The American Epilepsy Society (AES) is a medical and scientific professional society comprised of approximately 4,500 members committed to research and evidencebased clinical care for people with epilepsy. The membership
is composed of physicians, nurses, pharmacists, psychologists, social workers, and basic and clinical scientists focused on epilepsy. For more than 75 years, AES has provided a dynamic global forum where professionals from academia, private practice,
not-forprofit, government, and industry can learn, share, and grow. AES is dedicated to improving the lives of people with epilepsy (PWE).
Description of Issue
With the onset of the coronavirus 2019 (COVID-19) global pandemic caused by the
SARS-CoV-2 virus, telehealth has emerged as a highly valuable method for patient
care delivery, particularly for PWE. Therefore AES supports continuation of
telehealth as an option following the Public Health Emergency (PHE) and related
policies that 1) address access to care for PWE, 2) provide equitable reimbursement
for care providers, 3) reimburse telehealth care provided by multi-disciplinary
epilepsy care team members, 4) reduce issues related to liability and licensing
across state borders, and 5) allow for ongoing future improvements in telehealth
technology to optimize access for patients and providers.
Definition of Telehealth and Background
For the purposes of this statement, AES defines telehealth as delivery of patient
care that involves electronic communication with or without a synchronous video
component to enable providers to practice medicine, and patients to receive care,
from remote locations separate from the typical in-person clinical setting.
Telehealth has been a part of medical care for years, but its use and related
regulations have rapidly evolved in 2020. Care provided via telehealth
is high-quality and cost- and time-efficient for both patients and
providers, facilitates prompt patient care delivery, and
improves access to specialty care for patients. These
telehealth benefits are particularly applicable to PWE,
many of whom are unable to drive due to effects of medications or physical and
intellectual disabilities which are prevalent in this population. PWE may be
vulnerable to job loss due to risk of seizures or transportation challenges, so
minimizing lost work time is a priority. Transportation challenges are further
compounded for those PWE who live in rural or remote areas where specialty
resources such as comprehensive epilepsy care are not available.
Telehealth availability and reimbursement considerations
Telehealth should be a health care delivery option available to all people with
epilepsy. While telehealth cannot replace all in-person clinical assessments, it is a
valuable service and should be offered and reimbursed by all subscriber benefits
and insurance plans including commercial and government payors at rates that are
at parity with in-person clinic visits. The Centers for Medicare and Medicaid Services
(CMS) should support these efforts.
During the COVID-19 pandemic, CMS allowed for time-based evaluation and
management (E/M) billing for both video and audio-only telehealth. Time-based
telehealth reimbursement should continue after the PHE. In addition, medical
personnel and facility needs for providers of telehealth are similar to those for inperson medical care, and these necessary costs should be factored into
reimbursements for care provided by telehealth.
During the COVID-19 pandemic, epilepsy providers reported effective use of
telehealth.1 Preliminary data indicate that safe and effective care for new PWE can
be provided via telehealth.2-4 Although additional studies are needed, the ability to
see new patients via telehealth should remain an option available to providers and
patients after the PHE. For example, a model employing a mixture of telehealth and
in-person clinic visits may use initial video telehealth visits to screen which patients
need in-person care for future visits, for optimal quality of care and efficiency for
patients and providers alike.
Use of telehealth provides a viable option for patients who are not able to be seen
in person for routine care. In addition to virtual visits involving a video component,
the use of audio-only telephone visits and other electronic communication methods
have value in medical practice, should be included in the discussion about
reimbursement, and should remain a viable option for providers to utilize to
improve epilepsy care. Specifically, telehealth options that do not include video may
be the only access to epilepsy care providers for patients living in rural, remote, or
technology-deficient areas or otherwise impacted by the “digital divide”
(socioeconomic, educational, and other inequalities between those who do and those who do not have opportunities or skills enabling them to benefit from the
internet and online resources). The use of telehealth cannot increase disparities of
care and should represent an opportunity to improve equity for epilepsy care.
