Remote Neuromonitoring Survey

Results are in from the latest neuromonitoring survey! This time the questions focused on the “remote” model of neuromonitoring supervision.

Survey Description

I recently published a few questions on Survey Monkey and then contacted folks on LinkedIn and Facebook, asking them to complete the survey. Because I got so many responses, I decided to publish answers to each question separately. This is just the first of several surveys that I have planned to address different topics.

My survey began with the following instructions:

Neuromonitoring is performed in approximately 700,000 surgeries annually in the United States. Approximately 75-80% of those surgeries are monitored remotely, meaning that “supervision and interpretation” of IONM is provided by a physician through an internet connection. The following questions are posed in an effort to understand what IONM practitioners at all levels think about this model and its efficacy in term of delivering quality patient care. As always, responses are completely anonymous.

My Comments About the Survey:

Just on thing that I want to communicate about the survey. Unfortunately, there were quite a few people who took the survey thinking that “remote monitoring” meant that the supervisor was down the hall watching the case via internet, as opposed to watching the case from a different state…truly a remote location. When the supervisor is down the hall, or even in a different building, this is considered “onsite” supervision, and a lot of people who took the survey fall into this model. When the supervisor is onsite, they can pop into the OR whenever, and they usually have a rapport with the surgical team, neither of which is true or possible in the remote model. Nevertheless, given the variety of responses, I think I got a decent sample of different opinions. Please don’t confuse this with having a decent sample of the population. That’s not what I’m saying. In all, 54 people took the survey. I did not take it; rather, I’ve added my own comments under a different heading. As always, responses are anonymous.

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[toggle title=”Question 1″ open=”yes”]

Regarding supervision and interpretation of IONM, how do you think the remote model (via internet) compares with the onsite model (in the OR) in terms of quality of patient care?

My Comments:

I could have worded this question more clearly. As stated above, I should have indicated that “onsite” meant “in the hospital” instead of “in the OR”. One thing that really surprised me is that a couple of people thought the “remote” model was better for patients. Interesting.

Results:

Q1J

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[toggle title=”Question 2″ open=”no”]

A neuromonitoring team frequently consists of a neurophysiologist or technologist in the OR, and a physician remotely monitoring the case. What do you think is the current role of the monitoring physician?

My Comments:

I got a lot of e-mails from people who contested the wording of this question. What I should have done is emphasize the word “OR” between “neurophysiologist” and “technologist”. In their e-mails, many argue that a monitoring physician has very different roles in working with a neurophysiologist versus a technologist. In the former situation, many argue that the physician is there only for billing, while, in the latter situation, they argue that the physician is actually there for supervision and interpretation.

Executive Summary:

Responses were split down the middle. Some argue that the physician has no purpose other than billing, while others argue that their role is supposed to be more involved.

Individual Responses:

