Neurologists in academic and private practice alike are scrambling to embrace telemedicine as one part of their response to the COVID-19 pandemic.
While heartened by the Trump administration's announcement on March 17 that it is lifting many telemedicine restrictions, both on reimbursement and HIPAA compliance, neurologists nevertheless expressed anxiety and some confusion over how to handle the new reality—and how long it will last.
"We're trying to figure out how to avoid the chaos, stay on solid ground, and feel comfortable knowing everything will be all right eventually," said Brad C. Klein, MD, FAAN, a headache specialist at Abington Neurological Associates in Pennsylvania.
In private practice with nine fellow neurologists and privileges at nearby Abington Hospital, Dr. Klein said his group held an urgent meeting on the evening of March 15 to develop a response to the fast-evolving situation.
Even at a major academic neurology center with an established telemedicine program, efforts to protect physicians, staff, and patients are daunting.
"We are feeling our way," said Neil A. Busis, MD, FAAN, who arrived on March 1 at New York University Langone Health to lead its telemedicine program for the department of neurology. "Things are moving rapidly. NYU already has had a very robust virtual health program. Neurology has some pilot programs; it's my charge to develop a broader range of options. As you can imagine, right now we're overwhelmed."
Even so, telemedicine evangelists who have been preaching the benefits of digital communication for years say that neurologists will like the new normal, once they get used to it.
"I see almost all my patients over the internet," said Ray Dorsey, MD, MBA, the David M. Levy professor of neurology and director of the Center for Health Technology at the University of Rochester Medical Center in Rochester, NY.
"I haven't set foot in the clinic in six years. In general we shouldn't make patients come to the clinicians; we should bring care to them. Why do we ask people with compromised driving ability and mobility to come to us? It's crazy. You will learn a whole lot more about your patients and form a deeper relationship with them."
State, Federal Rules Loosened
For those not already running a telemedicine program, however, the challenges of building a program on the fly, in the face of a pandemic, are not trivial. But experts hope that an announcement by the White House would ease some restrictions.
In a White House press briefing on March 17, President Donald J. Trump announced that "Medicare patients can now visit any doctor by phone or videoconference at no additional cost, including with commonly used services like Facetime and Skype."
No longer will telemedicine benefits be restricted to Medicare patients in rural areas without access to physicians nearby.
Seema Verma, administrator of the Centers for Medicare and Medicaid Services (CMS), said at the news conference: "Medicare beneficiaries across the nation, no matter where they live, will now be able to receive a wide range of services via telehealth without ever having to leave home. And these services can also be provided in a variety of settings, including nursing homes, hospital outpatient departments, and more."
Alex Azar, Secretary of Health and Human Services, issued a press release stating that the administration will essentially stop enforcing elements of HIPAA that required physicians to use only secure telecommunication services when communicating with patients. For the time being, at any rate, physicians can use (and bill Medicare for) ordinary telephone and video links such as Skype and Zoom.
States are also taking action to speed access to medical care in the era of social distancing. On March 14, both New York Governor Andrew M. Cuomo and Colorado Governor Jared Polis announced that insurance companies in their states must waive co-pays for telehealth visits. The next day, Massachusetts Governor Charlie Baker announced emergency actions to address COVID-19, including ordering "all commercial insurers...to cover medically necessary telehealth services in the same manner they cover in-person services."
The moves come as patients around the nation are overwhelming telemedicine services, producing technical and procedural backlogs, Stat News reported.
In response to the changes in how telemedicine visits are being coded and reimbursed, the AAN has established a small working group of experts to develop a new guidance document for members, according to Luana Ciccarelli, the Academy's senior manager of reimbursement & coding.
A Relatively Smooth Adjustment
In place for more than 10 years, the Mayo Clinic Connected Care platform is taking on the recent uptick in telemedicine sessions relatively smoothly, according to Bart Demaerschalk, MD, FAAN, professor of neurology at Mayo Clinic's Phoenix campus and director of its telestroke program.
"To the degree possible, neurologists and neurology allied health staff are now working from home," said Dr. Demaerschalk. "Clinic appointments are being rescheduled whenever feasible to a telemedicine format. We are trying to utilize a wide variety of digital health tools to best serve and protect our patients including portal messages, telephone, eConsults, video telemedicine, and remote patient monitoring. Our acute-care neurology services, including stroke, can use robotic telepresence devices, allowing neurologists to participate in acute-care patient encounters from their home or office."
The robotic devices, he explained, are remotely driven—often autonomously—and include auto navigation and obstacle-avoidance capabilities. In addition to offering synchronous audio-video links, they usually employ such peripherals as stethoscopes, otoscopes, and ophthalmoscopes that a neurologist can deploy remotely. Even so, the availability of telemedicine services does not preclude in-person neurology care, Dr. Demaerschalk said.
"I've been in the emergency department several times today to treat an acute stroke syndrome, a seizure, and a patient with a brain tumor," he said. "We are abiding by the Centers for Disease Control and Prevention [CDC] recommendations. Mostly we are seeking to reduce the number of people in a given area and the theoretical risk of viral spread from those patients who might be asymptomatic."