Medications and prescribing considerations for epilepsy care
During the COVID-19 PHE, the Drug Enforcement Administration (DEA) is allowing
prescriptions for controlled substances to be written based on a telehealth visit
without requiring a prior in-person session between the prescriber and the patient
which enabled providers to ensure access to much-needed medications for new
patients with epilepsy. The ability to continue prescribing the full range of
antiseizure medications (ASMs) to patients during a telehealth visit, including a first
visit, should remain an important treatment option for providers to ensure quality
care for PWE after the PHE. A number of traditional and newer ASMs used in
epilepsy care, both ongoing care and emergency or “rescue” care, are DEA
scheduled drugs,5,6 so AES supports extension of regulatory flexibilities initiated
during the PHE in particular for medications used in epilepsy care.
Multi-disciplinary epilepsy care model considerations
Optimal care of PWE involves a multi-disciplinary care team.7-8 Epilepsy care
providers, including physicians and non-physician providers (nurse practitioners,
clinical nurse specialists, clinical pharmacists, physician assistants,
neuropsychologists, clinical psychologists, social workers, dietitians, and genetic
counselors) should be reimbursed equitably for services provided via telehealth, as
currently authorized during the COVID-19 PHE. Telehealth reimbursements for
these providers should be maintained after the PHE in accordance with these
professionals’ scope of practice and licensure.
Reimbursement should be provided for all billable providers even when two or more
specialty care providers participate in the same telehealth visit concurrently.
Separate E/M billable codes that allow for collaborative care should be created and
utilized for telehealth visits.
For example, care of PWE is significantly dependent upon medications with complex
pharmacology. Clinical pharmacists, working under collaborative practice
agreements with physicians and other provider types via telehealth visits can
coordinate medication management (e.g. medication selection and dose
adjustment, laboratory and adherence monitoring, and refill approval) with a net
result of streamlined patient access to care, improved efficiency in the care delivery
process, and enhanced quality of care.7
Licensure and liability considerations
All types of care providers, as delineated in the prior section, should have access to
a streamlined licensure process that is not state-dependent, allows easy portability,
and tracks individuals who are impaired or not competent. Comprehensive
malpractice insurance policies are important, and providing care via telehealth
should be covered under existing policies. These changes to professional licensure
processes and liability insurance policies to enable provision of epilepsy care across
state lines via telehealth and in-person are important especially for timeliness and
continuity of care for PWE living in rural or remote areas.
Patient Care Benefits
Direct economic benefits
Epilepsy care via telehealth has been demonstrated to improve access, costs,
medication safety, adherence to Healthcare Effectiveness Data and Information Set
(HEDIS) measures, in one study that compared care by audio-only telephone calls
to in-person care.9 Telehealth technology in patient care has been utilized
effectively for years within the Veterans Affairs (VA) system.10 Telehealth has been
demonstrated to improve patient satisfaction, decrease patient costs, and decrease
patient travel time and the need for patients to rely on a companion to travel to an
in-person clinic visit.11 A recent survey of PWE and their caregivers demonstrated
benefits in many areas including patient support, less lost work and school time,
decreased costs, and improved access to care.2 Other providers caring for patients
with various neurological illnesses have also seen similar advantages with
Improved access and quality of care
Decreasing the need for transportation is a major benefit for patients with active
seizures, as they cannot legally or safely drive, which affects their access to quality
epilepsy care. The economic benefit in decreased time off from jobs, school, etc. for
travel exists for both patients and their caregivers. In addition, seeing patients in
their home settings and interacting with family and caregivers more readily enable
providers to identify and reduce possible barriers to epilepsy care. Thus, both
patients and providers benefit, and epilepsy care is improved, when patients are
able to participate in telehealth visits from their homes.
Access to specialty expertise and reduced health disparities
For PWE, the use of telehealth improves access to comprehensive epilepsy centers
in rural or remote areas or in states where Level III and IV epilepsy centers accredited by the National Association of Epilepsy Centers (NAEC) are few in
number or do not exist. Access to such centers is an important gap in epilepsy care
and is a current American Academy of Neurology (AAN) epilepsy quality measure
supported by AES.17
Especially for patients with rare epilepsy syndromes, telehealth can facilitate access
to national experts in those specific conditions. Medication evaluations for those on
ASMs and more frequent evaluations for PWE can occur. Coordination of
multidisciplinary comprehensive care via virtual care teams addressing
comorbidities and quality of life may be easier with greater telehealth flexibility that
no longer requires care team members to be in one location. In addition, telehealth
enables virtual consultations for complicated epilepsy cases or patients in need of
urgent, emergent, or transfer of care during the inpatient or emergency room
setting.18 Finally, telehealth can be particularly beneficial in providing timely care of
adolescent patients with epilepsy in transition from pediatric to adult care.19
Addressing Potential Barriers
Educational resources for providers on performing effective neurological
examinations via telehealth will help ensure ongoing advancements in delivery of a
high level of quality care. Moving forward, definition and refinement of the ideal
telehealth platform and tools to optimize virtual care of PWE is needed, and AES
can take a lead role in these efforts.
