Developing an outline for teleneurology curriculum

A primer for teleneurology training.

Referencing this curriculum, departments can develop training modules to suit the needs of their individual programs. By writing the curriculum to align with ACGME's next accreditation system, we intend for this outline to reflect the knowledge, skills, attitudes, and performance milestones that are needed to produce highly competent providers who can meet the 21st century health care needs of the public.⁵

The Work Group identified equivalencies with which any practitioner of teleneurology should be familiar. The equivalencies described here are not unique to teleneurology, and are applicable to other health professions and disciplines. The use of the word “equivalency” instead of “competency” is to make the teleneurology skills and curriculum applicable to a broad range of health care providers consistent with the recommendation from the American Telemedicine Association and AAN's stated objective of developing a multidisciplinary care within telemedicine. The structure of the training is flexible and could take place continuously over a 4- to 6-week rotation or interspersed over the entire period of residency. The Work Group does not suggest the creation of a core rotation but rather a teleneurology elective. Comprehensive training in clinical bedside neurology is necessary to safely practice teleneurology and the components of this curriculum are an extension of that training.

Although this curriculum is intended primarily for residency programs, it can also be used to develop a clerkship curriculum for medical students, continuing medical education for practicing neurologists, or education for nurses, nurse practitioners, physician assistants, and other allied health professionals. Furthermore, it can be used to build simulation cases in those programs where residents are not able to get hands-on experience. The Work Group is collaborating with the AAN's Education Committee to build simulation cases (similar to the Objective Structured Clinical Examination) that can be used by residency programs.

The clinical application of teleneurology is diverse and varied. The purpose of this curriculum is not to define teleneurology or mandate where its use is appropriate, but rather to provide guidance on basic equivalencies that students, residents, and practitioners should know while practicing teleneurology. The Telemedicine Work Group is writing another publication to define the standards of care within neurology telemedicine, where many of the questions on the appropriate use of telemedicine will be explored further.

In the next few sections, we offer a detailed discussion on the rationale for the contents of this curriculum and conclude by providing a model curriculum (table 1) and an outline for evaluating residents' competencies in teleneurology (table 2).

Managing ethical issues in teleneurology: Conflict of interest, physician self-referral, and Stark laws.

Learning about the legal considerations in the business of medicine is only peripheral to medical school and neurology residency curricula, but it assumes greater significance in teleneurology. To prevent financial or perceived conflicts, providers cannot provide “equipment or services solely to induce referrals or services reimbursable by Medicare.” In addition, the US Department of Health and Human Services Office of the Inspector General Guidelines mandate that telemedicine equipment may not also be used for personal communication unrelated to medical care.⁹

We recommend a review of these laws in addition to providing real-life examples of violations as a part of instruction. As before, local human resources and legal departments can provide beneficial context.

Provider–patient relationship.

Developing a provider–patient relationship is the key to a successful therapeutic alliance and forms the basis of the art of healing. The rapid advancements in technology, increasing patient volume brought by financial demands, ubiquitous electronic medical records, and administrative responsibilities make this difficult even in traditional face-to-face encounters.¹⁰ These pressures may be greater in a teleneurology setting, where the technological component and lack of physical presence make it even more difficult to establish this relationship.

Overdependence on the technology must not compromise the patient–provider relationship, particularly in cases where the provider is meeting the patient for the first time. Recognizing this concern, certain medical societies have recommended that telemedicine only be used with established patients.¹¹ The idea of limiting telemedicine only to established patients is not pragmatic in neurology given the immobility of our patients and access of care issues.

It is imperative that we teach our residents the art and science of developing provider–patient relationships, especially in the context of teleneurology. The Work Group has identified 4 key components that could be included in this part of the curriculum. These include the following:

1. Understanding the technique behind developing a provider–patient relationship

2. Identifying challenges to developing a provider–patient relationship in teleneurology

3. Reviewing FSMB recommendations for developing provider–patient relationships in telemedicine

4. Discussion of value proposition with patients for use of telemedicine in enhancing care, wherein the telemedicine provider explains the reason for using telemedicine (for instance, quick access in case of telestroke, or additional expertise for neurology consultation in areas of poor access and neurologist resources)