In keeping with CDC recommendations, he said, a few staff members, including at least one neurologist, are currently self-quarantined at their homes after returning from domestic or international travel to areas with high numbers of COVID-19 cases.
At the Cleveland Clinic's Mellen Center for Multiple Sclerosis, staff neurologist and medical director Robert J. Fox, MD, FAAN, said they are taking their response to the outbreak in stride.
"First and foremost we are encouraging patients to use online visits as much as possible," said Dr. Fox. "We are also offering some clinicians at high risk for COVID-19 complications the opportunity to work from home if possible. About three-quarters of our follow-up visits are now being conducted online, which makes working from home possible."
While preparing for the possibility that neurologists who normally practice in the outpatient clinic will be pulled over to the inpatient service if hospitalizations rise due to COVID-19, relatively modest precautions are being taken for now. As at Mayo, the outpatient neurologists are not generally wearing gloves or masks, he said.
But, he said, "I haven't shaken hands with a patient in over a week, which is very unnatural for me. We're waving, we're doing virtual high fives, and we're washing our hands a lot."
After developing a telemedicine program at the University of Pittsburgh Medical Center, where he was clinical professor of neurology, Dr. Busis had the misfortune to arrive at NYU Langone at the beginning of March with an ordinary cold.
"The last thing I wanted to do on my first day on the job was to flip out patients and be seen as the COVID-19 equivalent of Typhoid Mary," Dr. Busis said. So he did what he recommends patients do: He arranged a virtual care appointment. After signing up for the NYU Langone service, he filled out an online questionnaire and then queued up in the virtual waiting room.
"When the provider showed up, I saw her on a split screen on my iPhone," Dr. Busis said. "She could see me, and I could see her. After talking, she told me, 'You have a cold. Wear a mask, wash your hands a lot, and be upfront with your patients.' That's what I did. When I saw my first patients, I told them, 'Don't worry, this is just out of an abundance of caution.' My patients accepted it fine."
Now digging into his job of ramping up the medical center's telemedicine program, not only in neurology but systemwide, Dr. Busis said the easiest part is the telemedicine visit.
"Setting up the audio and video at both ends is actually fairly easy," he said. "The harder part is documentation, coding, billing, how you notify people, and how you integrate the virtual visits into your workflow. You can't just do telemedicine at the end of the day; you need a schedule combining in-person and virtual visits. And of course you still have to figure out some sort of way to get reimbursed for services, especially if this is going to become sustainable over the long-term."
Until the changes announced by President Trump and other officials on March 17, coding for telemedicine visits was tricky, Dr. Busis said. Different insurers used different codes, and CMS had its own set of codes. Now, he said, "The reimbursement landscape is rapidly changing and many of the old restrictions are no longer in effect, at least temporarily. This is a welcome development. All of us wonder how long these restrictions will remain lifted and if they will ever be reinstated."
A Major Change in Practice
While Dr. Dorsey at the University of Rochester Medical Center has worked in telemedicine for years, the sudden transition to virtual care for other neurologists there has been bumpy.
"The move to telephone and video telemedicine work has been a major change for some of our providers, particularly some that are not as tech-savvy," said Adam G. Kelly, MD, FAAN, associate professor of neurology and director of the New York State Primary Stroke Center at Highland Hospital. "It's been a big paradigm shift for our clinic staff but they have done an awesome job modifying what they do in a very short time. This was an almost overnight switch on our institution's part."
With waiting rooms "extraordinarily quiet" because of the shift to telemedicine, Dr. Kelly said some neurologists there have had to self-quarantine after attending a medical conference where they were potentially exposed to the virus.
"Fortunately no one has developed symptoms yet," he said. But, he added, "We have had scheduling challenges related to the self-quarantining. We have also needed to build in multiple layers of back-up coverage in case providers become ill. We have asked some providers to minimize contact with one another to decrease the odds that a large group will all need to quarantine should one become ill."
Without the infrastructure and experience of a large institution to rely on, neurologists in private practice are facing what some fear could be an existential challenge.
"We had one of our telephone operators today tell our office manager that her son is a nurse who might have been exposed to someone with COVID-19," Dr. Klein said. "The administrator had to tell her: 'You're banned, you're not coming back into the office for 14 days.'"
Unlike academic telemedicine programs that merely need to ramp up to meet the current need for virtual visits, Dr. Klein's practice is facing the prospect of having to transition virtually overnight.
"We only last week started a process to understand the nuances of getting telemedicine into our office," he said. "We're trying to understand the reimbursement rules, who pays for it, what we do if the insurers don't cover it. We need to find the right vendor and get it up and running."
Politics aside, he and other neurologists said, greater leadership from the federal government, as well as from insurers, would be helpful.
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Dorsey ER, Venuto C, Venkataraman V, et al. Novel methods and technologies for 21st-century clinical trials: A review. JAMA Neurol 2015;72(5):582-588.