Letter: Telemedicine in Neurosurgery—A Timely Review

To the Editor: Unprecedented, the COVID-19 pandemic has impacted healthcare. Organizations have rapidly adapted to serve patients, provide safe environments, and maintain clinical operations. Telemedicine and telehealth have emerged instrumental in minimizing physical contact, respecting distancing practices, and delivering quality care. We review the role and impact of telemedicine in neurosurgery in today's current pandemic, potential pitfalls, and areas of growth. TELEHEALTH HISTORY Telehealth is the use of technology and telecommunication in healthcare.1 Telemedicine specifically centers on clinical services using technology for remote care.1 Used interchangeably,2 both enable providers to serve remote communities or populations.3 Telemedicine started in the 1800s, with the use of the telephone, to reduce unnecessary office visits.4 It has evolved, with technology, to allow for office-based and work-from-home medicine, now widely used in many facets of healthcare.5-9 Unsurprisingly, telemedicine was primed to be instrumental in the response to COVID-19. However, technical capabilities have not always aligned with policy and regulations. Until recently, the Centers for Medicare & Medicaid Services (CMS) required telemedicine reimbursement only for services delivered to patients in specific geographic locations at designated originating sites, excluding homes.10 However, due to COVID-19, CMS, under the Coronavirus Preparedness and Response Supplemental Appropriations Act and Section 1135 waiver, removed restrictions, approving home locations for telemedicine services.11,12 Significance of these regulatory changes is profound as other payors often follow CMS directives in their policies. PRESENT APPLICATIONS IN NEUROSURGERY As COVID-19 cases rise, healthcare systems have 2 priorities: work to support social distancing to prevent an overwhelming patient surge, “flattening the curve,”13 and prepare if this tactic is unsuccessful. With some cities hit earlier and harder than others, institutions across the United States are making more beds, halting elective surgeries, securing and recycling personal protective equipment (PPE), mobilizing ventilators, and ensuring a healthy workforce. Nationwide, neurosurgeons have delayed elective cases, performing only those considered emergent or urgent, aiming at decreasing COVID-19 spread, preparing for patient volume surges, preserving PPE, and freeing up resources. Some departments are reviewing surgical cases to evaluate urgency; others are imploring surgeons to self-regulate. Teams are reconfiguring to reduce potential exposures. Training programs are using online learning. National organizations are mobilizing to provide guidance. Patients with elective concerns are faced with postponement. Thus, telemedicine has emerged to continue outpatient care, enable patient communication, and provide a semblance of “business as usual.” Due to high acuity and limited specialists nationwide, neurosurgery has favored in-person visits over telemedicine.3 Thus, neurosurgical telemedicine has been mostly applied in outpatient postoperative care and follow-up visits.14 In acute roles, telemedicine and telehealth have enabled communication and transfer for critically ill patients.15,16 As neurosurgeons are not regionally evenly distributed, telemedicine may allow for real-time services, timely interventions, and facilitating care coordination, expanding its role.3 The COVID-19 pandemic has expedited the introduction of telemedicine to neurosurgical care. Two weeks after the “Work Safe, Stay Home” order was introduced in our county, we rapidly deployed telemedicine across all outpatient clinics. For neurosurgery specifically, all patients are offered telemedicine visits, unless optimal care can only be provided in-person. Our institution and compliance department have supported telemedicine and provider telecommute. In the 9 d since our statewide Executive Order to stay home, we reduced total clinic visits and shifted from no telehealth visits to 85%. Of the 85%, half used video and telephone each. As telemedicine is rapidly deployed in outpatient neurosurgery, we are seeing growing demands for inpatient video telemedicine, underscoring the importance of limiting provider exposure. With documented patient consent and attention to hospital facility regulations, video telemedicine visits can be performed and reimbursed. POTENTIAL PITFALLS AND AREAS OF FUTURE GROWTH Despite the growing technological infrastructure and surging need for telemedicine, there remain uncertainties and potential pitfalls regarding the role of telemedicine in practice. First, there is no universal access to necessary technology.17 From a data perspective, privacy and confidentiality concerns exist.3 However, during this crisis, the Office of Civil Rights is exercising enforcement discretion and not imposing penalties for telehealth providers making good faith efforts to deliver telehealth care.18 Regardless, organizations looking to expand telemedicine in the long term should aim to do so in Health Insurance Portability