Telemedicine: A Post-COVID Necessity

As healthcare professionals, we have all experienced profound changes to the way we deliver services following the sudden onset of the COVID-19 pandemic. Telemedicine rose up out of necessity during lockdowns—its use in April 2020 was 78 times higher than the February 2020 baseline, according to McKinsey. Two years later, this trend persists: telemedicine use is still 38 times higher than pre-COVID levels, prompting McKinsey’s assertion that $250 billion in healthcare services could potentially be virtualized.

Telemedicine is more than a trend born out of convenience. It can be a lifeline for patients—expanding access to previously unavailable care and providing a comfortable, immediate, affordable, and satisfying experience. It can also be a lifeline for healthcare providers—helping us keep a closer eye on patients, improve health outcomes, and do more, with fewer resources.

Telemedicine growth predicted to continue well beyond COVID crisis

Virtual healthcare is a win-win for everyone, according to Doximity’s second State of Telemedicine Report published in February 2022. Most clinicians surveyed (67%) said telemedicine helps “build or maintain trust with patients from marginalized communities,” and 55% of patients—up from 40% in 2020—believe telemedicine provides “comparable or better quality of care as in-person visits.” Over 73% of patients surveyed plan to continue receiving care through telemedicine in the coming years.

Through the pandemic, Doximity found the top uses for telemedicine covered everything from endocrinology, cardiology, immunology and neurology, to family medicine, geriatrics, pulmonology, and psychiatry.” More recently, clinicians are recognizing the benefits of telemedicine in autism care and occupational therapy.

With increased government support and reimbursement, telemedicine will only become more entrenched. For instance, U.S. legislators introduced a bipartisan bill in November that would permanently expand Medicare reimbursement for telehealth services provided by audiologists, occupational therapists, physical therapists, speech language pathologists, and potentially others. “Particularly in our rural communities, telehealth is no longer just an innovative option for accessing services, it has become a vital lifeline to care,” Senator Steve Daines (R-MT) explained in a statement.

A complex, but promising, path forward

Telemedicine has come a long way, but there’s still a long way to go. For instance, McKinsey has found there’s a gap in consumer interest (76%) and actual use of telemedicine (46%)—signifying a need to educate patients about telehealth offerings and healthcare providers whose services are offered virtually.

Further, the clinicians McKinsey surveyed remain wary of overreliance on technology, citing concerns about security, workflow integration, future reimbursement, and the effectiveness of telehealth compared to in-person visits.

MoCA via telemedicine provides results comparable to in-person testing

Fortunately, the telemedicine solutions clinicians need are sometimes simple—and already available.

MoCA offers telemedicine-adapted versions of the standard paper test, including:

• T-MoCA or MoCA Blind, the visually impaired test version (conducted by phone)
• MoCA 5 Minute, the abbreviated test version (conducted by phone)
• MoCA via Audiovisual Conference, the full-version test (conducted by video conference)

Updated test instructions enable clinicians to build trust with patients and deliver fast, reliable results.

Multiple peer-reviewed studies have validated the effectiveness of remote MoCA testing, including:

• “Videoconference-administered MoCA appears viable as an alternative to face-to-face- MoCA.” In 2020, researchers from Japan studied cognitive decline in 73 patients over age 60 to assess for cognitive decline. After comparing the results of MoCA teleconference and in-person follow-ups at two weeks and three months, they concluded videoconference tests were a viable alternative.¹
• “The agreement between remote and in-person administration of the visual component of the MoCA was excellent.” A randomized controlled trial validated the use of MoCA administered by videoconference for remote neurocognitive testing associated with Parkinson’s disease (PD) and obstructive sleep apnea (OSA). In-person follow-up at three months showed “fair to good” or “excellent” agreement with the teleconference baseline.²

