Without a doubt, the COVID-19 pandemic has been a catalyst for teleconsultations' rapid expansion in many health sectors. The impact of the pandemic, which forcibly halted in-person services in most sectors globally, sparked the rapid and massive adaptation of virtual communication due to social distancing restrictions . According to one study, teleconsultation requests in outpatient neurology were significantly associated with the subjectively perceived threat by SARS-CoV-2 (p = 0.004) . Since the start of the COVID-19 pandemic, teleconsultation has become an essential tool in outpatient service delivery . The rapid expansion of teleconsultation in outpatient neurology service has allowed us to gain new insight into service quality as the scope of adaptation has never been seen before in healthcare history.
This scoping review identified six key service process factors that affected the teleconsultation experiences at outpatient neurology services from both patients' and clinicians' perspectives. While four of the identified service factors, technical issues, logistical needs (convenience), communication, and ability to perform clinical activities, were consistent with findings from the pre-COVID era, the remaining two factors, appropriate triage and administrative support are new findings from this review. Our review has highlighted that appropriate triage is essential for a successful teleconsultation, especially considering patients' technological capacity, preference (logistical needs), disease characteristics, and the ability of their clinician to perform a physical examination for diagnosis and formulating a treatment plan. In addition, this review also determined that appropriate administrative support is essential to a successful teleconsultation visit by equipping both patients (by assessing patients' technological capacity, assisting technical issues, and supporting patients/caregivers) and clinicians (by providing well-prepared documents, accurate patient information, vital signs, and medication reconciliation) with the necessary tools, support, and information. Therefore, the findings from this review will be essential to ensuring a high-quality teleconsultation visit in neurology outpatient.
Exacerbated technical issues during COVID-19 for vulnerable population
Before the COVID-19 outbreak, there were not as many technical issues reported in outpatient neurology teleconsultation when done at a satellite clinic [18, 20, 62-64]. According to one study, veterans with chronic neurological diseases who had follow-up teleconsultations at satellite clinics rarely encountered technical problems . Additionally, according to another study, there were few same-day cancellations (2/64) in follow-up teleconsultation for rare neurological diseases due to technical issues . However, the amount and extent of the technical issue encountered became prominent in follow-up visits with teleconsultation from a home setting. Teleconsultations with patients at home were manifested with technical troubles and having to do with patients' discomfort with technology, which often necessitated assistance from younger caregivers [17, 65].
From a technological perspective, although the COVID-19 pandemic has significantly increased the use of digital technologies in nearly every aspect of our lives, it has also deepened digital inequity . Digital inequality exasperated by the rapid, large-scale adaptation in telecommunications has proven to be a significant barrier to the vulnerable patient population . Due to social distancing, much of the teleconsultations since the COVID-19 outbreak were conducted from the patients’ homes, rather than a satellite clinic. Without proper assistance and experience with telecommunication has gravely contributed to the technical difficulties encountered at the patients' end. Our review has confirmed that access to appropriate technology, patients’ digital literacy, language, physical or cognitive capability, coupled with the medical needs of the elderly and vulnerable population, have significantly limited access to teleconsultation [26, 53, 54, 56].
According to a cross-sectional population study based on data collected in 2018 of community-dwelling adults over the age of 65, 38% of all older adults in the United States were not ready for video visits, mainly because of inexperience with technology. In addition, telephone visits would be problematic for 20% of this population due to having hearing impairments, difficulty communicating or suffering from dementia . A literature-based framework explored the four key age-related barriers influencing mobile health usability, enabling further evaluation of teleconsultation in the geriatric population . Digital health literacy has become a new social determinant of health . As such, healthcare policymakers must consider technology-enabled services to counter the effects of this determinant . Both political and community interventions must be enacted to ensure that appropriate supports are in place and to mitigate the adverse effects of the pandemic and the social health inequalities .
