Telemedicine use among neurologists before and during COVID-19 pandemic

ABSTRACT Background: After the public health emergency due to COVID-19 was declared in Brazil, the federal government temporarily regulated and authorized the use of telemedicine services for patient consultation, monitoring, and diagnosis. For more than a decade, neurologists have recognized the benefits of telemedicine in the acute management of stroke patients. However, as the use of telemedicine was restricted until the COVID-19 pandemic, the view of Brazilian neurologists about telemedicine is unknown. Methods: All neurologists registered at the Brazilian Academy of Neurology were invited by e-mail to participate in a survey about personal perceptions on telemedicine use. Results: One hundred sixty-two neurologists from all regions of Brazil answered the online questionnaire. The survey showed that 18.5% of participants worked with telemedicine before the pandemic, while 63.6% reported working with telemedicine during the pandemic. The main telemedicine modalities used during the pandemic were teleorientation and teleconsultation. Discussion: According to our data, the COVID-19 pandemic deeply influenced the behavior of Brazilian neurologists, who developed a more favorable view about telemedicine and actively searched for information about telemedicine. As there is a need for more training in this area in Brazil, universities and medical societies must strive to improve telemedicine education. Expanding the use of high-quality teleneurology can contribute to a better care for patients with neurological diseases in Brazil.


INTRODUCTION
According to the World Health Organization, telemedicine is the remote provision of healthcare services when the distance between the providers and patients is a critical factor. Using information and communication technology, professionals exchange valid information for the diagnosis, treatment, and prevention of diseases, research, and continuing education 1 . The history of telemedicine begins in the early twentieth century, but the first structured system was created only in 1967, connecting the Massachusetts General Hospital with the Boston Logan Airport. With the emergence of the internet in 1990, the possibilities of telemedicine have expanded and there has been an increase in its use in several medical areas 2 . Telemedicine is used to integrate two or more physicians, and physicians with patients or with other health professionals, and it includes different modalities such as teleconsultation, teleorientation, telemonitoring, screening, and remote reports 3 .
In Brazil, telemedicine was initially regulated by the Federal Council of Medicine (CFM) in 2002 by the resolution 1643 4 . However, several telemedicine procedures, such as teleconsultation, were not regulated until the advent of the COVID-19 pandemic. The required social isolation determined by local health authorities imposed the need to regulate these procedures as a way to maintain medical care, not only for SARS-CoV2-infected patients but also to patients with other medical conditions. This was carried out through the ordinance 467 5 of the Ministry of Health and the Law 13.989 6 , of April 2020. Meanwhile, the CFM has been working along with Brazilian medical specialty societies in order to establish a broader and more definitive regulation of telemedicine in Brazil. In Neurology, telemedicine was first used more than a decade ago in the acute management of stroke patients 7 . More recently, other areas of Neurology have been addressed in controlled studies evaluating telemedicine safety, effectiveness, cost-benefit, and patient satisfaction 8 . With the regulation due to the pandemic, telemedicine use had a clear increase, particularly teleconsultations, among Brazilian physicians. However, the numbers of this expansion as well as the opinions of neurologists concerning this modality of care are still largely unknown. The aim of the present survey was to better understand the use of telemedicine by Brazilian neurologists and how the COVID-19 pandemic has changed its practice.

METHODS
E-mails were sent to all neurologists registered at the Brazilian Academy of Neurology (ABN -Academia Brasileira de Neurologia) (a total of 3,441) with an open invitation to participate in a survey on personal perceptions of telemedicine use. Students and non-neurologists were not included. An anonymous and confidential questionnaire was sent, with four demographic questions and eleven multiple choice questions related to neurological care and telemedicine prior to COVID-19 pandemic and after the telemedicine authorization. The estimated time to complete the questionnaire was seven minutes. The questionnaire was designed on the online platform Survey Monkey ® and it was available from April 28 to June 2, 2020, with confidentiality guarantee (the original questionnaire and its English version are available in the appendix). Because of the anonymity of the participants, the ABN authorized the use of the data and the publication of the results.

