The Clinical Neuropsychologist

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ntcn20

Transitioning to telehealth neuropsychology

service: considerations across adult and pediatric
care settings

Kelsey C. Hewitt , Sandra Rodgin , David W. Loring , Alison E. Pritchard & Lisa
A. Jacobson

To cite this article: Kelsey C. Hewitt , Sandra Rodgin , David W. Loring , Alison E.
Pritchard & Lisa A. Jacobson (2020): Transitioning to telehealth neuropsychology service:
considerations across adult and pediatric care settings, The Clinical Neuropsychologist, DOI:
10.1080/13854046.2020.1811891

To link to this article: https://doi.org/10.1080/13854046.2020.1811891

Published online: 26 Aug 2020.

Submit your article to this journal

Article views: 389

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=ntcn20
THE CLINICAL NEUROPSYCHOLOGIST
https://doi.org/10.1080/13854046.2020.1811891

Transitioning to telehealth neuropsychology service:

considerations across adult and pediatric care settings
Kelsey C. Hewitta , Sandra Rodginb,c, David W. Loringa,d, Alison E. Pritchardb,c ,
and Lisa A. Jacobsonb,c
a
Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA; bDepartment of
Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, USA; cDepartment of Psychiatry and
Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA; dDepartment of
Pediatrics, Emory University School of Medicine, Atlanta, GA, USA

ABSTRACT ARTICLE HISTORY

Objectives: In response to the 2020 COVID-19 pandemic, trad- Received 1 May 2020
itional, in-person neuropsychological assessment services paused Accepted 13 August 2020
in most settings. Neuropsychologists have sought to establish Published online 26 August
new guidelines and care models using telehealth neuropsych- 2020
ology (teleNP) services. The need to adapt to remote technology
KEYWORDS
became the most difficult challenge to date for existing practice Teleneuropsychology; tele-
models. Results: Primary considerations for transitioning to health; telemedicine;
teleNP include scope and limitations of the telehealth modality, practice models;
informed consent for telehealth services, patient privacy and con- healthcare delivery
fidentiality, test security, and validity of telehealth assessments.
Given timelines for fully re-opening clinical settings, access to
traditional models of neuropsychological care remains unclear.
These considerations will remain relevant even upon return to an
in-office practice, as many assessment models will likely continue
with teleNP to some extent. Specialists will need to consider the
unique needs of their populations in ensuring quality care, as
diagnostic differences and patient age will impact participation in
teleNP. Conclusions: As the COVID-19 pandemic lingers, teleNP
presents an opportunity as well as a challenge for neuropsycholo-
gists looking to provide patient care in the context of social dis-
tancing and stay-at-home restrictions. In this transformative time,
the field of neuropsychology has opportunities to advance
beyond traditional settings and focus on alternative delivery of
patient care.

Introduction
Neuropsychologists play many roles in various inpatient and outpatient settings, but
the primary purposes for clinical neuropsychological assessment generally include (1)
detecting cognitive dysfunction, (2) characterizing cognitive strengths and weaknesses
and changes therein, (3) guiding differential diagnosis, and (4) guiding

CONTACT Kelsey C. Hewitt kelsey.hewitt@emory.edu Department of Neurology, Emory University School of

Medicine, Atlanta, GA, USA.
ß 2020 Informa UK Limited, trading as Taylor & Francis Group
2 K. C. HEWITT ET AL.

recommendations regarding everyday life and treatment planning (Casaletto et al.,

2017). The practice of neuropsychology continues to evolve and presently faces chal-
lenges and opportunities to expand its repertoire and service models in response to
the 2020 COVID-19 pandemic.
China reported a cluster of cases with pneumonia on December 31, 2019, and on
January 7, 2020, Chinese health authorities confirmed these symptoms to result from a
novel coronavirus, COVID-19, which subsequently spread rapidly through Europe and
North America (Holshue et al., 2020). Within months, universities began campus clo-
sures and medical clinics soon followed suit for non-emergent care, which forced trad-
itional, in-person neuropsychological assessment services to pause in most settings.
Given that timelines for fully re-opening clinical settings to non-emergent care remain
unclear in some settings, access to traditional models of neuropsychological care will
likely remain limited for the foreseeable future. While some health systems and indi-
vidual practitioners never stopped or have returned to limited practice, the standard
care model was primarily shifted to provide diagnostic assessment services using tech-
nology and telehealth – while still maintaining high standards of care.

Traditional practice
With the onset of the COVID-19 pandemic, adapting neuropsychological methods for
remote technology became the most difficult challenge for existing practice models.
While most of medicine has incorporated technology to improve diagnostic precision,
neuropsychology has been slow to embrace computer technology; most practitioners
rely primarily on pencil and paper tests developed during the early to mid 20th cen-
tury (Bilder & Riese, 2019; Rabin et al., 2005). Traditional pencil and paper neuro-
psychological assessments – typically administered face-to-face in an office setting –
reflect decades of research supporting their use to understand individuals’ skills and
abilities (Kessels, 2019).

Considerations in transitioning to telehealth neuropsychology services

Given prior interest in telemedicine and videoconferencing, Grosch et al. (2011) pro-
vided initial recommendations for psychologists in need of guidelines and standards
of care. With continued use of computerized or tablet-based methods for assessing
neuropsychological functioning (Bauer et al., 2012; Cullum et al., 2014; Galusha-
Glasscock et al., 2016), and the current transition from in-person to telehealth assess-
ment methods in many locations, the field would benefit from continuously updated
guidelines to promote the highest level of care.
Given limitations associated with social distancing and institutional restrictions for
providing non-emergent clinical services, it was necessary for neuropsychologists to
modify traditional assessment methods for a different practice environment.
Videoconference-mediated telehealth has been successfully deployed across a variety
of clinical services (e.g., primary care, neurology, psychology, psychiatry, and radiology)
(Barneveld Binkhuysen & Ranschaert, 2011; Brearly et al., 2017; Davis et al., 2014;
Fortney et al., 2015; Johnson et al., 2015; Tensen et al., 2016; Wennergren et al., 2014).
 THE CLINICAL NEUROPSYCHOLOGIST 3

Additionally, the Veteran’s Administration Office of Rural Health reported success pro-
viding tablets to high-need patients experiencing barriers to traditional in-person serv-
ices (Zulman et al., 2019). Yet, neuropsychology has been reluctant to embrace
videoconference-mediated telehealth given a number of theoretical and practical
considerations.

