Telehealth in Multiple Sclerosis: Benefits and Challenges

Marisa McGinley, DO

In a recent Institutional Perspectives in Neurology: Multiple Sclerosis (MS) event, several specialists in MS offered their perspectives on the state of care for patients. One of those experts, Marisa McGinley, DO, staff neurologist, Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, spoke about a major topic of conversation over the last couple of years: the use of telehealth for the MS patient population.

McGinley offered up her clinical experience with telemedicine within the comprehensive care model and highlighted what the available literature suggests regarding its benefit for patients. The use of telehealth has blossomed in the medical field since the beginning of the COVID-19 pandemic, and for those individuals who require complex, comprehensive care, such as those with MS, telemedicine can provide a number of advantages from increasing access to providers to economic savings from less frequent travel to the office.

Although there are still challenges in reimbursement and coverage that need to be addressed for telehealth to permanently make its way into the care paradigm, the early signs suggest that it certainly has a place. In this conversation with NeurologyLive, McGinley summarized her talk and shared her insight.

NeurologyLive: Could you offer a brief overview of the presentation you gave at the Institutional Perspectives in Neurology: Multiple Sclerosis event?

Marisa McGinley, DO: I had the pleasure of giving a talk on telehealth for MS care, and really, the things that I discussed were around the use of telehealth for neurology visits. I think that there's a lot out there for how the neurologist can do things virtually. But then we also started to briefly touch on how we can do telehealth for comprehensive care. When we think about MS care, the MS clinician will often kind of quarterback a lot of those things, but all those other comprehensive care aspects are equally important to really think about our MS patients as a whole. So, we sort of talked through what data are currently available, and then obviously, the gaps.

One of the most important things of thinking about why we even care about telehealth was a focus, and so one part of that is emphasizing what the gaps in MS care are, and what we can do better. First, there's a shortage of neurologists, and so that really centralizes a lot of our MS patients to larger centers that may not be very convenient or accessible for patients. Then secondly, MS is expensive. It's expensive for the health care system and for patients themselves, and so that can definitely be a barrier to accessing care. And then lastly is that MS patients have a lot of barriers—they can be physical barriers, transportation barriers, and then also financial barriers. Really, the hope for telehealth that has been identified in the MS community, and also by the American Academy of Neurology in general, is that it has the potential to fill in some of those gaps to really bring neurologists to patients in a virtual manner, especially in places where maybe that's not as accessible. Also, potentially, if we can keep people in their communities, we can decrease the financial burden for patients and maybe even the system.

Although there's a lot of promise, there are definitely a lot of research gaps. A lot of the early-stage literature is primarily on satisfaction and feasibility. We talked about some of the studies that show some promise in those areas, but there's definitely a lot of work that needs to be done to show that it truly can fill those gaps.

When it comes to access, are the advantages telehealth offers in getting patients to other care providers enough to make a difference, and how do the neurologists—who rely on physical examination—affected?

I think it's huge for neurologists and all of our comprehensive care partners. From a neurologist perspective, we are very wedded, as you said, to our neurologic exam and so it's been a little bit of a slower uptake. But, in reality, as an MS neurologist, a lot of what I do is talk with the patients about their symptoms because, in MS, there's a lot of fluctuation that we can't even capture, necessarily, in our snapshot office visits. A lot of the discussion around symptoms and how people are doing doesn't necessarily require an exam—a lot can just be done by history. Then, MRI is hugely important, obviously, to our practice, and now that we can remotely upload MRIs and we can access MRIs from other institutions, we, again, don't necessarily need to have the patient in the office to review those types of aspects, which is really important. We can help kind of navigate their care and referrals and what we need to do remotely by talking about a lot of things.

At the Mellen Center, we are all about comprehensive care. We have an embedded health psychologist, a social worker, physical/occupational therapist (PT/OT), or speech therapist—I can't even say everybody that's involved. We do try to coordinate things when people come. Those providers are very uniquely specialized. You know, as a neurologist, I bring something unique as a fellowship-trained MS physician, but really our health psychologist or social work colleagues—MS is a unique thing for them to specialize in. So, I do think that's a huge thing to bring to people. Our health psychologists are almost exclusively virtual now because—there's something about a therapeutic touch and there's a need to bring patients into the office at times—but so much of what they can do can be virtual—again, through discussion. Same with social workers. Talking about what they need, what kind of resources are in their communities. I think that's another huge need: pharmacology. If we have pharmacists involved, they can discuss, adverse effects, risks, what to expect. A lot of that comprehensive care can be done virtually.

Some of the complexity is more on the therapy side of things with our PT/OT and speech therapy colleagues. There's a little more complexity with how they do that, and then, reimbursement and things like that are a little more complex. I was speaking with them, and part of that is because they have parallel home health colleagues, where there's historically a lot of PTs and OTs going into the home. I think that that is an area of growth, and part of the presentation was on how do we rethink what that virtual PT/OT looks like?

At Mellen and a lot of large MS centers, we have some sort of innovative technology in-house that we use with patients. But then the idea in the therapy fields is: How do we leverage tablet-based technology or gaming systems or something to think of new ways to develop therapy programs for patients? That's a cool thing, but definitely a different path forward, as opposed to our social worker and our psychology colleagues, where they can kind of almost completely translate what they do in the office virtually without any adaptations.

Will the data backing the early signs of telemedicine’s benefits get the wider community to start thinking creatively about how it can be incorporated as a tool for clinical care?