RESULTS
One hundred sixty-two neurologists answered the questionnaire. The mean age was 44.26 years, 87 were female (53.7%), and the mean time of neurology practice as specialist was 15.02 years. The participants were from all regions of Brazil, the majority from the Southeast (58.6%). The five states with the largest number of participants were São Paulo (53), Minas Gerais (23), Rio Grande do Sul (17), Rio de Janeiro (15), and Bahia (7).
The survey showed that only 18.5% of the participants worked with telemedicine before the pandemic. A small number of respondents declared previously having studied the teleneurology principles (31.7%) and 40.2% had participated in scientific meetings about telemedicine. During the pandemic, 82.7% declared having studied teleneurology, 63.6% to be applying telemedicine, and 68.5% declared to have attended at least one telemedicine scientific meeting in this period. Figure 1 shows the telemedicine modalities used by the survey participants. Among the 59 neurologists who said they were not applying telemedicine during the pandemic, 22 reported using at least one modality of telemedicine, the  Modalities of telemedicine used by the survey participants most used one being teleorientation (16 participants), indicating that they make unaware of their sporadic use of this technology. Among participants who did not use telemedicine before the pandemic, 85.4% reported using communication technology to remotely connect with patients. Communication tools included mobile phone, messaging app, e-mail, and recorded videos of patients. Among those who reported using telemedicine, 86.7% used such tools, showing that the difference was not significant.

DISCUSSION
The COVID-19 pandemic led to an improvement in the use of telemedicine in our country 9,10 . According to our data, the pandemic deeply influenced the behavior of Brazilian neurologists who have developed a more favorable idea about this modality of care and also determined a more active search for information about telemedicine. During the first months of the pandemic in Brazil, many online meetings on telemedicine were offered. The ABN also released information on telemedicine and remote neurological examination and organized a web conference on teleneurology.
About one third of participants who answered that they did not work with telemedicine actually reported using some telemedicine modality. One possible explanation for this is that telemedicine and teleconsultation are sometimes perceived as synonymous, indicating the need to increase the medical education in this area. Including telemedicine in the medical school curriculum would probably decrease this knowledge gap in the future. Another intriguing point was that some neurologists who reported not using telemedicine prior to the pandemic, actually used technological devices to communicate with patients, unaware that this use is included in the telemedicine concept, which reinforces the need to increase the medical knowledge in this field. It is important that these complimentary uses of telemedicine, such as exchanging messages with patients and using mobile videos for epileptic attacks recognition 11,12 , be recognized as telemedicine procedures that are subject to regulation, so that they can be carried out with safety for patients and neurologists.
Some previous Brazilian experiences with telemedicine have been published, including the Belo Horizonte-Telehealth (BH-Telehealth) Program 13 , teledermatology in primary care in São Paulo 14 , neurology teleinterconsultation in three capitals in Brazil 15 , the TelessaúdeRS-UFRGS 16 program for teleregulation of care 17 , neurosurgery emergency consultation 18 , teleophthalmology in primary care 19 , and medical support by teleconsultation in emergency departments 20 . Most of these initiatives have government support through public universities or hospitals that are members of the Institutional Development Support Program of the Unified Health System (PROADI-SUS).
Despite previous experiences, this is the first survey about the use of telemedicine among neurologists in Brazil. Since this modality of healthcare has not been previously regulated in the country, it seems that it was less used than in other countries 21 , which was reinforced by the low percentage of self-declared telemedicine users in our survey. The pandemic has led to a significant increase in the number of neurologists using telemedicine even in the United States, where teleneurology is more widespread 22 . With the pandemic and the need for rapid regulation, a change in the use of telemedicine resources by Brazilian physicians probably occurred, and our data suggest that this was the case among neurologists.
The current study had some limitations, such as the small number of respondents. Also, it is possible that respondents were more interested in this subject that non-respondents. In 2019, a vast debate about telemedicine was launched in Brazil with a new resolution by the Federal Council of Medicine that ended up being revoked, which probably also influenced the response rate of the survey. However, as a preliminary survey, the present findings show that a trend for change is under way concerning the use of telemedicine by neurologists in different regions of Brazil. In conclusion, this preliminary study indicates a huge increase in the use of, and in the level of interest in, telemedicine by neurologists in Brazil, influenced by the social restrictions imposed by the pandemic. The data also highlights the need to increase knowledge in this area. The more efficient application of high quality teleneurology according to international standards of safety will contribute to a better care for patients with neurological diseases in Brazil.