and Accountability Act (HIPAA)-compliant environments; we have leveraged our HIPAA-compliant electronic medical record platform with video-integrated visits. From a medical-legal perspective, there is uncertainty regarding malpractice liability, precedent, and interstate licensure reciprocity.3,14 From a business perspective, billing and coding for telemedicine is not well established and, while changing rapidly under new pandemic regulations, was not widely reimbursed to the same amount as in-person visits.3,14 Developing changes in CMS reimbursement and coding provides flexible responses to the COVID-19 emergency. Our experience is that other payors are following suit.10,19 Additionally, from a provider perspective, certain physical examination aspects are impossible to be adequately evaluated via telemedicine; however, despite inherent limitations, most urgent neurosurgical conditions can be detected by detailed history and video objective assessments of strength, coordination, and cranial nerve function. Factors integral to successful telemedicine implementation include centralized development, top-down organization, HIPAA compliance, end-user focus, staged and thoughtful roll-out, marketing of available services, and awareness of potential barriers to continually evolve. The Table summarizes barriers encountered when launching telemedicine in our neurosurgery department during this pandemic, highlighting special considerations and suggested solutions. TABLE. - Problems Encountered and Solutions Applied When Launching Telemedicine in Neurosurgery During the COVID-19 Pandemic Problem Considerations Solutions Patient access and barriers for elderly or nontechnologically accessible or knowledgeable patient populations Subsets of patients will not be able to utilize video-based telemedicine Telephone encounters can be used to determine clinical urgency and confirm if in-person assessment is needed Provide a helpdesk support team for both patients and providers Provider access Telemedicine not widely implemented for more than 1 provider to simultaneously connect with the patient Broaden video conferencing to support secure multiparty patient visits Providers need access to a room and equipment conducive to video visits Designate a location to perform video visits with an appropriate background and technology; practice with a nonpatient Limitations in physical examination capabilities Subtle neurological findings cannot be elicited through telemedicine Standardization and dissemination of a telemedicine neurological examination is critical; while many subtleties may be limited, gross neurological abnormalities can be evaluated for using video examinations Privacy and confidentiality concerns Process of obtaining patient consent for telehealth is unfamiliar to many patients Clear, accessible videos detailing processes are essential (https://www.youtube.com/watch?v=lL-7KOW1c3Y&t=8s) Involve organization's compliance teams in workflows Billing, coding, and payments Ensuring payors reimburse for telehealth visits Compliance teams continue to work with private and public agencies to communicate healthcare needs and facilitate coverage updates Evolving policies regarding inpatient telehealth consultations Provide ongoing, rapid updates to providers as the regulations continuously change Malpractice liabilities Malpractice coverage for telehealth may vary based on specialty or disease treated Practices must clearly understand liability issues In-person visits should always be considered if an adequate physical examination cannot be performed Medical licensure restrictions when treating patients out-of-state Largely, physicians must be licensed to practice in the state where the patient resides MD-to-MD consultations may be permissible after discussion with the institutional compliance department CMS has relaxed some of the regulations around state licensure limitations; these will need to be continuously monitored With potential benefits, including cost-savings, patient satisfaction, reduced wait-time, diminished travel time, and reduced lost work-time, telemedicine has significant potential.17 Telemedicine is cost-effective, efficient, and of value, but its widespread adoption is limited due to barriers in policy, regulations, and licensing requirements.3 Future directions must emphasize resource availability, policy and regulation barrier reductions, and a universal approach to the billing and payment of services rendered remotely. With a coordinated effort, clear understanding of limitations and roles, and buy-in from stakeholders, telemedicine can revolutionize neurosurgical care in our present pandemic and beyond. CONCLUSION We recognize the importance of adaptability and resourcefulness during the COVID-19 pandemic. We highlight telemedicine and the increasing role it will play in American healthcare, emphasizing key considerations when applied in neurosurgery, potential pitfalls, and areas for future advocacy. The experiences learned in the present environment may compel long-term advancements in telemedicine. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.