Sep 29, 2020

Telehealth Position Statement

Background Information

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.

AES Position

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 telehealth.12-16

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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6. United States Drug Enforcement Administration. Drug Scheduling. Drug Schedules. Accessed September 25, 2020.

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8. Institute of Medicine (US) Committee on the Public Health Dimensions of the Epilepsies, England MJ, Liverman CT, Schultz AM, Strawbridge LM, eds. Epilepsy Across the Spectrum: Promoting Health and Understanding. Washington (DC): National Academies Press (US); 2012.

9. Bahrani K, Singh MB, Bhatia R, et al. Telephonic review for outpatients with epilepsy-A prospective randomized, parallel group study. Seizure : the journal of the British Epilepsy Association 2017;53:55-61.

10. Hatcher-Martin JM, Adams JL, Anderson ER, et al. Telemedicine in neurology: Telemedicine Work Group of the American Academy of Neurology update. Neurology 2020;94:30-38.

11. Ahmed SN, Mann C, Sinclair DB, et al. Feasibility of epilepsy follow-up care through telemedicine: a pilot study on the patient's perspective. Epilepsia 2008;49:573-58.

12. Adams JL, Myers TL, Waddell EM, Spear KL, Schneider RB. Telemedicine: A valuable tool in neurodegenerative diseases. Current geriatrics reports 2020;9:72-81.

13. Appireddy R, Jalini S, Shukla G, Boissé Lomax L. Tackling the Burden of Neurological Diseases in Canada with Virtual Care During the COVID-19 Pandemic and Beyond. The Canadian journal of neurological sciences Le journal canadien des sciences neurologiques 2020:1-4.

14. Ganapathy K. Telemedicine and Neurological Practice in the COVID-19 Era. Neurology India 2020;68:555-559.

15. Miele G, Straccia G, Moccia M, et al. Telemedicine in Parkinson's Disease: How to Ensure Patient Needs and Continuity of Care at the Time of COVID-19 Pandemic. Telemedicine journal and e-health: the official journal of the American Telemedicine Association 2020.

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17. Patel AD BC, Franklin G, Herman ST, Hughes I, Meunier L, Moura LMVR, Munger Clary H, Parker-McFadden B, Pugh MJ, Schultz RJ, Spanaki MV, Bennett A, Josephson SA. Quality improvement in neurology: Epilepsy Quality Measurement Set 2017 Update. Neurology 2018;885624.

18. Sharma R, Zachrison KS, Viswanathan A, et al. Trends in Telestroke Care Delivery: A 15-Year Experience of an Academic Hub and Its Network of Spokes. Circulation Cardiovascular quality and outcomes 2020;13:e005903.

19. Raymond JK. Models of Care for Adolescents and Young Adults with Type 1 Diabetes in Transition: Shared Medical Appointments and Telemedicine. Pediatric annals 2017;46:e193-e197.

20. Statista. Percentage of households in the United States with a computer at home from 1984 to 2015. 2019. Accessed September 14, 2020.

21. Pew Research Center. Internet/broadband fact sheet. Feb 5, 2018. Accessed September 14, 2020.

22. Jiang, J. (2018, May 2). Millennials stand out for their technology use, but older generations also embrace digital life. Accessed September 14, 2020.

23. Pew Research Center. Tech adoption climbs among older adults. May 17, 2017. Accessed September 14, 2020.