Karen Appold

Telemedicine offers a lot of flexibility. “You can practice it from anywhere-in the office, at home, and even at the beach,” says Jaime Hatcher-Martin, MD, PhD, Assistant Professor of Neurology at Emory University School of Medicine in Atlanta, who uses telemedicine. “It also allows you to see patients for quick issues that don’t warrant a visit to the office.

This also allows you to bill for a visit that might not have occurred otherwise or that you would have only discussed over the phone. It can expand your catchment area for patients who would not have otherwise traveled to see you.” Telemedicine also eliminates some of the time constraints that traditional in-person visits require (

While telemedicine can be helpful in certain situations, it's important to understand what aspects of an exam can or cannot be adequately assessed via telemedicine. Dr. Martin often uses video to look at patients’ movements to determine if she needs to increase or decrease medications.

However, there’s no way to test reflexes without a telepresence (ie, a provider who is with the patient). In addition, you can only evaluate strength in limited ways and sensation is not possible without a telepresenter, so you can’t perform a detailed neuromuscular exam.

Another potential downside is that some providers feel that they will lose a personal connection if they don’t see patients face-to-face. “This was a concern for me in the beginning, as I’m very touchy-feely and affectionate with my patients,” she says. “I was pleasantly surprised that the connection was still there.

Within seconds of starting a visit, I forget that I’m even on camera. I still ask about families, recent vacations, work, and so forth. Patients still ask about my children and about other personal matters we discussed. If you are personable in person, that will still shine through in telemedicine.”

Billing issues can also be a potential problem. Currently, most insurance companies will only reimburse for visits if patients are in a subset of rural locations. Also, for insurance reimbursement, patients may need to be in an approved medical facility during a visit. “This can be circumvented in some instances when patients either pay out-of-pocket for direct-to-consumer telemedicine and forego insurance involvement or for patients whose insurance companies offer their own or contracted telemedicine service directly,” Dr. Martin says.  

Some states do not reimburse for tele-visits at the same rate they do for in-person visits. Other states have parity laws that require equivalent reimbursement for in-person versus telemedicine visits as long as an equivalent level of care is provided.

Many states require you to examine the patient for the first time in-person; you have to see the patient in-person at least once a year; or you cannot prescribe controlled substances if you only see a patient via telemedicine. “This can make things complicated if you’re seeing patients who live a distance away,” she says.

"You can practice telemedicine from anywhere-in the office, at home, and even at the beach.”
-Jaime Hatcher-Martin, MD, PhD.

Also, just like in-person, you have to be credentialed in each state in which you are seeing patients and you must be knowledgeable about the laws and regulations for practice in that state.

“The best thing neurologists can do right now is to advocate for increased coverage of various types of telemedicine services, dissolution of rural requirements, and the need for the patient to be in a medical facility for insurance coverage,” Dr. Martin says.

Healthcare providers, caregivers, and patients alike can advocate at the local, state, and federal levels for expanded coverage of 

. “Many professional societies and patient advocacy groups make it easy to write a letter to your representatives,” she says. The American Academy of Neurology offers fellowships that provide training on various aspects of the legislative process and how to effectively advocate.

“Many physicians want it, many patients are asking for it-we just need to ease the burden of regulations on where telemedicine can be practiced and how it is reimbursed,” she concludes.

 discusses things to consider before adding telemedicine to your neurology practice.

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Many physicians want it, many patients are asking for it. Here’s a look at the pros and cons-and the case for expanded coverage of telemedicine.

Telemedicine: Benefits and Challenges for Neurologists

As people grow more accustomed to having access to almost everything at their fingertips, virtual medical care (ie, telemedicine) will be an increasingly sought-after service. In neurology, the most common use of telemedicine is in acute settings-such as evaluation for stroke in the emergency department, monitoring in the ICU, or consultations in other inpatient settings.

