The pros and cons of teleneuropsychology

In an ideal world, neuropsychologists could do all patient assessments in person, sitting across a table from patients for the duration of the exam.

In reality, in-real-life assessments aren’t always possible.

Enter teleneuropsychology. This developing branch of the field comprises all instances where neuropsychological assessments are delivered remotely, whether by videoconference, telephone, or some other form of newfangled technology.

Before the Covid-19 pandemic, just about all neuropsychological assessments happened in person—patients would drive to an office and spend anywhere from two to eight hours (depending on the age and clinical condition of the patient) completing different parts of an exam. The exam wasn’t like the same tests we’ve had in school; it was more like a one-on-one review during which the evaluator assesses memory, attention, language skills, motor skills, coordination, organization, planning, problem-solving and overall cognition.

Covid, however, changed everything. With social distancing in place, the only way for neuropsychologists to complete neuropsychological assessments was to do so virtually (either over videoconferencing technology compliant with the Health Insurance Portability and Accountability Act, or by phone).

Between assessments conducted entirely over the Internet while the patient sat at home with their own computer or phone, and hybrid exams during which a clinician performed a virtual evaluation using a computer within their own clinic, but with the patient in a separate room, neuropsychological assessments experienced an evolution like never before. Virtually overnight, an entirely new wing of the practice was born.

Some say the development has revolutionized the way neuropsychologists apply science; others say it creates more problems than it’s worth. While most of the current literature (this piece, this piece, this piece, and this piece) say conducting neuropsychology virtually can be viable in many cases, almost every practitioner in America agrees the most foolproof way to do the job is still to assess a patient is to do so in person, directly, one-on-one.

“[Teleneuropsychology is] almost always going to be of lower quality than an in-person exam,” said Dr. Robert Bilder, a board-certified neuropsychologist who is the Tennenbaum Family distinguished professor of psychiatry and biobehavioral sciences and psychology at the University of California Los Angeles and Chief of Neuropsychology at UCLA Health. “Once you accept this, the questions are: How much worse? How much is it going to affect clinical decision-making? How much will it help?”

The upsides of teleneuropsych

Neuropsychologists say teleneuropsychology has several benefits.

One of the most significant benefits: Convenience. Especially if scheduling is difficult, or if a patient is infirmed and not otherwise able to travel from home to a doctor’s office easily, engaging in a neuropsychological assessment or evaluation online or over the phone can be an incredible relief for clinician and patient alike.

This was the case for Dr. Munro Cullum, vice chair and chief of the division of psychology in the department of psychiatry at the University of Texas Southwestern Medical Center. When Dr. Cullum first started with researching teleneuropsychology, he and colleagues included members of the American Indian population near Oklahoma City. Of course, the main clinic for the research was in Dallas, more than 200 miles away. Without teleneuropsychology, the researchers never would have gotten data from that subset.

“Sometimes it’s the only way,” Dr. Cullum said.

A related benefit: Improved efficiency. When patients can log on for an assessment from their homes, they no longer must take the time to travel to a clinician’s office to complete the task. This doesn’t only maximize the patient’s time; it also minimizes the burden on the local environment.

Dr. Bilder suggested it may even improve the results. “Is it better to examine somebody in the clinic after they’ve had to sit in traffic for a couple of hours or is it better to capture them when they’re at home and relatively comfortable, haven’t had to go through that experience?” he asked. (Teleneuropsychology delivers efficiency improvements for clinicians, too—without the need for welcoming patients into the office, clinicians can save time in prepping the office for visitors, and in cleaning the office after a session.)

There are other benefits, such as overall adaptation. Until Covid, the practice of neuropsychological assessments hadn’t changed much at all since World War II. Faced with the challenges of social distancing, the field had to evolve.

“Since World War II, a number of changes have taken place in the global technology landscape—most notably, the introduction of computers,” said Dr. Bilder. “Now that everybody has more computing power sitting in the palm of their hand than used to exist for all of the space administration, it opens up new possibilities for being able to assess psychological functions and neuropsychological functions.”

The downsides of teleneuropsych

Of course, teleneuropsychology has its shortcomings, too.

For starters, when a clinician engages in a virtual assessment with a patient at home, that clinician never knows what the patient’s Internet bandwidth is like, or how sophisticated the patient’s computer might be. According to Dr. Bilder, any number of variables can threaten the standard administration of teleneuropsychology, meaning some of the results may be compromised.

“In my home, we get 500 megabytes per second; in the clinic, we get 1 gigabyte per second, or twice the speed,” said Dr. Bilder, who also directs UCLA’s Tennenbaum Center for the Biology of Creativity. “A lot of people have much lower bandwidth—sometimes less than half of that. Depending on other issues such as poor WiFi, connections can be lost, speakers can malfunction, computer monitors can stop working. It is imperfect.”

