Teleneurology

[janjun18]

Does anyone here have recent experience with working Teleneurology full time? I hear that the work load can be intense with taking calls from the different hospitals. The one company I'm looking at is Tele-specialists. Has anyone heard of them? They look like they've been around for awhile but I heard that some Telemedicine companies don't last long.

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[JumpingLumberjacksofMaine]

I will be working with that group. They seem very stable and to be creating a scale-able model--I'm not so much worried about it being a "fly by night" company, as I am about losing skills that can't be replicated with telemedicine (certain portions of the exam--esp neuromuscular, outpatient issues, EMG). Feel free to send me a message if ?'s.

 

[Postictal Raiden]

I will be working with that group. They seem very stable and to be creating a scale-able model--I'm not so much worried about it being a "fly by night" company, as I am about losing skills that can't be replicated with telemedicine (certain portions of the exam--esp neuromuscular, outpatient issues, EMG). Feel free to send me a message if ?'s.

Will this be your side gig or FT job?

 

[Telamir]

I don't know how I feel about it, if I'm honest. Teleneurology is perfectly fine when it comes to evaluating stroke, but I feel it has its limitations for regular consults regarding physical exam, navigating new/confusing EMRs, etc. Also the few gigs I've heard of you get paid a rate to be on call, which is fine, but then you get X for a call, and X + Y if it's a TPA case, and X + Y + Z if it's a TPA + thrombectomy case which I find incentivizes giving TPA for things that are clearly not stroke (migraine, finger tingling, conversion, etc) which then puts whoever is on the followup end in a crappy position having to explain that to the patient. Anyway, this is what I heard from friends who do telemed, if it's not the case let me know. I'd love to be wrong.

 

[JumpingLumberjacksofMaine]

With this company at least it is not in anyway based upon giving/not-giving tpa, endovascular or not. No concerns in that regard. It is based on whether the consult is "stat" or not--I think this classification isn't even up to you, it's up to the hospital requesting the consult.

For TS compensation has a certain floor amount--which I'm told is almost never needed, as compensation based on productivity is usually significantly higher. They were very open with their numbers in this regard (in general, I've found them to be very open and aboveboard about everything). It started as a practice of 5 neurologists who evolved into tele-from coverage of local hospitals--I do get the feeling that they still have that small group, collegial mentality, and their turnover has been supremely low. As far as the EMR, we'll see, but I've been told that around 3-4 EMR systems comprise 98% of their business (Epic, Cerner, Sorian and some other one I can't remember)--I'm decently familiar with two already. I'm sure it will be a pain, but I figure I'll get the hang of it.

I'm happy to talk more, especially after I get started and get some experience under my belt. We'll see how it goes. I didn't have a lot of options as I am very geographically restricted for family reasons, and my city is a two-horse town for neurologists (excellent academic center, though compensation is pretty low; private hospital with some issues). I think I'll miss seeing patients (and doing EMG's), but I may try to keep that going in some way on the side (the nice thing about tele is when you're off, you're off--just like an ED doc).

 

[DocMom1]

My friend who graduated from residency here in Florida is a stay-at-home mom to her 3 kids and does part-time teleneuro 10 hours per week; her rate is $300/hour and so she ends up with $3000/week :: $156k/year.

 

[janjun18]

With this company at least it is not in anyway based upon giving/not-giving tpa, endovascular or not. No concerns in that regard. It is based on whether the consult is "stat" or not--I think this classification isn't even up to you, it's up to the hospital requesting the consult.

For TS compensation has a certain floor amount--which I'm told is almost never needed, as compensation based on productivity is usually significantly higher. They were very open with their numbers in this regard (in general, I've found them to be very open and aboveboard about everything). It started as a practice of 5 neurologists who evolved into tele-from coverage of local hospitals--I do get the feeling that they still have that small group, collegial mentality, and their turnover has been supremely low. As far as the EMR, we'll see, but I've been told that around 3-4 EMR systems comprise 98% of their business (Epic, Cerner, Sorian and some other one I can't remember)--I'm decently familiar with two already. I'm sure it will be a pain, but I figure I'll get the hang of it.