  1. The monitoring physician must be present in the OR.Remote monitoring, especially the commercially driven monitoring, could be extremely dangerous to the patient.
  2. The monitoring physician’s role is to provide a medical diagnosis in the event of an adverse change in data.
  3. Currently, the role of the monitoring physician takes form of the final arbiter for interpretation of changes in signals, whether they be surgical or otherwise, and to determine whether or not surgery should be redirected based on these changes.
  4. Billing. [I’m] really not sure what other functions [are] served.
  5. Primarily for billing and liability purposes. However, a select few of the monitoring physicians provide valuable input and education to the monitoring personnel.
  6. Not much if the person in the OR is a well trained Neurophysiologist (advanced degree).
  7. 90%-formal presence, 3%-real help when necessary, 7%-Source of frustration and distress
  8. #1 an NPI number #2 a consultant
  9. If the person in the room is board-certified (D.ABNM) with a doctoral degree (PhD, AuD, etc.), then there is no need for a remote physician other than billing.
  10. For Liability mostly. Remote physicians should ideally have some experience with IOM in the operative setting, preferably from some form of Neurophysiology fellowship . If not then there’s limited expertise they can offer.
  11. Supervise live iom
  12. If a doctoral level neurophysiologist is in the OR there is no need for a remote physician.
  13. Confirm baseline signals at the beginning of the case, and help reassure signal changes and help troubleshoot with technologist.
  14. To corroborate with the monitoring technician of the findings of the case and communicate any discrepancies and/or call attention to any changes that may occur.
  15. Supervise case and provide advice / diagnose changes
  16. Confirm quality of waveforms and provide a second set of eyes
  17. The PRIMARY role of the Supervising Neurophysiologist (licensed physician or delegated doctorate-level neurophysiologist) is to be IMMEDIATELY AVAILABLE to: (1) guide and advise the technologist; and (2) verbally consult (in person, over the phone, or other telecommunication methods) with members of the surgical team (surgeon, anesthesiologist, etc.) regarding the nature of a critical event and the IMMEDIATE CLINICAL IMPLICATION or PROJECTED OUTCOME of that event. The other roles include assuming the medical-legal liability of the clinical impression and the proper coding of the insurance billing.
  18. Professional back up neurologic support for the technician and surgeon.
  19. To support or deny any changes, to be an extra set of eyes and give suggestions to trouble shooting
  20. To provide oversight and recommendations to the technician. This is limited because if the high case count that they are monitoring at one time leaving gaps in time when you need assistance it’s not airways immediate which can be harmful to the patient.
  21. Currently, the role of the neurophysiologist is to make final decisions as it relates to the changes in data
  22. To interpret the data legally.
  23. The physician is responsible for interpretation of the neurophysiologic data acquired during the case.
  24. In my experience, the monitoring physician generally confirms the tech’s impressions of the data and occasionally makes interventional suggestions.
  25. To make money, by “interpreting” by the means of agreeing or disagreeing with the neurophysiologist or technologist that has literally done all of the work.
  26. It depends on the training and experience of the physician. Very few physicians have a professional history, which qualifies them to understand the nuances of IONM via a remote connection. Ideally, the remote physician should assume a vast majority of the responsibility for interpretation, diagnosis, and interventional strategy suggestion for cases. However, the practical application of this model is inconsistent, at best. Some remote physicians do little more than acknowledge statements from their OR clinicians while others may demand that technologists actually verbalize interpreter statements word-for-word to the surgical team turning the technologist into little more than a mindless puppet.
  27. A second opinion when there is some change or something unusual on the recording
  28. Some provide good support to the IOM professional in the OR. However, most are not able to help and can perhaps hinder as they are out of context. There is no other profession that claims to be relevant in such a way remotely. They largely leave the work and interpretation to the IOM professional in the room. They should be an extension of the OR personnel, providing relevant and timely information when needed. Sadly financial concerns dominate this relationship, rendering it of very limited use to patient safety.
  29. Determine possible neurological deficits or complications
  30. Constant live back-up and communication interpreting/discussing the data and to educate technologist as appropriate
  31. To oversee monitoring quality during the procedure and determine when alert is indicated.
  32. He oversees the neuromitoring session. He communicates with the technologist and the surgery team when necessary
  33. Billing proposes
  34. To be available for cases in real time when on line
  35. To develop relationships with surgeons and technologists and act as a knowledge source for both. To be the third member of the team comprising tech, surgeon and reading physician.
  36. We don’t have remote monitoring system.
  37. To provide the differential working diagnosis when there is a surgical event.
  38. Aid in interpretation of monitoring when equivocal findings are found
  39. They are there to give support. With past experience the surgeon listens to the tech more than the supervising remote physician if they don’t know the doc. If you have a good remote physican they will be with you every step of the case and give you he fed back and guidance needed when issues arise.
  40. It is an unnecessary redundancy that had created incentives for unethical practices
  41. To differentiate exogenous from endogenous cause for change in electrophysiologic data, to differentiate peripheral from central locus of change in electrophysiologic data, to identify and rule out possible causes of data changes, to generate and prioritize therapuetic options, to evaluate to effect of therapuetic actions upon neurophysiological status, and modifiy and guide further additional therapuetic interventions; all while maintaining communication wih the surgical team via the in-room technical support personnel.
  42. It’s absolutely pointless. They never answer in real time and they never make interpreted comments. I feel like they are there for legal purposes.
  43. Nothing significant. A well-trained Physiologist is good enough. Physician is just in there for monetary reasons.
  44. The interpreting physician is charged with evaluating the data that the monitoring clinician collects and making a determination about the quality of the data in relation to technical and/or iatrogenic events.
  45. To provide oversight for the neurophysiologist onsite, give a second opinion on signal changes, or to concur with the technologist’s interpretation for documentation purposes.
  46. Not as much as it should be. They say hello and thank you at the end and maybe “Looking good. “
  47. To oversee and interpret the neuromonitoring signals along with the neurophysiologist and be a 2nd set of eyes and help out with any issues that might occur during the case.
  48. Backup for technologist if medical advice is needed
  49. Interpreting data with patient’s clinical condition especially in the context of the surgical procedure being performed. Advising the Neurophysiologist as to appropriate modalities and timing of the modalities being performed. Advising on proper and timely documentation, issuing alerts and commenting on potential outcomes based on the neurophysiological data.
  50. Their role is twofold. Obviously, they enhance revenue capture and are ubiquitously used to make IONM more profitable. Also, as the quality of the tech or neurophysiologist in the room has steadily declined over the years, they can be used as quality oversight when/where appropriate (assuming the remote person is adequately trained themselves.)
  51. Ensuring the signal quality at the beginning and remotely comparing actual waveforms with baselines.
  52. They are there for billing purposes.
  53. Rubber stamp for billing. Not really needed.
  54. Having a supervising physician lends credibility to the field and gives the technologist a resource of sorts for questions, concerns or even ideas.

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[toggle title=”Question 3″ open=”no”]

What is the current role of the Neurophysiologist or Technologist in the OR?

My Comments:

Again, I got a lot of e-mails from people who contested the wording of this question. In their e-mails, many argue that the role of a neurophysiologist (PhD) is to supervise and interpret, while the role of a technologist is to set up electrodes and run tests. Some people point out that the technologist does all/most of the interpretation, anyway.

Executive Summary:

Responses varied widely.

Individual Responses:

