The COVID-19 crisis has produced seismic changes in the practice of neurosurgery. For weeks elective surgeries have been eliminated and shelter in place orders implemented. Patients still develop herniated discs with neurologic deficits, present with brain tumors and need neurosurgical treatment. Telemedicine has provided one option for remaining connected to our established patients and caring for new patients during the pandemic.
The Centers for Medicare & Medicaid Services (CMS) has been nimble in issuing rules and guidance around the use of telemedicine. CMS is now paying for telehealth visits at the same rate that they pay for an in-person visit. Documentation requirements have been modified and now focus on medical decision-making. Now you can bill based on time spent during the visit or on the complexity of medical decision making required in your assessment. CMS will pay for telemedicine if the physician is licensed in the state where the services are provided — regardless of where the patient is located.
There are several video conferencing and chat platforms that physicians may use. Setting up Health Insurance Portability and Accountability Act (HIPAA) compliant solutions may be beyond the capabilities of small practices, especially when they are trying to see patients now. If physicians act in good faith, CMS is currently allowing physicians to use other platforms without worrying about triggering an Office of Civil Rights audit for the failure to comply with HIPAA during this national public health emergency.
CMS has also issued specific guidance for teaching hospitals and addressed numerous questions about how learners may fit into the broader utilization of telemedicine. The agency has stated that teaching physicians can provide services with medical residents virtually through audio/video real-time communications technology, with the caveat that this does not apply in the case of surgical, high-risk, interventional, or other complex procedures, services performed through an endoscope, or anesthesia services.
Outpatient and Inpatient Visits
These new rules are not just for outpatient clinic visits. Inpatient consultations and emergency room care are also included in the list of services where telehealth is an option.
The use of telemedicine carts has been widespread in the evaluation and management of stroke patients. This same platform could be used to conduct consultations and rounds, supported by colleagues at the bedside. Some of the challenges around this concept require novel solutions, such as the creation of a tele-presenter role to:
- Be onsite and available through the paging system;
- Deploy the telemedicine equipment as directed by the physician;
- Introduce and explain the telemedicine process to the patient;
- Stay in the patient’s room while the consult is performed to assist with the exam;
- Interact and coordinate telemedicine deployment across multiple specialty teams; and
- Basic troubleshooting of any equipment malfunctions.
Technological innovations have enabled practices to continue to see patients while maintaining social distancing. While telemedicine may have a long-lasting and impactful future, and the health care system may not have explored all potential avenues of virtual health care delivery, there are some potential issues. For example, how are physicians who are currently working from home enabled to respond to the occasional inpatient consult that may arise during the day? Physicians working remotely may produce unique challenges.
Additionally, patient consent specific to telehealth is required for all visits. The consent needs to specify the unique risks of providing care virtually with a patient. Unauthorized access, breach of patient privacy and the inability to provide a thorough physical exam are limitations of telehealth.
Finally, the lack of a physical exam cannot be understated. Some aspects of the physical exam can be assessed, including height and weight, pulse, respiratory rate, observation of motor status and gait/balance, extraocular muscles, and facial symmetry. Many aspects of our examination simply do not translate to a virtual platform such as deep tendon reflexes, pathologic reflexes and a thorough sensory exam. Furthermore, direct patient contact is essential for fostering trust and in developing the doctor-patient relationship. The feeling of partnership with your patient when facing a difficult diagnosis may be challenging with a visit conducted through a smartphone screen.
Looking into the Crystal Ball
During the COVID-19 public health emergency, we have incorporated telehealth visits into our practices. In our experience, the move to telehealth has improved clinic efficiency and increased clinic throughput. Telehealth visits are an effective way to screen patients and provide an easy way to quickly assess whether a patient needs to be seen in person to determine the need for surgery.
While Medicare (and other third-party payors) has adopted these changes for the duration of the COVID-19 public health emergency, it is safe to say that telemedicine in neurosurgery is here to stay — and will have even further impact on our practices in the future.
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John Ratliff, MD, FAANS, FACS
Chair-elect, AANS/CNS Washington Committee
Stanford University Medical Center
Palo Alto, CA
Clemens M. Schirmer, MD, PhD, FAANS, FAHA
Chair, AANS/CNS Communications and Public Relations Committee
Wilkes Barre, PA