American Academy of Neurology Telehealth Position Statement

Access

Patients should have access to high-quality telehealth services in the United States and its territories and when traveling abroad. Initially, telehealth programs were focused on patients living in rural settings with no access to specialized ambulatory and inpatient health care services. However, many other patients also have barriers to health care access, including those (1) who live in nursing homes and rehabilitation facilities; (2) with conditions that make travel excessively burdensome; (3) who are unable to drive; (4) who live in remote military settings; (5) who live in densely populated urban areas where traveling even short distances can be time-consuming or expensive; (6) whose safety would be compromised by in-person visits (e.g., at risk for infection or with a need for home medical support equipment); and (7) who seek to improve continuity of care when they are traveling (including those who may spend several months of the year at another residence).

Telehealth should be an option for both new-to-practice and established ambulatory patients provided they are appropriately triaged to the visit type that meets their unique needs. In addition, care gaps affecting patients admitted to hospitals with no neurologic consultation coverage could be addressed by expanding inpatient teleneurology services.

One potential benefit of expanding telehealth as a national model of health care is improving convenience and democratizing access to expert subspecialists throughout the nation. However, an unintended consequence could be negatively affecting the sustainability of local practices that currently offer the benefits of in-person and long-term continuity of care. Furthermore, without the provider understanding community social and medical resources and local rules (such as driving restriction rules), the remotely practicing provider may be delivering care with significant gaps. Further investigation is required to address this paradox.

The AAN encourages actions to minimize the digital divide by supporting affordable nationwide high-speed Internet access to limit disenfranchisement of those with inadequate or unaffordable network connectivity and efforts to promote digital literacy and alleviate other technology or device limitations. Because some patients have barriers related to language and visual or hearing impairments, resources to assist with translator services and appropriate, easily accessed adaptive technology must be available and reimbursed at equitable rates. Telephone-only visits should be available for encounters that require real-time two-way interaction but in which an audio-video encounter may not be necessary, e.g., medication reconciliation, some counseling situations, discussion of treatment side effects, or when patients do not have or cannot use more advanced telehealth modalities.

Reimbursement and Payment Parity

The complexity of various coverage policies, service and procedure codes, reimbursement rates, and documentation standards across Medicare, Medicaid, and numerous private payers creates important barriers to providers trying to incorporate telehealth services into their practices. The definition of “parity” varies by state and insurer. Moreover, the cost borne by the patient is difficult to determine in advance of the provision of services. Reform should be based on the following principles:

• Patient financial responsibility (e.g., fees and copays) for telehealth encounters should not exceed comparable in-person expenses.

• Coverage and the professional component of reimbursement for two-way real-time interactive encounters should be independent of setting (in-person, audio-video, telephone), provided that standards of care for the encounters are met, because the provider's cognitive work is equivalent.

• The practice expense of providing a two-way real-time interactive telehealth service may be different from that of providing an in-person service and should be determined by evidence- and resource-based methodologies.

• Professional and practice expense reimbursement for providing other telehealth modalities such as store-and-forward digital evaluation and management services, interprofessional consultations, and remote physiologic monitoring should be evidence- and resource-based.

• To best address the needs of the patient and their health, the appropriateness of a telehealth evaluation should be determined on a case-by-case basis by the provider and the patient, not by the payer.

• When traveling out of state, patients should have coverage for telehealth access to their home state providers.

• If there are no local providers practicing a certain specialty, patients should have telehealth access covered for that specialty.

• Policies should support and encourage the development of telehealth care models in addition to audio-video encounters that can potentially improve patient outcomes and reduce costs. Examples may include remote monitoring and asynchronous evaluation and management services.

• In addition to fee-for-service reimbursement models, value-based telehealth models should be developed to optimize health care resource utilization at multiple levels: insurance, practice, patient, and society.

Telehealth Practice Across State Borders

Each state defines and regulates the practice of medicine, including telehealth, within its boundaries. State regulations dictate what constitutes a physician–patient relationship, what services are permissible once a relationship is established, if and what medications can be prescribed, scope of practice, and malpractice policies.¹⁷ These variations pose significant barriers to the practice of telehealth across state borders. Licensing, prescribing, and related policies should be simplified. A desirable solution could include blanket reciprocity and an expedited licensing process that would require one unrestricted state license, a new background check for each state in which telemedicine is practiced, and reduced annual fees for limited practices. This would ensure protection of patients' rights to receive telehealth services as they require. The Interstate Medical Licensure Compact (IMLC), an agreement among 29 participating US states, the District of Columbia, and Territory of Guam to streamline the state licensing process for physicians who qualify, maintains the state's authority to regulate the practice of medicine within its borders. Whereas the IMLC simplifies the application process, it does not standardize practice requirements.

