Current Use and Future Considerations for Concussion Telemedicine Healthcare in Canada

ABSTRACT: Objective: To examine the use of telemedicine among Canadian concussion providers and clinics before and after the COVID-19 pandemic onset and identify barriers and facilitators for future use. Methods: Ninety-nine concussion clinics and healthcare providers across Canada that offered one or more clinical concussion-related service were identified using standardized online searches and approached to complete a cross-sectional online survey. Results: Thirty clinics or providers completed the survey and two completed subsections of the survey (response rate of 32.3%). Only 28.1% of respondents indicated that they used telemedicine to provide care prior to the COVID-19 pandemic. Providers most commonly using telemedicine prior to the pandemic were occupational therapists and physicians, while the most commonly used services were in-person videoconferencing and eConsultation. Most respondents (87%) indicated their clinic’s use of telemedicine changed following the onset of the COVID-19 pandemic including new use of in-person video-conferencing, telephone calls, and eConsultation. Ninety-three percent indicated that they would consider using telemedicine to provide care to their concussion patients once the pandemic was over. Barriers needed to be overcome to facilitate use or greater use of telemedicine-based services were the inability to conduct a complete physical examination, lack of appropriate reimbursement, lack of start-up, and maintenance funding and medico-legal risk. Conclusion: Telemedicine was used by a minority of Canadian concussion clinics and providers prior to the COVID-19 pandemic but was rapidly adopted by many facilities. This study provides important insight into the factors that must be considered to optimize use of telemedicine in concussion care in the future.

Concussion affects thousands of Canadians annually. [1][2][3][4] Common mechanisms include falls, sports, motor vehicle collisions, and work-related injuries. Harmonized national concussion guidelines recommend that all children and adults with a suspected acute concussion undergo urgent medical assessment, comprehensive follow-up, and medical clearance to return to school, work, and sport-related activities. [5][6][7][8] It is also recommended that patients who develop persistent post-concussion symptoms (PPCS) be referred to inter-disciplinary concussion clinics that have access to physicians with expertise in traumatic brain injury who work with a team of professionals with expertise in disciplines such as neuropsychology, physiotherapy, neurology, otolaryngology, and psychiatry.
Unfortunately, research suggests that timely access to highquality primary and specialized concussion healthcare is not universally available throughout Canada. Deficiencies in concussion knowledge have been identified among Canadian primary care and emergency physicians, 9,10 and research suggests that a significant majority of pediatric concussion patients do not receive appropriate medical follow-up. 11 Patients living in remote and isolated regions of Canada face geographic, socioeconomic, and cultural barriers that limit access to primary and specialized healthcare services. [12][13][14][15] Furthermore, there is concern that many concussion clinics in Canada do not have access to physicians or the full complement of physician and allied healthcare professional specialists required to provide comprehensive interdisciplinary care. 7,16 In addition, the global COVID-19 pandemic has disrupted access to healthcare services throughout Canada. To limit the initial COVID-19 spread within healthcare facilities and conserve critical supplies of personal protective equipment, regional health authorities recommended limiting nonurgent visits to out-patient clinics and transitioning healthcare delivery to telemedicine wherever possible. These unique circumstances presented an unprecedented challenge for providers and patients, many of whom were forced to interface with models of healthcare delivery that they had limited or no previous experience using.
Over the past decade, telemedicine has emerged as a transformative tool to help overcome disparities in access to specialized healthcare services for patients with a wide range of neurological diseases. [17][18][19][20][21][22][23] More recently, a growing body of research has begun to demonstrate that telemedicine is a safe and cost-effective approach to delivering remote care to patients with concussion. [24][25][26][27] Similar to systems of care developed for acute stroke, 28,29 telemedicine-based networks centered around regional or provincial multi-disciplinary concussion clinics may be a novel approach to expand access to specialized care for patients living in remote, isolated, and medically underserviced communities throughout Canada. 30 Despite this innovative work, little is known about the use of telemedicine among Canadian concussion care providers and clinics, how use of this technology has changed during the COVID-19 pandemic, and what barriers must be overcome to promote greater adoption and sustainability of telemedicine to manage concussion. Therefore, the objective of this study was to evaluate the use of telemedicine among Canadian concussion healthcare providers and clinics before and after the onset of the COVID-19 pandemic and identify barriers and facilitators that must be considered to optimize its use.