  1. Define Neurophysiologist !! these days titles are used with a great degree of freedom.
  2. The OR ologist role is to provide technical expertise. Including reporting of technical findings that may represent adverse changes in data, and to provide expert troubleshooting to prevent false positive reporting to the surgeon.
  3. The current role of the NP/tech in the OR is to observe the surgery and the patient’s signals, watching for changes that may signify danger to the patient, and conferring with anesthesiology and the surgical team regarding the patient’s status throughout the procedure.
  4. Set up and Monitor the surgery
  5. In most cases, primary interpretation of the data is done essentially by the technologist.
  6. Usually, neurophysiologist = technologist
  7. My job as a neurologist is to supervise and interpret whomever is in the room, whether high school grad or PhD. Their job is to attach electrodes, copy and upload paperwork, and communicate what I say to the surgeon. No other distinction is merited.
  8. Very often The only Existing Truthful patient’s protector
  9. IOM service provider
  10. 99% of the billable work. Immediate interpretation – but not “official” interpretation
  11. tech support for interpretation in iom
  12. I am assuming that you refer to neurophysiologist to mean PhD and Technologist to mean CNIM. In the OR the technologist will set up the patient and can provide feed back regarding if signals decreased or increased. A neurophysiologist will be able to provide the mechanism causing that change and provide interpretation of its consequences as well as guidance to the surgeon regarding how to deal with it.
  13. Communicate with the surgeon about what is being seen throughout the case.
  14. To monitor the case and document all case findings, communicate with the monitoring physician findings and any changes to the data.
  15. Set up case correctly, monitor case, provide communication to surgeon
  16. Everything else
  17. Technologists (non-physician, non-doctorate allied health providers) should perform IOM under DIRECT (defined in CFR 42) Physician Supervision. DIRECT supervision means that the Supervisor does not have to be physically present throughout the performance of the encounter, but they must be immediately available if needed. The important role of the Technologist PERFORMING IOM is to rapidly report technical issues and critical changes/events (pending or actual) to the Supervising Neurophysiologist in real-time. Upon the guidance (real-time direction or “standing order” of pre-established alert criteria) from the Supervising Neurophysiologist, the Technologist is to then rapidly alert the surgeon and/or anesthesia personnel of signal changes that may be consistent with: (1) localization; or (2) irritation/pending injury to neural tissue or structures. Mid-Level Practitioners (non-physician, doctorate-level neurophysiologists) should perform and supervise IOM under GENERAL (defined in CFR 42) Physician Supervision. GENERAL supervision means that the Supervisor does not have to be present during the performance of the encounter. This means that a licensed physician is willing to assume the liability of a Mid-Level Practitioner’s work. For example, due to their advanced level of training, a PhD, AuD or DHcS with doctoral level training and proper qualifications in neurophysiology work under a sponsoring licensed supervising physician without the need for that supervising physician to be immediately available. The important role of the advanced Practitioner PERFORMING IOM is to rapidly report technical issues and critical changes/events (pending or actual) to the surgeon and/or anesthesia personnel of signal changes that may be consistent with: (1) localization; or (2) irritation/pending injury to neural tissue or structures.
  18. To monitor the integrity of the patients CNS and PNS to prevent SCI or nerve root damage. To alert the physician if any changes are seen right away.
  19. To obtain the requested evoked potentials, to maintain the relationship with the surgeons and OR staff that represents the company, to notify the surgeon of any critical changes, to assess the patients motor and sensory abilities and any changes to their symptoms pre and post op. To trouble shoot any noise or changes in the EPs and assess if they are real changes or not.
  20. Set up patient, conduct preop interview, communicate with surgical team, provide the best care possible for the patient.
  21. Currently, the role of the neurophysiologist is to make final decisions as it relates to the changes in data
  22. To perform the tests and communicate with the Surgeon and the rest of the OR team.
  23. Their current role is to setup electrodes and to physically run various neurophysiologic tests during the procedure.
  24. The technologist is responsible for understanding the procedure, helping to select reasonable monitoring modalities, acquiring data with a high signal to noise ratio, and describing the data.
  25. Establish credentialed rapport for facility compliance, commute to and from each facility, interview each patient, set up monitoring equipment and connect to patient, provide care for each patient, develop positive relations with surgeons and hospital staff.
  26. A problem with this question lies in the titles employed in the asking. Are a neurophysiologist and a technologist the same thing? Are they defined by education and training? Certification by third party organizations? Scope of practice? Cleary, at the base, both entities set-up IONM, collect data, and can identify changes in that data. Understanding the reasons behind those changes and interpreting the proximate causes to alerts versus non-alerts is more in question. Likewise, advising on outcome potential and making recommendations for the correction of IONM data alerts is also highly dependent on the practitioner, their performance guidelines, and how they are classified within their practice environment (as well as by external certification).
