Teleneurology— Welcome to the Newest Old Way of Practicing Medicine

Just in time for the safe distancing requirements of the COVID-19 response: Teleneurology is ready and able to deliver remote health care to some of medicine’s most fragile patients.

Do you remember the old punchline, “Take two aspirin and call me in the morning?” While that trope may have been over-used by 1960s-era comics in their standup routines, it was rooted in a real-life experience: Doctors who would consult with their patients on the phone, sometimes eliminating the need for an in-office visit.

So, what happened to the old-fashioned telephone consult? It took some turns on the way, but it’s definitely back, more robust than ever. Now the communication tool is video, and the virtual consults have evolved light years past the services offered by the general practitioner of yore.

Neurology is one medical specialty that is especially well-suited to remote delivery of services. Not only can some of medicine’s least mobile patients be treated without leaving their homes, but some of the most urgent cases—those in the so-called “golden hour” of stroke treatment—can be immediately evaluated in hospital settings with no stroke specialist on site.

Teleneurology has other, more routine benefits as well, ranging from a lower cost of service delivery (because less overhead or infrastructure is needed) to shorter wait times for patients seeking their first meeting with a neurologist.

And, just when virtual services are needed more than ever, remote delivery of neurology care is poised for exponential growth, thanks to the 2018 FAST Act (Furthering Access to Stroke Telemedicine), which opened the door to an equalized reimbursement process for telestroke care, regardless of where the patient is located. While the kinks are still being worked out, the bottom line from this development is that hospitals can better afford to enter a market that in the past had been sustainable only for private companies.

Two teleneurologists, on two different paths

Although telestroke and teleneurology are not new, the range of related career paths are more varied than ever before. Take the examples of Eric Anderson, MD, PhD, and Elaine C. Jones, MD, FAAN, both AAN members who have been active in furthering teleneurology, but with strikingly different career paths.

Eric Anderson, MD, PhD—teleneurology as the basis for a career

Anderson, who attended Emory University for his residency and epilepsy fellowship, has the distinction of pioneering the use of an iPhone 4 for in-hospital teleneurology trials when he was still an intern in 2010. As he tells it, “When I was a student, I was infatuated with the idea of telemedicine. If you believe that every minute counts with telestroke,

then the idea of bringing someone instantly to the bedside with tele-technology was fascinating. When I was interning at Emory, the iPhone 4 was just coming out. It had this feature called FaceTime, that had audio and video—but both people on the call had to have the same setup for it to work. My wife was kind enough to let me buy two iPhones, so I could experiment with other doctors using FaceTime to provide neurology services at the hospital. That got a lot of press at the time, and the attention of the Academy.”

Having seen the potential first-hand for teleneurology, Anderson started his own telemedicine service three years later, while completing his fellowship. Intensive Neuromonitoring, which he still operates, provides tele-EEG services to clinical practices in Georgia, and the surrounding area. From there, he added roles as a teleneurologist for CortiCare, Inc. in California—for which he is now the medical director—and as a teleneurologist for SOC Telemed—for which he is now the chair of neurology, in charge of 70 teleneurologists who handle up to 8,000 tele-visits each month. In other words, Anderson leads the teleneurology or telemedicine functions for three distinct companies simultaneously, while also providing direct teleneurology services himself.

When asked about his biggest challenge in this work, Anderson’s answer isn’t surprising: the schedule. “I balance three or four calendars,” he explains, “so I need to schedule several months in advance to minimize conflict and ensure a basic level of time off.” Even so, he admits that he is prone to adding more things to the calendar, such as his work on committees to improve telemedicine, and presenting or publishing on the topic. While the packed calendar challenges Anderson, it also demonstrates one of teleneurology’s benefits to medical professionals: The added availability of work time when you strip away non-medical processes, such as commuting to a clinic. As a bonus, working from home lets Anderson maximize downtime to interact with his family.

Perhaps the most surprising aspect of Anderson’s career path is this one fact: His entire medical practice since finishing his fellowship in 2014 has been conducted virtually. If there are other neurologists who can make the same claim, it would be a small cohort—but that situation could change with each new class of graduating residents and fellows.