I'm happy to talk more, especially after I get started and get some experience under my belt. We'll see how it goes. I didn't have a lot of options as I am very geographically restricted for family reasons, and my city is a two-horse town for neurologists (excellent academic center, though compensation is pretty low; private hospital with some issues). I think I'll miss seeing patients (and doing EMG's), but I may try to keep that going in some way on the side (the nice thing about tele is when you're off, you're off--just like an ED doc).

Can you let us know how it goes once you start in terms of how busy it is? Was thinking of maybe doing telemedicine Part time if the pay is good enough and if it's not to stressful.

 

[Phantom Spike]

I will be working with that group. They seem very stable and to be creating a scale-able model--I'm not so much worried about it being a "fly by night" company, as I am about losing skills that can't be replicated with telemedicine (certain portions of the exam--esp neuromuscular, outpatient issues, EMG). Feel free to send me a message if ?'s.

The other big company recruiting for teleneurology is SOC Telemed. Did you also consider them? If so, how do the two compare?
Was the application/credentialing process for Telespecialists particularly onerous? Is there a lot that needs to be done before they hire you?
I have also heard that you will need to get privileged at a mind-boggling number of hospitals to work for one of these companies. Is that a concern? If you decide to go back to a traditional Neurology practice some day and have to apply for privileges at a new hospital, I would imagine that the mountain of paperwork that your prior (teleneurology) work history would generate would pose quite a challenge.

 

[neurochica]

You also need to be careful as these companies have a non compete clauses with their hospitals and within 50-100 miles of each sites. These companies might have 200 hospitals around the country to you fully credential and thus might be hard to get a job at your desired location of this doesn’t work out for you.
good luck!

 

[JumpingLumberjacksofMaine]

I figured I owed everyone a reply after completing some work with the company.

Thus far--and I'm not trying to be a salesman here--I think it's been even better then expectations, though I could certainly see how it wouldn't be everyone's cup of tea.

On shift is very busy, especially because I tend to write more thorough notes and go back into the chart fairly extensively. My main worry is that I would not be able to provide quality of care via a telemedicine platform, at the pace required to make decent income (it is productivity based, above the floor), especially using the different platforms. Thus far, that has not been an issue--I've been able to do enough that I'm happy with the income I made, especially given time spent, and I'm satisfied that I provide good quality of care with a few exceptions (see below). But when I was on, I was really moving quickly (YMMV--because of my OCD tics, I tend to be fairly slow, and I can't stand getting too far behind on notes). For me the key was to pre-round well and leave a skeleton note ready to go the next day.

I never thought of myself as being particularly good with EMR, but it hasn't been much of an issue. I did worry about this upfront, especially given the speed issue as above, and so I took the time to really familiarize myself with the quirks of the hospitals I was rounding, making notes to myself about how to access, etc. Really though, thus far Cerner is Cerner regardless of hospital system--I had a passing familiarity with it from a few years ago so maybe that helped a bit, as did some googling for generic Cerner tips. Epic is my "native language" of EMR's, so no problem there. Meditech is incredibly archaic in a way that literally takes me back to my childhood in the 80's (no joke--it's clearly MS-DOS based--wow!), but so archaic and simplistic that I didn't have too much trouble dropping a note, putting in a few orders, finding and accessing labs etc.

As far as getting onboarded at different sites/hospitals/states--basically their credentialling dept is the main clearing-house taking care of that and then you do random signatures, tests/CME for each state/hospitals quirky requirements as needed--fairly minimal effort on my part, though I do have to be up on checking email.

I don't have the exact contract in front of me regarding non-competes, but I think that basically you can't join a different telemedicine company (I think for a year), or practice for a hospital that is currently a client--I don't think there's a restriction about the number of miles around the clients or anything like that.