  27. To set up the monitoring, check everything is working and optimal recordings are being achieved in the room, acquire baseline traces and monitor ongoing recordings for changes from baselines, interacting with anaesthesia and surgical teams to identify and eliminate artifacts, identify variations in traces and possible causes, communicate with all involved to minimize risk to patients and offer surgical team a warning of possible detrimental outcomes before they become irreversible.
  28. It depends on the type of environment one works in. In my situation it is to provide high quality IOM care to patients from highly qualified professionals. In many cases the IOM personnel is there to put in needles and provide a platform for a company to bill. Those people are often trained for months instead of years; it is an embarrassment to the entire field and holds us all back.
  29. Neurological complications, assessment of efficacy in some pathologies ( tremor) research
  30. Hands on technical, liaison to the peri operative team, constant communicator/documenter to both Neurologist and OR team
  31. patient assessment with input from remote reader, set up IONM methods, obtain waveforms, etc and be aware of variants that develop. Must have good interaction with surgical team.
  32. Does all the physical set up and hands on monitoring of the surgery. Communicates with patients and surgery team during the case
  33. Analyse and interpret
  34. technologist do the monitoring as requested
  35. to advocate for the patient and transmit vital information to the surgeon and reading physician during the procedure.
  36. As a Technologist, we r responsible for troubleshooting any kind of technical error, recording every minute as a cycle of Sep’s and Mep’s. Check anesthesia level frequently. If there is any change in potentials then inform to Neurophysiologist.
  37. To gather reliable and meaningful data, relay the information to both the oversight physician and surgeon.
  38. planning and execution of the monitoring, initial interpretation and communication.
  39. In remote monitoring, I feel that the tech is the do all be all. They are who the surgeon sees and who the surgeon listens to. Their job is very important. The confidence and skill that is needed is very high.
  40. The role had been dumbed down under the presumption that the remote physician is actually competent.
  41. To confer with the neurophysiological supervisory about medical history, diagnosis, planned monitored modalities, assure that data provided the the supervisor is of the highest quality, pertinent to the specific structures at risk, to document all pertinent surgical, anesthetic and electrophysiological events, to provide accurate intermediate communication between the supervisor and the operative team in a timely fashion.
  42. The monitorist’s role is to pre op, set up, monitor, and break down the patient. We leave a “tech” report in the chart for reviewing. I even write the professional report as the monitorist.
  43. Pivotal for monitoring
  44. The monitoring clinician is responsible for the collection of reliable data that can be interpreted by the reading physician with some degree of confidence.
  45. To provide excellent patient care, maintain smooth working relationships with surgeons and staff, safely and correctly apply electrodes and utilize monitoring programs and equipment to accurately obtain baselines and keep steady watch on patients’ neurological state, communicate with anasthesia and surgeons as appropriate and necessary, safely remove all electrodes and dispose of in sharps containers at close of case, and perform a sensorimotor evaluation following patient wake to assess neurological function and document any deficit or lack thereof.
  46. Do everything and hope if there’s a problem, that your remote monitor is reachable
  47. To setup the patient and do the monitoring while also interpreting the signals to the best of their abilities depending on experience with the help of an Reading Physician overseeing the whole thing.
  48. Basically runs the case from interviewing patient to determining which monitoring techniques best apply to the case and review with surgeon to setup and monitoring procedure and preparing final report and billing for review by physician
  49. Discussing the specific neurophysiological modalities with the surgical team, anesthesiologist and monitoring physician. Interviewing the patient to obtain relevant history and functional status, co-morbidity, potential contraindications in performing certain modalities. Prompt and detailed communication with team members, documentation of events, alerts, troubleshooting.
  50. Their role is to perform IONM and take care of the patient.
  51. Making the right connections (electrodes, cables, amplifiers, stimulators) ensuring that the IONM protocol matches the surgery and the expectations of the surgical team.
  52. Direct patient care giving immediate feedback to the surgeon.
  53. They perform the case responsible for both the technical and professional interpretation.
  54. Though legally the role of the technologist isn’t to interpret data there is no doubt that in real world scenarios it is absolutely necessary for the onside tech/neurphysiologist to make decisions and comments based on live recordings.ex. if you suddenly get a spike if EMG when at a critical time the tech will call out the finding. That is what’s best for patient care. We can not afford to wait for the supervising physician to acknowledge.