Elaine Jones, MD, FAAN—teleneurology as the antidote to burnout

If Anderson is the model for using teleneurology to serve as many patients as possible, Jones might be the model for leveraging it to achieve an enviable work-life balance. Although she has been working in telemedicine almost as long as Anderson (she has been with SOC Telemed for six years now), she entered the field at an entirely different point in her career. For Jones, teleneurology is more of a capstone than a launch pad, coming as it does after decades of private practice. In her words, “I started working with SOC while I was still in solo practice in Rhode Island. When I decided to close my practice three years ago and move to South Carolina where my parents are, I decided to go with SOC exclusively. I take the night shift, which means that I can have my days free to help my parents or go to the beach. Even if I’m on shift and I hear a big crash downstairs, I can run down and check. Just being home is a huge advantage with telemedicine.”

Although Jones doesn’t count herself as a night person, she has found that the schedule suits her workstyle as well as it does her home life. “The work at night is a little less hectic, a little more focused,” she says. “It tends to be more emergencies, but everyone is a little calmer.” To start her 10:00 p.m. shift, Jones can be ready at her computer in as little as 15 minutes after her post-dinner nap. Eventually, the call center will send a message alerting her to a new consult, after they’ve confirmed which neurologist is both available and licensed for the state where the patient is located. By 6:00 a.m., once she has finished with the last notes, Jones is done with her shift and ready to sleep—with no concerns about being needed for call or other work duties.

The night schedule also provides a good backdrop for Jones’ professional service, including her second term on the Academy’s board, and the three committees

she serves on for SOC. In addition, Jones has done significant work for the Academy on such issues as physician burnout, which brings her to this observation: “I think telemedicine provides one of the best opportunities there is for work-life balance for doctors. When your shift ends, you’re completely free for the other things in your life.”

When asked about down sides or challenges of being a teleneurologist, Jones doesn’t cite a lack of collegial interaction. That’s because she can use the chat feature on Zoom to send an image to other doctors on shift if she wants another viewpoint. When she was a solo practitioner, she says, “It was just me and Google.” Indeed, Jones has found that impromptu conversations with colleagues have helped keep her on the cutting edge—such as the recent look at hemorrhagic encephalitis from a patient with COVID-19 that was shared by an SOC teleneurologist for others doctors to see.

On the other hand, Jones does miss the face-to-face interaction with patients and the opportunity to keep up her “live skills.” As a remedy, she takes on-site locums jobs in different locations, sometimes filling her teleneurology shifts in the hotel at the end of the day. Or, she may separate the two activities, giving her the chance to enjoy the locums location more fully. That’s the plan she’s making for two weeks in Alaska later this year, where she hopes to get in some fishing and hiking when she’s off shift. To complete her customary 100 hours for SOC that month, she’ll simply compress her workdays together in one chunk—an accommodation she says the company is able to make because of the flexibility afforded by telemedicine. This adaptability, along with the other advantages, has made Jones reconsider her earlier career vision. “When I started, I always said that this was a temporary gig for me and I would be going back to private practice. But now I’m not so sure about that,” she says.

Is teleneurology right for you?

Whether you’re just starting out in your medical career, or you’ve been practicing for decades, teleneurology could be a good fit. To find out, you’ll want to consider some of these aspects of the work.

Equipment and space

For the moment, teleneurology is primarily conducted from the practitioner’s home space, although that could change if organizations in the future opt to provide the services from bricks-and-mortar locations. To be ready for home-based consults, you’ll need enough privacy to ensure patient confidentiality and uninterrupted sessions, as well as adequate broadband and the corresponding computer equipment. Having tried a number of configurations—including an ill-fated treadmill desk—Anderson has found his best setup includes a large 42” video screen that gives better visual acuity when working with patients.

Solo or employed?

Are you hanging out a shingle, or sending out a resume? Both options are available to you, but the details will matter. As a solo practitioner, you’ll be responsible for the billing, for example, and for ensuring credentialing with client hospitals. But you’ll also have full authority over your schedule and work. On the other hand, as the employee of a telemedicine company, you’ll trade some of that autonomy, and possibly some of your income, for the benefit of having someone else mind the administrative details.