He continued: “If we bring people into the clinic and do the same things there with a computer, at least we know the computer. We know the display. We know the microphone. We know the speakers. We know the bandwidth of the connection. It removes a lot of the uncontrolled variables that occur with in-home teleneuropsychology.”

Dr. Bilder added that because at-home Internet bandwidth can differ so much between households, especially in disadvantaged areas, one could argue that teleneuropsychology selectively discriminates against people who don’t have access to the resources to procure and maintain high bandwidth.

(In many ways, this is a neuropsychological impact of the digital divide.)

Another potential pitfall of having patients participating from home: Distractions. Maybe a cat walks across the keyboard. Maybe a dog barges in. Maybe a young child needs attention. There’s no limit to the number of things that could happen at a patient’s home during a teleneuropsychological assessment, and they’re all things a clinician can’t control.

Dr. Cullum was quick to note that when a patient completes a neuropsychological assessment remotely, there’s also no way to tell with certainty that the patient isn’t getting some sort of assistance in secret.

“If we are engaging in teleneuropsychology and I read you a list of words, what’s to stop you from writing them down?” said Dr. Cullum, who holds the Pamela Blumenthal Distinguished Professorship in Clinical Psychology, and is also a past president of NAN. “My camera is up high. Yours is down low. The screen can be off. Depending on where things are positioned. I might not be able to tell if you’re writing down the words. [Suddenly,] the results of that test become suspect. And one might never know.”

Practical applications

Teleneuropsychology can be more effective in certain situations—at least according to some experts.

If you see that someone has perfectly good performance on a neuropsychological assessment from their home environment, it suggests their cognitive abilities likely are strong. The real conundrum arises when a patient’s performance yields problematic results.

“How much of the problem we see is due to person’s brain function, and how much is due to the fact that it was done at home?” asks Dr. Bilder. “If the diagnosis is leaning toward a particular disorder, I would recommend having it double checked with in-person examination. I think that’s the best practice is to make sure before we make a positive diagnosis of a brain disease that we get the best information possible. We always [must] use our clinical judgement to figure out whether any indicator of impairment is valid or not.”

Dr. Cullum has a more rigorous sense of where teleneuropsychology can and can’t work.

“I have gone on record as saying that I’m not a big fan of remote detailed assessment in medicolegal or forensic environments,” he said. “I want to see those people across the table from me or my assistant during that evaluation to really observe them.”

As scientists continue to redefine rules for teleneuropsychology, it seems this branch of the field will continue to grow. Already, progress has been made in this area.

During the early stages of the Covid-19 pandemic, A collaborative panel of experts from major professional organizations developed provisional guidance for neuropsychological practice. Stakeholders for this initiative included NAN, the American Academy of Clinical Neuropsychology/American Board of Clinical Neuropsychology, Division 40 of the American Psychological Association, the American Board of Professional Neuropsychology, and the American Psychological Association Services, Inc. Findings were peer-reviewed and eventually chronicled in this article and this article for The Clinical Neuropsychologist.

Dr. Cullum said Covid-19 was just the beginning, predicting that teleneuropsychology will become more prevalent over the months and years ahead.

“I’d hate to use the term precipice, but I think it can happen if we can [grow] our knowledge of brain assessment and think outside the traditional neuropsychology testing toolkit box and start developing new measures of brain function,” he said. “[It’s] important to also incorporate the tele-element [so] that we don’t see the tele interaction as a big obstacle, but that we instead utilize it to our advantage.”

As an example, Dr. Cullum cited a relatively new company in Spain that purports to perform rudimentary teleneuropsychology screenings of patients by incorporating machine learning to analyze their speech patterns.

He said envisions a time with other companies monitoring other physical aspects get into the game, too.

“Are there mannerisms? Are there abnormal movements? Or is there a lack of movement that helps with a machine learning approach to detecting pathology or something that’s normal versus abnormal?” he asked. “We are in the early stages of figuring this out.”

Dr. Cullum said he sees the future presenting a “smorgasbord” of different technologies and options for various levels of teleneuropsychology. In his future, patients come in for evaluations and get hooked up to a futuristic electroencephalogram (EEG) cap or device that measures advanced brain physiologic responses. The way Dr. Cullum sees it, clinicians can leverage these tools to look at patients’ brain responses while they’re performing these future neuropsychological measures so clinicians can tell what’s going on in their brains in real-time.

Eventually, when clinicians in this futurescape get enough data on enough patients with certain disorders and certain stages of certain disorders, they can have their computers do the assessment all together and spit out profiles based on similarities to a group or groups in the massive database.

“Whether we’re ready or not, this is what’s next,” he said.

This article has been factchecked. For more about that process, click here.