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[toggle title=”Question 4″ open=”no”]

Thinking about questions 2 and 3 above, how would you like to see these roles change, if at all?

Executive Summary:

A lot of people would like to see the role of the remote physician down-played or eliminated. Others disagree.

Individual Responses:

  1. Titles and roles must be precisely defined with greater oversight from government and professional organizations
  2. None.
  3. It would be nice if the role of determining whether or not changes in signals should result in surgical intervention would lie more in the hands of the NP/tech rather than the remote physician. The tech has the advantage of having been in the case throughout the procedure and has a better sense of what might be causing changes in signals than a remote reading physician.
  4. Not sure how remote monitor improves outcomes so on site person should provide professional component
  5. Remote supervision has certain as a consult to an expert. However, the concept of unobserved remote personnel being responsible for interpreting data changes is terrifying. The person immediately observing the data needs to be qualified, able and authorized to interpret it as well.
  6. Technologist & Neurophysiologist
  7. The monitoring physician has to have the OR experience for 3 weeks at least
  8. Cut the fat by eliminating redundancy of physician services in the OR- require an academic degree with clinical training in IOM- there are certainly enough PhD’s involved in IOM to establish a university program to adequately train an autonomous allied health profession capable of reporting information directly to the surgeon or anesthesiologist – the physicians responsible for treatment and care decisions of the surgical patient- that is the practice of medicine.
  9. Liability will always be a huge issue. Not sure much can change
  10. tech have more control of their interpretation
  11. As long as you have an attentive online physician, i think these roles are prefect. The online physician is there to reassure a technician, help the communicate with the surgeon during surgery, and help diagnose extreme problems during the procedure and help technician and surgeon with options on how to deal with the case. Unfortunately, this is not always the case. Some online readers are not as attentive or even as knowledgeable troubleshooting a procedure and can even cause more confusion or no help at all.
  12. I think that the monitoring physician should be more involved in the case, not just a supervisor. They are present in the case, and should relay noted information to the technologist and confirm any changes seen.
  13. N/A
  14. I’m content with the current model
  15. I want to see LICENSURE for the Technologists (non-physician, non-doctorate allied health providers) and the Mid-Level Practitioners (non-physician, doctorate-level neurophysiologists) that properly and legally defines the title and the scope of practice. I also want to see individual state guidelines that allow Mid-Level Practitioners (non-physician, doctorate-level neurophysiologists) to supervise the Technologists. While this is not currently the case in most states, it is hopeful that in the near future legislation will exist that will allow Technologists (non-physician, non-doctorate allied health providers) to perform IOM under DIRECT Supervision by a Delegated Doctorate-Level Neurophysiologist. In this case, the Technologist would work under the direct supervision of either a Licensed Physician, or a Delegated Practitioner that is immediately available.
  16. The ideal online reading physician has been in the operating room with a technician and has experience in the operating room environment.
  17. I would like the physicians to have some hands on experience in the OR so they can accurately assess any changes. I would also like them to be familiar with the machines the techs are using to monitor. I would also like in writing on one sheet, what they look for ex: Do not consider a waveform present if it is not replicating 3 times in a row, Or EMG is not valid unless there is 4/4 twitches. Screws are not valid unless 4 full twitches are present. Also when they want the surgeon alerted. ex: when monitoring EMG and no twitches are present surgeon must be alerted. This way I could pass this sheet on to the surgeon and anesthesia. Techs need to be thorough on what they are doing to trouble shoot, what is going on during the procedure and ask for confirmation in how they are interpreting the readings and any changes.
  18. Give tech more responsibility to inform surgeon of changes and interpret data. Have physicians online be more attentive
  19. We should continue to support the module that is currently in place
  20. No difference. Except the Technologist get recognized by the insurance companies. The technologist is doing all of the real work.
  21. The neurophysiologist in the OR must be capable of, at the very least, sharing the responsibility of data interpretation. Ideally, they should be entirely responsible for this component since they are in the best position to account for all factors that might influence the interpretation of the data.
  22. I would like to see neurologists become more involved in making interpretations and medical recommendations and less involved in rubber stamping technical descriptions of data. Technologists need to take ownership of acquiring high quality data.
  23. Eliminate one or the other. There really is no need for both.
  24. Attempts have been made to more clearly define professional versus technical (IONM-P vs IONM-T) provider scope. It is unclear how effective or how well adopted these ideas have been. The clear definition of title to scope of defined practice is an important first step in understanding potential change. If this can be established, a three tiered system may be developed, which sets standards of performance for CNIM, neurophysiologist, and physician. It is possible that a relationship similar to that currently employed in medicine with tiered responses from CNAs, RNs, Midlevel practitioners, and physician providers, may emerge.
  25. Remote readers must find a way to stay in context and relevant in the surgeries that they are claiming to add patient safety to. IOM professionals should continue to push a set of national standards that will entirely eliminate poorly trained personnel in the OR; using the ASET standards would be a wonderful beginning.
  26. I think they are going to change with the improvement of new technologies, images, recording internet and so on
  27. Roles are fine in most situations
  28. not at all
  29. Focus should be on onsite monitoring, with well qualified neurophysiologist and remote monitoring should be phased out
  30. MD should be present for cases that are not routine; tumors; cranis
  31. I would like to see higher standards applied to techs and reading physicians. The qualifications are all over the map and the surgeon doesn’t know who to trust.
  32. I think remote monitoring is much better option because most of the time Technologist is sitting there in OR. If the Neurophysiologist doesn’t want to come to OR atleast they can monitor in there room.
  33. More training of the neuropsychologist or technologist in order to help bridge the gap of not enough trained and reliable oversight physician.
  34. it is hard if at all possible for a technologist to do it all, and difficult for a remote person to interpret adequately
  35. The tech already has much responsibility. With past experience more of a physican presence makes get be nice. Whether it’s with a doc box or just having a constant set doc with certain surgeons so trust and a relationship can be built with the whole team.
  36. The neurphysiologist in the room should have responsibility, and thus, the training to obtain and interpret data.
  37. I would like to see greater demonstrated training and competence of supervisors in the technical aspects of data acquisition. I would lime to see greater training of the technical staff in medico-legal implications of record keeping and data acquisition.
  38. I have actually thought about this a lot and there is a lot that would need to change. DABNM should be the authority on IOM over site. I wish we had more so we could more over to them for all over site. I have worked with many physicians that have no idea what we actually do or what we are looking for. I think they should have some kind of credential providing they know what’s going on. If they did something like that this model could work and they need to make interpretive comments within a case log.
  39. Physiologist is solely responsible. Physician can be done away with.
  40. I think these roles are appropriate for each individual’s level of expertise.
  41. I am content with the status quo for remote monitoring. I only wish to be regarded and paid as the highly educated clinician I am.
  42. More interaction between them and us. I document to the point of exhaustion for their benefit mostly and their communication leaves much to be desired.
  43. Roles are fine as I see them but each has to understand each other’s jobs and how it works. So maybe if the reading physician can step into an OR every now and then and the neurophysiologist can see how a reading physician does his job then that would help understand each other a little more and create more respect between the two.
  44. I would like to see independent neurophysiologists preforming monitoring and interpreting data for surgeon without over sight, license for profession if that could be obtained
  45. No [change]
  46. Better training of both the IONM practitioner taking care of the patient and the remote clinician are necessary. Although the remote model is great to make IONM for lucrative, it has greatly increased the rate of false positives in the profession. It’s hard not to practice defensively when you are watching simultaneous cases with three to ten people you don’t know and a surgeon/patient with whom you have no relationship.
  47. For me the team in the OR is by far more important than the remote physician and it should remain like that.
  48. Eliminate Remote monitoring
  49. Eliminate the remote position.
  50. In O.R. personnel’s scope of practice should include onsite interpretation to an extent.

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[toggle title=”Question 5″ open=”no”]

Does your surgeon know that a physician/neurologist is attending to the case online?

My Comments:

I have to say that I was surprised by the outcome of this question. In my travels around the country, and working for a variety of different groups, I’ve met very few surgeons who are aware that a physician is online and billing for the case.

Results:

Q5J

[/toggle]

[toggle title=”Question 6″ open=”no”]

If you answered “no” or “not sure” to the question above, how do you think your surgeon would react if he/she knew that a physician/neurologist was attending to the case via internet connection?

My Comments:

My personal experience in speaking with surgeons from various disciplines is that they tend to fall into two groups when told that a physician is online. Group 1 could care less whether a physician is there or not. Group 2 are angry and want them removed from the case.

Individual Responses:

