Embracing the Future of Telehealth for Adult & Children Epilepsy Patients
The unthinkable has happened. COVID-19 is here and has changed the way we practice medicine, probably forever. Even though the effects of this pandemic are scary and far-reaching, there are ways we can use this time to reexamine the way we do things and use this as a catalyst to make the way we take care of patients more efficient, more practical, and more convenient.
How can we still take care of patients in this new world? As medical professionals, we are obligated to find ways to provide immediate care that is safe for our patients and their families, and for ourselves. The best protection we have from COVID-19 is social distancing, and we are unlikely to go back to previous ways of interacting with each other for a long time. Luckily, we now have the technology to do much of medical care, if not most, virtually. Is seeing a patient virtually better than seeing them face to face? Right now it is. Eventually, the answer may become; some of the time, but not always. We have become used to having the patient come to our office for an appointment, having the patient travel to get labs, travel to get tests. We expect the patient to do everything during “regular business hours,” and we take for granted that it is also the patient and parent’s responsibility to miss work, miss school, or arrange childcare, so that they can follow our orders for their care. In pre-pandemic days, it was not unusual for a patient in Texas to travel 2-4 hours each direction for a 20 or 30-minute office appointment with a doctor in a medical center, or to come for an elective stay in the hospital for multiple nights to perform a video-EEG evaluation. If the patient is a child with disabilities, this can mean bringing wheelchairs and equipment, and many risks and inconveniences. During this time of pandemic, we can no longer make these assumptions, and we are finding ways to bring what the patient needs to them, in their home. Being forced by the pandemic to bring medical care to the patient and family makes us wonder: was that really the best way to do things anyway?
For some situations, yes, the patient needs to be physically examined by a medical professional, an MRI cannot be done at home, and surgeries have to be performed in an operating room. But the pandemic has made us realize that most patient visits and exams can be done by telemedicine, with the patient at home or close to home, on their smartphone or other devices, which almost all patients now have (regardless of socioeconomic status). Blood draws can be done at the patient’s home, prolonged video-EEGs can be done at home, medical professionals can consult remotely and discuss patient management by video conferences. This pandemic has also forced the rest of healthcare to change– telemedicine will now be reimbursed like an in-person visit. Finally, we are able to come to terms with what was already true: technology has made travel less necessary, and has in many ways, removed distance and location as a barrier to quality medical care.
Although encouraging our patients with epilepsy and their families to stay home right now is the best thing providers can do to minimize their risk of infection and the risk of community spread of COVID-19, it is important for us to keep in mind that staying home brings new risks to children with epilepsy. Parents may be trying to work from home or dealing with new unemployment. Children are expected to attend school remotely, but now lack the structure of school and organized activities. This combination often results in family stress, changes in schedule or lack thereof, missed medication doses, or disrupted sleep patterns, all of which can increase stress, and the risk of seizures for the child or adolescent with epilepsy. These factors can also contribute to increased risks of domestic violence in the home, as well as child abuse, substance abuse, and suicidality.
Children and adolescents with epilepsy have 4-10 times the incidence of anxiety, depression, and other psychiatric problems, compared to children and adolescents without epilepsy. Unfortunately, many pediatric epilepsy patients with these co-morbidities go undiagnosed. We must be especially vigilant in our current circumstances of the pandemic, to screen carefully for symptoms of anxiety and depression, and to be aware of the substantially higher risks of these in our patients.
Beyond inquiring about seizure frequency, during our virtual visits it is also important to emphasize medication compliance and timing, encourage regular sleep schedules and stress reduction techniques, and to screen for parental and family distress. Reassure your patients and their families that epilepsy does not convey a higher risk of infection with COVID-19. If a child with epilepsy does develop symptoms such as fever, cough, sore throat, or diarrhea, the best way to reduce the chance that this will precipitate seizures is to control fever with acetaminophen or ibuprofen, keep them well hydrated, let them rest, and make sure they take their anticonvulsant medications as scheduled. Refilling prescriptions in 90-day supplies when possible is also a step that will help ensure compliance and relieve anxiety.
Making the effort to educate, prepare, and reassure your patients and families, whether by telephone, telemedicine, text, or email, can go a long way towards preventing accidents and trips to the emergency room, and decreasing family stress. Sometimes it takes a crisis to facilitate change. This is an opportunity for all of us in the epilepsy community to embrace change for the better: to use technology to better serve our patients, to be more aware of psychiatric co-morbidities, and to incorporate regular screening techniques and advice about stress reduction into each encounter with our pediatric epilepsy patients and their families.
Gretchen Von Allmen. MD, has been the Director of the Pediatric Epilepsy Program and Medical Director of the Pediatric Epilepsy Monitoring Unit at the University of Texas Health Science Center at Houston for more than 12 years. Dr. Von Allmen earned her medical degree at Emory University School of Medicine and completed residencies at Emory and Northwestern University, as well as fellowships at the University of Chicago and Baylor College of Medicine. She has expertise evaluating children undergoing non-invasive and invasive procedures for epilepsy surgery, namely in the utilization and interpretation of Stereo-EEG and Magnetoencephalography. She has published peer-reviewed articles in Epilepsia and Nature, and also contributed to the writing of a book chapter on Vagus Nerve Stimulation (VNS) for Intractable Epilepsy. Dr. Von Allmen is an editorial ad-hoc reviewer for the Journal of Clinical Neurophysiology and sits on the board of the Epilepsy Foundation of Texas, Houston chapter.