Service platform
Options for transitioning from traditional in-office visits to telehealth neuropsychology
(teleNP) services depend upon available computer/phone platforms with which pro-
viders and patients interact. TeleNP services refer to the application of audiovisual
technologies to enable remote clinical encounters with patients to conduct modified
neuropsychological assessments (Bilder et al., 2020). Most major third-party payors
now permit video conferencing or telephone-only modalities in response to this pan-
demic for at least some aspects of neuropsychological care (Bilder et al., 2020). Valid
teleNP care, however, depends on a patient’s comfort, access to, and level of familiar-
ity with electronic devices (e.g., desktop computer, laptop computer, tablet or iPad,
smartphone, cell phone), and the type of device or platform available may drive the
assessment strategies that can be used. The 2016 American Community Survey (ACS;
Ryan, 2018) reported that 89% of households have a computer and the 2016 U.S.
Census Bureau reported that 76% of households had a smartphone, 58% had a tablet,
and 77% owned a desktop or laptop. In addition to considering the platform, teleNP
likely requires high speed internet connectivity. According to the ACS, 82% of house-
holds had a subscription to broadband internet (i.e., high speed such as cable, fiber
optic, or digital subscriber line); however, households headed by people aged 65 years
and older were least likely to have broadband internet (Ryan, 2018).

Approach to service
Transitioning to teleNP practice requires neuropsychologists to meaningfully transform
their practice models, recognizing that the type and complexity of assessment strat-
egies will vary across settings and patient referrals. For example, research applications
to characterize cognitive status in adults have included remote cognitive screening
(e.g., Telephone Interview for Cognitive Status; TICS) (Brandt et al., 1998). Given restric-
tions to clinic access due to social distancing regulations or closure of “non-essential”
services, neuropsychologists will need to make decisions about the scope and mode
of services that can be offered in their own practice.
A comprehensive clinical interview – which lends itself more easily than testing to a
teleNP model – may be used to clarify diagnostic questions and identify needed
resources or interventions. It can also serve as the decision point for making the deter-
mination regarding the necessity for additional teleNP strategies, such as obtaining
symptom or behavior ratings or conducting future testing, as well as informing
whether that testing can happen via telehealth or needs to be done in person. Thus, a
clinical interview and review of records can serve as an intervention in itself but can
also be useful in accurately triaging testing cases. Practice models for triage and
4 K. C. HEWITT ET AL.

decision-making are described elsewhere in this issue (Hewitt & Loring, 2020; Peterson
et al., 2020; Pritchard et al., 2020).

Ethical principles
The American Psychological Association’s (APA) Ethical Principles of Psychologists and
Code of Conduct standards are not intended to be exhaustive (APA, 2017), but can
guide specific and meaningful actions that address current needs and challenges. These
guidelines require practitioners to apply existing standards even when they do not spe-
cifically address an area of practice (e.g., use of remote, electronically delivered services)
(Grosch et al., 2011). In order to establish teleNP standards, the field must follow existing
standards in place to guide ethical implementation of novel practice models.
TeleNP transition necessitates the balance of Principle A (Beneficence and
Nonmaleficence) with Principle D (Justice) as psychologists’ actions may affect the lives
of others (APA, 2017). Neuropsychologists face a dilemma since waiting to provide
services until in-person testing is feasible means that patients who need timely care
will not receive it (i.e., maleficence), yet moving forward with teleNP testing could be
harmful if the telehealth format changes the ‘meaning’ of the tests administered, limit-
ing their interpretability or contributing to misinterpretation of findings. Thus, a quan-
dary exists with teleNP between providing necessary care under conditions that may
or may not invalidate test findings. Indeed, it remains unknown whether remote
administration of specific measures is sufficiently different from face-to-face adminis-
tration to render results incomparable. An argument can certainly be made that analo-
gous to the off-label use of medication that is common practice in medicine, the
remote administration and interpretation of neuropsychological measures may be tol-
erable in cases where (1) there is not existing evidence to support a substantive differ-
ence between face-to-face and remote administration, (2) there is reason to believe
that remote administration may, in fact, measure the same thing as face-to-face
administration, and (3) the benefit of completing testing remotely outweighs the
potential risk of breaking standardization.
Issues related to justice also arise in terms of equitable access to care via telehealth.
As mentioned earlier, access to an appropriate device and broad band internet are
critical for provision of telehealth services. Unfortunately, those patients who may be
most in need of neuropsychological services may also be least likely to have access to
telehealth infrastructure. Thus, access to technology can be a barrier to telehealth
services in the same way that access to transportation can be a barrier to in-person
services for disadvantaged patients. Finding creative ways to address these challenges
will be of the utmost importance in ensuring that neuropsychological services are pro-
vided in the most just manner moving forward.
TeleNP must also balance the needs of the clinic and the patient. Given the extent
of the pause and continued uncertainty about re-opening plans, if clinical face-to-face
services remain limited, neuropsychologists, as well as other clinical and administrative
staff, may be furloughed or laid off, thereby further limiting access to care. If timely
care is not provided to patients, their functioning may suffer. For instance, adults with
even mild cognitive difficulties might be less successful in managing their instrumental
 THE CLINICAL NEUROPSYCHOLOGIST 5

activities of daily living and children with learning difficulties will fall farther behind
their typically developing peers academically.

Considerations in implementing teleNP services

Primary considerations for engaging in teleNP include scope and limitations of the tel-
ehealth modality, informed consent for telehealth services, patient privacy and confi-
dentiality, test security, and validity of telehealth assessment. These considerations
need to be balanced against the uncertainty of the timeline for a return to an in-
office, in-person assessment model and the ethical concerns described above.

Informed consent
While the APA has developed a guide for informed consent in telepsychology more
broadly (APA, 2020a), there are considerations for consent specific to teleNP assess-
ment services. In line with the APA Ethics Code (APA, 2017), limitations and expecta-
tions regarding the purpose and utility of services offered should be discussed at the
outset of the visit. For example, if the aim of the assessment is a comprehensive
evaluation for application to disability support services, it would be important to dis-
cuss that it is currently unclear whether related organizations will accept test results
obtained via telehealth modalities as evidence of cognitive impairment.