A provider–patient relationship occurs when a provider renders health services for a patient's benefit, either with express or implied consent.⁹ The components involved in establishing this partnership have been discussed thoroughly elsewhere.¹²

While neurologists may display appropriate nonverbal gestures in a face-to-face encounter, this interaction may not be the same when the patient and provider appear on a computer screen. Patients could interpret the provider's body language or preoccupation with technology setup as lack of empathy, negatively affecting the entire encounter. Thus, it is important that the provider be comfortable with the technology and have access to technical assistance when needed. The Work Group suggests mindfully developing and displaying these nonverbal cues while providing periodic feedback to residents about their interactions. See specifics in table 4.^13,14

Trainees could learn the FSMB-recommended 4-step process to establish a provider–patient relationship in a telemedicine setting. The FSMB recommends that every clinical encounter should involve verifying the location and identity of the requesting patient, disclosing the provider's identity and credentials, providing disclosures regarding delivery models and treatment methods, and obtaining appropriate consent from patients (see reference 15 for more detail).

Displaying professionalism.

Professionalism in teleneurology includes mannerisms displayed by the clinician and the environment in which the encounter takes place (background, attire, lighting). Our focus here is on clinician mannerisms.

Webside manners.

Webside manners refers to the verbal and nonverbal soft skills used while interacting with patients via telemedicine.¹⁶ Appropriate bedside manner is one of the cornerstones of medical school and residency training and evaluation. Although teleneurology removes the in-person encounter, displaying appropriate webside manners is of the utmost importance. While there are many commercially available teaching modules,¹⁷ direct physician mentoring with constant feedback on improving webside manners is the most dynamic teaching method. Future training programs could also develop their own objective structured clinical examination–type modules to train and evaluate residents in webside manners.

The neurologic history and examination.

The neurologic history and examination need to begin with the expectation from the provider that the patient will receive the same standard of care as with any other encounter. Prior studies have demonstrated that neurologists felt that teleneurology was equivalent to in-person care 63% of the time, inferior 31% of the time, and superior 3% of the time. Ratings of equivalence to in-person care differed depending upon specific diseases.²¹

Prior to beginning an encounter, it is important for the provider and telepresenter (health care professional colocated with the patient) to discuss expectations. This telepresenter can be a registered nurse, physician assistant, nurse practitioner, telehealth technician, or referring physician. In some cases, as when telemedicine visits occur in the home, there may be no telepresenter. To help ensure diagnostic accuracy for the encounter, the provider should inquire about the telepresenter's level of training and experience with the neurologic examination. Because the telepresenter provides critical portions of the examination, communication and trust between the remote neurologist and the telepresenter is often necessary to give confidence to the examination. Ideally, the telepresenter would be trained by the remote neurologist, but in many cases this is not possible. There is no evidence to date as to what level of training and experience an ideal telepresenter should have. Most importantly, both the provider and telepresenter should be comfortable with the telemedicine format and have discussed their expectations prior to the patient encounter.²²

The initial conversations should discuss the importance of the neurologic examination, necessary equipment, and performance of specific testing. This discussion can take place via telemedicine with a simulated patient or on-site prior to beginning an actual patient encounter. Residents should be comfortable with this unique aspect of practice.

Telemedicine is effective for obtaining a complete neurologic history if the provider has clear communication and effective interpersonal skills. It is vital to demonstrate these skills with both the patient and the telepresenter. The telepresenter performs a major role in the examination and residents must know how to build rapport and demonstrate clear communication to get accurate physical examination findings. The providers should follow a structured format equivalent to an in-person visit.

Technological competence is a key component of the successful teleneurology encounter. The provider must be comfortable with using technology to review the patient's medical records, move cameras, and perform other functions. Practicing with simulated patients will help improve the teleneurologic experience for both patients and providers.

The providers should review grading systems together prior to the encounter so that the telepresenter may communicate any asymmetry. Certain standardized examinations, such as the Mini-Mental State Examination, NIH Stroke Scale, Expanded Disability Status Scale, and Full Outline of Unresponsiveness score, have been proven to be reliable when performed via telemedicine and should be reviewed before beginning the encounter to ensure validity.^23,24

The Work Group has identified certain aspects of the neurologic examination that may or may not be appropriate for teleneurologic consultation.²⁵ We again emphasize caution as these are only the Work Group's current recommendations and may not necessarily reflect the evolving and diverse practice of telemedicine. See table 5 for our recommendations.

