EDITORIAL
Hold the Smartphone! Tele-epilepsy in a
PosteCOVID-19 World
See also page 29
E
pilepsy is the third leading contributor
to the global burden of disease for
neurologic disorders, affecting 65
million people worldwide.1 Besides the
direct impact of seizures, people with epi-
lepsy (PWE) face problems including
disruption to work and education, psycho-
logical stress, and social stigma. PWE also
require regular outpatient visits for optimi-
zation of antiseizure medication (ASM)
therapy, management of epilepsy-related
psychological problems, and counseling on
family planning. Unfortunately, PWE often
have restricted driving privileges that can
hinder traveling for these visits. The
containment measures established to face
the coronavirus disease 2019 (COVID-19)
pandemic have further compounded this
problem.2 Luckily, the rapid emergence of
telemedicine, catalyzed by the COVID-19
pandemic, using smartphone applications
(apps) offers unique opportunities to address
these.3 The integration of telemedicine in the
health care systems has been accelerated by
the increase in smartphone users, with the
latest figures estimating more than 3.5
billion users worldwide.4
In this issue of Mayo Clinic Proceedings,
Tatum and Acton5 discuss the clinical utility
of smartphones for PWE in the poste
COVID-19 world. The authors highlighted
the massive potential of smartphone-based
telehealth in epilepsy care, including the
diagnostic value of smartphone videos
(Figure). The technology can also facilitate
remote management of the adverse conse-
quences of recurrent seizures in PWE. Be-
sides, smartphone-based seizure diaries and
other apps can help track and document
seizure frequency, ASM use, and nondrug
therapy administration. Furthermore,
smartphone-accessible online communities
can be used to improve patient education, to
4 Mayo Clin Proc. n January 2021;96(1):4-6 n https://doi.org/10.1016/j.mayocp.2020.11.010
www.mayoclinicproceedings.org n ª 2020 Mayo Foundation for Medical Education and Research
increase health literacy, and to widen sup-
port networks for PWE.
An increasing number of patients seeking
care and a shortage of neurologists have
limited access to neurologic care. This is
especially true in epilepsy care, for which a
significant shortage of specialists exists. This
burden has become even larger with the
COVID-19 pandemic because of the self-
isolation and strict lockdowns.2 Fortu-
nately, access to smartphones and high-
speed Internet has now become ubiquitous
in both developed and many developing
countries.3 These advances have made tele-
epilepsy a “new normal.” Ample evidence
supports the successful use of tele-epilepsy
for the diagnosis and follow-up of PWE.6 A
tele-epilepsy initial visit can help diagnose
patients living in areas remote from centers
with epilepsy expertise. It can also facilitate
early identification and referral for an epi-
lepsy surgery evaluation. Follow-up outpa-
tient visits for PWE that focus on seizure
control, ASM adherence, ASM adverse
effects, and counseling can also be easily
performed using this platform. Besides, tele-
epilepsy enables direct communication with
community providers and allows patients to
stay with their local providers while
improving consultation and access to higher
level epilepsy care when it is needed.6
Differentiating an epileptic seizure from
a psychogenic nonepileptic seizure (PNES)
remains a clinical art, one that is supported
by video encephalography (EEG). The wide
availability of smartphones incorporating a
camera makes it possible to obtain a video
recording of the ictal event. Examining these
videos can help improve the diagnostic ac-
curacy of PNES, especially when motor signs
are present. A recent multicenter trial found
that a physician review of a high-quality
smartphone seizure video resulted in the
EDITORIAL

diagnostic accuracy of epilepsy and PNES

>95% of the time.7 Clinicians also had more
confidence in a diagnosis when it included a
smartphone video. The ability to identify
patients without epilepsy just by reviewing a
smartphone video could help realign health
care resources to patients for whom the need
is highest.7 During the peak of COVID-19,
most medical centers had closed their epi-
lepsy monitoring units either to free beds for
patients with COVID-19 or as part of
temporarily stopping elective procedures.
The diagnosis of PNES by review of smart-
phone videos certainly can eliminate un-
necessary epilepsy monitoring unit
admissions in the posteCOVID-19 world.
Current methods for assessing treatment
outcomes in epilepsy focus on reducing
seizure activity; however, self-reported seizure
occurrence can be unreliable. This along with
the need to prevent seizure-related injuries
has fostered the development of wearable de-
vices, paired with smartphones, to detect sei-
zures in real-time continuously.8 Seizure
detection devices use single modalities or
combinations of EEG, video, accelerometry, FIGURE. Smartphone-assisted tele-epilepsy in a posteCOVID-19 world.
electromyography, electrocardiography, pho-
toplethysmography, and electrodermal activ-
ity.8 Almost all smartphones have built-in Smartphones also have the potential to
global positioning system receivers, sensing change the dynamics of epilepsy self-
capabilities, and motion detectors or acceler- management. For example, smartphone
ometers, enabling clinicians to “close the medication apps can help detect potential
loop” by timely detecting seizures. Seizure medication interactions and remind patients
alarms and safety devices are particularly to take their medication on time.10 The latter
crucial for those with ASM-resistant epilepsy increases medication compliance, one of the
who are at risk of prolonged convulsive sei- most significant issues in PWE. On the other
zures; left unattended, this could lead to hand, seizure diary apps allow patients to re-
sudden unexpected death in epilepsy. Along cord information that may give insight into a
the same lines, the development of patient’s seizure triggers.10 Information in the
smartphone-compatible electrode caps offers form of a medication and seizure diary also
an opportunity for complete EEG systems makes it possible for neurologists to tailor the
(“tele-EEG”) that are portable and user- treatment plan. Besides, online epilepsy self-
friendly.9 Continuous tele-EEG monitoring management programs such as Internet-
could detect spikes that typically precede sei- based psychosocial interventions can be easily
zures and alert patients in advance (ie, seizure integrated using smartphone apps. Further-
forecasting). Tele-EEG also has the potential more, smartphone apps, including music and
to increase access to EEG services in remote therapeutic video games, present new op-
and resource-limited settings.9 Certainly, portunities to incorporate nonpharmacologic
there is a need for remote monitoring capa- interventions.10 In addition, smartphone-
bilities to manage PWE in the posteCOVID- accessible online communities provide self-
19 world. learning by providing relevant educational
Mayo Clin Proc. n January 2021;96(1):4-6 n https://doi.org/10.1016/j.mayocp.2020.11.010 5
www.mayoclinicproceedings.org