It comes both from a data standpoint of making sure that outcome-wise our patients are doing just as well or potentially better, with the incorporation of virtual care. We're definitely going to need that, just so both the providers and the patients feel comfortable, not coming into the office. We'll need some of that data. Then, there's also the practical side of things—coverage and payers—and so I think that that's where some of the non-large academic centers where we've got a different kind of embedded payment structure come into play. It's important to make sure that people are getting reimbursed for this, that patients are getting these visits covered. I would say even pre-pandemic, that was probably one of the bigger barriers to things. It wasn't even necessarily neurologists not seeing the utility of incorporating these visits, it was more like practical aspects of, “Well, I don't want to offer something to a patient that they have to pay out of pocket for, or I don't get paid for.” I think that the policy side of things is going to be important.

We've seen the needle move a lot more for the neurology-type visits. But again, from a comprehensive care perspective, really watching how that policy impacts all of our other colleagues, too, is going to be important to maintain that. Then, in addition to the outcome data, I think the other data we'll need is the dosing. It's something that I've talked to a lot of people about: How often are you doing in-person versus virtual? As much as we can give guidance to clinicians about what the appropriate visit schedule is—"Can I not see my patient for a year in person? Two years? When do I have to, not mandate, but say we need to have you come in?”—that sort of thing. In addition to making sure that we show outcome data that our patients are doing fine and doing OK with not coming in, the other thing we need is to really fine-tune what the safe and also the most advantageous kind of schedule for visits is.

Will that data be the main driver in helping these visits get coverage, or is part of that also the wider physician community clamoring for it?

I think a little bit of both. Definitely, for coverage, they need to show that. In MS, I would say that our coverage has not been as tied to quality metrics and things like that of care, so it's not been a huge part of our reimbursement structure. But it is still a thing, right? That's the reason that the American Academy of Neurology has a committee on developing quality measures for neurologists to show the value of their care. Really, when you look at those, a lot of those quality measures can be done either in person or virtually. Those types of things can help from our academies leveraging and showing that we can provide really a high level of care virtually, even though it's maybe a little bit different in documentation. A lot of us still can document based on time and counseling, and all of those things are being more accepted, so I think that with some of our comprehensive care colleagues, that can be done virtually very, very well and efficiently. That'll be very helpful, maintaining that.

The other aspect is, is licensure. As someone practicing in Cleveland, patients in Pennsylvania, or even Michigan, can be closer to me than my southern Ohio patients. But then there are licensure barriers when it comes to feasibility. Policy aspects around that too, especially for neurologists and people practicing on borders of states where a lot of their practice may be outside of their state boundaries, are going to be another thing that will evolve and help a little bit more with adoption, both from a provider and a patient perspective.

Are the patients receptive to telemedicine? Is this something that they're interested in?

Yeah, absolutely. Patients overwhelmingly have a very positive experience with telehealth. But definitely, as with anything in medicine, it's not a one-size-fits-all. There need to be more studies on understanding patient perspectives and perceptions on their virtual care and how they want to incorporate that. There may be different populations or individuals, whether it's just the comfort level of how they like to access their care. Feasibility from an internet and technology standpoint are 2 things that we will need to keep in mind when we're setting up the schedule for our patients because it's not going to be like a single prescription of “This is how we do the visits for all of our MS patients, and that's what's going to work.” Incorporating patients as a care partner is super important, so we do need to understand that a little bit more. But definitely, overwhelmingly, patients are very pro-virtual visits. Partly because again, as I mentioned earlier on, a lot of what we do is around symptoms and discussions about their activities of daily living, how things are impacted, and what do they look like at the end of the day versus at the beginning of the day—stuff that I need them to tell me the story about in their life. We can do that really well virtually, and sometimes we don't waste a lot of time with some perfunctory aspects of the in-person visit. Patients really like that, if we’re just checking in and making sure we go over their labs or their MRI, we can do that quickly on their lunch break, and they don’t have to take time off of work. I would say that patients really like that. They clearly want it as kind of a mix, right? I don't have patients saying, “I never want to come in and see you.” But they definitely say “I'm not going back. I don't want to ever not do virtually.” It's definitely an important aspect of my care now.

Anything else you think is important to note?

From a future perspective, the payer aspect and the licensure aspect will be big things. I believe CMS just extended the COVID-19 coverage. We're still a little bit in this limbo area of what the final legal decisions about things are. In the next 1-2 years, we're going to—hopefully—settle out and understand where we sit there and how that'll impact how we incorporate this long-term.

The other big aspect is going to be—which I didn't get into largely in the talk—things around the neurologic exam and remote monitoring of our patients, and how we really continue to capture objective data on our patients so that we can monitor things closely. Neurology, in general, has been moving towards that a little bit more. It's been very much an art with our exam, which is great, and you can pick up a lot of things. But how do we really document that and monitor that over time? That's an aspect where there are going to be more telehealth solutions that will be to be vetted and scrutinized by the community from a research standpoint. But I think that that is where things, in the long run, are headed to augment those telehealth visits. It's about the conversation. It's about making sure you have that access to the patient more consistently. It'll also mean that maybe we can't have our hands on that individual, but we do have really vetted ways of monitoring the neurologic function.

Transcript edited for clarity. For more coverage of the Institutional Perspectives in Neurology: Multiple Sclerosis events, click here.