  1. He/she must be extremely concerned
  2. Not sure
  3. Neutral
  4. There was no option for this model for question 5- we do not utilize remote monitoring services- and yes our surgeons are aware we are reading the data and reporting information directly to them from across the room- information with which they choose to use to make treatment decisions given what they know about their surgical patient moment to moment.
  5. yes. some surgeons won’t progress without a doctoral-level neurophysiologist in the room or a neurologist on line.
  6. In my company, the surgeons in one region tried to throw our company out of the hospital when they found out that physicians were online because they were so used to relying on the doctoral-level neurophysiologists in the room. They didn’t trust the physicians, and they thought the physician presence was fraudulent and unnecessary.
  7. Would probably feel more confident having two pairs of eyes watching over the procedure then one.
  8. All my surgeons know. One did ask me if they could not have oversight. They were worried about what the patients were paying and know that we can identify changes
  9. N/A
  10. When they do know, they don’t care. They only care about the tech. And when they don’t know, it’s again, because they don’t care about the online physician.
  11. As a neurophysiologist/technologist, I would assume that my surgeon may have less confidence in my opinion of data.
  12. Both surgeons and patients should be informed that another medical professional will be involved in their care. To provide consultation without informing the team and patient is a violation of informed consent and the patient’s right to autonomy.
  13. Unhappy – would prefer someone in the room
  14. He will not be impress
  15. Don’t Know.
  16. We have in house remote physican mostly. However when we do have remote physicians covering our surgeons are not happy with the service and rely much more heavily on the tech than they should.
  17. Our surgeons trust the personnel in the OR and think remote personnel are a waste.
  18. Surgeon will get skeptical about the proceedings.
  19. I have never had a surgeon feel it necessary to double-check my own alerts and description of signal changes.
  20. i don’t think they would be overly impressed one way or the other if they have a competent neurophysiologist
  21. A more appropriate selection to question #5 would have been sometimes. Most surgeons don’t seem to mind, but its good to be up front with the model. Our group does use remote physicians or audiologist for cases where third parties require it to bill, and we have told most of our surgeons over the years. Some see the hypocrisy in telemedicine used in this manner, but most really don’t mind unless the remote doctor wants to participate formally in the case or uses inappropriate billing practices with their patients (often not the doctor’s fault, but the company they work for.)
  22. He/she shouldn’t worry but seeing it as added safety since any additional pair of experienced eyes helps to avoid mistake or overlook important signal changes.
  23. They could care less
  24. We do not have one

[/toggle]

[toggle title=”Question 7″ open=”no”]

How frequently does your surgeon/anesthesiologist request information directly from the remote physician/neurologist?

My Comments:

No surprise here. In my own experience with involvement of approximately 15,000 surgeries in the “remote model”, I’ve never once had a surgeon ask, “what does the neurologist think?”, or “can you ask the neurologist..?”. On one occasion I had to go to the attending surgeon and tell him that there was a disagreement between the remote physician and I about the interpretation of an important test. I presented both sides in a very fair and balanced way. The surgeon immediately became irate because he knew the remote physician was wrong and it endangered the care of his patient. From that day-on, every single time I worked with that surgeon, he said something nasty about the remote physician. It made things awkward and permanently changed our relationship.

Results:

Q7J

[/toggle]

[toggle title=”Question 8″ open=”no”]

Do you think there are any surgeries that simply cannot be safely monitored remotely?

My Comments:

Personally, I think that any surgery that requires frequent and immediate feedback to the surgeon definitely cannot be monitored remotely. In these cases, the person in the room must be cleared to interpret and supervise neuromonitoring. These procedures include DBS, posterior fossa, ENT, peripheral nerve/CNAP, and all brain mapping. This is where licensing comes in. We need to be in a place where the person in the room is licensed to perform those tests. Just my opinion.

Results:

Q8J

Executive Summary:

While there is some variability, most agree with what I said above in terms of the specific cases that cannot be monitored/supervised remotely.

Individual Responses:

  1. Electrocorticography is just and example of cases the SHOULD NOT be monitored remotely. If i were a patient, and I am paying for a physician to monitor the surgery, I expect that physician to be present in the OR. If physician want to exist virtually, I think they should be paid with virtual money as well.
  2. Mapping cases (awake language/motor, asleep motor).
  3. A remote person has access to only a small percentage of real time information. They also cannot interact with the entire surgical team in real time.
  4. Tumor, Craniotomy, Aneurysm, etc
  5. If a surgery requires the direction of a 3rd physician to the team of physicians already physically present in the OR- surgeon and anesthesiologist- it is best practice that physician be physically present as well to make informed treatment and care decisions.
  6. live emg, parotids, thyroid, were reactions are reported after the fact
  7. Selective Dorsal Rhizotomy Deep Brain Stimulation implantation Dorsal column mapping Central sulcus mapping
  8. But rarely I would imagine and for procedures I personally do not encounter.
  9. DBS … motion disorders … and awake brain surgeries that require real-time neurological physician assessment. Bottom line is a Licensed Physician should always carry the responsibility of deciding WHEN a particular case should be escalated to in-person/in-house supervision. As a CNIM, I would never be offended or try to discourage the Supervising Neurophysiologist from being physically present with me in the OR. That ultimately is the decision of the licensed physician or the delegated supervisor.
  10. It would be beneficial to the Neuromonitoring online physician to attend some of the more complex cases. It would most likely make the patient and surgeon feel more secure should a change happen during the procedure. This is not a must but would be beneficial for the surgeon/online reader relationship as well.
  11. Most surgeries cannot be monitored safely utilizing a remote supervision model. IONM is based on the premise that quick intervention can prevent or reduce the severity of postoperative deficits. The inherent delay associated with the remote model decreases the speed and efficacy with which interventions can be made. Additionally, there are numerous perioperative factors that can influence neurophysiologic data and its interpretation and these factors can only be learned and appreciated through extensive experience monitoring cases while physically in the OR.
  12. Surgeries requiring real time evaluation of EMG are not realistic to be monitored remotely.
  13. CEA, aneurysm clipping, SCS, any mapping or any time sensitive moments of any surgery.
  14. Procedures where a timely assessment, which guides surgical decision making (like neural mapping cases) can make remote interpretation ineffective and can actually cause the in-room monitorist to become distracted in trying to communicate with the remote. An example of this might be for phase reversal sensory studies, motor cortex mapping, mapping of neural elements involving nerves or nerve roots, thyroidectomies, parotidectomies, CNAP testing, DBS mapping, or even cases like selective dorsal rhizotomy.
  15. When remote from the room you simply can’t be aware of everything that is going on in a case, Blood pressure, blood loss, interventions and the actions of the surgical team all contribute the the resultant monitoring signals, you are relying on someone else to correctly position and secure leads, and check them if something changes, and report all interventions so everything is at least second hand information, nothing beats being on-hand in the room, observing and interacting directly.
  16. Due to the nature of surgery, and the internet, the IOM professional in the room must be qualified to do the case that is taking place, after all internet connections do go down routinely. Which means that any case that cannot be individually handled by the IOM professional in the OR cannot be safely monitored remotely.
  17. In certain mapping situations a team in OR approach is best, especially when monitoring ADs. Stimming, documenting, sharing with surgical team and AD detection difficult for one
  18. Direct brain stimulation procedures, if the surgeon is not trained in the neurophysiology of the case.
  19. Many cranial, acoustics and spinal cord tumor need instant interpretation and communication, action from the surgeon might be needed immediately upon those.
  20. I believe that craniotomy surgeries and some neuro cases need a supervising physician present or at least in the hospital. There is so much that can happen very quickly that the physican should be available.
  21. ENT cases and other cases with spontaneous activity and data that requires immediate interpretation and near constant interaction between surgeon and neurophysiologist
  22. However some sort of FaceTime program could be helpful for more complex procedure.
  23. No surgery can be.
  24. Cerebral vascular cases.
  25. I believe, in general, the safest situation for any surgery is to have the onsite neurophysiologist be a competent, well-educated professional who is able to interpret their own signals in real time without reliance on a remote reader. A reader should not have to tell a neurophysiologist when to alert and what the signals indicate; that should be knowledge the technologist already possesses. Time is of the essence, and internet connections and the attention of the remote are not always 100% reliable.
  26. Any spine that involves instrumentation and graft implants
  27. Not a fair question. We all know that there are cases where certain neurologists won’t monitor remotely, but this isn’t really a safety issue (DBS, motor mapping, etc.) It’s only a safety issue if the neurophysiologist or tech performing the IONM in the room is under-qualified…and if that’s the case, then even testing pedicle screws is unsafe to monitor remotely.
  28. Surgeries that involve speech testing.
  29. I believe all surgeries are equally critical and can not be safely monitored remotely.
  30. All of them