Study Participants
Institutional ethics approval for this study was obtained from the University of Manitoba.
At present, there is no formal registry or accreditation process for interdisciplinary concussion clinics or providers in Canada. We conducted standardized online searches to identify a generalized sample of Canadian concussion healthcare providers and clinics. We defined a concussion provider or clinic as a facility that advertised providing one or more clinical concussion-related services on their website. Using the Google.ca search engine, we conducted standardized online searches using the terms "concussion clinic" and each Canadian province or territory. For each search, we recorded the top 10 concussion providers and clinics identified within the first 10 pages of Internet searches. To identify any university-based concussion clinics that may not have been identified during the initial online searches, we also completed searches using the terms "concussion clinic" and the name of all Canadian universities with medical school programs. Once the final list was generated, a research assistant searched each individual concussion provider and clinic's website to identify an appropriate representative to approach to participate in the study (e.g., clinic director, manager) and recorded their contact email. If a contact email was not available, the research assistant telephoned the facility to obtain the email address of an appropriate representative who could be approached to participate in the study. The original online searches for Canadian concussion healthcare providers were completed on May 11, 2020. Additional searches to identify any missed university-based concussion clinics were completed on May 12, 2020.

Online Telemedicine Survey
Using Survey Monkey, we developed an electronic survey composed in the English language that collected provider or clinic information, multiple choice and open-ended questions that assessed the use of telemedicine prior to and after the onset of the COVID-19 pandemic, the types of telemedicine services used and which healthcare providers at these facilities used telemedicine and for what purposes (see PDF, supplemental digital content 1, to view survey). The survey included questions addressing limitations, barriers, and concerns that must be considered to facilitate the use of telemedicine in the future. Prior to completing the survey, all participants provided informed consent and were ensured that data collected from the study would be presented in a de-identified fashion. The electronic survey was emailed to the identified representative from each concussion healthcare provider or clinic. If a response was not received after three email attempts, the research assistant telephoned the representative to inquire about whether they were interested in participating in the study. Provider and clinic representatives were recruited to participate in the study starting on May 22, 2020, and reminders were sent in four-to five-week intervals until August 7, 2020.

Statistical Analysis
The results of the surveys were downloaded from Survey Monkey and imported into an Excel spreadsheet for analysis. Survey responses were tabulated and proportions were calculated.

Results
Overall, 106 individual concussion healthcare providers or clinics were identified. For 99 (93.4%) of these facilities, an appropriate representative was identified and invited to participate. Of the 99 eligible representatives, 30 returned fully completed surveys and two participants completed only subsections of the survey but were included in the final analysis. Three representatives declined to participate. The overall response rate was 32.3%, and the characteristics of respondents appear in Table 1. Among participants, 59.3% indicated they had on-site access to a physician with expertise in concussion, 75.0% had access to two or more other multidisciplinary professionals, 96.9% followed national concussion management guidelines, and one representative did not respond to any of these questions. Overall, 62.5% indicated they provided care to patients living in rural and remote northern communities in Canada and 34.3% indicated they provided care to patients living outside the province or territory in which they reside (one representative did not respond).
Most (86.7%) of respondents indicated their clinic's use of telemedicine changed since the onset of the COVID-19 pandemic and two respondents did not answer. Among the 26 clinics that changed their telemedicine services during the COVID-19 pandemic, the most common additions were the use of in-person videoconferencing (69.2%), telephone call appointments (65.4%), eConsultation (19.2%), and other (11.5%). Ninety percent of the 29 respondents indicated that telemedicine had helped provide care to their patients during the pandemic and 13 of 28 respondents (46.4%) indicated that new tariffs or billing codes were introduced in their province or territory to allow providers to bill for telemedicine-based services that were previously unavailable prior to the pandemic. The potential barriers to increase the use of telemedicine-based services appear in Table 2. While 8.3% were unsure, most (22/24; 91.7%) indicated that with appropriate training, equipment, financial support, and supportive evidence they would be open to using telemedicine to assist with the care of select concussion patients in the future. Ninety-three percent of the 30 respondents indicated that they would consider using telemedicine to provide care to their concussion patients once the COVID-19 pandemic crisis was over, and two respondents did not indicate their future plans.

