Digital Diagnosis

August 26, 2016

With a variety of potential applications, telehealth is an emerging sports medicine tool. A new project from the University of Mississippi Medical Center is testing its effectiveness at evaluating head injuries during high school football games.

This article first appeared in the September 2016 issue of Training & Conditioning.

By Elizabeth Joseph

Elizabeth Joseph, MS, is a Project Manager in the Center for Telehealth at the University of Mississippi Medical Center. She can be reached at: ejoseph@umc.edu.

Picture a high school football game on a Mississippi Friday night. A receiver takes a shot to the head after catching a pass up the middle, and he’s unsteady on his feet as he heads to the sideline. Complaining of a headache and dizziness, he’s escorted to the locker room for further evaluation. Instead of an in-person assessment, however, a tablet is fired up, and the player videoconferences with a physician who determines whether he has sustained a concussion.

As we are beginning to see the long-term effects of sports concussions, head injuries in athletics have become a major topic of emphasis and study. The numbers highlight why sports concussions are such a concern for high school student-athletes. For instance, the most recent statistics compiled by the Centers for Disease Control and Prevention (CDC) show nearly 250,000 children age 19 and younger were diagnosed and treated for a concussion or traumatic brain injury (TBI) in an emergency department in 2009. Furthermore, the rate of sports- and recreation-related concussion and TBI diagnoses in emergency departments for this population rose by 57 percent from 2001 to 2009, the CDC says.

These statistics are only compounded by the fact that some high schools across the country lack access to full-time athletic trainers to provide needed care to their student-athletes. Therefore, athletes may not receive a complete evaluation of their concussion injury until they can see a doctor days after it occurs. Because of these alleged lapses in care, student-athletes have brought lawsuits against school districts, state high school associations, and even the NFHS.

The scenario at the beginning of this article illustrates how telehealth can play an important role in bringing concussion diagnosis to high school athletic events. To address concerns surrounding TBI and determine if telehealth could indeed be the solution for improved, more timely concussion care, the NFHS sought a partner to pilot telehealth for head injury evaluations in high school football players during the 2015 season. After consulting with the American Telemedicine Association and accepting proposals from possible telehealth providers nationwide, the NFHS selected the Center for Telehealth at the University of Mississippi Medical Center (UMMC) to implement the Mississippi Telehealth Concussion Project.

The UMMC Center for Telehealth is a recognized national leader in providing innovative telehealth solutions. Since 2003, we’ve been using telehealth to deliver the expertise of our academic medical center to remote locations around the state. Currently, we offer consults in 35 medical specialties at more than 200 sites of service throughout Mississippi.

Because telehealth has been proven in our practice to provide quality care with outcomes that are on par with in-person care, we believe telehealth could be an effective way to improve concussion recognition and treatment, particularly at the high school level and in small or rural schools where resources are limited. Applicable for schools with or without an athletic trainer, telehealth allows a physician trained in recognition of sports concussions to perform the same assessment they would in person over a secure video connection. Athletes get an answer immediately, and they can then be kept out of games if necessary—avoiding the risk of dangerous reinjury—and treatment protocols can be implemented.

Started in fall 2015, the Mississippi Telehealth Concussion Project was recently renewed for a second year. With continued success, we hope that our example will be replicated in other states to grow the use of telehealth as a diagnostic sports medicine tool.

GETTING STARTED

To begin the Mississippi Telehealth Concussion Project, the Mississippi High School Activities Association (MHSAA) selected the high schools that would be participating in the program. The MHSAA chose 11 high schools for the pilot, which are all located in rural areas and represent all regions of Mississippi.

After the schools were set, we began compiling our program materials. We began constant communication with the schools via phone and e-mail, and this communication lasted throughout the season. We sent a packet home with each football player that included an educational piece on the program, consent for the athlete’s participation in the program and treatment, and the Notice of Privacy Practices—a HIPAA form that must be signed as a UMMC requirement.

The consent form was especially important, as we would not allow a school to begin the Mississippi Telehealth Concussion Project until every football player’s form was submitted. From a player safety standpoint, we wanted to avoid a situation where we could only provide the telehealth service to some players but not all. Only six schools submitted all the required paperwork, enabling them to move forward in the pilot program. The six schools were: Holmes County Central High School in Lexington, John F. Kennedy High School in Mound Bayou, Jefferson County High School in Fayette, Noxubee County High School in Macon, Prentiss High School in Prentiss, and South Delta High School in Rolling Fork.

Next, we established a “champion” for the Mississippi Telehealth Concussion Project at each location. The champions were usually the head football coach at each school or his designee.