Downsides:
--Assessing patients with giveway/functional weakness is very difficult
--I did a lot of neuromuscular stuff (clinical neurophys fellowship)--on the relatively few cases that are peripheral/neuromuscular it just doesn't lend itself to tele-consults
--Vertigo--Dix-Hall-Pike, Epley--I used to like this (I mean initially in my career I hated it, then I started to like it as I studied up on it) is a difficult assessment
--Mainly I'm worried about skill atrophy for the above; at some point I'd like to open a very small outpatient practice to keep EMG and other skills up (either working with a group in town, or through the local academic hospital)--I really enjoy the physical exam part of neuro, and I don't want to lose this
--There is always going to be a threat that something in medicine will change the business model and make tele more difficult; or the tele-neuro-companies could consolidate and the easiest way to improve the bottom line is to squeeze the neurologist salaries--I haven't seen/heard of this yet, but it's certainly possible

Lots of other details, but this post is getting long already. Feel free to reach out for more info.

 

[JumpingLumberjacksofMaine]

Re: PS comments. Credentialling has been surprisingly easy/not a big deal.

I didn't consider the other company, though I have thought about teleneuro companies in the past. I'm in a bit of a unique situation in that I am very anchored geographically for family reasons, in a state and in particular in a city that isn't great for neurologists (one very large academic department--great dept and I trained there, but you have to accept the academic salary which is a big disadvantage if you just want to be clinical; one private hospital system that I worked for that has a relentlessly political neuro dept, very poorly managed with excessive doc/employee turnover). So yeah, options were limited.

I'd have to guess that the hospital employer would mainly be interested in the fact that I worked at Telespecialists--I don't think they'd overly care about the number of different hospitals. I suppose an exceptionally OCD credentialling dept could insist that I fill out the different hospitals I was credentialled at and not accept TS as the overall employer of record. I'm more worried about not doing live patient care and then trying to go back to it if things change--I have to figure I have somewhat of a shelf life in that regard, though locums/part time etc would probably help there.

 

[Phantom Spike]

I figured I owed everyone a reply after completing some work with the company.

Thanks very much for your input, your comments have been immensely helpful. A few more questions if you don't mind.

How many hospitals are you "rounding at" a day? Are you able to complete rounds at one hospital and then move to another, or are you switching back and forth between patients? The way I manage rounding on an inpatient Neurology service is to print out a list, create a handwritten "skeleton note" for each patient by reviewing the entire medical record (unless I find one of my own old notes on that patient, in which case I wouldn't need to go back any further since I would have already done that when I created that old note) and then look at the information from current admission. I like to sit down and do this for all patients at once at the beginning of the day and then start rounding, so that the actual rounds themselves go much quicker since you're not sitting down at a computer in between each patient. At the end of the day I sit down and do all my dictations at once by hospital phone system. Is this system feasible with the Teleneurology group you work with? I understand you have a rounding nurse to push the cart around and examine the patients with you. How do you decide what time to make contact with this nurse during your shift, etc.? And who decides that?

Re: credentialing, if for example, they're going to have you get privileged at 150 hospitals and licensed in 15 states, will your references be getting 200+ forms to fill out? Or will the hospitals simply accept the central credentialing done by Telespecialists?

And re: non-compete clause, if there's no geographic component, that's certainly reassuring, but will you have a say in what states/hospital;s they assign you to? For example, if there's a certain area, city or hospital you might want to work in some day, can you request that you not be be asked to work there through them? Although if it's only a year, that may not be a deal-breaker.

Thanks again for your feedback!

EDIT: Oh, and another question; are you rounding at the same hospital for a reasonable time period? For example, a week or two weeks at a time? I guess I mean, do you get to follow-up and sign off on cases, etc., and how is sign-off between the neurologists handled? And do you get any breaks for lunch, etc. during your 12-hr shifts like a traditional hospitalist would?

 

[neurochica]

What is your schedule like?
Are you rounding and doing strokes at the same time?
What is your patient load per day?