Confidentiality and patient privacy

As part of the informed consent process, the APA and the Inter Organizational
Practice Committee (IOPC) advise clinicians to ask the patient who else is in the home
and if the patient gives permission for others to overhear any information discussed in
the visit (APA, 2020a; IOPC, 2020). Many patients may not have adequate space in
their home to fully separate from their family which raises concerns regarding privacy
and confidentiality. Having others in close proximity may alter the information pro-
vided and impact testing performance (e.g., performance anxiety related to others
possibly overhearing their recollection of information on a memory task). Likewise,
there may not be a private place to conduct the clinical interview, which, in turn, has
the potential to influence patient/caregiver willingness to disclose information and
potentially impact diagnostic accuracy.
Some institutions are using secure hospital videoconferencing accounts that are
Health Insurance Portability and Accountability Act (HIPAA)-compliant to ensure the
security of protected health information. Providers in these institutions can therefore
use secure video conference platforms (i.e., Zoom, Vidyo), some of which are embedded
within electronic medical records systems. With less secure videoconferencing formats
(e.g., FaceTime, Skype), telehealth sessions are vulnerable to privacy breaches.
Additionally, at the beginning of the teleNP visit, clinicians are advised to obtain the
patient’s phone number and current address or other identifying information to ensure
identity and safety (i.e., should a patient disclose suicidal ideation or abruptly exit the
session, clinicians have a way to contact the patient or caregiver).
6 K. C. HEWITT ET AL.

Test security
Security of testing materials is always a concern, both during in-person evaluations (e.g.,
patients/informants taking pictures of test forms, recording from their phone unbe-
knownst to the clinician) and during teleNP testing. When obtaining informed consent
for telehealth evaluation services, neuropsychologists should ask patients and families to
refrain from recording information during the assessment to ensure test security, and
document their agreement. Some videoconference platforms (i.e., Zoom) allow restric-
tions on recording unless the host grants permission, while other platforms provide
alerts to participants that someone is recording (i.e., Skype for Business).
Many test publishers have issued guidance regarding their position on telehealth
(i.e., Multi-Health Systems Inc., Pearson, Psychological Assessment Resources, and
Western Psychological Services), and have provided electronic versions of stimuli and
guidelines for administration (e.g., current Wechsler measures from Pearson’s Q-
GlobalV R Library). Even in the context of COVID-19 and remote patient care, publishers

have not granted permission to photocopy/scan protocols or email scanned rating

forms to patients and caregivers. Leniency of administration is intended to support
practical live delivery of the telehealth services without modification of the original
test content as it currently appears (Pearson, 2020).
Given limited home access to testing materials, neuropsychologists who are not
conducting teleNP from their office may have to be creative with their protocol to
include measures that are in the public domain; among others, these tests include the
Rey Auditory Verbal Learning Test (Rey, 1941; Schmidt, 1996), Rey-Osterrieth Complex
Figure (Fastenau, 1996; Loring et al., 1990; Osterrieth, 1944), Trail Making Test (Army,
1944), Animal Fluency (Rosen, 1980), and Controlled Oral Word Association (Spreen &
Benton, 1977) (Hewitt & Loring, 2020).

Validity
It is important to establish whether neuropsychological assessments developed for
traditional on-site administration can be administered via videoconference-mediated
telehealth, and the best ways to efficiently address the potential related concerns.
These questions about how to operationalize teleNP are critical to neuropsychology’s
ability to adjust during the pandemic and specific considerations are described below.
The validity of remote neuropsychological measures with adult patients has been
demonstrated across a series of reports (Cullum et al., 2006, 2014; Galusha-Glasscock
et al., 2016; Hildebrand et al., 2004; Jacobsen et al., 2003; Loh et al., 2004; Poon et al.,
2005; Vestal et al., 2006; Wadsworth et al., 2018). Brearly et al. (2017) conducted a sys-
tematic review and meta-analysis of 12 studies examining adult neuropsychological
assessments via videoconferencing across multiple clinical populations, reporting that
verbally administered tasks including digit span, verbal fluency, and list learning, are
minimally impacted by the videoconference format. However, most teleNP research
was conducted via a facilitated remote testing site and does not take into account the
current health situation and social distancing restrictions. Marra et al. (2020) recently
expanded the literature to emphasize test-level validity, finding good support for
teleNP assessments in older adults.
 THE CLINICAL NEUROPSYCHOLOGIST 7

In contrast, there are few published pediatric neuropsychology-specific studies that

have explored the validity of remote or teleNP administration. Harder and colleagues
found performance did not significant differ on any of the measures administered
between face-to-face vs. teleconference administration of a comprehensive assessment
battery (Harder et al., 2020). Examination of video conference administration of the
Clinical Evaluation of Language Fundamentals, Fourth Edition (CELF-4) in school-age
children with autism spectrum disorder found strong interrater reliability between tele-
health and face-to-face conditions (Sutherland et al., 2019). Additionally, there is evi-
dence to support the validity, utility, and predictive power of online versions of paper
and pencil rating forms (Patrick et al., 2013; Pritchard et al., 2017).
Certain measures introduce specific issues for standardization. For visually presented
tasks, in particular, it is important to consider differences in the display and varying
type, size, and resolution across devices. A desktop or laptop computer is recom-
mended for patients to view visual stimuli included in a telehealth assessment proto-
col; if a smartphone is utilized, the nature of a visuo-construction task will be altered
as a patient may unintentionally miss part of the figure or enlarge the figure to ensure
accuracy. Additionally, variability in video/audio quality during the videoconference
(e.g., lags in transmission) may increase the risk that timed/speeded tasks may be inva-
lidated. To mitigate this risk, task instructions and responses may be conducted using
phone while still maintaining video contact. To mitigate the risk that patients could
write down certain task stimuli, they should be instructed to move themselves or their
camera so that they are full view (or at least show their hands) so the clinician can
observe that they are not engaging in behaviors that undermine the standardization
or security of the test. It is helpful to observe patients in the largest view (e.g.,
“pinning” the video so the patient remains in Speaker View) to ensure that behavioral
observations are best captured. Additionally, task expectations should be clarified (e.g.,
“You do not need anything for this next task. I want you to listen carefully,” or “You
will need your pen, blank piece of paper, and folder for this next task”).
Certain measures are not readily adaptable for teleNP administration, and clinicians
may therefore not be able to assess all cognitive or neurobehavioral domains (e.g.,
Wisconsin Card Sorting Task, comprehensive motor exam). Presentation of results in
visit documentation might note that the teleNP modality allowed screening of specific
cognitive domains but may not comprehensively describe the patient’s neurocognitive
profile of strengths and weaknesses. Additionally, for follow-up visits designed to
establish interval change, it remains unclear whether teleNP test results can be validly
compared to previous in-person performance.