Clinical activities: clinicians’ moral distress and the role of physical examination
The limitation of the remote physical examination has been a significant concern in outpatient neurology teleconsultation before the COVID-19 pandemic. This was likely the primary reason that majority of teleconsultations were done only for follow-up patients after the initial in-person assessment. In fact, prior to the outbreak, teleconsultation was positioned as an optimal solution for remote longitudinal care as a physical examination is not as vital for follow-up patients . Studies examining new but non-urgent neurology patients assessed via teleconsultation conducted in satellite clinics with the aid of a professional telepresenter, demonstrated the noninferiority of virtual consultations for diagnosis, especially given the high level of patient acceptance [19, 20]. In fact, the assistance of a professional telepresenter could highly enhance the accuracy of remote physical examinations by ensuring that any vital signs and symptoms that are relevant to diagnosis are not overlooked . A 2019 review of telemedicine in neurology by the American Academy of Neurology established that diagnosis in traumatic brain injury, dementia, Parkinson’s disease (PD), and MS, via teleconsultation, can be as effective as in person. However, this study had several limitations. For instance, the analysis did not distinguish between studies that evaluated inpatient versus outpatient groups. Moreover, some of the studies included were performed in artificial settings, involved the aid of a telepresenter, had a small sample size, or only comprised of the stable, unchanged non-acute patient population .
Since the COVID-19 outbreak, teleconsultation has been widely utilized with new and follow-up patients in a home setting without the luxury of a professional telepresenter to assist with the technology or the examination. The rapid adoption of teleconsultation in neurology has compelled many clinicians to provide care without appropriate training or credentialing to use this unique service delivery model effectively. Performing remote physical examinations without providing patients appropriate assistance and clinicians the needed training could gravely affect diagnosis and treatment plan. Our review confirms that the constraints of conducting a physical examination virtually has often been translated into a sense of diminished confidence in service quality for the clinician . The impact of the COVID-19 outbreak on health care has immensely altered the standard practice model, compelling clinicians to compromise on the widely accepted care standards to reduce the impact of the highly infectious and virulent disease. The lack of standard best practice guidelines for teleconsultation among neurology sub-specialties has pressured the ethical and moral responsibility of providing good quality of care directly in the hands of individual clinicians. According to Courtney et al., clinicians' heightened awareness of the risks associated with diagnostic uncertainty led to much of the reluctance with virtual examination resulting in ‘unknown unknowns’ . Therefore, we recommend further research investigating clinicians' moral distress in teleconsultation during COVID-19.
Despite the explosion of teleconsultation in neurology, some neurology specialties still have yet to adopt physical examination into a digital landscape [50, 54, 56]. For example, Casares et al. found that providers preferred in-person appointments for complex cases in a follow-up epilepsy clinic during the COVID-19 pandemic, even when the visits rely mainly on the interview rather than the physical examination . The limitations with adopting traditional neurological examinations into a teleconsultation model could be addressed with innovations in digital health and the use of remote monitoring devices [47, 54]. With a vulnerable patient population, having family members assist clinicians with remote physical examinations has proven vital in ensuring patients' safety . Therefore, it would be beneficial to conduct further research on the reliability and safety of family-supported remote physical examinations in undiagnosed patients. Lastly, further research identifying the components of the in-person examination that are essential for the clinical decision-making process needs to be deciphered to meet documentation requirements [47, 57].
Communication: more negative perceived by clinicians
Before the COVID-19 pandemic, patients' satisfaction with the quality of communication during teleconsultation was high but mostly among follow-up patients or in outpatient neurology satellite clinics with the assistance of a telepresenter [20, 61-64]. Contrarily, some follow-up patients at home-setting expressed discomfort with telecommunication and indicated a preference for in-person interaction as they experienced greater ease communicating and found the physical interaction more reassuring and personal [17, 65]. Unfortunately, clinicians' satisfaction with teleconsultation communication quality was less examined in outpatient neurology settings.
