The American Academy of Neurology’s position paper on Telemedicine:
The American Academy of Neurology (AAN) is a professional organization of
more than 28,000 practicing neurologists and neuroscientists with a deep
and abiding interest in assuring the best possible care of patients with all types
of neurologic disorders. With policymakers at the state and federal levels
considering new policies regarding telemedicine, and with many neurologists
moving to include telemedicine within their practices, it is important for the
American Academy of Neurology to have an official position on the issue in
order to advocate appropriately for its members.
Description of Issue
With telemedicine rapidly emerging as a form of patient care, it is important
that policymakers consider access issues, reimbursement, liability issues, and
licensing across state borders when discussing telemedicine policy.
While telemedicine cannot replace many of the hands-on skills and in-office
assessments neurologists provide, patients in all US states, territories, and the
District of Columbia should have access to telemedicine, regardless of location,
and should have telemedicine services included in all subscriber benefits
and insurance plans (Medicare, Medicaid, and private insurance). Physicians
should be reimbursed equitably for telemedicine services and have access
to a streamlined state medical license process. Comprehensive malpractice
insurance policies are also needed.
Definition of Telemedicine
Telemedicine involves the use of electronic communications—telephone, email,
videoconference, digital imaging, and other forms of Internet technology—
to practice medicine from a location that is remote for the patient. It is an
effective and efficient form of health care delivery, instantly connecting
patients and physicians. The telephone and email are commonly used forms of
communication to address patient care issues and are often used to develop
or share a fairly detailed assessment of the patient’s condition, including
ordering tests, starting or changing medications, with discussions of side effects,
expected effects, etc. Telemedicine is a rapidly developing field, evolving as
communications technologies change. It is enabling high-quality care, often
allowing patients to avoid transfer to another facility while also improving the
financial viability of the hospital that receives the service. Rural populations and
military personnel in combat are increasingly using telemedicine to overcome
barriers of distance and delay by bringing the physician and patient together in
real time. It is used in the inpatient setting to provide care to patients who are
seen in a remote emergency room, or are admitted to a remote hospital for an
acute illness or chronic disorder.
Telemedicine for neurologic care, often called teleneurology, is most often
applied to emergency stroke care and neurocritical care (Ganapathy, 2005). But
it also has evolved to include long-term care for chronic neurologic conditions
such as epilepsy (Ahmed et al., 2008), Parkinson disease (Samii et al., 2006),
multiple sclerosis (Kane et al., 2008), dementia (Loh et al., 2007), and migraine
headaches (Cottrell et al., 2007).
Patients should have access to telemedicine in all states, the District of
Columbia, and US territories, as it is well-suited to provide medical care in
both rural and urban locations lacking access to physician specialists such as
neurologists. Access issues also can affect patients residing in nursing homes
and rehabilitation facilities, as well as those unable to drive due to physical
Legislative action is recommended at both state and federal levels to include the
benefits of telemedicine to populations with limited access to care regardless of
location and the health insurance coverage they might have.
Cost-effectiveness and Reimbursement/Payment Parity
Telemedicine has been shown to be cost-effective, efficient, and equal in
therapeutic value to face-to-face encounters. However, the technical costs and
incongruent physician and hospital reimbursement have been a barrier to further
dissemination. Telemedicine costs include the increased workforce of dedicated
network program managers and personnel, higher estimates of inpatient care,
inter-hospital transfer, rehabilitation, long-term care, caregiver costs, and a
wider range of spoke-to-hub hospital network transfer rates.
Present data support the cost effectiveness of telemedicine for stroke from both
the societal and hospital perspectives. For example, researchers at the Mayo
Clinic have found that rural patients treated for stroke care via telemedicine
incurred cost savings of $1,436 per patient, while also increasing their quality of
life, when compared with seeing the stroke patient in person (Demaerschalk et
These results demonstrate that an upfront investment in telemedicine
technology, connectivity, infrastructure, and stroke network personnel can
be justified in our health system. The AAN supports the reimbursement of
telemedicine consultations in the same fashion as face-to-face, telephonic, and
email clinical encounters.
Liability and Multistate Licensing
Risk management is an important consideration in telemedicine practice, as
physicians could be legally liable across state borders. The major issues include
defining what constitutes telemedicine malpractice and determining where
and against whom claims can be brought, because the care provided as part of
telemedicine may be across state borders.
For example, the decision to administer or not administer thrombolysis for
acute stroke is a prominent source of malpractice claims for neurologists, and
telemedicine physicians managing acute stroke patients may be exposed to FOR MORE INFORMATION
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AAN Legislative Position Statement on Telemedicine 3
complex liability issues. Legislative policies are needed to clarify liability issues in
the practice of telemedicine as well as to protect patients from adverse events.
Broad, comprehensive malpractice insurance policies and clear telemedicine
practice guidelines are required to protect physicians.
Standards for the engagement, training, and supervision of telemedicine
providers are necessary. Advocating for appropriate competency of telemedicine
physicians in evaluation and management; readily available technological
support; careful and detailed informed consent discussions; and detailed,
accurate chart documentation may best protect telemedicine physicians and
patients alike. Guidelines for protecting patient confidentiality and following
HIPAA regulations are important aspects that should be standardized to be
applicable to telemedicine services.
The AAN also supports efforts to streamline state medical license processes for
those physicians looking to practice across state borders and use telemedicine
to treat patients living in rural areas.
Position Statement History
Drafted by Vernice Bates, MD; Pushpa Narayanaswami, MBBS, MD, FAAN; Sarah
Song, MD; Jeffrey A. Switzer, DO; Jack W. Tsao MD, DPhil, FAAN; Tim Miller (AAN
Reviewed and approved by the following AAN Committees: Government
Relations, Medical Economics, Practice, and the AAN Board of Directors.
Ganapathy K. Telemedicine and neurosciences. Journal of clinical neuroscience: Office Journal of the
Neurological Society of Australia 2005;12:851-862.
Ahmed SN, Mann C, Sinclair DB, et al. Feasibility of epilepsy follow-up care through telemedicine: a pilot study