Parkinson's Telemedicine Application No.2: China Set to Become a Global Epicenter of Parkinson’s Disease?

As discussed previously, regarding the past and present applications of telemedicine for Parkinson’s disease, how will it develop in various countries in the present and future?

The Future: The Emergence of Telemedicine

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As technological innovation and application updates accelerate, promising telemedicine applications will expand rapidly. In the future (Figure 2), telemedicine applications will encompass areas such as diagnosis and treatment, training, and clinical research.

Regarding diagnosis and treatment, as demonstrated by the practical experiences of Canada and Kaiser Permanente, the scale of virtual visits will expand rapidly once existing health insurance policies catch up. Once reimbursement becomes available, virtual visits will become a more attractive option for care delivery, owing to their favorable clinical outcomes, convenience, and comfort.

Virtual consultations are also regarded as the premier alternative for managing chronic diseases, replacing costly clinic-based medical care. Integrated healthcare networks, such as Parkinson’s disease networks and Veterans Affairs hospitals, will implement and deploy services provided by diverse healthcare professionals—including physical therapists, exercise coaches, and dietitians—thereby extending far beyond the traditional doctor-patient relationship.

In addition, the application of technology can also achieve scale(e.g., one coach can guide multiple patients)and gain an advantage in synchronous diagnosis and treatment, such as by simultaneously transmitting recorded videos of patients' abnormal motor manifestations to multiple physicians for collaborative consultation.

Figure 2

The most significant shift in technology lies in,By 2017, the number of smartphones or other mobile devices will exceed 3 billion, accounting for nearly half of the world's population.These mobile devices will play a significant role in the healthcare sectors of developing countries, such as China, which has the world’s largest number of mobile phone users but lags behind in traditional medical infrastructure (hospitals, clinics, and physicians). In these regions, Parkinson’s disease patients can only rely on management by less experienced doctors.

These technical solutions will also support the education and training of professionals.In the United States, a renowned community healthcare organization leverages video technology to train local physicians, equipping them with specialized expertise in the diagnosis and management of chronic diseases, such as hepatitis C. With enhanced engagement from local physicians and robust reimbursement support, this telemedicine model for Parkinson’s disease can be scaled across the United States and globally. Such a healthcare model is particularly critical for countries lacking sufficient specialists, where the majority of Parkinson’s patients must be managed by general neurologists.

To date, although telemedicine has seen limited application in clinical research on Parkinson’s disease, this is expected to improve. Current clinical trials of drugs for neurodegenerative diseases involve only a very limited number of patients. For Alzheimer’s disease, caregiver involvement and home-based consultations can enhance engagement among both physicians and patients.

Gradually, the application of telemedicine in clinical drug trials will become increasingly prevalent. Initial applications may involve using telemedicine to confirm whether subjects meet the diagnostic criteria for Parkinson’s disease. Furthermore, telemedicine can be employed to monitor individuals susceptible to Parkinson’s disease (such as LRRK2 mutation carriers) who are distributed across regions worldwide lacking specialist expertise. This healthcare model can save substantial time and travel costs, while centralized assessments enhance consistency, reduce expenditures, and decrease the number of required clinical centers.

Over time, remote video consultations can be applied in clinical trials to screen subjects, conduct efficacy assessments (similar to what is currently referred to as audio-based evaluations), or perform long-term follow-up assessments of drug efficacy (such as during open-label extension phases). This type of remote assessment is applicable to nearly all clinical trials and holds particular significance for patients with advanced-stage disease or Parkinson’s disease patients with comorbid dementia.

PerhapsThe most significant shift in future technologies will be the remote monitoring of patients’ clinical management or participants in clinical trials.Current outcome measures used in clinical trials for Parkinson’s disease rely on subjective, fragmented, and instantaneous observations rather than assessing overall changes over time, resulting in insensitive endpoints. Consequently, large-scale, costly, and long-duration clinical studies are required to determine the efficacy of the investigational drug or intervention.

The number of devices for assessing Parkinson’s disease symptoms is increasing rapidly. Whether monitoring abnormalities in movement, gait, or voice, these devices ensure more objective, frequent, and sensitive results. These assessment tools are expected to be utilized in the clinical management and research of Parkinson’s disease.

These technologies were initially applied to monitor the condition of patients with advanced-stage diseases and those undergoing relatively expensive treatments, such as deep brain stimulation (DBS) and levodopa-carbidopa intestinal gel. Similar to cardiac pacemakers and defibrillators, deep brain stimulators can collect data during stimulation therapy and also gather motion data via built-in motion accelerometers.