Since the COVID-19 outbreak, teleconsultation visits have been mainly conducted with patients from a home setting. Many of these teleconsultations have been with new patients who have had no established relationship with the clinician, which may have contributed negatively to their perceived quality of communication. Interestingly, teleconsultation studies show that patients had more positive perceptions than clinicians. Four studies that used telephone and video modalities indicated that most patients felt communication was effective and sufficient with teleconsultations [44, 45, 53, 57]. Contrarily, clinicians expressed more negative experiences towards communication in five of the studies that used both telephone and video modalities, especially regarding concerns about decreased personal connections and risk of misunderstanding [26, 42, 49, 54, 55]. Further research is needed to explore patient-clinician relationships in a virtual setting in terms of the role of verbal and non-verbal communication from both clinicians' and patients' perspectives. Non-verbal communication enables the clinician to observe patients' physical appearance, eye contact, or emotions and assess the home environment, providing more information in formulating diagnosis and treatment plans [26, 70]. The added value of non-verbal communication on patient-clinician relationships and the ability to perform clinical activities may differ among specialties and diverse patient populations, requiring further exploration.
Meeting logistical needs (convenience): A contributing factor
A systematic review of telehealth services pre-COVID-19 concluded that convenience (travel-saving, time-saving, and cost-saving) is one of the most significant factors influencing patients' satisfaction . The outpatient neurology teleconsultation is no exception. Convenience by meeting patients' logistical needs (travel, transportation, missing work and finical constrain) is one factor that influences patients' positive perceptions of the personal benefits of teleconsultation [3, 12, 15-17, 61, 63, 65]. Interestingly, the distance was not statistically associated with patient satisfaction in outpatient neurology teleconsultation [18, 61]. Another study that examined outpatient neurological teleconsultation follow-up visits found that 30% of local patients chose teleconsultation, which indicated that patients might benefit for a variety of reasons other than distance .
With COVID-19 restrictions, teleconsultation is undoubtedly preferable to the alternative, not receiving any care . Our review confirmed that both patients and clinicians appreciated the convenience of teleconsultation as a factor swaying their positive perceptions of the teleconsultation service quality. However, convenience does not equate to quality of care. Therefore, although convenience is an important factor, understandably, preference for it could easily influence patients' evaluation of teleconsultation service regarding the quality of care .
A new triage system: finding the middle ground
A new insight revealed in this review is that teleconsultation triage has become a complex collaborative process involving both patients and clinicians. Patient selection for teleconsultation requires careful consideration to optimize care and respect preferences from both patients' and clinicians' points of view . A new triage system needs to be established by considering patients' technological capacity, their preference, disease characteristics, and the role of physical examination in the diagnosis and formulation of a treatment plan [25, 26, 44, 48, 49-51, 53-55, 57].
Prior to the outbreak, teleconsultation in outpatient neurology was mainly limited to follow-up patients with a confirmed diagnosis. With this mentality, many clinicians tend to regard teleconsultation as unsuitable for new referrals or follow-up patients with worsening symptoms [26, 46, 49, 53]. Interestingly, in contrast, one of the studies observed that the utilization of teleconsultation was high for both new and returning patients. However, it could have been due to underlying fears of contracting COVID-19 confounding this observation . Clinicians believe that medical conditions that depend on medical history-guided diagnostic decision-making are more appropriate than those that are neurological examination-guided [25, 51, 57]. Certain conditions (e.g., headache and epilepsy) were perceived as more suitable for teleconsultation than others (e.g., MS, movement disorders, or myelopathy) [25, 50]. As a result, a disease-specific triage algorithm is necessary to guide patient selection.