Technological concerns
TeleNP care will be limited by the patient’s/caregiver’s ability to navigate the technol-
ogy involved in accessing these services. Fortunately, most schools and universities
now provide instruction via remote learning, and children and their parents are
increasingly familiar with videoconferencing technology. Additionally, many adults
now use videoconferencing in the context of working from home, and many patients
have had successful telehealth medical visits during the pandemic, both of which
8 K. C. HEWITT ET AL.

have provided experience with remote video conferencing. In older adults, however,
there is greater concern for the effects of the videoconference environment on cogni-
tively impaired patients. This has been addressed previously by the inclusion of a
trained facilitator, if needed, to sit with the patient during testing (Cullum et al., 2006);
however, limitations exist with training facilitators outside clinic walls. Providing an
illustrated patient-friendly tip sheet on the platform being used can help increase pro-
ficiency, efficiency, and comfort in patients engaging in teleNP services.
When conducting an initial interview, clinicians should consider if the existing tech-
nology lends itself to testing – for example, transmission lag and network connection
difficulties may suggest that proceeding to testing might be contraindicated.
Alternatively, clinicians could use the combination of telephone audio and muted
video, as described above, to mitigate concerns for transmission stability. One strategy
to determine the connection stability is to begin with untimed verbal tasks to ensure
that the connection appears to be stable before proceeding to timed tasks. It will be
important to monitor throughout the teleNP assessment whether the patient had any
difficulty hearing or viewing information provided since there may be lapses in con-
nection that may go unrecognized by the clinician. If difficulties do occur, these
should be noted in the validity statement of the report as a potential confounding fac-
tor in the patient’s performance. Trusting the patient’s report that they were not able
to understand certain information or stimuli is necessary. To circumvent early discon-
tinuation of a task due to transmission errors, examiners can return to the item in
question after completion of the subtest (e.g., if a patient misunderstood a forward
digit span sequence, proceed to the next set for testing limits and return to the mis-
heard item at the end).

Distractions in teleNP testing administration

Distractions in teleNP testing need to be considered, and if possible, avoided or miti-
gated. This concern is heightened in the current context of statewide stay-at-home
orders making it more likely that family members will be in the home during the assess-
ment session. Adults may struggle to keep their children from coming into a room.
Children and adolescents may be distracted by noise from their siblings in an adjacent
room. As noted in the APA Office of Technology Checklist for Telepsychological Services
and IOPC teleNP guidelines, strategies may include asking patients to (1) find a quiet
room with a closed door and use a “do not disturb” sign, if possible, (2) ensure that
pets and other people do not enter the room during testing, (3) silence electronic devi-
ces, (4) turn off any other devices that make noise, and (5) hide “self-view” on videocon-
ference (APA, 2020a; Bilder et al., 2020). Additionally, use of headphones may be
beneficial to reduce some unpredictable audio distractions (i.e., pets or family members).
Although noise-cancelling headphones would be the most beneficial, not all patients
will have access to this quality equipment. It is also important that while participating in
the telehealth session, both the clinician and patient mute or close email and messaging
platforms to avoid alert notifications as a source of distraction. Furthermore, it is critical
that the clinician close windows on their computer that contain information that should
not be visible to the patient before sharing their screen (e.g., electronic medical records).
 THE CLINICAL NEUROPSYCHOLOGIST 9

Should the patient access the teleNP visit via phone or tablet, the clinician may advise
their patients to turn on “Do Not Disturb” functions to eliminate any notifications.
Should disruptions occur, this should be documented in the validity section and consid-
ered in the interpretation of data where applicable.

TeleNP considerations for subspecialties in neuropsychology

There are unique population-specific considerations for the provision of teleNP serv-
ices. Diagnostic differences exist between children and adults, though in both groups
capabilities vary widely and impact participation in telehealth assessments. Specialists
will need to consider the unique needs of their populations in ensuring quality neuro-
psychological care.

Etiology-specific considerations
Linking a neurocognitive profile with brain-based deficits is inherent to the profession
regardless of symptom etiology. A majority of the studies that have established cogni-
tive profiles observed in certain medical populations have used in-person assessment
measures. Telehealth assessment has been examined in a few specific adult clinical
populations, to include traumatic brain injury (Cole et al., 2018; Iverson & Schatz, 2015;
Resch et al., 2013), multiple sclerosis (Barcellos et al., 2018), and dementia (Cullum
et al., 2006, Cullum et al., 2014, Galusha-Glasscock et al., 2016; Harrel et al., 2014;
Vestal et al., 2006). As discussed above, however, clinicians may not be able to assess
all domains of cognitive functioning via teleNP, so it is important to consider if the
area(s) of cognitive weakness associated with the medical condition can be validly
assessed via videoconference.
Some specific referral questions may preclude teleNP assessment. For example, in
epilepsy pre-surgical evaluations, non-essential surgical procedures may be canceled/
postponed in certain hospitals; given an unknown waiting period, the patient’s pre-
surgical functioning may best be determined closer to the time of the surgery without
the confounding factors associated with the COVID-19 state of emergency (e.g., the
stress of social distancing) and the limitations associated with teleNP testing.
Specifically, the Neuropsychology Task Force of the International League Against
Epilepsy (ILAE) has issued a statement against performing abbreviated evaluations via
telehealth and proceeding to surgery with any patient that has not undergone a com-
prehensive pre surgical neuropsychological evaluation using standard procedures
(International League against Epilepsy, 2020).

Pediatric considerations
An important consideration for many pediatric referrals is access to educational or
other therapeutic interventions. Initially, school and therapy services were placed on
pause across many jurisdictions; however, many schools and private therapies are
resuming via videoconference formats. Thus, evaluations completed to determine if
such supports and services should be initiated remain relevant and timely. It is
10 K. C. HEWITT ET AL.