[/toggle]

[toggle title=”Question 9″ open=”no”]

Do you believe the intraoperative neuromonitoring is the practice of medicine?

My Comments:

I was personally surprised by the outcome of this question, but that is probably just a reflection of the company that I keep. My personal opinion is no.

Results:

Q9J

Executive Summary:

N/A – responses vary significantly.

Individual Responses:

  1. The practice of medicine is nothing more than an opinion statement set forth by the AMA. They could opine that space flight is the practice of medicine if they wanted to. It wouldn’t change the fact that astronauts are the most qualified.
  2. Yes, when remotely supervised by a MD or DO neurologist.
  3. Practice of medicine in real terms means something that should be under the purview of state medical boards. So, no. It is an area of medicine, it involves some degree of diagnosis, but certainly not treatment, and is certainly far less the “practice of medicine” than several other allied health fields.
  4. Yes and can be delegated
  5. Overall I believe the practice of neuromonitoring is beneficial for both the surgeon and the patient’s safety. Where I think we become something of a joke to the medical field is when technicians who are not skilled enough to run a case on their own is put in a case too soon. There needs to be more regulation on when a technologist can be alone in the OR. There are WAY to many technicians running cases on their own in the OR who do not know how to communicate with the surgeon or describe what is happening and then the surgeon loses his confidence in monitoring.
  6. Though we are certified in our field, we are not licensed in the medical field as physicians.
  7. Sure. It’s certainly a part of it, and on the path to becoming standard of care.
  8. The performance of IOM is NOT the practice of medicine … just like performing respiratory therapy, or operating an MRI or X-ray system, or providing nursing care, or performing perfusion during surgery …. these things are NOT the practice of medicine. IF performing IOM is deemed the practice of medicine, then more than 3,000 CNIMs, DABNMs and Audiologists are guilty of practicing medicine without a license. The determination of CLINICAL FINDINGS and PREDICTED CLINICAL OUTCOME and recommended medical treatments and intervention is the practice of medicine.
  9. Let me just say this: If your mother, father, sister, brother, child etc.. Were to have a spinal fusion or a craniotomy would you want someone there watching to make sure they do not have nerve injury or a SCI? Or the possibility of intraoperative stroke? We are taking about death, brain damage, and paralysis. Intraoperative neuromonitoring is very beneficial for the integrity of the CNS and PNS during procedures that are at risk for loss of function. With the combined force of the anesthesiologist/technician/ surgeon relationship the patient can rest assure that they are getting the highest quality of care they possibly can during which time they put trust of their life into someone else’s hands.
  10. The technologist is really interpreting the data in real time due to all of the factors in the room. The online physician is only good for weak technologists.
  11. Neurophysiology is a very specific scientific discipline with direct clinical applications. The tools and techniques associated with this field were largely developed by audiologists, neuroscientists, and other non-MDs.
  12. We must know the elements of other specialties in order to do our job correctly. New methods and technologies are developed constantly, and must be kept up with.
  13. However, medicine is not only practiced by physicians. It is not exclusive. Medicine is practiced in many forms by many levels of practitioners in the United States. Licenses, which specify standards of medical practice include clinicians like Physician Assistants and others. You can call it the practice of surgical neurophysiology or any other term, which feels less threatening to medical doctors, but still incorporates patient care: Including sound decision making, certifications of competency, sound knowledge bases, and clinical judgement.
  14. It is at least 50% technical
  15. Absolutely!!!!!
  16. Yes
  17. Neurophysiologist with at least MSc in neurophysiology
  18. LIke CRNA’s, IOM Technologists are adjuncts to surgery overseen by a licensed physician.
  19. possibly an hybrid tech-physician 🙂
  20. I believe it is advance medical testing that generates impressions of patient state and implications for the patient. I believe IONM presents a range of possible outcomes and interventions. I believe to surgeons application of that information to guide the treatment of the patient is “medicine”.
  21. By definition no it isn’t.
  22. Yes, in the way any invasive or noninvasive diagnostic practice in healthcare constitutes the practice of medicine. Nurses practice medicine. Sonographers practice medicine. Phlebotomists practice medicine.
  23. but I’m sure the AMA would beg to differ
  24. I can get a group of wizards together to declare IONM the practice of magic, but that does not make it so.
  25. Since we only describe data, no diagnosis or treatment involved in addition the surgeon has the final say in the progress of surgery then neuromonitoing should be considered a service to aid the surgeon.

