Multiple Sclerosis 

& Telehealth

New Models of Care

Mitchell T. Wallin, MD, MPH Clinical Associate Director, MSCoE-East 

Associate Professor of Neurology, Georgetown University & University of Maryland

Mitchell.Wallin@va.gov

Joseph Finkelstein MD, PhD

Director, Chronic Disease Informatics Program

Associate Professor of Medicine, Johns Hopkins University School of Medicine

jfinkel9@jhmi.edu

1 

www.va.gov/ms
Faculty Affiliation and Disclosure

Grant support from Biogen-Idec, Inc, NMSS and VA 

Merit Review Grant System
MS & Telehealth 

Topical Outline

• Telehealth Overview

• Neurology and Telehealth

• MS Telehealth Studies

– MS Home Automated Telemanagement (MS HAT)

– Remote neurological exam in MS

– Physical telerehabilitation in MS
We’ve Come a Long Way
Taking Charge of Your Health 

Care

When and Where you Need it

• Telehealth: a means of utilizing technology so that 

patients and providers can communicate remotely, 

enabling patients to receive health care through 

telecommunications

• Clinical Video Telehealth

• Home Telehealth

• Store & Forward 

 

• 

4 5 
My HealtheVet 

https://www.myhealth.va.gov 
Health Care Reform

The Affordable Care Act

• Patient-Centered Medical Home

– Health homes would be composed of a team of health 

professionals and would provide a comprehensive set 

of medical services, including care coordination.

• Honoring America’s Veterans Act of 

2011

– Optimization of health IT capabilities to improve the 

healthcare delivery system for Veterans. 
Patient-Centered Medical Home

Joint Principles (Kirschner, 2010) 

• Personal physician

• Whole-person orientation

• Integrated care

• Quality and Safety

• Enhanced Access
Patient-Centered Medical Home 

 Joint Principles 

• An approach to primary care that ensures care 

is integrated:

• Comprehensive care

• Patient-centered care

• Coordinated care

• Accessible services

• Committed to quality and safety

http://pcmh.ahrq.gov/portal/server.pt/community/pcmh__home/1483/PCMH_Defining%

20the%20PCMH_v2
Patient-Centered Medical Home 

Joint Principle Endorsement

• 18 Specialty Medical Societies: including Am 

Acad Neurology, Am College Cardiology, Am College Chest 

Physicians, Am Soc Clin Oncology, Infec Dis Soc America, 

Soc of Critical Care Medicine

• Promise of improved coordination, quality & 

efficiency

• Concerns:

– Unrealistic expectations

– How will new services be reimbursed

– Implementation challenges for small practices 
Telehealth Implementation Challenges

• Variability and unpredictability of symptoms

• Patient confidentiality & data security

• Limited computer skills 

• Reimbursement of telehealth care

• Standards for telemedicine equipment and 

competencies of health care professionals 

using telehealth
Telehealth & Neurology

(Agarwal S. J Neurol 2011)

Telestroke: initiated in 1990s for acute stroke 

thrombolysis consultation, AHA Class I evidence for 

reliability of remote NIH Stroke Scale exam 

Teleneurology Pilots:

• Parkinson’s Disease

• Epilepsy

• Neurorehabilitation

• Multiple Sclerosis
Teleneurology & Cost Effectiveness

• Epilepsy : savings of ~10% based on travel & 

related expenses (Ahmed S. Epilepsia 2008) 

• Neurocritical Care: robotic monitoring of ICU 

patients produced an annual cost savings of 

$1.1 million (Vespa P. Surg Neurol 2007) 

• Parkinson’s Disease: outpatient follow-up 

costs reduced in a community cohort of 

patients (Samii A. J Telemed Telecare 2006) 
Telemedicine in Leading US 

Neurology Departments

(George B. Neurohospitalist 2012)

