Tailored Online Neurosurgical Evaluation in the Outpatient Setting during COVID-19 Pandemic—The Maldives Experience

Background: The recent COVID-19 pandemic has revealed important obstacles in our health care systems, including online specialist consultations, with relevance to the Maldives. Amidst mass lockdowns and social distancing, we observed the importance of developing a consistent method of performing effective neurological examinations that yield accurate results in a time-efficient manner. Objectives: To describe our experience in the Maldives of performing an effective online neurological examination. Methodology: We designed and implemented a platform for patients to register for online consultation, collected a comprehensive neurological history, including pictures/scroll-videos of past radiological reports, and guided the patient and their aide through neurological examination methodsboth verbally through online video consultation and informative pictorials that depict exactly how-to perform said examinations. Conclusion: Neurological examinations are timeconsuming, detailed, and require skill and expertise to be performed appropriately. Yet, it can be customized and adapted to be performed remotely. Proper guidance by examiner and assistance by family or friend with the use of pictorials can conclude a thorough online examination.


INTRODUCTION
According to Mehrotra et al., there has been almost a 60 percent decline in outpatient visits to hospitals during the COVID-19 pandemic.
[1] Hence, virtual consultations are increasing rapidly and are being regarded as an acceptable new norm in many hospitals in different parts of the world. Thus, we must develop better ways to conduct online consultations for patients in need, especially neurosurgical patients where a delay in treatment may cause a permanent deficit or loss of life. The

Tailored Online Neurosurgical Evaluation in the Outpatient Setting during COVID-19 Pandemic-The Maldives Experience Technical Note
Neurosurgery Department of ADK Hospital, Malé, Republic of Maldives serves the majority of patients with disorders related to the brain, spine, and peripheral nervous system throughout the Republic of Maldives. Hence, we intend to present an overview of our online consultation procedure, with details on how to conduct a full neurological examination. Please refer to Figure 1, which shows our hospital's general guide on how to prepare for an online consultation.  Figure 1]. Before the consultation, the preparation of the patient and family are asked according to the instructions given. The patient should have reliable internet capabilities, good headphones, and at least one assistant. As online consultation starts, visual identification and a short introduction (via video) of consultant, patient, and bystander is the first step. Any outpatient department (OPD) consultation, online or

METHOD
To conduct a neurological examination, we created an online Neuro-exam template, so that no maneuvers are otherwise comprises three parts; 1.History taking 2.Clinical examination 3.Report review and decision.
[2] Hence, thorough history taking proceeds the introduction. For the examination part, patients are first asked to upload the pictures and videos of already performed examinations according to instruction and guide pictorials. The remaining required neurological examinations will then commence live with demonstrations by clinicians followed by patients.  Asking them to stand up from a chair with crossed arms.
Giving the same type of squeezable balls to both hands and asking them press to access hand grip.
Asking them to use hand against resistance in a different direction and assessing the tension in the muscle group and their ability to lift the loads.
Regarding OPD consultations, our population of new patients and post-operative follow-up cases were being  [22] While in the Maldives there is no such law, in our opinion it comes down to a judgment call of using the most ideal service to reach as many patients as we can and attending to their medical needs -which ultimately takes precedent over any confidentiality risks. In addition, the patient's consent should always be confirmed for video evaluation, pictures, and so forth.
Another interesting aspect of video consultations is ensuring correct patient and doctor; having a routine introduction a few minutes to confirm identity is essential in every session. Mistaken patient identity is more common than we would like to believe; in fact, the ECRI Institute notes that more than 7,000 patient identification events, many with serious consequences, were found in its database over a period of about 2.5 years. [23] Another research shows that 11% of 1200 errors in the NICU were attended via Viber audio, video, and chat consultations. Our hospital had adopted the use of this social media app as our main means of communication due to its availability and frequency of use in the Maldives. This method worked decently and was especially useful for general consultations. However, the use of 3rd party applications such as Viber is always controversial due to privacy concerns, nonetheless, it is noteworthy that they contain end-to-end encryption. For a service to be used in the United States this way, HIPAA compliance is critical.19 Some web conferencing services such as Zoom is HIPAA compliant as they contain authentication and access control measures, as well as end-to-end encryption. [20,21] However, consumer-grade several apps lack the features and security controls essential for ensuring the confidentiality, integrity, and availability of electronically protected health information that is form of involving family members during a consultation if possible; exploring history taking via audio rather than a text while simultaneously receiving images or short videos (e.g. skin lesions, localization of pain); online prescription centers developed by private hospitals and state trading organizations with door-step delivery; older documents and records being scanned and sent to the hospital/doctor before the consultation, medical and radiological images were scanned or scroll videos were made for consultations and instruction tutorials were sent out to inform patients of what exactly was required of them, and explanation of disease condition was explained in short videos and treatment drawn on paper as an algorithm for easy understanding. Too lengthy sentences in this paragraph make them precise.  related to patient misidentification. [24] Of course, the number one priority is that the correct patient gets the medical attention they need but it can also help to avoid any legal repercussions.   detailed, requiring skill and expertise, so for the majority of these examinations, we have to keep in mind that the helper's (family, friend) ability to perform these tests and potential bias toward a specific result can be an unfortunate but unavoidable factor. Misinterpretation of instructions and results could also occur. There is no replacement for certain examinations such as tactile sensation, fundoscopy examination, accurate motor grading (muscle power).

RECOMMENDATIONS
Ideally, this visual neurological examination program will be more effective if accompanied by a prepared form/questionnaire required by patients to fill in regards to their history and current symptoms before the online consultation. In comparison to direct verbal questioning via Viber, this is more time-effective and a step-wise order to the questions to ensure patients have more time to think of their answer so that no important detail is missed. However, this could require the expertise of trained front-office staff or an MBBS doctor that can advise patients in case of any queries; as consultant specialists should dedicate all of their time to the actual consultations themselves. Also, instructional tutorial videos could be more helpful than pictorials as patient and helper can see exactly how an examination is performed. Some specific equipment such as reflex hammer or lens for smartphone fundoscopy can also be recommended to already diagnosed patients that can afford it, so that progression of the disease can be assessed by consultants. Therefore, our recommendation is to fulfill these obligations for an even better experience in online consultations.