TECHNOLOGY IN NEUROLOGY
Telemedicine offers a lot of flexibility. “You can practice it from anywhere—in the office, at home, and even at the beach,” says Jaime Hatcher-Martin, MD, PhD, Assistant Professor of Neurology at Emory University School of Medicine in Atlanta, who uses telemedicine. “It also allows you to see patients for quick issues that don’t warrant a visit to the office.
This also allows you to bill for a visit that might not have occurred otherwise or that you would have only discussed over the phone. It can expand your catchment area for patients who would not have otherwise traveled to see you.” Telemedicine also eliminates some of the time constraints that traditional in-person visits require (Table).
While telemedicine can be helpful in certain situations, it's important to understand what aspects of an exam can or cannot be adequately assessed via telemedicine. Dr. Martin often uses video to look at patients’ movements to determine if she needs to increase or decrease medications.
However, there’s no way to test reflexes without a telepresence (ie, a provider who is with the patient). In addition, you can only evaluate strength in limited ways and sensation is not possible without a telepresenter, so you can’t perform a detailed neuromuscular exam.
Another potential downside is that some providers feel that they will lose a personal connection if they don’t see patients face-to-face. “This was a concern for me in the beginning, as I’m very touchy-feely and affectionate with my patients,” she says. “I was pleasantly surprised that the connection was still there.
Within seconds of starting a visit, I forget that I’m even on camera. I still ask about families, recent vacations, work, and so forth. Patients still ask about my children and about other personal matters we discussed. If you are personable in person, that will still shine through in telemedicine.”
Billing issues can also be a potential problem. Currently, most insurance companies will only reimburse for visits if patients are in a subset of rural locations. Also, for insurance reimbursement, patients may need to be in an approved medical facility during a visit. “This can be circumvented in some instances when patients either pay out-of-pocket for direct-to-consumer telemedicine and forego insurance involvement or for patients whose insurance companies offer their own or contracted telemedicine service directly,” Dr. Martin says.
Some states do not reimburse for tele-visits at the same rate they do for in-person visits. Other states have parity laws that require equivalent reimbursement for in-person versus telemedicine visits as long as an equivalent level of care is provided.
Many states require you to examine the patient for the first time in-person; you have to see the patient in-person at least once a year; or you cannot prescribe controlled substances if you only see a patient via telemedicine. “This can make things complicated if you’re seeing patients who live a distance away,” she says.
-Jaime Hatcher-Martin, MD, PhD.
Also, just like in-person, you have to be credentialed in each state in which you are seeing patients and you must be knowledgeable about the laws and regulations for practice in that state.
“The best thing neurologists can do right now is to advocate for increased coverage of various types of telemedicine services, dissolution of rural requirements, and the need for the patient to be in a medical facility for insurance coverage,” Dr. Martin says.
Healthcare providers, caregivers, and patients alike can advocate at the local, state, and federal levels for expanded coverage of telemedicine. “Many professional societies and patient advocacy groups make it easy to write a letter to your representatives,” she says. The American Academy of Neurology offers fellowships that provide training on various aspects of the legislative process and how to effectively advocate.
“Many physicians want it, many patients are asking for it—we just need to ease the burden of regulations on where telemedicine can be practiced and how it is reimbursed,” she concludes.
Editor's note: Part 1 of this article discusses things to consider before adding telemedicine to your neurology practice.