“Telemedicine is also being used to evaluate patients in nursing homes or remote sites, including rural areas in the United States and in remote locations in other countries to determine which patients need to be transferred to higher level care,” says Jaime Hatcher-Martin, MD, PhD, Assistant Professor of Neurology at Emory University School of Medicine in Atlanta, who uses telemedicine. “More recently, there has been a push to incorporate telemedicine into the care of patients with chronic neurologic conditions, such as dementia, Parkinson’s disease, and multiple sclerosis.”

If you are looking to incorporate telemedicine into your practice, what you’ll need depends on the types of patients you see and who will use the equipment. If you’re just starting out in practice and will only be doing telemedicine minimally, you don’t need a lot of expensive equipment. Dr. Martin started out with a laptop, basic webcam, and an Internet connection.

Many fancy telemedicine carts that offer all kinds of bells and whistles exist. “These are great if either a lot of providers will use the equipment or if the set-up needs to be mobile,” she says. “However, for most of us doing chronic outpatient care, the setup stays in one room so limited tools are adequate.”

Telemedicine improves access to care for patients by reducing the need to travel for those who live remotely or have limited mobility. Thus it offers both convenience and cost savings.

You will also need conferencing software. “Obviously, you want something that is secure and HIPAA-compliant,” she says. “Some use freely available software. Others use software that is either inexpensive, or-as in my case-they use something their institution already had a license to use.”

Dr. Martin says no specific training is required, although various medical organizations offer training courses. “I started out testing the software with family members and then with some patients that I trusted,” she says. “You can even try comparing a telemedicine exam with an in-person exam (ie, have the patient in another room and do the virtual exam first, then verify your findings with an in-person exam).

Telemedicine improves access to care for patients by reducing the need to travel for those who live remotely or have mobility limitations. Thus it offers both convenience and cost savings. “This allows patients access to the best specialized care,” Dr. Martin says.

Patients who pay out-of-pocket or who have insurance that pays for direct-to-consumer telemedicine may not even need to leave their home for a visit.

Recently, Dr. Martin was out of town when a patient needed to be seen urgently. “We were able to schedule a quick telemedicine visit, which allowed him to avoid going to an emergency room,” she says.

Besides living in an area where telemedicine is covered by insurance, patients also need to have some basic computer or smartphone knowledge and competency. “Patients who are seen at home need to have an Internet connection fast enough for an adequate audio/video feed. It’s hard to evaluate tremor or fine motor movements if the video feed is jumpy and delayed,” Dr. Martin says.

Editor’s note: Part 2 of this article will discuss the pros and cons of telemedicine in specific settings.

If you are thinking of adding telemedicine to your practice, here are the benefits-and things to consider.

Telemedicine in Your Neurology Practice?

Throughout her career, Amy W. Amara, MD, PhD, Assistant Professor of Neurology at the University of Alabama at Birmingham, has benefitted from having many mentors. Most often, she searched for a mentor because she recognized that she needed guidance in a certain area, such as in career development or clinical research. “It’s rare for one single person to be able to provide guidance on every aspect of your career trajectory,” she says.

Other reasons to seek out a mentor might be to gain self-confidence, increase motivation, avoid pitfalls, or resolve a problem.

When considering whether to pursue a mentorship, make sure you are willing to commit the time to it. Be willing to listen and seriously consider a mentor’s advice.

To find a mentor, Dr. Amara recommends seeking out someone with whom you have a good rapport so that you’re comfortable seeking advice from them. This might be a former Professor, a colleague, or someone you’ve met while networking at an event in your field. Sometimes a mentoring relationship may evolve where you least expect it.

Find out if potential mentors have successfully mentored others by speaking to some previous mentees to learn about their experiences, Dr. Amara suggests. Be cautious about choosing a mentor who has many adversarial relationships with others in the department or field.

To narrow down the candidate pool, meet with a potential mentor to learn about his or her availability and discuss mutual expectations of the mentoring relationship, Dr. Amara recommends. Have clear goals for what you desire from the partnership, so you and the potential mentor can determine if you can meet those needs.

For mentors in the area of research, look for similar research interests, but also ask about the prospects of carving out your own niche so that you can separate your work from that of your mentor.