These data can be collected remotely to guide the optimization of stimulation parameters, as well as pharmacological and non-pharmacological management strategies. For treatments that require substantial human involvement, such as levodopa infusion therapy, dosages can be adjusted based on remote monitoring results, thereby directly assisting patients and their families in treatment application. In fact, AbbVie is currently conducting clinical trials to determine whether healthcare providers can effectively manage continuous intestinal levodopa infusion through the use of telemedicine.

These technological innovations will also give rise to various concerns, with privacy being the most prominent. There is growing apprehension about the collection of data on individuals’ activity levels and locations. However, such data are crucial for elucidating the pathophysiology of Parkinson’s disease and monitoring therapeutic efficacy; therefore, restricting other uses of these data will pose a significant challenge. While monitoring daily life can promote better health, potential privacy breaches are becoming increasingly common.

Beyond privacy, future assessments of new devices will be more rigorous, focusing on their utility, the relevance of measured indicators, and their ability to detect subclinical signals. A more comprehensive grasp of disease progression, including symptom fluctuations and associated disabilities, will enable better disease management for Parkinson’s patients and accelerate the development of new therapeutic strategies.

The prospects for telemedicine in Parkinson’s disease patients are promising. To realize the substantial potential of telemedicineIt requires time, viable policy support, and the backing of patients, healthcare providers, and financial sponsors for this new healthcare model.These explorations can significantly expand the scope of medical services, promote and enhance participation in clinical trials, and deepen our understanding of Parkinson’s disease.

Mature Projects

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Canada

Canada’s telemedicine programs are supported by its universal healthcare system, making them relatively mature. The largest of these is the Ontario Telemedicine Network (OTN), a non-profit enterprise primarily funded by the Ontario Ministry of Health and Long-Term Care. Last year, more than 300,000 patients across over 1,600 locations received telemedicine consultations (see Appendix Figure 1). More than 900 physicians regularly use this network, and the total number of patients treated last year increased by over 50%. Mental health and addiction disorders accounted for more than 60% of all cases, with OTN providing all prescribed medications.

This government-funded healthcare system provides reimbursement for telemedicine services at parity with in-person consultations, and offers additional financial incentives to further encourage their adoption (see Appendix Figure 1). Medical malpractice insurance covers telemedicine services, and physicians are not restricted by geographic licensing boundaries. The network infrastructure includes high-cost conference-room-style video systems as well as updated personal computer systems, enabling physicians to connect with patients from their homes, offices, or healthcare facilities, thereby integrating comprehensive medical care with educational resources.

Appendix Figure 1

The Movement Disorders Centre in Markham, Ontario, Canada, began providing clinical services to patients with Parkinson’s disease, Huntington’s disease, and other movement disorders in 2001. Currently, more than 600 patients are managed annually through telemedicine, a number that continues to grow. Initial consultations are conducted in person, while follow-up assessments are carried out via video conferencing.

Patients may visit local hospitals with ample nursing and professional staff, community health clinics, physicians’ offices, or medical stations. Prior to the consultation, a local telehealth coordinator will communicate with the patient for 15 to 30 minutes and then transmit the information to the Movement Disorders Center for diagnosis and treatment.

With the support of community branches, technical issues and service disruptions are rare. The electronic medical record (EMR) system generates reports and prescriptions, which local coordinators can use as references for physical therapy, social work, and occupational therapy. Primary care physicians can order imaging studies and conduct tests. Physicians advise patients to contact a neurology specialist if any changes or issues arise during the assessment period.

If the patient is hospitalized locally, local physicians can use video consultations to manage the patient’s Parkinson’s disease in Ontario.

Patients reported high satisfaction with telemedicine. Seventy-three patients interviewed at the satellite medical center(Following face-to-face assessment, subsequent follow-ups will be conducted via telemedicine)Ninety percent reported that the telemedicine experience was as effective as, or even better than, in-person consultations. They cited proximity to home, reduced travel time, and lower travel-related risks as advantages of telemedicine.

However, a minority of patients perceive telemedicine as lacking a personal touch and opportunities for interaction with physicians; some report difficulties in communicating sensitive issues, and others opt for at least one annual in-person evaluation. Despite these limitations, telemedicine has become an integral and mainstream component of the Canadian healthcare system.

Netherlands

In the Netherlands, ParkinsonNet—a nationwide network of specialized healthcare professionals—employs various telehealth approaches to enhance communication and care quality. Despite its limited pool of specialized healthcare providers, these diverse telehealth pathways enable patients to receive high-quality care at home.