We also identified who would be the “telepresenter” for each school—the person who would facilitate the telehealth consult when a football player was suspected of having a concussion. The head football coach or his designated champion selected the telepresenters. Ideally, we’d use athletic trainers for this position, but only three of the initial 11 high schools eligible for the project had athletic trainers that worked with their programs. For the rest of the schools, we enlisted athletic directors, assistant coaches, other sport coaches, a retired teacher, and a school nurse.

To meet an aggressive timeline for the program implementation, project development took place over a period of six days. We traveled to each school to distribute equipment, train the telepresenters, and ensure that they understood the process and were prepared to facilitate a consult. We wanted to be sure that the telepresenters were well-trained because the head football coaches’ focus would be on the field during a game and not on the particulars of the telehealth program.

As part of the telepresenter training, the project’s primary physician created a presentation on how to identify a concussion, when to use the telehealth system, and the possible outcomes of the consult. This presentation was loaded onto each school’s tablet for training. We made it clear that the telehealth service was only for scenarios in which an athlete was demonstrating the symptoms of a concussion after a blow to the head or neck. It wasn’t designed for emergency situations involving major neck or spinal injuries, and we emphasized that those injuries should be immediately transferred to the nearest emergency department. In addition, we expressed that telehealth was only going to be available for games during the pilot.

As a leave-behind from the training, we put together a comprehensive binder for each telepresenter. It included the steps for completing the telehealth consult, a list of frequently asked questions, and follow-up information for injured players and their parents or guardians.

Beyond the telepresenter training, we discussed the Mississippi Telehealth Concussion Project with each school’s head football coach and administrators, as we were able. The MHSAA helped us with ongoing communication with the schools, encouraging them to have student-athletes submit their paperwork so they could participate in the program. The NFHS provided ongoing financial support throughout the season.

TECH SAVVY

Naturally, for any telehealth initiative to be successful, technology has to be involved. So while we were training the telepresenters for the Mississippi Telehealth Concussion Project, we were also working with a number of vendors to get the tech squared away. Dell donated tablets for the program, and each school received one. The tablets came equipped with a high-definition video camera that would allow athletes to video chat with the UMMC physician. VSee, a HIPAA-compliant telemedicine video platform, contributed the software for the concussion evaluation.

By design, the system and process for the evaluation were simple and utilized familiar technology. We showed the telepresenters a video on how to use the tablets, which we then uploaded onto the machine so they could review it or use it to train someone else if needed.

C Spire, a Mississippi-based telecommunications provider, was our partner for connectivity. We used C Spire’s MiFi devices, which are mobile hotspots that utilize cellular data, for the connection.

Before the Mississippi Telehealth Concussion Project kicked off, C Spire provided a report on the available connectivity for the sites where the program would be used during the football season. With this information, we could determine locations where coverage may be a concern. Fortunately, most of our locations had adequate coverage.

If Internet service was disrupted at any point during a concussion evaluation, we set up the program so telepresenters could reconnect to complete their consult. If needed, UMMC’s 24-hour IT team would help troubleshoot.

COMING TOGETHER

Once the paperwork was in, the telepresenters were trained, and the technology was ready, the Mississippi Telehealth Concussion Project could go live at the participating schools. Each Friday evening in fall 2015, one UMMC emergency medicine physician who specialized in sports concussions was designated as the on-call physician. A second physician served as back up in the event that several calls arrived at the same time.

Each school decided whether telepresenters had the authority to pull players from games if they sustained a blow to the head or neck and demonstrated symptoms of a concussion. If this did occur, the athlete and the telepresenter would move to the locker room or another quiet location to conduct the telehealth assessment. This ensured that the physician was able to complete the consult without the noise of the game and protected the privacy of the athlete. The telepresenter then gathered baseline information on the athlete to report to the physician and requested a telehealth consult on the tablet.

From there, coordinators at the UMMC Center for Telehealth connected the telepresenter and athlete with the on-call UMMC physician, who then used the SCAT3 test to determine if the player had a concussion. With the help of the telepresenter, the physician watched the balance portion of the test and collected other data from the rest of the SCAT3 to complete an accurate assessment. The telepresenter stayed with the student-athlete through the duration of the exam to guarantee that it was completed successfully.

At the conclusion of the consult, the physician issued his diagnosis and provided discharge instructions for the athlete, recommending if he was safe to return to play, should be observed on the sidelines, should be released to his parents or guardians, or should be transferred to the nearest emergency department. The telepresenter then provided educational information to parents or guardians to help care for the injured athlete following the evaluation and diagnosis of the concussion injury.