As a career locum doc, I will tell you that you will have to provide a reference form from each and every hospital you ever credentialed. your employer can help with that, but there is no way around that. I tried it before, I worked for x locum company in a number of different hospitals etc....please use locum company for reference. NO GO.

Happy to hear this is working for you. Are you in Portland ME?

 

[JumpingLumberjacksofMaine]

Apologies--I'm so bad at checking in.
;
Phantom spike--specific workflow is a bit of a longer convo--feel free to shoot me a message and we can plan to chat by phone. I'm early on enough that my workflow is evolving.

Neuro chica--there's different options--one is ppl who are mostly responding to acute emergencies (probably 80% stroke vs stroke mimic) + a few follow-ups. A different group does mainly rounding. You're only on one "case" at a time, and usually via nurse managers they try to minimize interruptions (e.g., calling back a doctor for a patient you saw who has a question; dropping everything in the middle of rounds for a true stat), but basically the division between ppl just doing stroke/acute stuff and ppl just doing more routine stuff has, thus far, minimized the bouncing back and forth.

I will say the pace is fairly intense, though again, I'd say I'm on the more OCD/slower side. I'm still getting more efficient, but my most recent 12 hour shift I saw 30 pts, roughly 1/3rd new--much more then I've ever seen live. Definitely at the end of 12 hours I'm pretty worn out, but if I can do it I'm sure most people would do just fine. The appeal though is that I'm either totally on, or totally off. No being on-call, responding to patient messages or the like. My schedule is 7am-7pm, 7 on/7 off.

That is absolutely crazy to hear about the reference from all hospitals--one tiny silver lining of the coronavirus issue is that it may clear up some of the licensing/credentialling insanity. Probably more going from state to state then hospital to hospital though.

 

[cerebral edema]

My friend who graduated from residency here in Florida is a stay-at-home mom to her 3 kids and does part-time teleneuro 10 hours per week; her rate is $300/hour and so she ends up with $3000/week :: $156k/year.

really? Mind giving out the company name?

 

[neurochica]

My friend who graduated from residency here in Florida is a stay-at-home mom to her 3 kids and does part-time teleneuro 10 hours per week; her rate is $300/hour and so she ends up with $3000/week :: $156k/year.

i would also like to know the Name is this company.

 

[Neurogeneral]

I will say the pace is fairly intense, though again, I'd say I'm on the more OCD/slower side. I'm still getting more efficient, but my most recent 12 hour shift I saw 30 pts, roughly 1/3rd new--much more then I've ever seen live. Definitely at the end of 12 hours I'm pretty worn out, but if I can do it I'm sure most people would do just fine. The appeal though is that I'm either totally on, or totally off. No being on-call, responding to patient messages or the like. My schedule is 7am-7pm, 7 on/7 off.

I think generally speaking that is the typical volume for these 7 on/7 off neurohospital jobs. For the compensation that they offer, the number of patients you end up seeing is roughly double what you would end up seeing if you were working every week. So instead of 15 to 20 patients per day, you end up seeing 30 to 40 patients per day. Obviously, the benefit is you are off half the time.

 

[Postictal Raiden]

I think generally speaking that is the typical volume for these 7 on/7 off neurohospital jobs. For the compensation that they offer, the number of patients you end up seeing is roughly double what you would end up seeing if you were working every week. So instead of 15 to 20 patients per day, you end up seeing 30 to 40 patients per day. Obviously, the benefit is you are off half the time.

Most people I know that do neurohospitalist see less than 20 pts a day, some far less. All make 300k+.

I can't imagine seeing 30+ hospitalized patients a day.

 

[JumpingLumberjacksofMaine]

Teleneuro visits tend to be quicker in my experience.

For me, it's been a big boost in pay, especially relative to hours worked. That said, I'm in a low paying area of a low paying state in a department that had a lot of politics and very high turnover of staff at all levels. Family reasons meant I was very geographically restricted.