Technological applications are primarily focused on online self-monitoring, utilizing tools such as motion detectors to track physical activity and display exercise outcomes via web platforms. Autonomous training equipment equipped with interactive computer screens enables patients to adhere to medical advice, while web-based applications empower them to use self-care software to gain a clear understanding of their health status and progress, facilitating knowledge exchange through online communities. Customized telemedicine video systems allow communication with individual physicians or even multidisciplinary medical teams. While some of these approaches have been implemented and widely adopted, others are still under development. However, establishing a sustainable economic model that requires purchase by patients or physicians, or reimbursement through health insurance, remains a challenge.

As patients have benefited significantly from management by multidisciplinary integrated healthcare teams, ParkinsonNet has created a public online tool, the Parkinson Healthcare Finder, enabling patients to select their physicians based on the clinicians’ prior training experience and the number of cases managed.

United States

Healthcare services in the United States are characterized by high costs, fragmentation, and complexity, encompassing a diverse array of healthcare programs, including Veterans Health Administration (VA) hospitals, Kaiser Permanente, private health insurance companies, and Medicare for individuals aged 65 and older. Each program varies in its objectives and expenditures, and the landscape of telemedicine applications in the U.S. reflects this diversity.

····U.S. Department of Veterans Affairs
As early as 1968, the U.S. Department of Veterans Affairs Health Administration began implementing telemedicine, which has expanded rapidly in recent years. The 2013 Performance and Accountability Report showed that clinical services based on telemedicine provided by the Veterans Health Administration increased by 24% in 2013, thereby bringing care to more veterans in remote areas and saving unnecessary travel costs. The Department of Veterans Affairs' telemedicine is divided into three types: home healthcare involving data transmission, such as transmitting disease information from veterans' homes to hospitals; store-and-forward imaging data awaiting expert diagnosis; and direct telemedicine video services for remote veteran clinics or homes. These programs include clinical drug trials and physician training. According to research statistics, out of 5 million veterans, 603,532 received treatment through telemedicine.

This nationwide VA Parkinson’s Disease Research, Education, and Clinical Center (PADRECC) is an outstanding multidisciplinary comprehensive center for Parkinson’s disease patients. It is uniquely positioned to leverage telemedicine for the treatment and study of Parkinson’s disease. The video telehealth program has been in operation for over a decade, encompassing new patient consultations, follow-up care, pre- and post-operative assessments for deep brain stimulation (DBS), patient and physician education programs, and provider-to-provider consultations.

These initiatives have extensively leveraged live video streaming to connect with outpatient centers at local hospitals, but this technology has recently become capable of reaching patients in their homes. The U.S. Department of Veterans Affairs allows physicians to provide care across state lines without requiring corresponding medical licenses in each state. Currently, more than 400 veterans with Parkinson’s disease are receiving treatment via telemedicine. The Philadelphia VA Medical Center is conducting the largest randomized controlled trial in this area, with results expected to guide the future development of telehealth. In addition, numerous home-based motion monitoring devices, such as Great Lakes NeuroTechnologies’ Kinesia system, will soon be piloted.

Future project development will encompass mental health, physical rehabilitation, speech reconstruction, social work, palliative care, and physician training programs. The challenge lies in organizing and implementing these initiatives with efficiency, standardization, and sustainability.

Caesar Medical Institution
Kaiser Permanente in the United States is a large, integrated healthcare system operating on a prepaid model. Kaiser Permanente in Northern California serves nearly 8,000 patients with Parkinson’s disease but has only five movement disorder specialists. To expand its care coverage, Kaiser Permanente leverages a unified electronic health record system to enable telemedicine, telephone consultations, secure messaging, and video visits.

Virtual consultations are conducted via video conferencing, and patients must complete an online informed consent form. The treating physician creates a consultation record in the patient’s telehealth medical record, and the patient contacts the physician from home at the scheduled appointment time. Over the past two years, hundreds of new patients and those receiving follow-up care(Movement Disorders, Pediatric Neurology, Neuro-Oncology)Register on this system.

Kaiser Permanente in Northern California has successfully integrated video conferencing technology to facilitate virtual consultations among physicians, enabling general neurologists and movement disorder specialists to remotely pre-screen patients for suitability for deep brain stimulation (DBS) surgery. Within five years, the proportion of virtual consultations for movement disorders is projected to reach 50%.

Sanatorium
Approximately 40% of patients with Parkinson’s disease require care in specialized nursing homes, where the proportion of residents with Parkinson’s disease can reach 7%. Many Parkinson’s patients who require institutional care exhibit cognitive impairment and behavioral disturbances, such as delirium, which significantly impact their quality of life. In addition to the growing number of patients in these facilities, there is a shortage of specialized neurological care, resulting in fewer than half of the patients receiving optimal care.