• 60% of respondents provide 

limited telemedicine services

– Stroke

– Movement disorders

– Neurology critical care

• Most programs started 2008-

2010 

• External funding sources
Integrated MS Care

• Comprehensive & coordinated care 

between health and social sectors

– Many unmet needs found in review of MS 

care delivery in part due to fragmentation 

and discontinuity of the health care system

– Multidisciplinary community team worked 

with MS specialists

– Home-based care interdisciplinary team 

intervention 
Existing approaches of care using 

telehealth 

• do not utilize constructs 

from evidence-based 

models for chronic care 

which were shown to 

successfully improve 

quality of care;

• current technology is not 

cost-effective;

• existing IT tools are not 

fully integrated into the 

health information systems 
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MSCoE 

Regional 

Center 
Telehealth Projects at MSCoE 

(www.va.gov/ms) –Home Telehealth: 

• MS Viterion® Symptom Survey (Turner A. et al IJMSC in press)

• Telehealth Pilot 2: USB Cameras-Clinic to Home EDSS

• VA Central Office IT Project: MS HAT Demo Project 

• MS Physical Telerehabilitation Randomized Trial

• MS Adherence Pilot (INF beta and Vitamin D)

• MS Cognitive Rehabilitation Pilot Project

–Clinical Video Telehealth:

• Telehealth Pilot 1: Polycom ® VAMC-DC to VAMC- Baltimore 

• Telehealth consultation between MS Regional Centers & other specialty 

centers

–Store & Forward Telehealth: 

• Remote cognitive assessment project

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Home Telehealth

Beyond the Basics: Your MS Care

• Home-based teleneurology is just-in-time care

• When transportation is a challenge

• What our research has shown:

– The remote neurological exam is similar to the live exam

– Patient satisfaction is high 

– Cost of care is less

– Multidisciplinary care is enhanced 
Home Automated 

Telemanagement (HAT) System

 HAT was developed by J. Finkelstein/JHU 

Chronic Disease Informatics Dept and has been 

designed to:

 Help patients in following their self-care plans

 Help health care practitioners to follow their patients’ selfmanagement process

 Facilitate multi-component chronic disease management 

according to the current clinical guidelines
Technical Design of HAT

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Data Collection

Module

Computing 

Module

HAT

Database 

HAT Web 

Server

Decision 

Support

Module

Communication

Module

Presentation

Module

Patient Unit HAT Server Clinician Unit

Communication

Module

Presentation

Module

EMR Link
22

MS HAT: Information Infrastructure
23

MS HAT

VA Demonstration Project

MSCoE and Johns Hopkins U

2011-2013 

Home Unit

HAT Server

(Austin Automation Center)

CPRS-VISTA

Home Unit

Home Unit
MS Telemanagement Evaluation

• Interactive patient education and counseling

• Telerehabilitation

• Remote Neurological Examination

• Telemanagement

Finkelstein J, Wood J. Design and implementation of Home Automated 

Telemanagement system for patients with multiple sclerosis. Conf Proc IEEE Eng 

Med Biol Soc. 2009;2009:6091-4.

Cha E, Castro HK, Provance P, Finkelstein J. Acceptance of home telemanagement 

is high in patients with multiple sclerosis. AMIA Annu Symp Proc. 2007 Oct 11:893.
Computer-Assisted Education in MS Patients 
Feasibility of Computer-Assisted Education (CO-ED)

in MS Patients

• Convenience sample of 23 consecutive patients was 

 enrolled into the study

• Patient age was in the range of 31 to 59 years

• 40% did not have any computer experience

• 91% stated that they prefer using CO-ED as an education tool 

rather than a brochure

• 100% claimed that they would advice other patients to use 

CO-ED for disease-specific education

• 92% felt that using CO-ED was not complicated at all

• More than 50% stated that they learned new information 

about their disease using CO-ED

• 98% felt that immediate feedback was very helpful

• 22.5% improvement in knowledge score

Finkelstein J, Martin C, Bhushan A, et al. Feasibility of computer-assisted education in 

patients with multiple sclerosis. Proc. of the 17th IEEE Symposium on Computer-Based 

Medical Systems. CBMS-2004;2004:254-261. 
Home Physical Telerehabilitation in MS

• Life-long rehabilitation measures, together with medication 

treatment, are the major components of MS patient 

management.