Some clinicians expressed that teleconsultation might empower their patients with management options, leading to an excessive number of consultations in an already overused and high-demand specialty . Clinicians also expressed concerns that patients may find teleconsultation too convenient and opt-out of recommended in-person visits . Thus, they were apprehensive about patients preferring the convenience of teleconsultation against their clinical recommendation for an in-person visit. This finding has not been reported in studies before the COVID-19 pandemic. The possible reasons could be that the COVID-19 restrictions compelled many new patient intakes via teleconsultation prior to developing clear patient selection criteria or virtual care guidelines.
Administrative support: a new virtual care workflow
Another new insight uncovered from this review is that lack of proper administrative support negatively affected clinicians' perceptions of teleconsultation [26, 53, 55, 59]. The lack of protocols prior to the teleconsultation, specifically with regards to technology set up, check-in processes, procedures with vital sign assessment, and medication reconciliation, reflect a need to establish a new administrative virtual care workflow [26, 47, 49, 53]. Unfortunately, teleconsultation, compared to an in-person visit, seems to have generated more work for clinicians and administrative staff. This, in turn, is affecting workflow efficiency and widening the gap between the needs of a successful teleconsultation and the actual administrative support available [26, 47, 49]. The rapid adaptation of teleconsultation since the onset of the COVID-19 pandemic, without the appropriate organizational planning and support, in addition to the strains of staffing deployment due to COVID-related care as well as keeping pace with transitioning workflow between telephone, video, and in-person visits, may have contributed to the maladaptation . The onus of establishing new administrative protocols to manage virtual workflow rests at the organizational level rather than with the individual clinicians. Keeping in mind that technology is a "tool", not the "solution.", it necessitates building a sustainable administrative virtual workflow model to support the frontline clinicians .
Future teleconsultation service model in outpatient neurology
Our review has highlighted six key service process factors that must be addressed to improve teleconsultation service quality. Two models of care could address some of the issues highlighted in the six key service process factors identified. On the one hand, a hybrid model or a multimodal system that is comprised of both virtual and in-person visits would help mitigate some of the barriers faced by vulnerable patient populations, such as those who have disabilities or issues accessing transportation . The added value of teleconsultation affords new opportunities to collaborate, incorporate family support, and ensure continuity of care [25, 26, 34]. On the other hand, a disease-specific model would address the diverse needs of the various neurology subspecialty groups. For instance, while some subspecialties, such as oncology neurosurgery, could accommodate follow-up patient intake with teleconsultation, others, such as functional neurosurgery, may be stringent with follow-up visits to be done in-person . As such, further research is needed to identify the types of disease and the needs of varying patient populations to ensure that appropriate care is delivered using best practices to accommodate both clinicians' and patients' provisions.
Strengths and limitations
There are two strengths of this review. First, we strictly applied the systematic scoping review framework. Second, we applied the SERVQUAL model as a theoretical framework to classify the factors that impact the perceptions of teleconsultation. This review focuses on experiences of teleconsultation during the COVID-19 outbreak based on qualitative, quantitative, or mixed-method peer-reviewed original research published from January 2020 to April 2021. Due to the restrictions imposed during the COVID-19 pandemic, many of the well-established protocols and standards of practices relating to privacy, security, reimbursement, and appropriate credentialing in the pre-COVID era were relaxed [3, 18]. The teleconsultations conducted with the onset of the COVID-19 pandemic have vastly broadened the width and depth of teleconsultation adoption in both urban and remote areas, with new and follow-up patients accessing care from a home setting, who have or have yet to be diagnosed. Our review has contributed to gaining a better understanding of outpatient teleconsultation service quality at-home settings.
Our scoping review has many limitations. First, due to the nature of a scoping review, it is challenging to interpret patients' or clinicians' experiences when the little context was provided during the coding process. Second, the selected studies were conducted in broad geographic areas, across many neurology specialties, with varying methodologies. The heterogeneous nature of the selected studies made it challenging to identify specific factors in a particular group of the patient population. However, in line with the advantages of a scoping review methodology, is that it offers a broader lens as it allows for analysis of a variety of study designs and patient populations in mapping the unfamiliar phenomenon .