Telemedicine will benefit another segment of patients. In a randomized controlled trial comparing routine care for Parkinson’s disease patients in nursing homes with and without telemedicine services, telemedicine provided greater specialist support and achieved better clinical outcomes. This study delivered specialized care to nearly 200 patients in New York nursing homes. The program benefited nursing homes through Medicare reimbursement and training programs for nurses and caregivers.

For nursing homes, the barriers to implementing telemedicine primarily include reimbursement issues, credentialing, and various requirements for in-person visits prior to care delivery. In the United States, Medicare reimbursement for telemedicine services in nursing homes is limited to rural areas. However, many nursing homes that similarly lack adequate medical resources do not meet this criterion. Nursing homes also require physicians providing telemedicine consultations to hold proper credentials, which poses another obstacle. Finally, state regulations mandate an in-person evaluation before telemedicine services can be rendered, particularly when prescribing medications, thereby preventing patients in urgent need of telemedicine from accessing such care.

····Rural Clinic
The U.S. population is dispersed, with access to extremely limited medical services. Consequently, in rural areas, telemedicine is regarded as a cost-effective alternative to traditional healthcare services, and reimbursement policies are targeted exclusively at those rural regions with insufficient medical resources. In these areas, healthcare systems will gradually adopt telemedicine to expand service coverage.

Gundersen Health System in La Crosse, Wisconsin, is a comprehensive network with more than 700 specialist physicians, providing medical services to a population of 585,000 across Wisconsin, Minnesota, and Iowa within a 100-mile radius. Currently, 62 physicians are utilizing telemedicine in 21 different locations.

The telemedicine program was launched in 2003, with Parkinson’s disease included within its scope in 2010. The Gunderson Parkinson’s Disease and Movement Disorders Center employs neurologists and nurses holding medical licenses in the aforementioned three states. From June 2010 to May 2013, a total of 73 patients were enrolled.(61% Parkinson’s disease patients, 4% essential tremor, and the remaining 35% movement disorder patients)A total of 114 telemedicine records were generated. Through the telemedicine program, patients in remote areas can now receive treatment from their primary care physicians. The typical consultation process involves on-site nurses measuring vital signs and muscle tone, after which patients communicate with the physician via video conference. Care coordination is facilitated through shared telemedicine records, and medication prescriptions are automatically faxed to local pharmacies.

Gundersen Health System’s telemedicine services are constrained by several factors, including patient acceptance, physician adoption rates, and equipment maintenance costs. Enhancing the acceptance of telemedicine services and increasing reimbursement rates in the future will greatly benefit the growing population.

····Home
Although more than 40% of Parkinson’s disease patients have health insurance, they do not seek medical care. Barriers include long distances, mobility limitations, and uneven distribution of healthcare resources. Telemedicine delivered to the home can address these challenges. A randomized trial comparing telemedicine with traditional in-person care for subsequent patient health monitoring demonstrated that virtual consultations are feasible.(93% of virtual consultations were completed as scheduled), each consultation saves doctors and patients an average of 100 miles in travel distance and 3 hours in transit time. The study results indicate that 85% of participants expressed greater interest in telemedicine.

A recent case series evaluated virtual visits for 50 Parkinson’s disease patients across five states who had no prior experience with telemedicine. The results similarly demonstrated that virtual consultations are feasible, widely recommended, and well accepted by patients.(100% of patients would recommend telemedicine to their friends). Patients reported that telemedicine provided them with professional treatment and the convenience and comfort of receiving care at home.

Telemedicine requires patients or their families to be proficient in using the internet, and licensing laws mandate that physicians must hold a medical license in the jurisdiction where the patient is located. Neither national health insurance nor private insurers provide reimbursement for telemedicine services. With technological advancements and the removal of regulatory barriers, this healthcare model holds significant potential for patient-centered care.

Projects in Development

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Cameroon

As life expectancy increases in sub-Saharan Africa, Parkinson’s disease is becoming increasingly prevalent. Due to a shortage of specialized healthcare professionals, most patients do not even have the opportunity to receive a diagnosis, while those who are diagnosed fail to receive optimal treatment and face a rising mortality rate. The World Health Organization, telecommunications operators, and medical organizations are showing growing interest in telemedicine projects in developing countries; however, the information and communication technology infrastructure is often inadequate.