Limitations in broadband internet access and other necessary equipment available
to patients, part of the “digital divide,” need to be addressed and improved to
ensure access to telehealth exists for all PWE. Adult and older patients have
decreased access to and fluency with advanced technology such as smartphones
and equipment needed for a video appointment and may also have challenges
utilizing such tools, as documented by a 2015 Pew survey and other research
(Table 1).20-23 Due to technological limitations, audio-only visits or other electronic
forms of clinical visits may be the only telehealth options available to some PWE,
reinforcing the need to maintain reimbursement of these services as well as video
telehealth visits. Proper translation resources need to be available for patients that
do not speak English as their primary language, and translation services may be
more readily available via telehealth than at in-person clinic visits.
Table 1. Patient access to technologies typically used for video telehealth
US households with a computer 86.8%20
US adults who use the internet 89%21
Smartphone ownership, by generation22
Millennials (23-38 years old) 92%
Gen Xers (38-53 years old) 85%
Baby Boomers (54-72 years old) 67%
Silent Generation (73+ years old) 30%
Americans >65 years old comprise 15% of the total population23
42% own smartphones
67% use the Internet
Future Advancement of Epilepsy Care through Telehealth
Many technological and operational investments have been made by providers and
their institutions to enable delivery of care via telehealth during the PHE. With this
expanded use of telehealth and payer support for it, innovations, improvements
and collaborations between technology companies and health providers have
substantially improved the content and quality of health care. Ongoing payer
support will continue this trend of enhanced capabilities and encourage advances
toward optimal utilization of telehealth in health care. AES supports regulatory and
statutory policies that facilitate flexibility in care delivery options for providers and
patients and enable ongoing advancements in the use of telehealth technologies to
optimize care for PWE.
To this end, AES supports proactive steps to address potential gaps in
implementation of next generation technology such as 5G service and adoption of
remote stimulator technology, wearable technology for seizure detection and
forecasting, and other advances in remote monitoring for PWE. Workflows should
incorporate technologies that enable accurate assessment of seizure frequency,
adverse effects of medications, cognitive disorders, psychosocial concerns, quality
of life, and other important patient-reported outcomes. Such ongoing developments
in technology to assist with patient care will help overcome some geographic and
technological barriers that exist for patients.. Comfort and training in utilizing
telehealth and other technology must occur for both PWE and providers that have a
limited knowledge or ability to navigate the technology. Continued attention to
improvements in technologies, along with policies that enable flexibility in use of
video and audio-only telehealth services, will continue to minimize potential
technology-related disparities in care.
One of the many lessons learned from COVID-19 is the need for improved
processes to advance patient care and continuity of care for those with epilepsy. In
this unique situation, AES epilepsy care providers have collaborated to embrace
change and develop innovative solutions, as described in this statement.
Given the strong patient care benefits of telehealth experienced by patients and
providers alike during the COVID-19 PHE, and the potential for telehealth-related
continuing advancements of future care of PWE,4 AES supports policy that enables
continued use and reimbursement of epilepsy care via telehealth following the
current pandemic. All aspects of telehealth, including care delivered via audio-only
and other electronic technologies, as well as video technology, should be
reimbursed by payers. Legislative and regulatory action is needed at both state and
federal levels to ensure continuation of access to telehealth care for all PWE at
home, regardless of geographic location or insurance coverage. Healthcare
providers and institutions should continue to address technological needs to
optimize telehealth as a tool for patient care. Proper telehealth technological
implementation and reimbursements will continue to build on telehealth
experiences during COVID-19 and continue to advance the quality of care
experienced by people with epilepsy.
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Care: A Survey of the American Epilepsy Society Membership. Epilepsy
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https://www.statista.com/statistics/214641/household-adoption-rate-ofcomputer-in-the-us-since-1997/. Accessed September 14, 2020.
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22. Jiang, J. (2018, May 2). Millennials stand out for their technology use, but
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