TO THE FUTURE

In the end, we did not receive any requests for telehealth consults during the 2015 pilot project. Several factors likely contributed to this outcome, but one that played a major role was the lack of concussion injuries suffered during games. The only head injury we were made aware of was a player complaining of a migraine, and he was treated by the on-site ambulance personnel at that game. We believe with ongoing education and training on concussion injuries, the Mississippi Telehealth Concussion Project may alter these results in the future.

Concussion underreporting could have also played a role in the lack of telehealth consults. To help combat this in the future, we held the first statewide Mississippi Student-Athlete Health Forum on May 19 in Jackson to provide education from experts on the importance of quality student-athlete health and safety. We hope that this program will turn into an annual event where coaches, athletic directors, athletic trainers, administrators, parents, and others come to learn about these issues.

Although the UMMC telehealth system was not utilized in 2015, there was great enthusiasm for the service statewide and beyond. Therefore, the NFHS has decided to conduct a second year of the pilot study during the 2016 football season and expand it to include more schools.

We have taken a lot of the lessons learned from the 2015 season into 2016. For starters, because the 2015 pilot project ramped up quickly, it was difficult for all of the schools to submit the required paperwork in time. To prevent that from happening again, we provided the needed consent forms and equipment before preseason football camp. This way, the schools had everything they needed before the football season began, and they had more time to obtain the paperwork from their athletes.

In addition, we learned that we needed to educate ambulance/EMS personnel stationed at games about the Mississippi Telehealth Concussion Project so that they knew to use the system where medically appropriate instead of transferring a student-athlete to the emergency department unnecessarily. With more widespread knowledge of the program, other health care providers will be more apt to use it.

During the Mississippi Telehealth Concussion Project’s second season, we hope to provide outcomes to show that telehealth for concussion assessments works so that we can grow the program across other sports and states. With telehealth, we see a great opportunity to meet a tremendous need for high school athletes, and the time is right to make it happen.

Sidebar:

OFF TO A GOOD START

By David Stern

As the sports medicine field continues to search for effective methods to diagnose concussions, telehealth has recently emerged as a potential option. Though still relatively new, it has already shown promising results.

From 2013 to 2015, the Mayo Clinic in Phoenix conducted a study where a robot was used to diagnose concussions that occurred during Northern Arizona University football games. Through a camera mounted on the robot, a Mayo Clinic neurologist watched games remotely. When a player was suspected of having a head injury, the physician used videoconferencing to conduct a concussion assessment, utilizing the SCAT3 tool and King–Devick Test. The results were then compared to a separate evaluation done by the NAU athletic trainers on the sideline.

“We found that there was almost complete agreement between the remote neurologist and the face-to-face evaluator,” says Bert Vargas, MD, a former neurologist at the Mayo Clinic who worked on this study. “The decision of whether to pull someone out of the game was in complete agreement, as well.”

In addition to the research at NAU, Vargas and the team at the Mayo Clinic conducted a similar study at an emergency room in Show Low, Ariz. There, they found that telehealth was also effective at diagnosing concussions several days after the injury occurred.

Now an Associate Professor of Neurology at the University of Texas Southwestern Medical Center, Vargas says the findings of both studies are promising for the future of telehealth because they show that a remote diagnosis can match up to the gold standard of face-to-face evaluation. “With telehealth, the physician carries out a specific protocol that’s well-accepted and doesn’t require them to actually put their hand on the patient. So concussion is a perfect injury to diagnose with this method,” he says.

Vargas’ next goal is to use telehealth to diagnose concussions at rural high schools in Texas, where he thinks the technology will make a big difference. “In many rural areas, high schools and middle schools don’t have primary care physicians or sports medicine specialists who can do concussion evaluations,” he says. “Telehealth is ideal for these communities.”

Of course, schools that don’t have access to sports medicine specialists are unlikely to have enough money to afford the $5,000 robot used in the NAU study. Vargas has already started thinking of possible solutions to this financial dilemma. “In reality, a smartphone could accomplish the telehealth assessment,” he says. “A coach or athlete would need to have a smartphone on the other end, but since most people already own or have access to one, it shouldn’t be too much of an issue.”

Another obstacle for high schools with limited resources is finding a way to pay doctors. Although they’d only be needed for a few hours during games, they’d still have to be compensated for their time.

Vargas explains that telehealth would be more affordable if schools teamed up to use it. “If you enrolled hundreds of schools, they’d all pay very small amounts to have doctors scheduled to cover events,” he says. “You’d be lowering the cost for each school, but the doctors would still receive the same payment.”

With his plans to bring telehealth to rural high schools in Texas, Vargas hopes to continue expanding its reach. “Because a lot of these communities don’t have expertise in this area, I see our work making a lasting impact,” he says.

David Stern is an Assistant Editor at Training & Conditioning magazine. He can be reached at: dstern@momentummedia.com.