So far I've really enjoyed it; my one quibble is I miss doing some of the things--in-person exams, LP's, EMG/NCS--that I used to do and really don't want these skills to atrophy.

 

[Neurogeneral]

How are you guys billing these televisits?

I mean, are you still able to bill at the same level for each televisit as you would in person? I mean, I have been told that it is best to bill by time, but that can be quite limiting from my experience because I end spending less time face to face with the patient and the amount of counseling and coordination of care can be quite variable.

I recently started to bill at least some of the virtual visits based more on the history , exam, and medical decision making. I can’t do a full neuro exam as I can’t check the fundus. Instead I do a slightly abbreviated neuro exam but also cover 7 additional systems (vitals, general, psych, cardiovascular, HEENT, Neck, extremities, Abdomen, skin, etc).

Any feedback or advice on this matter?

 

[JumpingLumberjacksofMaine]

As far as I know none of my work is billed to an insurance company--the hospital eats the cost. Some of the telestroke acute visits may be billed though, and this may change in the future.

This is another side effect of cognitive care being so de-valued, IMO. For strokes, the saying that I always heard is that with stroke admits, the radiologist gets paid the most for reading the CT and MRI, then cardiologist gets paid the second most for reading the echo, and the stroke doc who has the patient on their service for a couple of days gets paid the least. So I think hospitals are A-ok not being able to bill for in-person or tele services as long as they can keep the stroke business in-house.

I read an article once that stated medicare/medicaid spending for radiology exams ordered by neurologists was about twice what they paid for any services (all inpatient/outpatient visits, EMG, EEG etc) performed by neurologists. So yeah, from a strict financial/RVU standpoint, what we do is pretty negligible for the hospital bottom line, so having unbilled tele visits isn't a big deal.

 

[Neurologo]

Most people I know that do neurohospitalist see less than 20 pts a day, some far less. All make 300k+.

I can't imagine seeing 30+ hospitalized patients a day.

I second this. One should not see more than 15-18 cases a day. For small to medium size hospitals, one typically averages 5 to 12 cases a day. If more than these, one should get paid per cases rather than a set salary/fee. Otherwise you are being robbed.

I did talk with Tele-specialists a while back. At that time I was put off by the fact that they were not only doing tele for emergent cases but also rounding daily via tele. But now that is becoming more common I guess. Good for their business. But I still prefer tele service for only emergent calls and in-person visits for rounding to ensure reliable exams and decision making. For clinics, those cases that do not require in depth neuro exams can all be done via tele. But not for those that require checking reflexes, tonicity, and distribution of sensory defects.

 

[JumpingLumberjacksofMaine]

A couple of points.

I worked as a quasi-neuro-hospitalist for a couple of years--both a medium sized hospital (200-300 beds) and a tertiary/non-academic hub (450 I think?), so this is what my comparative experience is based on.

Regarding volume, I would say that it is about as busy as I was on a fairly busy service in residency or as an attending. If this were structured week in, week out then I think burnout and inevitable sloppiness that comes with overly high volumes would be an issue. I honestly don't think this is the case--tele visits are quicker and less of my day is caught up in mundane stuff that doesn't directly affect care of the hospital patient--random paperwork, hospital mandatory meetings, or just physically going to the different rooms. Also, the above number is a significant outlier, not the average. The end result is that I'm busy, but I'm able to maintain quality of care (no one can objectively rate themselves here, but as far as thoroughness at least, I was always on the OCD end of the spectrum, and I haven't had to compromise this).

I somewhat hear you regarding the in-person versus tele difference--ideally every place that can support a neurologist full-time would, with tele reserved for places that are too small to allow for this. But tele allows the small hospitals to avoid the expense of transferring a patient for a lacunar stroke, or an isolated seizure (probably 20 years ago these would have been managed comfortably by the hospitalist, but times have changed and it was always a losing battle to manage by phone).

