Since the late 1990s neurologists have been involved in the remote care of patients using telemedicine. This has primarily been through telestroke programs, but the application of this technology-driven mode of care has increased to include more than just stroke patients. Today, according to the American Hospital Association, “[Seventy-six] percent of U.S. hospitals connect with patients and consulting practitioners at a distance through the use of video and other technology.”

With this increase in use has come some perspective. Eric Anderson, MD, PhD, a national leader in telemedicine, shared some of his in a talk,Telemedicine Fails: What Not to Do in a Telemedicine Encounter, at the 2019 annual meeting of the American Academy of Neurology (AAN). One of his main takeaways: Telemedicine is just a tool, and remote physicians should know its limitations.

In other words, there are a lot of things you can do with telemedicine, but there are also quite a few things you should not do.

Patient talking to doctor via videochat

Don’t accept all consults

Not every patient is appropriate for a telemedicine encounter. Some patients simply require more nuanced evaluation than can be accomplished remotely, even with the help of a medical assistant. Also, technological failure sometimes makes a full evaluation or critical image reading impossible. Anderson says, “Be comfortable with saying ‘I am unable to evaluate this.’”

This is not just best practice, it is also a matter of law. According to a New Jersey telemedicine law passed in 2017, says Anderson, “the provider must determine whether or not he or she can meet the standard of care—and that’s at the onset of the consult.”

Don’t assume your order will be carried out appropriately

Anderson presented the case of a stroke patient who was seen by a neurologist via telemedicine. The evaluation was completed, TPA was appropriately ordered, and the neurologist signed off the call. Then, due to unforeseen circumstances at the local facility, the TPA wasn’t administered until the patient was outside the appropriate time window, and the patient died.

According to Anderson, best practice is to stay on camera through the administration of treatment. “If a neurologist is involved in stroke care, they should be responsible for that care, and if TPA is recommended or ordered, they should oversee the process. Which includes stopping it.”

Don’t assume recommendations carry less weight than orders

The case above brought about some questions from the audience as to whether the telemedicine doctor would be less culpable if TPA was recommended rather than ordered. Anderson says that despite a common assumption that recommendations weigh less than orders, they are essentially the same. “If you’re involved in a case and your involvement changed the management or care of that patient, you’d be liable regardless of whether you wrote a recommendation or an order.”

Don’t just use an app on your phone

Despite the advancements in technology that have made telemedicine possible, equipment failures and internet outages are not uncommon. When this happens, it is tempting for physicians and even patients to reach for their mobile phones to re-establish a connection—say, via FaceTime. But just as with all patient encounters, HIPAA compliance must be considered.

“It’s controversial,” says Anderson of the use of commercial video apps. “Some hospitals say that it’s okay. Others say that it’s not.” The decision to allow certain apps and devices during a telemedicine encounter should be a matter of policy and is often informed by the HIPAA Conduit Exception. This ruling “applies to entities that transmit private health information (PHI) but do not have access to the transmitted information and do not store copies of data. They simply act as conduits through which PHI flows.”

Anderson’s talk was a popular one at the AAN meeting this year, and it engendered a lively discussion among the neurologists that attended. No doubt, as more neurologists begin practicing telemedicine, more lessons-learned will emerge and the practice of telemedicine will be the better for it.

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