Discussion
This is the first study to examine the use of telemedicine among Canadian concussion clinics and providers. Only 28% of respondents indicated they used telemedicine to deliver clinical care prior to the COVID-19 pandemic. Among the participating clinics and providers, telemedicine was most commonly used by physicians and occupational therapists and the most common service was in-person videoconferencing. The results also suggested that providers were predominantly using this technology to provide follow-up care of patients who had previously undergone in-person assessment with a smaller proportion using it to conduct initial assessments of concussion patients. Overall, these findings are consistent with the preliminary reported literature that examined the use of telemedicine to deliver primary and multidisciplinary concussion care.
To date, research suggests that telemedicine, including the use of in-person videoconferencing, is a safe, feasible, and cost-effective approach for physicians to provide initial medical assessment and follow-up care of carefully selected pediatric concussion patients living in rural and remote underserviced regions. 24  The role of occupational therapists in concussion management continues to expand 31,32 as does the literature suggesting a role for virtual delivery of out-patient rehabilitation to patients with neurological disorders. 33 There is also a strong body of evidence to support the delivery of virtual psychiatric services. 19 Recent work has suggested that the development of formal hub-and-spoke type telemedicine-based networks composed of provincial or regional multidisciplinary concussion clinics linked to multiple hospitals and healthcare centres within rural and remote communities may be a novel approach to expand access to concussion care in Canada. 30 Very few study respondents indicated they had established formal telemedicine networks, however nearly all felt these networks could improve access to primary and specialized concussion care in Canada. The most common motivating factors for using telemedicine prior to the COVID-19 pandemic were improving access to care for patients living in remote and underserved communities, decreasing travel time for patients, improving clinical outcomes, and ensuring greater clinical coverage for clinic catchment area. Despite few Canadian concussion healthcare providers using telemedicine prior to the COVID-19 pandemic, the vast majority felt their patients could benefit from the adoption of these services. The results of this study suggest COVID-19 pandemic increased the use of telemedicine among Canadian concussion providers and clinics. The evolving pandemic likely led practitioners to rapidly modify their practices and begin using telemedicine-based platforms they had never used previously. Furthermore, many provincial health care systems quickly developed payment structures for telemedicine. Indeed, 87% of respondents indicated their clinic began to use services such as in-person video-conferencing, telephone call appointments, eConsultation after the onset of the COVID-19 pandemic. Almost all of respondents indicated that telemedicine helped provide care and 93% indicated they would consider using telemedicine to provide concussion care once the pandemic was over.
This study identified a number of key barriers that must be overcome to promote use or greater use of telemedicine among Canadian concussion providers and clinics. The barriers were consistent with the published literature on teleneurology. 23,34 First, survey respondents identified the inability to perform a comprehensive physical exam was a barrier. Canadian national concussion guidelines suggest that all children and adults with a suspected concussion undergo a medical assessment performed by a physician or nurse practitioner that includes a clinical history and physical examination. 5,6,8 A comprehensive physical examination should ideally include assessment of mental status, speech and communication, as well as objective testing of cranial nerve, motor, sensory, cerebellar, balance, vestibulo-ocular, and cervical spine functioning. The comprehensive testing of vision, motor, and sensory functioning as well as palpation of the cervical spine and tests to evaluate peripheral vestibular functioning cannot be performed without the assistance of a trained telepresenter. Nonetheless, a study by Ellis et al. 24 suggested that carefully selected pediatric concussion patients living in remote communities who have undergone a previous medical assessment can be managed safely and exclusively through telemedicine. The same authors introduced a preliminary clinical algorithm and adapted physical examination as well as standardized resources to guide the remote medical assessment and longitudinal care of pediatric patients living in remote and isolated communities in northern Canada. 25 A second barrier was the lack of appropriate reimbursement; however, the COVID-19 pandemic has helped to address concerns about provider renumeration and licensing. As demonstrated here, many concussion healthcare providers and clinics benefitted from the regional development of new tariffs and billing codes created during the COVID-19 pandemic that allowed providers to be reimbursed for certain telemedicine-based services.