• “The MoCA 5-minute protocol is a free, valid, and reliable cognitive screen for stroke and transient ischemic attack.” Researchers at The National Institute of Neurological Disorders and Stroke came to this conclusion after using the MoCA 5-minute protocol by phone to assess 104 patients with stroke or transient ischemic attack, including 53 with normal cognition. One month later, patients were retested using MoCA standard paper tests, which yielded a reliable 0.89 intraclass correlation coefficient.³
• “All participants completed every item in the MoCA when administered remotely… All patients expressed a positive experience with the rater and using the web-based video conferencing tool.” Research published in the Health Informatics Journal found that remote MoCA screenings were effectively deployed for patients with Parkinson’s and Huntington’s diseases. The reduced burden on caregivers and reduced time commuting or waiting in offices were cited as benefits of remote assessment, without sacrificing accuracy.⁴
• “Implementation of the T-MoCA in a telemedicine-based PAT setting is feasible.” Researchers at the Montefiore Medical Center in the Bronx used telephone MoCA assessments to screen for cognitive impairment as a risk factor for postoperative delirium. This postoperative complication—associated with increased hospitalization stays and mortality—affects up to 70% of patients over 60 years old. In the study’s cohort, most patients who consented to the test completed it, and more than half scored positively, which had implications for pre-operative planning and post-operative recovery.⁵
• “Researchers are actively developing normative data to support MoCA by videoconference.” For example, 230 participants, all 50 years and older, were recruited in Quebec, Canada for a recent study which provided normative data that was in line with existing published data for in-person MoCA assessments.⁶

Telemedicine is here to stay for many healthcare professionals. The use of telehealth allows clinicians the opportunity to evaluate neurologic function at the earliest possible time. With a few minor adjustments, clinicians can conduct routine MoCA screening tests in a new way that streamlines the efficiency of their offices, reduces risks during periods of outbreak, and provides a convenient option for patients with mobility issues.

References:

1 Iiboshi, K., Yoshida, K., Yamaoka, Y., Eguchi, Y., Sato, D., Kishimoto, M., … & Kishimoto, T. (2019). A Validation Study of the Remotely Administered Montreal Cognitive Assessment Tool in the Elderly Japanese Population. Telemedicine and e-Health.

2 Lajoie, A. C., Crane, J., Robinson, A. R., Lafontaine, A. L., Benedetti, A., Kimoff, R. J., & Kaminska, M. (2021). Feasibility of remote neurocognitive assessment: pandemic adaptations for a clinical trial, the Cognition and Obstructive Sleep Apnea in Parkinson’s Disease, Effect of Positive Airway Pressure Therapy (COPE-PAP) study. Trials, 22(1), 910. https://doi.org/10.1186/s13063-021-05879-1

3 Wong, Adrian et al. “Montreal Cognitive Assessment 5-minute protocol is a brief, valid, reliable, and feasible cognitive screen for telephone administration.” Stroke vol. 46,4 (2015): 1059-64. doi:10.1161/STROKEAHA.114.007253

4 Abdolahi, A., Bull, M. T., Darwin, K. C., Venkataraman, V., Grana, M. J., Dorsey, E. R., & Biglan, K. M. (2016). A feasibility study of conducting the Montreal Cognitive Assessment remotely in individuals with movement disorders. Health informatics journal, 22(2), 304-311.

5 Nick C. Yu, Denzel Zhu, Kara L. Watts, Nitya Abraham, Curtis Choice, Implementation of the telephone montreal cognitive assessment in a telemedicine based pre-admission testing clinic during COVID-19, Perioperative Care and Operating Room Management, Volume 24, 2021, 100191, ISSN 2405-6030,
https://doi.org/10.1016/j.pcorm.2021.100191

⁶ Gagnon, C., Olmand, M., Dupuy, E.G. et al. Videoconference version of the Montreal Cognitive Assessment: normative data for Quebec-French people aged 50 years and older. Aging Clin Exp Res (2022). https://doi.org/10.1007/s40520-022-02092-1

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