important to note that in some cases the need for such services may be determined
through clinical interview and record review, without requiring testing at all. Of note,
the degree to which outside teleNP testing will be considered in school decisions to
provide services and accommodations remains unclear, although state and federal
departments of education have issued guidance (e.g., Maryland State Department of
Education, 2020) indicating that school teams must maintain compliance with special
education eligibility timelines, which will likely require them to also engage in at least
some evaluation via videoconference. If external teleNP testing is not ultimately
accepted by schools when they re-open, and the student requires in person reassess-
ment in order to access school-based services, then such reassessment may be more
challenging, given the student’s recent exposure to certain stimulus materials via
teleNP. In this case, school-based clinicians reassessing a student in person will have
to consider use of alternative forms and measures.
Another consideration in pediatric teleNP is the involvement of caregivers in test-
ing. While many school-age children and adolescents appear comfortable navigating
the telehealth platform, they may need assistance from their caregivers to set up and
make changes to their view (e.g., “pin” videos to Speaker View, hide self-view). For
young children or children with behavioral regulation difficulties that impact testing
engagement, caregivers may be used to encourage their child to participate. For
example, during a teleNP assessment of a 4 year-old patient, a caregiver may need to
sit beside the child and help redirect their attention to the task; however, it is critical
to standardization that the clinician first instruct the caregiver not to hint at or provide
responses. The APA, IOPC, and several test publishers have provided guidelines for tel-
ehealth administration of child measures, suggesting that caregivers can also be used
as onsite facilitators, at the clinician’s discretion. For example, a caregiver could be
asked to open a mailed envelope with rating scales and give the measures to the
child to complete during the session. For certain pediatric patients, particularly those
who need substantial behavioral support, the neuropsychologist may choose to obtain
the vast majority of relevant assessment data via diagnostic interviewing of the par-
ent/caregiver, record review, and administration of parent rating scales (i.e., Tier 1 serv-
ices; Pritchard et al., 2020), minimizing or omitting performance-based measures
entirely. Likewise, given the limitations of using teleNP for children, the APA has also
reinforced the importance of behavioral observations, the clinical interview, and review
of records, noting that these data acquisition methods can help to support test results
obtained via telehealth (APA, 2020b).

Adult considerations
The Centers for Disease Control and Prevention (CDC) announced that people 65 years
and older and people of all ages with underlying medical conditions, particularly if not
well controlled, are the most vulnerable to COVID-19. In response, many neurologists
now provide telehealth assessment to decrease patient exposure risks but which may
limit certain aspects of the physical examinations (e.g., sensory assessment, visual field
examination; Hewitt & Loring, 2020). With medical models transitioning to telehealth,
 THE CLINICAL NEUROPSYCHOLOGIST 11

neuropsychologists were urged to adapt the traditional model of care to teleNP serv-
ices to best address continuing referrals.
Similar to pediatric teleNP, the involvement of caregivers during testing may be
necessary within the adult population. As in traditional face-to-face testing, teleNP will
also need to consider the need for collateral information in the clinical interview, as
adults with even mild cognitive difficulties may present as poor historians. In a trad-
itional setting, caregivers leave the room after the clinical interview, however if
patients are expected to manipulate items over an unfamiliar interface (i.e., computer/
smartphone), a caregiver may be needed. Standardized protocols to handle these sit-
uations may be necessary to address (1) determination of need for a facilitator, (2)
training or instruction of caregivers to reduce inadvertent coaching or assistance with
item content, and (3) guidelines for asking the caregiver to leave the room when the
clinical interview is over.
Another consideration is technology familiarity since telehealth barriers are often
technology-specific (Kruse et al., 2018). During the COVID-19 pandemic, these barriers
remain constant; when reviewing responses for willingness to complete remote teleNP
in place of on-site testing at a university medical setting, the most common barrier
was lack of confidence with technology skills (Hewitt & Loring, 2020).
As in all cases, clinicians are encouraged to complete a thorough review of records
to understand how to best answer the referral question, in the face of limitations for
certain populations (e.g., level of cognitive difficulty, surgical candidates, litigation,
non-neurological etiological concerns). For adult patients, it may be useful to perform
a screening test (e.g., Montreal Cognitive Assessment; MoCA) part of the clinical diag-
nostic interview to help establish whether a patient is likely to undergo valid assess-
ment with a modified teleNP protocol (Hewitt & Loring, 2020).

Forensic considerations
The APA has not yet issued guidance on teleNP or general assessment for forensic
cases, and a major consideration in this subspecialty is whether or not the findings
would be considered valid in medico-legal contexts. In some settings, institutions
needed to change practices to continue evaluations for compensation and pension
(C&P) programs. For example, the Department of Veteran’s Affairs, transitioned to tele-
health with the need to continue evaluating veterans for C&P purposes. Initially few
veterans participated in telehealth due to attorney concerns. However, with COVID-19
lingering many veterans began to seek telehealth services. As a whole, unless there
are strong reasons to proceed in individual cases, forensic evaluations may be least
likely to proceed via telehealth given questions about standardization and interpret-
ation of scores and concerns for potential coaching and recording.

Rehabilitation considerations
For inpatient rehabilitation, there are a variety of telehealth service models that can
be considered. Neuropsychologists may remotely join face-to-face treatment sessions
with speech-language, occupational, and physical therapies, to collect data on factors
12 K. C. HEWITT ET AL.

such as level of arousal, attention, fine and gross motor functioning, and speech-lan-
guage proficiency. Additionally, neuropsychologists may collect qualitative data, such
as asking a patient to remember several words and then asking for recall at the end
of the session. In-person therapists, if willing, may facilitate compensatory cognitive
measures, such as orienting patients to a calendar at the beginning of each session.
Day rehabilitation programs have started to transition to daily virtual therapy sessions
in some settings. In this context, the neuropsychologist may conduct individual tele-
health sessions for evaluation or cognitive rehabilitative interventions. Previous studies
have provided evidence in support of adult telehealth-based cognitive rehabilitation
for stroke (Lawson et al., 2020), traumatic brain injury (Tsaousides et al., 2014), and pri-
mary brain tumors (van der Linden et al., 2018). There is limited information on teleNP
in pediatric rehabilitation settings – one study examined solely home-based online
cognitive rehabilitation for children with cancer-related brain injury, and found
improvements in processing speed, cognitive flexibility, memory, and activation of the
pre-frontal cortex, when compared to baseline (Kesler et al., 2011). Videoconferencing
can be utilized for interdisciplinary meetings for both inpatient and day rehabilitation
settings to continue gathering information and collaborating to establish treatment
plans and goals (Tenforde et al., 2017). Lastly, telehealth may be ideal for offering con-
sultative services such as providing caregivers with psychoeducation on how to man-
age their child’s impulsive behaviors during recovery from brain injury.

