Andrew Lee, MD, Andrew Carey, MD, and Elizabeth Fortin, MD, sit down on this episode of the NeuroOp Guru to discuss neuro-ophthalmology, interprofessional eConsults, and whether they provide timely and valuable guidance
Editor's note - This transcript has been edited for clarity.
Hello, and welcome again to another edition of the NeuroOp Guru. Today, we are very excited to have a new guest. Conductor Drew Carey from Johns Hopkins. Drew. Hi.
Hi, Andy. Thanks for having me. I'm a longtime listener, first time caller.
Well, we're hoping to make the guest conductor role, something of a recurring theme. And Drew you get to be our first guinea pig. And of course, Elizabeth Fortin, our usual NeuroOp Guru. So today we're going to be talking about neuro-ophthalmology, interprofessional econsults, and whether they provide timely and valuable guidance, so maybe Drew, you could just kick us off and tell us what exactly is an interprofessional econsult?
Yeah, I think that's a really important question. So these are consults doctor to doctor with no patient interaction for the consultant. It's something that is newly approved by Medicare as a billable service, where if an ophthalmologist sees a patient or an optometrist sees a patient, and they say, "well, I really like to have the opinion of somebody with specialty training, and I've already done field tests or pictures, and I'd just like to get their opinion, I have this specific question." They could ask a neuro-ophthalmologist a neuro-ophthalmology question. And they could, the neuro-ophthalmologist would be able to review the records and generate a report and send that back to the doctor.
Wow. So it's kind of like a curbside consult.
A formal curbside, which I don't know if that's the sidewalk, or what you call a formal curbside.
And, Elizabeth, have you done any of these econsults?
Elizabeth Fortin, MD:
So personally, I haven't done any of these. So I've done telemedicine, but where I had a direct interaction with the patient, but I have yet to do some of these econsults inter-professionally, actually. So I haven't myself.
And Drew, have you done any of these?
I've done a few for patients seen within our health system. For instance, if it was a patient who came in and had double vision, and they saw one of our optometrists who was, you know, had some expertise in prism measurements, and they did a motility and they said, "Gosh, this doesn't look like a strabismus breakdown. But maybe we should have the neuro-ophthalmologist look at it." And then I could, you know, review the history that they took, the measurements that they did, and I would say, "Oh, this looks like childhood onset fourth nerve palsy, no need for further workup." Or be like, "Oh, that looks like a third nerve palsy, you know, [and] recommend next steps."
So Elizabeth, what did this paper show? Does it work?
So it was a very interesting results. So they evaluated retrospectively 80 inter-professional consults over three years, like you can see in there. And what was interesting is that they were able to provide diagnostic, diagnosis or treatment guidance in, you know, almost half of the patients. So that's a significant proportion of patients. They had to see the patient in about 30% of the cases. And of course, like you can see in the right hand side, sometimes they needed additional testing. So they could provide guidance if the patient needed, for example, neuro-imaging in 34%, visual field in 33%, or OCT or labs in other patients. So it's still a significant proportion of patients that ended up with a diagnosis at the end of the process, which was 75%, I think that we can see on the graph there. But just from the econsult itself, 44% had enough information to provide the diagnosis. So I think it was interesting to see that you know, just with the information provided by other providers, such as ophthalmologists, or neurologists, sometimes you can come to a conclusion and diagnosis. This allows us to have more information than if you're just doing an in-consultation directly with a patient because you can, you know, have the visual field testing, for example, neural imaging, which is a benefit over just a standard econsultation in my sense.
And Drew, do you think this is going to help reduce the backlog that we are all experiencing in NeuroOp or is it going to create workforce?
I think it could help to reduce the backlog. I don't know about your institutions, but at mine, it may be up to six months for a new neuro-ophthalmology evaluation. And if you know the patient was seen in a glaucoma clinic and they said, "Oh, we don't know if this optic neuropathy is glaucoma, but we already did fields, and OCTs and photos, we could review that relatively quickly without having to do you know, the whole history, had the patient come into the office. And in this paper, they were able to do very quick turnarounds for these evaluations. And so I think this may really help to reduce some of the lower priority referrals and provide reassurance to the consulting doctor and even the patients and also help to expedite the urgent things. Just you know, say like hey we laid eyes on this, this is something we need to get an expedite or send to the ER.
The reimbursement the patient gets a bill for this, or the doctor?
What's interesting is the doctor requesting that consult has a CPT code that they can generate. And the consulting doctor, the neuro-ophthalmologist that does the review has a CPT code they can generate, and then the insurance and patient get billed. And so the doctor requesting the consult does have to disclose that to the patient that they are going to request this consult and their insurance would be billed for it. Just like they should disclose if they're going to order an MRI scan or visual field test that that's a medical test that's going to have a bill generated for it.
And Elizabeth, do you think this would work in the Canadian system, too?
It would be interesting to see because actually telemedicine has some codes for them, but interprofessional econsults. Not to my knowledge yet. I think it could and it could really help the shortage of neuro-ophthalmologist that we have also in Canada. But I would be interested because to my knowledge interprofessional econsults don't have a specific code front for the moment.
I think it's fascinating. And I think we got to need a follow up on this to see if it can really pick up some steam and momentum and if other people have a similar type of experience. But I think it's fascinating, and it's a very interesting project. And I want to thank my guests, Drew Carey. Thanks for joining us, Drew and Elizabeth as always, and we'll see you guys next time on the NeuroOp Guru.