time commitment is doubled because someone else must bring them. Alan Lundin figures that his visits to Goetz total about 13 hours for him and his wife, who often has to take the day off work. Their round trip drive from Rockford, Illinois, for his appointment takes well over four hours, plus additional time spent at Rush apart from the appointment itself.

"That's pretty much the whole day spent on something that now takes half an hour" in his home, Ludin says.

Preparing for tomorrow's telemedicine today

Another difference between an in-person and video visit is that Rush does not charge patients for these appointments, because insurance currently doesn't cover them. Some health care organizations are waiting to develop telehealth capabilities until Illinois joins approximately half of the states that currently require private insurers to cover telehealth the same as in-person services.

Rush instead has chosen instead to absorb the cost of these appointments and pilot telemedicine services now.

"In order to prepare ourselves for the future, we are perfecting the system," Goetz says. "Rush had the vision to set up the infrastructure and have everything in place so that when the day comes that we can be reimbursed for providing these services on a wider scale , we'll be able to launch immediately."

Brian Patty, MD, Rush's chief medical information office and chairman of Rush's Telemedicine Steering Committee, adds that Rush has several telemedicine pilot projects underway "in areas like neurology where telemedicine can likely have the most patient impact.

"When the laws catch up with the technology," Patty says, "Rush will be ready. "