CONCUSSION CARE VIA TELEMEDICINE EBOOK

Is Telemedicine Right For Your Concussion Care Practice?

While there are many clear benefits to using telemedicine, there are other things to consider when deciding if telemedicine is a good fit for your concussion care practice.

Ask yourself the following questions:

Am I comfortable performing my evaluation or follow up of the patient using telemedicine?

It’s important that the healthcare provider conducting telemedicine visits be comfortable using the technology and carrying out the visit. Ideally, this person would be a Credentialed ImPACT Consultant (CIC) – a qualified healthcare provider who has been specially trained in the management of a concussion. If this is not you, is there someone on your team who could meet this requirement?

What parts of my concussion evaluation and follow up can be done or can’t be done via telemedicine?

You may find that telemedicine is more appropriate for some aspects of your concussion care than others. For example, you may feel confident in using telemedicine to monitor an existing patient’s progress, but prefer to conduct a new patient evaluation face-to-face.

Is telemedicine appropriate for my patient?

Telemedicine will be more appropriate for some patients than others. Some considerations will include access to technology, risk of injury due to significant deficits, and need for supervision by a parent or caretaker.

Have policies and procedures been put in place for dealing with disruptions and impediments to my telemedicine appointment?

For example, technical issues may cause appointments to be rescheduled. What will your cancellation policy be?

What legal issues will govern my telemedicine practice?

State laws determine the who, what, and how of your telemedicine practice including reimbursement and policies covered. Laws and regulations will be based on the state that the patient is located, not the provider. Thoroughly research state laws that govern telemedicine before deciding on the scope of your telemedicine practice.

What kind of technology will you need to conduct concussion care via telemedicine?

In order to have a successful telemedicine program you’ll need to have the appropriate technology.

• Bandwidth. All transmissions, and particularly video transmissions, are heavily impacted by bandwidth issues. It is important to test your clinician-side internet speed and connections.
• Patient-side Connectivity. It is recommended that patients use a private WiFi or hard-wired connection rather than working on a public WiFi.
• HIPPA compliance. It’s the responsibility of the healthcare provider to follow privacy guidelines and convey those to the patient.

ImPACT Via Telemedicine

Bench studies have shown no significant difference with ImPACT taken at home versus in a controlled environment, however, there are still steps you can take to minimize threats to validity. 

• Before the patient completes the test, review the test instructions with them and ask them if they have any questions. (They will also receive detailed test instructions in an email alongside their unique testing link that they are required to review before taking their ImPACT baseline or post-injury test.)
• Make sure patients have the needed equipment and meet technical requirements.
  • Make sure they are using either the current version or the immediately previous version of their browser
  • If they have a pop-up blocker installed, they must turn it off for the duration of the test
  • Their browser must accept cookies
  • JavaScript must be enabled in their browser
  • Close all other computer programs before taking the test
  • They need a broadband Internet connection
  • The screen must be 12 inches or larger
• Make sure patients have a suitable environment in which they can complete the test.
  • The physical environment should be quiet and free of noise.
  • All cell phones, music players, and other electronic devices should be turned off.
  • The test taker should not be engaging in another activity or conversing with others.
  • Testing outdoors in direct sunlight is not recommended due to potential issues with glare.

• Instruct the patient not to complete testing after vigorous exercise, under the influence of alcohol or recreational drugs, or if not well-rested.
• Supervise test administration via video call.
• Take advantage of ImPACT’s built in validity indicators to screen for invalid scores that need to be re-done.
• Document any threats to validity that might have occurred.
• Once you feel confident that all requirements have been met, you can administer an ImPACT post-injury test via telemedicine.

Telemedicine Appointment Workflow

When incorporating a telemedicine component in your concussion care practice, it’s critical to have a reliable workflow in place. Here is a typical concussion telemedicine appointment workflow:
 
Referral and intake
 
The first step in any telemedicine workflow is determining whether your patient is appropriate for telemedicine services or not. Here are some questions to ask when determining if telemedicine is appropriate for your concussion patient:

• Is their clinical and cognitive status suitable for a telemedicine appointment?
• Is there a need for someone else to be present with the patient during the appointment?
• Are there any language barriers that need to be accounted for?
• Do they have appropriate technology and access to that technology for the appointment?
• Do they have a quiet place and/or environment for the appointment?
• Are they willing to do a pre-appointment walk-through to make sure that they meet the guidelines listed above?

If telemedicine is determined to be appropriate, schedule a telemedicine appointment, check the patient’s technical specifications, send out any pre-appointment paperwork such as the post concussion symptom scale, and send their unique ImPACT post-injury test link.
 
One day prior to the scheduled appointment, give the patient a call to review how the telemedicine appointment will work and answer any questions. This is also your chance to check again on technical specifications, test environment, and instructions for taking ImPACT to ensure a “standardized” administration.
 
Telemedicine appointment 

1. On the day of the telemedicine appointment, review the patient’s medical history, self-evaluation forms, and ImPACT clinical report.
2. At the start of the telemedicine appointment, review your telemedicine policy with the patient (This should also be included in your documentation).
3. Properly educate your patient on concussions and what they can expect throughout recovery.
   1. Concussion 101 Guide
   2. Concussion Myths
4. Review their medical history with them.
5. Review their ImPACT clinical report with them.
6. Carry out your concussion assessment and evaluation.
7. Provide treatment recommendations. These may include referrals to other specialists such as Neurology, Vestibular Therapy, NeuroOphthalmology/Neuro-Optometry, Physical Therapy, Orthopedics, Audiology, Psychiatry/Psychology, etc…

 
Post-appointment

• Document your telemedicine visit including any disruptions to the appointment.
• Get reimbursed for your telemedicine visit by utilizing the right CPT billing codes.