Proper scope of Tele neurology

[Neurologo]

What do you think is currently acceptable scope of tele neurology service?
I think it is ok to manage ED stroke codes and perhaps status epilepticus and requests for transfers via tele medicine. But the hospital I work with is now asking me to function as a virtual inpatient neurologist to cover neurological patients in her satellite facilities. This means I will be covering inpatient strokes work-ups, Dx and Rx and even other neurological issues. The idea of making assessments and treatments without actually seeing and touching patients seems unlawful and unethical. The hospital will save money for doing this since they are not paying me any extra for this but patient care will suffer and my license will be in danger. What is your view or experience? Greatly appreciate your input.

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[typhoonegator]

We do outpatient follow-up visits, inpatient consults (new and follow-up), and are starting neuroICU consults via telemedicine. In addition to telestroke/emergency neurology. In 4 states.

The greatest benefit is to the patients, who can remain closer to home and family while still receiving specialty care. If you don't feel that you can reach a diagnosis or properly recommend management via telemedicine for a particular patient, you should be requesting transfer for those patients. Frankly, there should be a script and an SOP for that in your telemedicine manual of procedures (MOP). It's a great service, but there are definitely limits.

Why wouldn't you get paid for this? Your hospital almost certainly has them under contract, or at the very least your department is directly benefiting from the service. Our telestroke and teleneurology providers are reimbursed for their services.

For outpatient visits, you can bill for telemedicine visits as you would an in-person visit (different code and requirements, but same idea). It's not unlawful, but you do need to be licensed in the state you are providing teleneurology, as well as credentialed at the hospital, and you should clarify with your malpractice insurer that telemedicine counts in your policy as would local care.

 

[Neurologo]

It's not unlawful, but you do need to be licensed in the state you are providing teleneurology, as well as credentialed at the hospital, and you should clarify with your malpractice insurer that telemedicine counts in your policy as would local care.

It is interesting to hear that so much is done via telemedicine. But in case of a malpractice lawsuit, how would you respond to the prosecutor who asks, "So how confident were you with your assessments and treatment decisions without even examining the patient in person?"

As you said, obviously if a case is unclear, a transfer should be requested so as to avoid such lawsuit. But we can still be named in a lawsuit where someone else in the treatment team made a mistake simply because we were listed as a consultant.

Also how is this usually compensated? A base pay and wRUV per each facility covered?

Greatly appreciate your sharing.

 

[typhoonegator]

There is a growing precedent for the utility and benefit of telemedicine. A plaintiff's attorney could bring it up, but it's not a trap or anything. It will be clear that your hospital set up this service and that you're a provider for it -- it's not like you're pulling a fast one and getting rich off it. You can certainly get named in a suit if you were the telemedicine consultant. We keep logs of all the calls and document our observations and recs for that reason. I have a pretty low threshold for saying that I'm not comfortable managing something from a distance, but everyone has their preferences. Honestly, most of it is TIA/small stroke workups where you can review the studies and make recommendations for the hospitalist to follow. Or incidental findings on MRIs obtained for migraine, stuff like that. It works best for things where the imaging and labs carry a lot of weight and the exam is more confirmatory. I don't think anyone is working up rapidly progressive dementias or encephalitides.

Compensation can follow many models. Typically these are agreements between departments or hospitals within a certain framework based on number of expected consults, video vs. telephone consultation split, etc. Some are set up like a subscription where their hospital gives yours a big pile of money each year and expect full service whenever they call, and others are set up with a flat retainer rate and then a fixed number of dollars for each telephone or video consultation (utilization-based). But that is hospital to hospital. Your facility then decides how to pay you separately. I've seen models where providers get a fixed payment for each shift (with nights worth more than days), and models where you get a small "inconvenience fee" for holding the pager, and a set amount of money for each call you get. I personally prefer the former, as it's annoying to hold the pager regardless of whether it goes off, and it's not my fault if it is a quiet shift. Obviously, the more facilities covered, the more work you'll have to do but also the more money your hospital will be bringing in for the service you are providing.

 

[Neurologo]

Greatly appreciate your detailed input.
I feel better positioned to engage in a dialogue with the hospital in taking on this new mode of working.