• Physical exercise has a positive impact on patients’ quality of 

life and their functional capacities.

• Interactive, web-based telemanagement systems may facilitate 

patient adherence to rehabilitation plans.
Primary Objective

• To assess the feasibility and acceptance of 

the Home Automated Telemanagement 

(HAT) system for MS patients 

participating in a structured exercise 

program. 
29
30
MS HAT Home Station: Menu
Home Station: Exercise Directions

32

40 34 34
41 35
Home Physical Telerehabilitation in 

MS Pilot Study

• N=12 patients with MS

• Mean Age: 52 years

• Mean number of years with MS: 13

• 83% females

• Mean Education: 15 years 

Finkelstein J, Lapshin O, Castro H, Cha E, Provance PG. Home-Based Physical 

Telerehabilitation in Patients with Multiple Sclerosis: A Pilot Study. Journal of 

Rehabilitation Research and Development 2008;45(9):1361-1374.
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38
MS HAT: Remote Neuro Exam

Background 

• Physician care is routinely carried out in doctor’s 

offices and hospitals.

• Patients with MS are often separated from 

specialty care due to disability or distance.

• The value of low-cost webcams as a tool for 

remote neurological exam has not been 

systematically evaluated.
MS HAT: Remote Neuro Exam

Objective 

• A videoconferencing application utilizing low- cost webcam was developed to assist patients in 

remote neurological evaluation.

• This study evaluated the feasibility of using 

regular webcam and microphone as a tool to aid 

in the management of multiple sclerosis (MS). 
MS HAT Webcam System Design
MS HAT: Remote Neuro Exam

Study Design

• A total of 20 patients with MS were recruited 

• Trained study asst. played role of patient’s caregiver 

• Two MS clinicians examined each patient at the clinic using 

the Kurtzke Expanded Disability Scale (EDSS). 

• On a single visit, each patient underwent two identical sets of 

neurological assessment: 

– Traditional in-person evaluation

– Remote assessment using portable webcams
MS HAT: Remote Neuro Exam 

Kurtzke Expanded Disability Scale Scores (EDSS) 
MS HAT: Remote Neuro Exam

Telemedicine Satisfaction Survey

• Overall, the remote assessment system received 

positive ratings from both patients and 

providers.

– 100% - Patients felt comfortable with the equipment used.

– 85% - Patients were satisfied with the telemedicine parts of this 

examination.

– 90% - Providers were able to obtain adequate information 

interviewing the patients via video chat. 

– 95% - Providers felt confident in the final assessment.

Finkelstein J, Wood J, Shan Y. Implementing physical telerehabilitation system for 

patients with multiple sclerosis. Proc. of the 4th International Conference on 

Biomedical Engineering and Informatics, BMEI-2011;2011:1883-1886. 
Successful User Interface

• Large font

• Color markers

• One task per screen

• Prompts in each screen

• Adaptation to various disabilities

• Persistence and respect in training

• Clear statement of individual advantages

• Tailored content and functionality

• Multiple health communication channels

• Ability to increase user self-efficacy
MS HAT: 

Home Unit
MS HAT: 

Clinician 

Unit
Attitudinal Survey (N=40)
Attitudinal Survey (N=40)
Week

% 

Adherence 

to SelfTesting 

Regimen 

(N=20)

Finkelstein J, Cha E, Wood J, 

Wallin MT. Predictors of 

Successful Acceptance of 

Home Telemanagement in 

Veterans with Multiple 

Sclerosis, 2013, in press
Predictors of Successful Acceptance

Attitudinal survey score Parameter T value P value

estimates

How long have you had MS? -0.9 -2.9 0.02*

(years)

Age 0.2 0.5 0.6

Computer use at home -20.1 -3.5 0.007*

Never/Once a month or 

less/Once a week (0)

Once a day (1)

English proficiency 16.3 4.0 0.003*

Excellent (1)

Good/Poor/None (0)

Education (years) -0.7 -0.9 0.4

Race -5.1 -0.9 0.4

White (0)

African American (1)
Patient Feedback about MS HAT

• “Using the computer was easier than using the remote 

control.” 