Subspecialty

According to Jones, some specialties, such as headache and stroke, might be especially adaptable to teleneurology processes, while others requiring in-person procedures or evaluations might be less amenable. Anderson notes that most of the aspects of in-person care valued by neurologists will still be possible online, regardless of the discipline. “When we think of neurologists, in our minds, there’s been kind of a schism between emergency neurology and outpatient neurology,” he says. “We didn’t used to have treatment for stroke but now, with all the emergency treatments we can provide, there’s this branch that’s all go-go-go instead of let’s cerebrate on this. I think that what’s satisfying for neurologists—being a bit of a detective and coming up with an answer for the patient—that’s not missing with teleneurology, as much as people think it will be.”

The business of teleneurology

Although the tele- aspect of this service delivery model gets most of the attention, virtual health care can’t happen if the administrative side isn’t managed. Chief among the issues are billing, licensing, and liability.

Billing

The conversation about billing can be complex in any aspect of medicine, and especially when you add an entirely new mode of service delivery. From their professional service committees, both Anderson and Jones have delved into the issue of billing as it relates to telemedicine. Their conclusion might be summed up with “Not quite there yet.” On the one hand, the 2018 FAST Act represented a tremendous leap forward by ensuring equity in reimbursement for telestroke, which removed the main barrier to hospitals providing the service. On the other hand, after more than a year, Jones notes that the unique aspects of telemedicine create equally unique problems—such as the confusion caused by some insurers billing from where the doctor is located while others bill from the patient’s location, while none of them seem to be using the same codes for the work.

Licensing

It’s possible that future physicians will see the licensure issue as one of the growing pains for telemedicine. How else would you describe the result of Elaine Jones’ work—licensure in an eyepopping 21 states, and counting? Since physicians in the United States must currently hold licensure for the state in which their patient is “seen,” telemedicine practitioners have little choice but to pile on the licensures—and the attendant fees and CME requirements. Hospital credentialing adds to the paperwork tangle, with most systems requiring annual renewals that the physician must either initiate or at least review and corroborate, depending on whether they work for an agency or for themselves. In Jones’ case, licensure in 21 states translates to 150 credentialing organizations, none of which is on the same annual schedule for processing renewals. Perhaps it’s no wonder that one of the groups she’s chosen to help with at SOC Telemed is the credentialing committee, which she chairs.

Malpractice

In some ways, this might be the easiest of the administrative balls to juggle since the physician’s carrier or broker usually takes the lead on the process. Even so, Anderson warns that the teleneurologist should still pay attention to the details. For example, he ended up altering his practice when his broker advised him that carrying malpractice in some states was significantly more expensive than in others. He also learned that not every carrier will cover every state, which may create another set of decisions for the practitioner.

What does the future hold for teleneurology?

After taking decades to reach its current level of acceptance, teleneurology finally seems poised for a major leap forward. The new burst is fueled by a perfect storm of circumstance: the near universal access to high-quality electronics for practitioners and at least a smartphone for patients; the breakthrough in billing opportunities represented by the FAST Act; and the unprecedented need for homebased services demanded by the COVID-19 crisis. It’s the moment that Anderson, Jones, and so many of their colleagues have been building towards as they perfect the process of delivering health care remotely.

“I keep thinking there might be a return to doctorcontrolled medicine and solo practices with the COVID-19 impact,” Anderson says. “The virtual doctor has a lot more in common with the country doctor than with the employed doctor.”

Even if this genie could be put back in the bottle, Jones, for one, doesn’t believe that would happen. “I don’t think it will ever go back to where it was,” she says. “I think doctors and patients have realized the convenience of it and won’t want to go back. But the problem will be, how will things shift when this (the pandemic) is over? What’s going to lag behind is the payment system and that’s going to impact everything else.”

Unless, that is, the payment system doesn’t matter anymore. With the current prevalence of highdeductible insurance plans, Anderson anticipates that some doctors might revert to direct-to-thepatient billing that benefits both parties by cutting out insurance altogether. “If you don’t have a brickand-mortar operation to finance, why wouldn’t you just charge the patient their co-pay amount, instead of going through the insurance? It’s the same cost for the patient and you can afford to charge less if you don’t have overhead.”

Billing issues aside, both Jones and Anderson are optimistic about the future of teleneurology. “It’s an exciting time to be a neurologist,” Jones says. “Neurology has really led the way with telemedicine anyway, even before this. I think if we continue to innovate, we will be a great boon to our patients, and to medicine. We’re going to be out there fighting hard for it to remain.” •