Documentation in teleneurology.

The importance of proper clinical documentation is evident in the classic saying, “If it isn't documented in the medical chart, then it never happened.” Documenting the teleneurology encounter is substantially different from documenting an in-person encounter and residents must be taught to appropriately document all aspects of the encounter.²⁶

The names of everyone involved in the teleneurology encounter (including the provider who requested the consultation, the provider the consult will be reported to, and the telepresenter) should be appropriately noted.

The components to be documented at the beginning of each encounter are (1) that informed consent was obtained (where required); (2) identification of the patient, physician, and physician's credentials; and (3) the patient's agreement and understanding that the consulting physician will determine whether the condition being diagnosed or treated is appropriate for the telemedicine encounter.^15,27

When documenting a telemedicine examination, residents need to make the distinction between the components of the physical examination that they observed themselves, those that are communicated by the telepresenter, and those that are subjective. For example, a facial droop can be easily observed on camera and documented as such. However, assessment of tone, give way weakness, strength, and other findings rely on the telepresenter's ability to correctly assess these features. In such situations, it is best to document that “per the bedside examiner…” Documenting in this way helps to delineate which components of the examination the remote practitioner can be most confident in when making an assessment.

Regarding documenting ancillary studies, residents will generally have access to any imaging performed through an accessible server. However, imaging may not be available to them outside of a verbal or written report and should be documented. For instance, “Images were not available for my personal review, but per the report provided by staff…” Making note of the health care provider that supplied or read the report can be helpful in accounting for all the information that contributes to an assessment, should there be any future discrepancy or change in the report.

Any relevant examination components that cannot be assessed due to lack of expertise or technical limitations at the originating site should be documented. For example, if there is a need to assess for papilledema, but there is no funduscopic camera or peripheral device that allows for remote personal review of the optic nerve head, then these limitations must be documented. This can be explained as such: “Due to the limitations of the telemedicine examination, I was unable to personally assess the fundus.” Any other technical limitations that prevent a remote examiner from performing key components of the examination should be recorded to account for an incomplete patient examination that may affect assessment and management.

Technical difficulties are not uncommon in telemedicine practice, and residents should be prepared to document factors that could affect teleneurology care, such as a technical disturbance or interruption of the remote connection. The provider should document any error that limits, interferes with, or otherwise delays the telemedicine encounter. Disturbances, either at the remote or originating sites, could include unstable Internet connectivity, poor signal quality, misplacement of the telemedical equipment, camera or device malfunction, absentee telepresenter, limited technical capacity of the patient, and unavailable records.²⁸

Teleneurology is ideal for quality improvement projects. For instance, it is very important from both a quality improvement as well as a patient care standpoint to document specific times in emergency neurology cases. Documenting when the remote physician was contacted to provide emergency services, the time that physician was connected to video, when that physician recommended treatment, and when the treatment was provided (especially in the case of thrombolytic therapy or status epilepticus) are crucial to identifying any delays or interruptions in the workflow. Should a critical treatment window be missed or treatment excessively delayed, documentation can serve as a source of data to help streamline the future workflow and ultimately improve patient care.²⁹

When discussing the plan of care with the referring provider, it is best to ensure that, as a consultant, residents can answer any key questions and that everyone involved agrees moving forward. The provider should document any disagreement in how to proceed that cannot be resolved. Documenting discussions with the patient and his or her family is as important in a telemedicine encounter as it is in an in-person encounter for establishing current and future care plans.

Ultimately, the teleneurology encounter involves more logistical considerations than an in-person encounter, accounting for technology and additional personnel. Proper documentation is crucial to determine accountability for different components of the workflow and to identify areas for improvement.

The interplay of these equivalencies will ultimately result in the development of highly effective interdisciplinary care teams. Telemedicine is particularly suited to supporting interdisciplinary care teams, streamlining communication, and information-sharing between providers.³⁰