The evaluation of guideline-based interviews revealed differentiated answers to the research questions and the benefits and challenges of telemedical structures in physician-patient relationship for neurological patients.
In general, the answers point to two different types of neurological patients. On the one hand a group of patients with a pronounced need for a close physician-patient relationship, on the other hand a group of patients who prefer a certain distance between them and the physician. Telemedicine and telecommunications, with their different elements, offer instruments for both types of patients to meet their different needs. It is important to adjust and apply these possibilities individually to the needs of the patients (Figure 2).
Arguments for an appointment reminder via text message as well as via call could be collected. Advantages of text messages (E3, E4) supporting the patients' desire for independence. The advantages of a call are in contrast (D4, D6). This confirms the patients' need for a closer physician-patient relationship.
In practice, the question arises as to whether a call or text message is more effective. Previous studies indicated that the kind of reminder system is irrelevant and that it is its presence that generates patient satisfaction , so we should stop thinking about the way of reminding. For the first time, we can confirm this for neurological patients, too. For example, the fact, that a reminder won’t be forgotten could have been categorized as an advantage for the phone call and the text message either.
Reminder systems can be important in different ways and the therapeutic range can be great. For example a high vaccination rate can be achieved with the help of reminder systems . Especially in relation to the COVID19 pandemic, it’s important to ensure broad immunization as quickly as possible and to enable normal social and economic life.
The patients mentioned advantages of telemedical care (L2; L1) in the course of the demographic change, especially for a sparsely-populated state (such as Mecklenburg-Pomerania), most often.
Also, the possibility of an intense treatment of chronic diseases as an advantage (L7) could have been categorized. At the same time, the acceptance of telemedical care with regard to more complex diseases, including chronic neurological diseases (such as multiple sclerosis or Parkinson's disease), wasn’t sufficient everywhere (M3). Although the interviews were conducted with patients who had been diagnosed with these neurological disorders, opinions are divided. This is one of the strengths of this study, as it shows that there is no blanket approval or rejection of telemedical care for this group of patients. Patients, who weren’t included in this study, are patients with dementia. Characterizing the needs of this patient group can be a task for future studies.
A further problem in telemedical care for some of the study participants was the treatment of mental illnesses (M6). Reviews show that telemedical psychotherapy can also offer important advantages . In view of the low density of medical specialists  such telemedical psychotherapies will be necessary because the risk of chronicity of such diseases if professional help isn’t available . Especially for neurological patients these possibilities should be addressed more openly, because patients with neurological disorders like multiple sclerosis  or Parkinson’s disease  are more frequently affected by psychiatric illnesses.
“Emergencies” are named as situations which are suitable and not suitable for telemedical care. This shows, that the right use of telemedicine depends on the patient’s needs.
Independent of the basic illness, telemedical procedures would be suitable for example for the pure discussion of findings (N3) or for follow-up-appointments (N1). Therefore, we have to use telemedical care in such situations more often and discuss the possibilities more openly with neurological patients. This study shows for the first time, that there is an openness in neurological patients to this form of therapy.
Former studies show, that there is no deterioration of the physician-patient relationship in patients receiving telemedical care . A fact which has to be discusses with neurological patients, because our study shows, that almost 50 % of the interviewees said that telemedical care is too impersonal (M14) and such care lead into a difficult diagnosis (M2) because of a missing physical examination or invasive diagnostics (M16). This supports the thesis, that neurological patients see a chance for telemedical treatment especially for follow-up-appointments.
In summary, in contrast to the reminding service, different types of patients can be identified. On the one hand patients named as advantages, which shows a certain striving for independence (L9, L2). On the other hand, some categories build up a close relationship with the doctor (L10). All this increases the patients' satisfaction with the therapy, which is of decisive importance for the quality of care as well as for health benefits . This study first shows, that for this both types of neurological patients telemedical care can satisfy the individual needs.
Patients were asked about the advantages and disadvantages of evaluation portals on the internet. It turned out that for neurological patients the online evaluations don’t seem to influence the choice of the physician. The half of the interviews showed, that these portals aren’t serious. The "lack of objectivity" is not only a feeling of the patient. In 2018, the German online portal “Jameda” was forced to delete a physician´s account after a doctor brought legal action. The use of moderators could intervene to make these portals more trustworthy. This offers the opportunity for the doctor and the practice to improve internal quality management . Support and information for the patients would not only help the patients get a first impression of the physician, but also improve the medical work in order to stand up to the competition. In order to increase the probability that the practice is presented as positive, it is important to know the types of patients described in this paper. A broad orientation of the offer improves the perception
Strengths, outlook and future perspectives
In summary, we can report that clinical experience largely coincides with the results of this study: Neurological patients aren’t interested in evaluation portals, there is no preferred way for them of getting reminded on their appointment and they for characterizing can be devided in two groups. Despite their skepticism towards telemedicine, the patients were also able to collect numerous positive arguments for telemedical treatment. For the first time, the needs of neurological outpatients and conclusions for optimizing clinical pathways could have been characterized.
Taking the Covid-19 pandemic into account, digital care is gaining importance. The study shows that neurological patients with their various needs were aware of the opportunities and possibilities of "digital medicine". But not only the on-site visit treatment gets in focus by the pandemic, also the organization of the doctor’s practice. Appointments get rarer and waiting time increases. Missing such an appointment can have negative consequences on patient’s health. Reminder services can be helpful.
In the future, neurological patients should be encouraged to make use of telemedicine and telecommunications and to establish the necessary infrastructure. However, this study shows that suitable telemedical tools exist for different needs of patients which determine the choice. Central telecommunication structures are health advice and an individual reminder service.