The three areas of shortcoming I run into via tele are vestibular disorders, neuromuscular disorders and somatic disorders; being able to do a fundoscopic exam is missed as well (there are technical solutions to all these--non-mydriatic photography, automated HINTS testing etc). Certainly there may be some degree of over-imaging in these cases, though given current trends, probably not as dramatic as previously. I was fairly conscientious about getting patients out of the hospital and avoiding extra testing in-person--now less so as I have less of an exam to document why the million dollar workup is unnecessary.

In all, I think my biggest concern going in was that I wouldn't be able to provide quality and that I'd be more of a "rubber stamp" neuro consult that let hospitals keep stroke patients for the lucrative imaging/echo etc billing. Obviously I'm biased, but I think it's still possible to do a quality job, with some minor quibbles as above. IMO the issue isn't so much teleneurology, as that neurology has been always treated as a commodity good where volume and pace really outweigh any gradations in quality--cursory examinations and by rote assessment and plans happen in person just as well as remotely.

 

[Neurogeneral]

As far as I know none of my work is billed to an insurance company--the hospital eats the cost. Some of the telestroke acute visits may be billed though, and this may change in the future.

This is another side effect of cognitive care being so de-valued, IMO. For strokes, the saying that I always heard is that with stroke admits, the radiologist gets paid the most for reading the CT and MRI, then cardiologist gets paid the second most for reading the echo, and the stroke doc who has the patient on their service for a couple of days gets paid the least. So I think hospitals are A-ok not being able to bill for in-person or tele services as long as they can keep the stroke business in-house.

I read an article once that stated medicare/medicaid spending for radiology exams ordered by neurologists was about twice what they paid for any services (all inpatient/outpatient visits, EMG, EEG etc) performed by neurologists. So yeah, from a strict financial/RVU standpoint, what we do is pretty negligible for the hospital bottom line, so having unbilled tele visits isn't a big deal.

So my understanding is that your company has a contract with multiple hospitals to provide neurology coverage and they pay your company a certain rate for the number of consults seen or maybe even a flat fee for yearly coverage.

I am surprised though that your telemedicine company does not bill the visits itself. That’s still decent money left on the table. With these inpatient neuro consults, they are almost always level 5 in terms of billing. And now virtual visits can be billed at the same rate/level as an in-person visit...

 

[Hockeyfan23]

Sort of new to this whole thing but very interested. I’m finishing residency next year and going to start my job as a neurohospitalist in my home state Next July. I have already been asked to possibly help with night and weekend coverage for the teleneurology program within my current system after residency. I am not planning on doing fellowship but was wondering if that is necessary for most teleneurology positions? Or is it okay to have neurohospitalist/tele experience in place of a fellowship (ie: stroke)?

 

[JumpingLumberjacksofMaine]

They probably are starting to drop bills for some of this stuff--I'm new, things have changed rapidly even in a few months. I heard that for the acute/stroke stuff even pre-covid they were sometimes trying to bill their work--that said for my non-acute stuff I haven't been putting in the billing codes like I used to for in-person care.

Obviously YMMV--I'm one guy with one company, and tele-anything has exploded. I guess the only things I can say with certitainty is that for me it's been a very viable career move thus far, the company seems to be run by decent people and I think I've been able to provide a quality service that helps patients. It is different from IRL though; ideally I'd figure out a way to do both.

Feel free to shot me a PM if anybody has any specific questions--neurologists gotta look out for other neurologists.

 

[Phantom Spike]

They look like they've been around for awhile but I heard that some Telemedicine companies don't last long.

From a practical point of view, though, does it really matter if these companies "don't last long"? Unlike a traditional practice, you are not relocating and uprooting your life and family, so if these companies disappear one day, you're back where you started at worst. I would assume that any non-compete clause (forbidding working for another teleneurology company) would also become void in that case. Of course, this is assuming that you had been provided malpractice insurance with tail through a reputable insurance company (which is a prerequisite for any position, virtual or traditional); your malpractice coverage should continue to protect you even if the teleneurology company dissolved.