content and expand support networks in the
posteCOVID-19 world.
The authors acknowledged that although
the possibilities of smartphone-assisted tele-
epilepsy care are endless, ethical and legal is-
sues remain a concern. When the pandemic
begins to resolve, due diligence is required to
ensure that privacy is addressed appropri-
ately. Gaps in Internet and smartphone ac-
cess, confidentiality, medical errors, and
malpractice potential also require attention.
Smartphone apps may share sensitive data
with advertisers and other third parties in
ways not anticipated by users. Besides, devices
and sensors designed to detect seizures may
collect information on the household’s activ-
ities that a patient wishes to keep private.
From a diagnostic standpoint, smartphone
videos may not capture the entire ictal period
or may capture only the postictal period,
potentially misguiding the correct diagnosis.7
Importantly, although the technology is wide-
reaching, it cannot replace face-to-face visits
(“doctor’s touch”) in some circumstances.
Smartphone technology, combined with
artificial intelligence, is advancing rapidly.3
Integrating this technology with tele-
epilepsy care will increase health care ac-
cess for the underserved and rural patients
and improves comanagement between local
neurologists and epilepsy providers. In the
era of increasing medical costs, tele-epilepsy
has the potential to reduce health care sys-
tem costs. Besides, smartphone apps allow
continuous monitoring of PWE and use of
this information to inform management de-
cisions. Smartphone-assisted seizure detec-
tion devices have also opened new avenues
to improve both the safety and treatment of
PWE. Furthermore, smartphone-assisted
tele-EEG will undoubtedly increase access
to EEG services to remote and resource-
limited populations. Practical tele-epilepsy
tools, supported by smartphones, will
n n
6 Mayo Clin Proc.
MAYO CLINIC PROCEEDINGS
indeed become the “new normal” for PWE’s
long-term management in the posteCOVID-
19 world. However, the platform requires
regulation and standardization to ensure
consistency and quality in its application to
the care of PWE and to safeguard issues
pertaining to privacy and security.
Anteneh M. Feyissa, MD, MSc
Department of Neurology
Mayo Clinic
Jacksonville, FL
Potential Competing Interests: The author reports no
competing interests.
Correspondence: Address to Anteneh M. Feyissa, MD, MSc,
Department of Neurology, Mayo Clinic, 4500 San Pablo Rd,
Jacksonville, FL 32224 (Feyissa.Anteneh@mayo.edu).
REFERENCES
1. Ngugi AK, Bottomley C, Kleinschmidt I, Sander JW,
Newton CR. Estimation of the burden of active and life-time
epilepsy: a meta-analytic approach. Epilepsia. 2010;51(5):883-
890.
2. Fesler JR, Stanton S, Merner K, et al. Bridging the gap in epilepsy
care: a single-center experience of 3700 outpatient tele-
epilepsy visits. Epilepsia. 2020 [Online ahead of print].
3. Lopez-Jimenez F, Attia Z, Arruda-Olson AM, et al. Artificial in-
telligence in cardiology: present and future. Mayo Clin Proc.
2020;95(5):1015-1039.
4. Statista. Number of smartphone users worldwide from 2016 to
2021. https://www.statista.com/statistics/330695/number-of-
smartphone-users-worldwide/. Accessed October 21, 2020.
5. Tatum WO, Acton EK. Smartphones in epilepsy: the new age
of Aquarius. Mayo Clin Proc. 2021;96(1):29-31.
6. Hatcher-Martin JM, Adams JL, Anderson ER, et al. Telemed-
icine in neurology: Telemedicine Work Group of the Amer-
ican Academy of Neurology update. Neurology. 2020;94(1):
30-38.
7. Tatum WO, Hirsch LJ, Gelfand MA, et al. Assessment of
the predictive value of outpatient smartphone videos for
diagnosis of epileptic seizures. JAMA Neurol. 2020;77(5):
593-600.
8. Bruno E, Viana PF, Sperling MR, Richardson MP. Seizure detec-
tion at home: do devices on the market match the needs of
people living with epilepsy and their caregivers? Epilepsia.
2020 [Online ahead of print].
9. McKenzie ED, Lim AS, Leung EC, et al. Validation of a
smartphone-based EEG among people with epilepsy: a pro-
spective study. Sci Rep. 2017;7:45567.
10. Afra P, Bruggers CS, Sweney M, et al. Mobile Software as a
medical device (SaMD) for the treatment of epilepsy: develop-
ment of digital therapeutics comprising behavioral and music-
based interventions for neurological disorders. Front Hum Neu-
rosci. 2018;12:171.
January 2021;96(1):4-6 https://doi.org/10.1016/j.mayocp.2020.11.010
www.mayoclinicproceedings.org