Other barriers included concerns related to lack of start-up and maintenance funding and medico-legal risk. Despite the recent advances in the use of telemedicine for concussion care, long-term solutions are needed to address concerns related to funding and medico-legal risk. The results of this study provide strong support for developing a national working group to help address these challenges. Indeed during the COVID-19 pandemic, the Living Guideline on Pediatric Concussion Care published a domain that describes evidence-based and expert consensus recommendations and guidelines for the use of telemedicine in concussion. 6 Medicolegal risks include risk of malpractice allegations because of inability to perform clinical examinations, risk of injury during remote examinations, and challenges of developing therapeutic rapport over videoconference could be addressed by establishing standards for telehealth examinations and ensuring informed consent from patients regarding the limitations of telehealth.
To date there is minimal evidence regarding patient satisfaction of virtual concussion care. However, a small randomized controlled trial comparing in-person versus telehealth concussion care among pediatric athletes found that patient satisfaction was similar between both treatment options. 35 Moving forward, there is a need to build a strong foundation of evidence that evaluates patient satisfaction with virtual care, examines the societal and economic benefits of this approach, and addresses the extent to which concussion-related healthcare services (i.e. cervical spine and vestibular physiotherapy, neuropsychological testing, occupational therapy) can be safely and cost-effectively delivered via telemedicine to patients living in medically underserved communities.
This study has several important limitations. First, the response rate for this survey study was 32.3%. Although the authors used multiple strategies to contact the identified concussion healthcare clinics and providers, many chose not to participate. The survey was received when many aspects of professional and personal lives were moved online and people were experiencing screen and computer fatigue which may have decreased participation. Also, it is possible that those clinics and providers who were not using telemedicine to deliver concussion care were more likely to decline participating in the study if they did not perceive that the survey was relevant to their current practice. Second, this study was conducted during the COVID-19 pandemic, which may have impacted survey responses. Many clinicians were logistically unable to provide in-person care and were forced to adopt virtual models of concussion care delivery. Given these evolving circumstances, this may have led to an overestimation of the use of telemedicine prior to the COVID-19 pandemic among those who anticipated the impact of this looming public health crisis and therefore chose to adopt these practices immediately prior to regional recommendations to limit in-person patient visits. Third, the survey was not translated into French, and this may have resulted in fewer responses from Quebec. Future research is needed to evaluate whether the increased use of telemedicine-based services translates into the long-term adoption and sustainability of these practices moving forward.
In conclusion, telemedicine was used by a minority of Canadian concussion clinics prior to the COVID-19 pandemic and mostly used by occupational therapists and physicians. Although telemedicine increased following the onset of the COVID-19 pandemic, several barriers must be addressed to facilitate increased adoption of telemedicine-based services and virtual care into the routine clinical practice of interdisciplinary providers in the future.
Supplementary Material. To view supplementary material for this article, please visit https://doi.org/10.1017/cjn.2022.18 Disclosures. Judith Gargaro was an employee of ONF and contributed to the development of the ONF guidelines for concussion and mild TBI. Dr Bayley received funding for development of the ONF guidelines.