Discussion
Psychologists are being called upon to embrace their many roles – clinician,
researcher, educator, diagnostician, therapist, supervisor, consultant, and now pioneer.
Because of the COVID-19 pandemic, telehealth has become a leading service modality
as evidenced by neuropsychology listserv topics and hits within popular search
engines (e.g., PubMed). TeleNP presents an opportunity as well as a challenge for
those wishing to continue to provide patient care in the context of social distancing
and stay-at-home restrictions. Institutions must consider cultural and health disparities,
as the majority of the population can access electronic devices, but the assumption
that everyone owns a device that is adequate for telehealth is false. For example, an
emailed survey to parents of scheduled or waitlisted pediatric neuropsychology
patients (N ¼ 222, 26% response rate) suggested that although 94% of respondents
were interested in a telehealth appointment, only 74% of those owned either a desk-
top or laptop computer with a camera (Pritchard et al., 2020). The ability to reach a
larger and more remote patient population is possible with teleNP; however, as clini-
cians and researchers begin to explore the opportunities this technology offers, its lim-
itations must be identified and respected. On-site, in-person evaluation remains the
gold standard, but current and future use of teleNP provides hope for broadening ser-
vice delivery and care. It is clear that teleNP will represent an essential part of the clin-
ical setting for the foreseeable future, on the condition that newly developed
telehealth-modified neuropsychological batteries are eventually validated against cur-
rent practices.
 THE CLINICAL NEUROPSYCHOLOGIST 13

The pandemic has advanced the field of neuropsychology by forcing the discipline
to evolve beyond traditional settings and begin to focus on alternative delivery of
patient care. The full impact of and potential benefits of telehealth administration on
neuropsychological assessment as a field remain to be established. Patients living at a
considerable distance from specialty services could readily access needed expertise.
TeleNP could allow for normal cognition to be measured and monitored at home, pin-
pointing specific areas of cognitive difficulties in adults and children and helping iden-
tify an optimal time for in-person comprehensive evaluation. It is likely that most
practices will eventually return to traditional, on-site, in-person, pencil and paper
assessments, until the evidence accrues to assure the field of the psychometric equiva-
lence and clinical utility of teleNP models. With an unexpected incentive to transition
to telehealth, however, the field of neuropsychology has an opportunity to expand
into the modern era of technology and offer care in ways not at all anticipated – but
that offer promise for the future.

Disclosure statement
No potential conflict of interest was reported by the authors.

ORCID
Kelsey C. Hewitt https://orcid.org/0000-0003-1448-2664
Alison E. Pritchard http://orcid.org/0000-0003-4436-0262
Lisa A. Jacobson https://orcid.org/0000-0002-6992-029X

References
American Psychological Association. (2017). Ethical principles of psychologists and code of conduct
(2002, Amended June 1, 2010 and January 1, 2017). http://www.apa.org/ethics/code/index.aspx
American Psychological Association. (2020a). COVID-19 telehealth state summary. https://www.
apaservices.org/practice/clinic/covid-19-telehealth-state-summary
American Psychological Association. (2020b). Telehealth testing with children: Important factors to
consider. https://www.apaservices.org/practice/legal/technology/telehealth-testing-children-
covid-19
Army. (1944). Army individual test battery. Manual of directions and scorings. U.S. War
Department, Adjutant General’s Office.
Barcellos, L. F., Bellesis, K. H., Shen, L., Chinn, T., Schaefer, C., Shao, X., Frndak, S., Drake, A.,
Benedict, R. H. B., Bakshi, N., & Marcus, J. (2018). Remote assessment of verbal memory in MS
patients using the California Verbal Learning Test. Multiple Sclerosis (Houndmills, Basingstoke,
England), 24(3), 354–357. https://doi.org/10.1177/1352458517694087
Barneveld Binkhuysen, F. H., & Ranschaert, E. R. (2011). Teleradiology: Evolution and concepts.
European Journal of Radiology, 78(2), 205–209. https://doi.org/10.1016/j.ejrad.2010.08.027
Bauer, R. M., Iverson, G. L., Cernich, A. N., Binder, L. M., Ruff, R. M., & Naugle, R. I. (2012).
Computerized neuropsychological assessment devices: Joint position paper of the American
Academy of Clinical Neuropsychology and the National Academy of Neuropsychology†.
Archives of Clinical Neuropsychology : The Official Journal of the National Academy of
Neuropsychologists, 27(3), 362–373. https://doi.org/10.1093/arclin/acs027
Bilder, R. M., Postal, K. S., Barisa, M., Aase, D. M., Cullum, C. M., Gillaspy, S. R., … Woodhouse, J.
(2020). InterOrganizational practice committee recommendations/guidance for
14 K. C. HEWITT ET AL.

