Telemedicine could help schools assess concussions

CHARLOTTESVILLE, Va. – Picture this: You are the parent of a football player who plays at a high school in a rural, farming community in the foothills of the Appalachian Mountains. One Friday night your son, the quarterback, is sacked on the field on a fourth down. The school’s athletic trainer races to your son’s side and helps him off the field, suspecting he may have a concussion.

You panic.

The nearest health facility is a small, primary care clinic in town, but you know the nearest neurological specialist is at a hospital hours away. You know it could take many long drives, a lot of gas and time to get your son’s brain injury assessed and cared for.

Doctors and scientists at the University of Virginia’s Center for Telehealth are hoping in the not-too-distant-future such worries will weigh less heavily on families who live in rural areas. The center is exploring what it hopes will lead to the use of telehealth — audio-video links connecting a patient in one location to a physician in another — to assess concussions and other sports-related injuries in rural areas.

This is new territory. The Mayo Clinic in 2013 teamed up with Northern Arizona University to study how to assess concussions on the athletic field in real-time. But this has not yet been attempted on any kind of large scale.

David Gordon, director of the UVa. Office of Telemedicine, said telehealth has widespread use across medical specialties today, and neuroscience has helped to lead the way. He said stroke patients were among the first to be assessed through the use of telehealth; later, its use spread to assessing and diagnosing post-traumatic stress disorder and traumatic brain injury in veterans.

“One day the light goes on and everybody understands that this is the way to provide care,” he said.

And although the marriage between telehealth and sports concussion diagnoses is just now being explored, the assessments of all traumatic brain injuries are similar, said Dr. Katherine Wibberly, director of the Mid-Atlantic Telehealth Resource Center, located at UVa.’s Telehealth Center.

“So there’s an effort right now to think through, ‘How much of this [sports concussion] assessment can be done by telemedicine, and how much of it can’t?’ ” Wibberly asked.

Jason Freeman, a neuropsychologist at UVa., said a concussion assessment could be done remotely over an audio-video link. On one end would be the specialist, and on the other would be the patient and either another doctor or a nurse practitioner helping with assessment. The doctor on the remote end could easily observe the physical challenges used to diagnose a concussion “such as heel-to-toe walking, opening and closing of the eyes and extending hands to either side,” he said.

Testing response and comprehension to auditory commands could also be done orally through an audio-video connection, Freeman said, and “there may be some measures that can be done remotely that involve pencil-paper and timed decision making.”

On the patient’s end, Freeman said there doesn’t seem to be a preference, at least in older populations, when it comes to having a face-to-face cognitive assessment vs. a telemedicine assessment. “So at least there’s some preliminary research out there that is showing patients, and in this case, student athletes, would be open to that concept.”

Wibberly said studies have shown the patient no-show rate decreases significantly when a tele-assessment is an option.

“If you’re sending someone 45 minutes to an hour for a consult, the no-show rate is very high,” she said. “You send someone to their local community center via telemedicine, and the no-show rate drops considerably. ”

Billings said 20 states, including Maryland and Virginia, allow a physician-patient relationship to be established via a remote assessment. But some states, such as Texas, require the patient to be in a medical facility for the initial assessment.

Additionally, Billings said states differ in their laws about licensing requirements for consultations with doctors in other states via telehealth. He said most states — including Maryland and Virginia — allow for consultations with out-of-state doctors to take place, without the remote doctor needing a medical license in the patient’s state.