Medical liability for telehealth services varies from carrier to carrier. Unless this changes, neurologists must understand individual carrier policies to ensure that telehealth encounters are covered by their policy and apply to the states in which their patients are located.

Hospital Credentialing

Hospital credentialing requirements and procedures vary between hospitals. This complex process can delay patient access to needed care. Simplification of hospital credentialing requirements and widespread utilization of certified credentials verification organizations would improve patient access to inpatient teleneurology services.

Streamlining Other Telehealth Processes

Currently there is considerable variability across payers, sites of service, and health care organizations regarding the need and type of consent required prior to a telehealth encounter, requirements for billing compliance, and the necessity for an in-person encounter prior to a virtual encounter. Barriers to practicing telehealth would be decreased if these processes were simplified or standardized.

Delineation of Roles and Responsibilities

To prevent confusion and maximize quality and safety of the telehealth care provided, the roles and responsibilities of participating facilities, clinicians (including, but not limited to, physicians, advanced practice providers, nurses, and trainees), and hospital and practice staff should be clearly delineated. In view of the limitations of telehealth (e.g., requiring nuanced or detailed neuromuscular, ophthalmologic, and vestibular examinations), the medical community should practice responsible behavior regarding appropriate remote evaluation in instances where the lack of an in-person examination may compromise medical decision-making. It is also helpful to clarify the expected nature and duration of the therapeutic relationship, including the relationship between a consultant seen via telehealth for a second opinion relative to the patient's usual care team and expected follow-up if the provider is prescribing medications or suggesting diagnostic testing.

In instances in which telehealth services are provided to a remote clinic or hospital, the AAN agrees with the American College of Emergency Physicians that “the best patient care occurs when there is no ambiguity as to which provider is responsible for care of a patient.”¹⁸ Agreements between local and remote sites need strict clarification of respective roles prior to initiating patient care. This includes, but is not limited to, the scheduled availability of the telehealth provider; who is responsible for placing orders, following up test results, and assessing the patient after consultation; billing responsibilities; and IT support.

Adequacy of Telehealth Evaluations

As telehealth becomes more commonplace, including telehealth encounters with patients in their homes, it is important that patients and consumers understand the benefits, limitations, and their rights regarding these services. The ability to effectively triage new patients and concerns via telehealth has not been well-studied. Although telehealth can be used to evaluate new patients or new symptoms, it may be difficult to determine whether the appropriate assessment and medical decision-making can be adequately performed via telehealth. Patients and referring health care providers should be informed of the possibility that patients may still need to seek in-person care if their concerns cannot be safely addressed via telehealth. In addition, a provider may lack knowledge about, and availability of, social and medical resources near the patient. National initiatives to educate patients and provide standard language regarding the use of telehealth can help inform and protect patients and providers.

Cost

The initial economic investment to establish a telehealth practice may be a limitation for some practices and is based on the settings where telehealth will be provided; the proportion of the practice consisting of telehealth; necessary staff to help with setting up, scheduling, triaging, and greeting the patient during the telehealth visit prior to the provider connecting to the visit; coding; and billing. Additional expenses potentially include the cost of the platform used and hardware such as computers, tablets, carts, or accessories such as microphones and cameras at the provider and patient locations. In addition, the need for information technology support and new staff or training of existing staff are factors to be considered.

Fraud

Telehealth modalities can provide substantial benefits to patients, but these care models are potentially vulnerable to the same fraudulent practices that may occur with in-person evaluations.¹⁹ Payers are concerned the cost of care could increase if patients are asked to follow-up more often than necessary or that visits could be fabricated or billed at levels higher than warranted. Providers fear that these concerns may prompt regulators to inappropriately limit telehealth access or lead to a disproportionate cost of compliance for providers offering telehealth services. Data on billing behavior can help determine whether fraud or abuse has occurred, and the digital footprint of visits is traceable, thus reducing the risk of fabricated visits. The programs in place to monitor in-person activities will be adequate to monitor for telehealth fraud.

Cybersecurity

Telehealth expansion raises concerns for cybersecurity and risk of access to private patient information, malware infections, ransomware attacks, and system breaches. Although not specific to telehealth, these concerns must be considered and addressed given increased risk of compromise for practices that do not appropriately protect their systems.