teleneuropsychology (TeleNP) in response to the COVID-19 pandemic. The Clinical

Neuropsychologist, 34(7), XXX-XXX.
Bilder, R. M., & Reise, S. P. (2019). Neuropsychological tests of the future: How do we get there
from here? The Clinical Neuropsychologist, 33(2), 220–245. https://doi.org/10.1080/13854046.
2018.1521993
Brandt, J., Spencer, M., & Folstein, M. (1988). The telephone interview for cognitive status.
Neuropsychiatry. Neuropsychology, and Behavioral Neurology, 1, 111–117.
Brearly, T., Shura, R., Martindale, S., Lazowski, R., Luxton, D., Shenal, B., & Rowland, J. (2017).
Neuropsychological test administration by videoconference: A systematic review and meta-
analysis. Neuropsychology Review, 27(2), 174–186. https://doi.org/10.1007/s11065-017-9349-1
Casaletto, K. B., Heaton, R. K., Grant, I., Haaland, K. Y., & Rao, S. M. (2017). Neuropsychological
assessment: Past and future. Journal of the International Neuropsychological Society: JINS,
23(9–10), 778–790. https://doi.org/10.1017/S1355617717001060
Cole, W. R., Arrieux, J. P., Ivins, B. J., Schwab, K. A., & Qashu, F. M. (2018). A Comparison of four
computerized neurocognitive assessment tools to a traditional neuropsychological test bat-
tery in service members with and without mild traumatic brain injury. Archives of Clinical
Neuropsychology : The Official Journal of the National Academy of Neuropsychologists, 33(1),
102–119. https://doi.org/10.1093/arclin/acx036
Cullum, C. M., Weiner, M. F., Gehrmann, H. R., & Hynan, L. S. (2006). Feasibility of telecognitive
assessment in dementia. Assessment, 13(4), 385–390. https://doi.org/10.1177/1073191106289065
Cullum, C. M., Hynan, L. S., Grosch, M., Parikh, M., & Weiner, M. F. (2014). Teleneuropsychology:
Evidence for video teleconference-based neuropsychological assessment. Journal of the
International Neuropsychological Society: JINS, 20(10), 1028–1033. https://doi.org/10.1017/
S1355617714000873
Davis, L. E., Coleman, J., Harnar, J., & King, M. K. (2014). Teleneurology: Successful delivery of
chronic neurologic care to 354 patients living remotely in a rural state. Telemedicine and e-
Health, 20(5), 473–477. https://doi.org/10.1089/tmj.2013.0217
Fastenau, P. S. (1996). Development and preliminary standardization of the "extended complex
figure test" (ECFT). Journal of Clinical and Experimental Neuropsychology, 18(1), 63–76. https://
doi.org/10.1080/01688639608408263
Fortney, J. C., Pyne, J. M., Kimbrell, T. A., Hudson, T. J., Robinson, D. E., Schneider, R., Moore,
W. M., Custer, P. J., Grubbs, K. M., & Schnurr, P. P. (2015). Telemedicine-based collaborative
care for posttraumatic stress disorder: A randomized clinical trial. JAMA Psychiatry, 72(1),
58–67. https://doi.org/10.1001/jamapsychiatry.2014.1575
Galusha-Glasscock, J. M., Horton, D. K., Weiner, M. F., & Cullum, C. M. (2016). Video teleconfer-
ence administration of the Repeatable Battery for the Assessment of Neuropsychological
Status. Archives of Clinical Neuropsychology: The Official Journal of the National Academy of
Neuropsychologists, 31(1), 8–11. https://doi.org/10.1093/arclin/acv058
Grosch, M. C., Gottlieb, M. C., & Cullum, C. M. (2011). Initial practice recommendations for tele-
neuropsychology. The Clinical Neuropsychologist, 25(7), 1119–1133. https://doi.org/10.1080/
13854046.2011.609840
Harder, L., Stolwyk, R., Hammer, D. B., & Cullum, C. M. (2020). Teleneuropsychology (TeleNP) in
response toCOVID-19: Practical guidelines to balancing validity concerns with clinical need
[Video webinar]. The International Neuropsychological Society. Retrieved from https://www.
the-ins.org/webinars/.
Harrel, K. M., Wilkins, S. S., Connor, M. K., & Chodosh, J. (2014). Telemedicine and the evaluation
of cognitive impairment: The additive value of neuropsychological assessment. Journal of the
American Medical Directors Association, 15(8), 600–606.
Hewitt, K. C., & Loring, D. W. (2020). Emory university telehealth development and implementa-
tion in response to the COVID-19 pandemic. The Clinical Neuropsychologist, 34(7).
Hildebrand, R., Chow, H., Williams, C., Nelson, M., & Wass, P. (2004). Feasibility of neuropsycho-
logical testing of older adults via videoconference: Implications for assessing the capacity for
independent living. Journal of Telemedicine and Telecare, 10(3), 130–134. https://doi.org/10.
1258/135763304323070751
 THE CLINICAL NEUROPSYCHOLOGIST 15

Holshue, M. L., DeBolt, C., Lindquist, S., Lofy, K. H., Wiesman, J., Bruce, H., Spitters, C., Ericson, K.,
Wilkerson, S., Tural, A., Diaz, G., Cohn, A., Fox, L., Patel, A., Gerber, S. I., Kim, L., Tong, S., Lu, X.,
Lindstrom, S., … Pillai, S. K. (2020). First case of 2019 novel coronavirus in the United States.
The New England Journal of Medicine, 382(10), 929–936. https://doi.org/10.1056/
NEJMoa2001191
Inter Organizational Practice Committee. (2020). Recommendations/guidance for teleneuropsychol-
ogy (TeleNP) in response to the COVID-19 pandemic. https://iopc.online/teleneuropsychology
International League against Epilepsy. (2020). Neuropsycholoigcal assessments for epilepsy surgery
during COVID-19 restrictions. https://www.ilae.org/files/dmfile/Neuropsychological-Assessments-
for-Epilepsy-Surgery-.pdf
Iverson, G. L., & Schatz, P. (2015). Advanced topics in neuropsychological assessment following
sport-related concussion. Brain Injury, 29(2), 263–275. https://doi.org/10.3109/02699052.2014.
965214
Jacobsen, S. E., Sprenger, T., Andersson, S., & Krogstad, J.-M. (2003). Neuropsychological assess-
ment and telemedicine: A preliminary study examining the reliability of neuropsychology
services performed via telecommunication. Journal of the International Neuropsychological
Society : JINS, 9(3), 472–478. https://doi.org/10.1017/S1355617703930128
Johnson, K. A., Meyer, J., Yazar, S., & Turner, A. W. (2015). Real-time teleophthalmology in rural
Western Australia. The Australian Journal of Rural Health, 23(3), 142–149. https://doi.org/10.
1111/ajr.12150
Kesler, S. R., Lacayo, N. J., & Jo, B. (2011). A pilot study of an online cognitive rehabilitation pro-
gram for executive function skills in children with cancer-related brain injury. Brain Injury,
25(1), 101–112. https://doi.org/10.3109/02699052.2010.536194
Kessels, R. P. C. (2019). Improving precision in neuropsychological assessment: Bridging the gap
between classic paper-and-pencil tests and paradigms from cognitive neuroscience. The
Clinical Neuropsychologist, 33(2), 357–368. https://doi.org/10.1080/13854046.2018.1518489
Kruse, C., Karem, P., Shifflett, K., Vegi, L., Ravi, K., & Brooks, M. (2018). Evaluating barriers to
adopting telemedicine worldwide: A systematic review. Journal of Telemedicine and Telecare,
24(1), 4–12. https://doi.org/10.1177/1357633X16674087.
Lawson, D., Stolwyk, R., Ponsford, J., McKenzie, D., Downing, M., & Wong, D. (2020). Telehealth
delivery of memory rehabilitation following stroke. Journal of the International
Neuropsychological Society: JINS, 26(1), 58–71. https://doi.org/10.1017/S1355617719000651
Loh, P., Ramesh, P., Maher, S., Saligari, J., Flicker, L., & Goldswain, P. (2004). Can patients with
dementia be assessed at a distance? The use of telehealth and standardised assessments.
Internal Medicine Journal, 34(5), 239–242. https://doi.org/10.1111/j.1444-0903.2004.00531.x
Loring, D. W., Martin, R. C., Meador, K. J., & Lee, G. P. (1990). Psychometric construction of the
Rey-Osterrieth complex figure: Methodological considerations and interrater reliability.
Archives of Clinical Neuropsychology: The Official Journal of the National Academy of
Neuropsychologists, 5(1), 1–14.
Marra, D. E., Hamlet, K., Bauer, R., & Bowers, D. (2020). Validity of teleneuropsychology for older
adults in response to COVID-19: A systematic and critical review. The Clinical Neuropsychologist,
34(7).
Maryland State Department of Education. (2020). Serving children with disabilities under idea dur-
ing school closures due to the covid-19 pandemic. http://marylandpublicschools.org/programs/
Documents/Special-Ed/TAB/20-01ServingchildrenunderCOVID-19Pandemic.pdf
Osterrieth, P. A. (1944). Le test de copied’une figure complexe. Archives de Psychologie, 30,
206–356.
Patrick, K. E., McCurdy, M. D., Chute, D. L., Mahone, E. M., Zabel, T. A., & Jacobson, L. A. (2013).
Clinical utility of the Colorado learning difficultiesquestionnaire. Pediatrics, 132(5), e1257.
https://doi.org/10.1542/peds.2013-1530
Pearson. (2020). Telepractice and the WISC-V. https://www.pearsonassessments.com/professional-
assessments/digitalsolutions/telepractice/telepractice-and-the-wiscv.html?gclid=EAIaIQobChMI
qNPp3qOR6QIVRpyzCh3frAnrEAAYASAAEgLi4PD_wE
16 K. C. HEWITT ET AL.