Mentors can provide a point of view gained through experience. They provide advice for making career-related decisions and can help you identify good opportunities and decline those that might not be useful at your career stage.

Research mentors can teach you how to approach research questions or design experiments, teach techniques, and recommend a direction for your research ideas. They can provide you with insightful feedback and make suggestions to improve your skills.

Mentors can also serve as sounding boards for you to test ideas and discuss your viewpoints confidentially. In addition, they can introduce you to influential people and promote your work.

Dr. Amara’s mentors have recommended her for leadership programs, clinical research design courses, and other opportunities that advanced her career. “Mentors have advised me against participating in certain endeavors that would not have helped my career, and that would have taken valuable time away from my other goals,” she says. “My mentors have helped me to identify other mentors to help in areas in which they were not experts.”

Finally, remember that having a mentor is not all about you-it’s a two-way street. The mentor should also grow and learn from you, glean satisfaction from the relationship, and share in your successes.

Here are a number of compelling reasons to consider seeking out a mentor to help you with your neurology career.

Tips on Finding and Choosing a Mentor

For Cynthia L. Comella, MD, FAAN, professor, Rush University Medical Center Department of Neurological Sciences, Chicago, Illinois, being a mentor ensures the future of her subspecialty in movement disorders as well as the field of neurology in general. “Unless you bring new physicians forward and upward, an area of expertise may not be sustainable,” she says.

Dr. Comella, who has served as a mentor and is a proponent of these relationships, also finds mentoring very satisfying: “When you mentor someone and they are successful, you share in that success.” Moreover, mentors can gain insight from mentees: “Mentees have some great ideas; you actually thrive on each other.”

Mentees might have more than one mentor. “Always keep in mind that at any level of your career, there may be someone else from whom you can learn. This can be a formal or informal relationship. It is important that you are always open to seeking advice,” Dr. Comella says. “Mentors can help you to succeed without taking the painful wrong turns of trial and error that you would most likely make on your own.”

Mentors might be older or younger than their mentees-it’s their experience that matters. “As a mentor, you’re providing your knowledge in navigating situations to someone who hasn’t had that experience yet,” Dr. Comella says.

As a mentor, you must allot time for the mentee and maintain communication with him or her. “That’s where many relationships go astray,” Dr. Comella says. “You also need to be a good listener. Mentors not only provides advice, direction, and guidance, but they also need to understand the mentee’s goals for the relationship.”

A mentor may have different roles. He or she may provide advice related to science, grantsmanship, or leadership. Or, a mentor plays the role of champion, or someone who provides opportunities for the mentee to succeed, such as a speaking engagement or being a principle investigator of a study. “As a champion mentor, you must have the humility to share opportunities that could be yours with your mentee,” Comella says. And, a mentor can be a coach, “It’s important to provide clear and thoughtful suggestions for problems a mentee may encounter.”

As the relationship forms, both parties need to determine what role the mentor will play. Does the mentee need advice regarding handling a difficult situation, getting a promotion or leadership role, obtaining a research grant, or participating in a research project?

A mentee might be intimidated by a mentor and not feel comfortable reaching out. “Try to work with a mentee to overcome such barriers,” Dr. Comella says. “Make it clear that you are there to provide guidance-not to instruct or criticize. The mentee will need to be willing to discuss your insights, but should not feel obligated to take your advice. When you develop that degree of trust, it will take your relationship to a new level.”

It might also be challenging for the mentee to understand that the purpose of your relationship is not to be a best friend-rather, it’s to have a professional relationship where the mentee’s goals are met. The relationship may change as the mentee advances, but with good mentorship, attaining goals may prove to be less daunting.

Mentors might be older or younger than their mentees-it’s their experience that matters

Karen Appold

Articles

Telemedicine: Benefits and Challenges for Neurologists

Telemedicine in Your Neurology Practice?

Tips on Finding and Choosing a Mentor

Insights on Being a Mentor: What It Takes and What It Entails