To help expand coverage and train healthcare professionals in the use of this technology, the International Parkinson and Movement Disorder Society (IPMDS) sponsored a pilot medical education project through its Africa Task Force, with one such initiative also established in Cameroon. This telemedicine project in Cameroon aims to pioneer a regionally networked educational program for movement disorders. The 12-month project includes twelve lectures for physicians and other non-specialists, connecting participants with movement disorder experts via live video streaming, presentations, chat discussions, and audio conferences. Participants have the opportunity to obtain IPMDS membership and associated benefits, including specialized training on the use of rating scales.

Networked connectivity can ensure the sustainability of telemedicine initiatives involving local governments, enterprises, foreign language education, and health departments. Telemedicine can eliminate or at least mitigate barriers—particularly those arising from social and geographical conditions in rural areas near sub-Saharan Africa. Addressing the challenges to broader telemedicine adoption requires providing stable broadband services across the region to ensure alignment with local cultures, while perhaps the most significant challenge lies in delivering affordable and sustainable pharmaceutical treatments.

China

China’s improving economic conditions have led to increased life expectancy, ultimately resulting in a growing number of Parkinson’s disease patients. Currently, there are at least 2 million Parkinson’s patients in China, although this figure is likely a significant underestimate, as surveys indicate that 68% of rural cases and 37% of urban cases remain undiagnosed and untreated. Between 2005 and 2030, the number of patients is projected to double. As the world’s most populous country, China will account for more than 50% of the global total of Parkinson’s disease patients.

In addition to the increasingly heavy disease burden, China has a limited number of neurologists, with fewer than 100 specialists in Parkinson’s disease and movement disorders. At certain research centers, Parkinson’s disease specialists see up to 80 patients per day, resulting in insufficiently comprehensive patient management. For most patients, long distances, overcrowded specialized hospitals, and transportation issues remain major barriers.

The International Parkinson and Movement Disorder Society recently sponsored a project to evaluate whether neurologists who receive support and training from movement disorder specialists via telemedicine can improve patient disease management. From August to October 2013, neurologists were randomly assigned to receive telemedicine support, with each physician following 10 Parkinson’s disease patients for 12 months. Physicians assigned to the telemedicine support group received regular guidance and consultation from a movement disorder specialist through telemedicine.

In addition, neurologists, patients, and caregivers will participate in educational workshops to help establish a virtual Parkinson’s disease center. The strong willingness of many neurologists to volunteer demonstrates a keen desire among Chinese neurologists for additional training opportunities. Furthermore, patient enrollment is currently underway, and the study results will be analyzed after the assessment of the last enrolled patient is completed.

Remote training and consultation guided by movement disorder specialists have marked the first step in telemedicine for Parkinson’s disease patients in China. Future plans include expanding this initiative to other mobile devices and web-based mobile applications. As is well known, China already has the largest population of mobile phone users in the world.

····Specialized Applications→→→Deep Brain Stimulation (DBS)
The geographic mismatch between patients and physicians is particularly severe for the implementation of deep brain stimulation, as this procedure requires advanced medical equipment and highly specialized skills.

Remote sensing technology and remote medical management have been confirmed for use in cardiac pacemakers. Controlled studies have shown that remote monitoring is beneficial and convenient compared with face-to-face assessments, with a safety profile no inferior to that of traditional methods. It enables shorter detection times for actionable events (such as arrhythmias), reduces hospital stays and clinic visits, decreases the incidence of inappropriate shocks, prolongs device longevity, and to some extent lowers the risk of mortality.

Recent technological breakthroughs such as the “Brain Broadcast” Activa PC+S(Methods for Sensing and Recording During Deep Brain Stimulation), reading, remote storage, and sharing of specific deep brain stimulation (DBS) parameters from implanted devices are already technically feasible. At a minimum, device usage information, battery status, and hardware integrity can be monitored remotely. Many patients previously had to travel long distances for DBS health check-ups; this burden can now be significantly reduced through telemetry technology. These technologies will soon be applied in clinical safety and efficacy trials.

Subsequently, more advanced remote devices will undergo evaluation. With an increasingly diverse array of ambulatory monitors and electrophysiological tracking devices, changes in data from continuous clinical monitoring can automatically adjust deep brain stimulation (DBS) parameters across a range of possible values until optimal settings are achieved. This remote DBS therapy minimizes the burden of travel and is likely to yield better outcomes than traditional periodic, short-duration clinical visits.

We extend our special thanks to Professor Chen Biao for his guidance and assistance in manuscript preparation.
Professor Chen Biao, a professor at Xuanwu Hospital of Capital Medical University and a core member of the Telemedicine Expert Committee of the International Parkinson and Movement Disorder Society, is the author of this article. This year, Professor Chen participated in research on an Apple Watch app designed for monitoring Parkinson’s disease symptoms.

Compiled by Zhou Yanxun
Edited by | Mo Renying