Peterson, R. K., Ludwig, N. N., & Jashar, D. T. (2020). A case series illustrating the implementation
of a novel tele-neuropsychology service model during COVID-19 for children with complex
medical and neurodevelopmental conditions: A companion to Pritchard et al., 2020. The
Clinical Neuropsychologist, 34(7).
Poon, P., Hui, E., Dai, D., Kwok, T., & Woo, J. (2005). Cognitive intervention for community-dwell-
ing older persons with memory problems: Telemedicine versus face-to-face treatment .
International Journal of Geriatric Psychiatry, 20(3), 285–286. https://doi.org/10.1002/gps.1282
Pritchard, A. E., Stephan, C. M., Zabel, T. A., & Jacobson, L. A. (2017). Is this the wave of the
future? Examining the psychometric properties of child behavior ratings administered online.
Computers in Human Behavior, 70, 518–522. https://doi.org/10.1016/j.chb.2017.01.030
Pritchard, A. E., Sweeney, K., Salorio, C. F., & Jacobson, L. A. (2020). Pediatric neuropsychological
evaluation via telehealth: Novel models of care. The Clinical Neuropsychologist, 34(7).
Rabin, L. A., Barr, W. B., & Burton, L. A. (2005). Assessment practices of clinical neuropsycholo-
gists in the United States and Canada: A survey of INS, NAN, and APA Division 40 members.
Archives of Clinical Neuropsychology: The Official Journal of the National Academy of
Neuropsychologists, 20(1), 33–65. https://doi.org/10.1016/j.acn.2004.02.005
Resch, J. E., McCrea, M. A., & Cullum, C. M. (2013). Computerized neurocognitive testing in the
management of sport-related concussion: An update. Neuropsychology Review, 23(4), 335–349.
https://doi.org/10.1007/s11065-013-9242-5
Rey, A. (1941). L’examenpsychologiquedans les casd’encephalopathietraumatique. Archives de
Psychologie, 28, 286–340.
Rosen, W. G. (1980). Verbal fluency in aging and dementia. Journal of Clinical Neuropsychology,
2(2), 135–146. https://doi.org/10.1080/01688638008403788
Ryan, C. L. (2018). Computer and internet use in the United States. U.S. Department of Commerce,
Economics and Statistics Administration, U.S. Census Bureau. https://purl.fdlp.gov/GPO/
gpo108054
Schmidt, M. (1996). Rey auditory and verbal learning test: A handbook. Western Psychological
Services.
Spreen, O., & Benton, A. L. (1977). Neurosensory Center Comprehensive Examination for Aphasia.
University of Victoria, Psychology Laboratory.
Sutherland, R., Trembath, D., Hodge, M. A., Rose, V., & Roberts, J. (2019). Telehealth and autism:
Are telehealth language assessments reliable and feasible for children with autism?
International Journal of Language & Communication Disorders, 54(2), 281–291. https://doi.org/
10.1111/1460-6984.12440
Tenforde, A. S., Hefner, J. E., Kodish-Wachs, J. E., Iaccarino, M. A., & Paganoni, S. (2017).
Telehealth in physical medicine and rehabilitation: A narrative review. Pm&R, 9(5), 51–58.
Tensen, E., van der Heijden, J. P., Jaspers, M. W. M., & Witkamp, L. (2016). Two decades of tele-
dermatology: Current status and integration in national healthcare systems. Current
Dermatology Reports, 5(2), 96–104. https://doi.org/10.1007/s13671-016-0136-7
Tsaousides, T., D’Antonio, E., Varbanova, V., & Spielman, L. (2014). Delivering group treatment via
videoconference to individuals with traumatic brain injury: A feasibility study.
Neuropsychological Rehabilitation, 24(5), 784–803. https://doi.org/10.1080/09602011.2014.
907186
van der Linden, S. D., Sitskoorn, M. M., Rutten, G. M., & Gehring, K. (2018). Feasibility of the evi-
dence-based cognitive telerehabilitation program Remind for patients with primary brain
tumors. Journal of Neuro-Oncology, 137(3), 523–532. https://doi.org/10.1007/s11060-017-2738-
8
Vestal, L., Smith-Olinde, L., Hicks, G., Hutton, T., & Hart, J. (2006). Efficacy of language assessment
in Alzheimer’s disease: Comparing in-person examination and telemedicine. Clinical
Interventions in Aging, 1(4), 467–471. https://doi.org/10.2147/ciia.2006.1.4.467
Wadsworth, H. E., Dhima, K., Womack, K. B., Hart, J., Weiner, M. F., Hynan, L. S., & Cullum, C. M.
(2018). Validity of Teleneuropsychological Assessment in older patients with cognitive disor-
ders. Archives of Clinical Neuropsychology: The Official Journal of the National Academy of
Neuropsychologists, 33(8), 1040–1045. https://doi.org/10.1093/arclin/acx140
 THE CLINICAL NEUROPSYCHOLOGIST 17

Wennergren, J., Munshi, I., Fajardo, A. D., & George, V. V. (2014). Implementation of clinical video
telemedicine (CVT) within a VA medical center is cost effective and well received by veterans.
International Journal of Clinical Medicine, 5(12), 711–716. https://doi.org/10.4236/ijcm.2014.
512097
Zulman, D. M., Wong, E. P., Slightam, C., Gregory, A., Jacobs, J. C., Kimerling, R., Blonigen, D. M.,
Peters, J., & Heyworth, L. (2019). Making connections: Nationwide implementation of video
telehealth tablets to address access barriers in veterans. JAMIA Open, 2(3), 323–329. https://
doi.org/10.1093/jamiaopen/ooz024]