• “I liked the whole concept of self-testing.” 

• “My symptom may disappear by the time I meet my 

doctor. MS patients have memory problem, too. If I 

don’t record it, I will forget to tell my doctor. It keeps 

you mindful and aware of your condition.”

• “I thought it would give a better sense how patients 

are feeling on daily basis.” 

• “It is very important to me that my doctors can review 

my results from the diary. I would only review them 

occasionally.” 
Patient Feedback about MS HAT

• “I could go through the diary as many times as 

needed, but I would prefer to go through it three 

times a week at the most.” 

• “I also want to document side effects from 

medication. I may get flu-like symptoms from 

medication.” 

• “Education was good. It’s a good part of the 

program. It helps to reinforce the knowledge.” 

• “I like how there was a question after each 

message and the quiz is a good way to help with 

memory, and get you to remember the 

information that you read.” 
Patient Feedback about MS HAT

• “The webcam would be good for me to talk with my doctor 

if I have any problems. The doctor would be able to see 

what is wrong and I would not have to try to remember any 

problems that I had in between doctor visits.”

• “I can access it anytime according to my schedule and it 

makes me more confident to report how I feel.” 

• “I think computer is the best way to digitize the symptoms 

and see the trend. It has a positive impact on the ability to 

manage the disease.” 

• “I feel more confident with managing MS while being 

monitored via computer. It was very convenient that I can 

do it at home, no driving involved.”
Home Automated Telemedicine (HAT): 

Comprehensive Support for MS Care

MSCoE & JHU Collaboration

• Evaluation & tracking of 

individualized treatment plans

• Secure messaging services to 

exchange information with health 

care provider

• Medication monitoring & 

adherence enhancement

• Physical and Occupational 

Therapy with evaluation of 

efficacy and safety

• Neurologic symptom monitoring

55

• MS Disease modifying therapy 

(initiation, monitoring & support)

• Integration & data transfers with 

national CPRS

• Social support (virtual patient 

groups, message boards)

• Home televisits 

• Telecognitive assessments and 

cognitive rehabilitation 
MS Therapy Adherence Trial 

Utilizing HAT

• Randomized study to improve adherence to 

MS therapy for up to 1 year

• Quarterly follow-up visits in the home

• Sponsors: Biogen-Idec, Inc & MSCoE

• Study candidates:

– Diagnosis of MS

– Taking interferon-beta 1a weekly & Vitamin D supplement

– 18-65 years
MS Physical Telerehabilitation Trial 

• Randomized study of MS HAT vs. optimal with a primary aim to 

improve walking speed and balance in patients with MS 

• 6 month trial with follow-up visits at 3 and 6 months (DC/Baltimore 

region)

• Sponsors: VA Merit Review & MSCoE

• Study candidates:

– Diagnosis of MS

– Able to walk with or without gait aids

– 18-65 years
Conclusions: 

Telehealth & MS Care 

• Telehealth can improve access and integration of care for 

patients with MS 

• MS HAT can be an efficient platform for the management 

of MS patients when and where they need it:

– Telerehabilitation and MS RCT (VA Merit Review)

– MS Therapy Adherence Study (Biogen-Idec)

– Home telecognitive assessment Pilot (Vista Partners) 

• Telehealth tools must be tested in the clinical setting to evaluate their 

value for patients & providers 
MS HAT Collaborative Team

VA MSCoE & Johns Hopkins University

• McKenzie Bedra, MPH (JHU/MSCoE)

• Amy Cha, MPH (JHU/MSCoE)

• Sean McGrath, BA (JHU/MSCoE)

• Jeffrey Wood, BS (JHU/MSCoE)

• Heidi Maloni, PhD, ANP-BC (VAMC-DC/MSCoE)

• Jill Settle, MA (MSCoE/VAMC-DC)

• Stephanie Robinson, MA (MSCoE/VAMC-DC)

• Danny Brody (MSCoE/VAMC-DC)