[/toggle]

[toggle title=”Question 10″ open=”no”]

Use this space to talk about any gripes, pet peeves, favorite or horrific moments that you would anonymously like to share about your experiences with the remote model of IONM supervision and interpretation.

My Comments:

Personally, my gripe is that some remote physicians ask for too much from me. I know what I’m doing, and I prefer to be left alone to do my thing. I know that other people really need and/or appreciate the constant back-and-forth. Just not me. So, I find it vexing when I’m constantly being asked questions, or asked to do some ridiculous task. And, I certainly don’t like to be bothered when I’m mapping nerves in the posterior fossa and constantly going between stim and document. The extra layer, in that circumstance can actually work to hurt patients if you miss something. That’s just me, though. Like I said, I know others really need/like to be told what to do and say.

Executive Summary:

N/A – Responses vary.

Individual Responses:

  1. IONM companies should be more concerned with patient safety than with making profit.
  2. N/A.
  3. The reading physician is not always there when you need them which can cause surgical delays. The remote model also creates a situation in which the OR tech may have excellent reason to disagree with the reading physician’s decisions about a change in signals, but because they much defer to the doctor above them their hands on experience during the surgery is discounted.
  4. Currently they are being told to interact more on the chat panel to attempt justify participation. Remarks are superficial and have no bearing on case
  5. When I performed intraoperative neuromonitoring previously, on several occasions I have had a neurologist note that he/she was going to bed in the chat record and to call them if anything went wrong. No explanation needed. The individuals who undertake remote monitoring are 50/50 in terms of having psychotic tendencies. There are safe, professional remote providers as well.
  6. … it will be too sad
  7. Unfortunately- there are too few trained professional providers- and our services are in high demand- our service limitations are due to staffing- and the remote service providers are currently able to meet the staffing demands with rotating in-house training programs requiring little in prerequisite employment requirements. Economics is driving the route to remote IOM models- I don’t foresee that changing.
  8. It is frustrating, with some readers, that they do not comment on the case or answer any questions when there needs to be clarification on a finding. It does not feel, always, that the reader shares the same responsibility for the case. Documentation is everything!
  9. Connection issues, not adequately present/attention spread to thin
  10. Too many to list here. I’ll have to write an article.
  11. I am a Intraoperative monitoring technician and have been a technician in the neurodiagnostic side of Neurology. I love neurophysiology. I understand how they are two different worlds of neurology (Neurosurgery/clinical neurology) and would love for the online physicians to become more familiar on what the technologists position is in the operating room and how the procedures work. To experience simple spine, ENT, to complex crainis in the OR if not just for one time. We are doing a great thing here as long as we keep the communication open and put patient safety first, it is a win/win situation. We all signed up because we care about the GP. Lets continue taking care of our patients when they are at their most vulnerable state and supply the surgeon and anesthesia with valuable information to protect the patients wellbeing and integrity. question number 7: 7. How frequently does your surgeon/anesthesiologist request information directly from the remote physician/neurologist? In my experience the surgeon would ask the online physicians opinion during a change (If he decides to) or if the surgeon questions the reliability of a technician.
  12. I disagreed with a Remote reader on whether or not a waveform was present or not. Other than that I’m pretty easy. I give them what they request and even in the past when they asked to connect to RTNA I did. I just don’t like alarming my surgeons when there isn’t a reason too. It just makes me look badly as a technician and I don’t like reporting something I don’t believe. I also had a remote doctor tell me screws aren’t valid with 4/4 with a fade. It has to be 4 full twitches. that is something I should’ve been aware of before the case. The surgeon I was working with doesn’t usually give twitches so to have 4 at all was a feet. then to be told continuously to alert him that EMG and screws were not valid without 4/4 full twitches was annoying. The surgeon later asked that he receive these changes in writing.
  13. N/A
  14. N/A
  15. Too many to list. The training most remote physicians receive is atrocious as evidence by the frequency of incorrect interpretation of data. I routinely have to correct my remote doc on simple matters such as the difference between EKG artifact and myogenic EMG responses. The system is broken.
  16. Hate when I put in a load of effort and focus into my job as a neurophysiologist/technologist and my remote physician literally just says agree. I know they agree because the information is in front of my face and it needn’t any further interpretation. IONM began without any remote physician over watch and still is not needed, unless maybe the individual monitoring is inexperienced. We are not robots without brains, we practice, study, work, interact, provide care and it sometimes seems to go unnoticed or undervalued. I bet, if the physicians who “provide patient care via the Internet” were put in a position to do both roles, collect and interpret they’re own data, they’d seek a different career path.
  17. I have witnessed (while visiting an operating room to speak with an anaesthetist about an upcoming case) the use of surgeon controlled monitoring where the surgeon placed the leads as directed by a medical rep who set up the machine and then reported the adequate protection of nerve roots in a lateral case when the muscles he had selected and was monitoring from were not those innervated by the roots at the level the surgeon was operating on. I have also been asked to give an opinion on the possible cause in a case I had not been involved in where monitoring was described as unchanged from baselines throughout but when the patient woke at the end of the case there was a significant neurological injury, my conclusion was that without seeing the recordings it was impossible to identify but my guess would be that the baseline traces were artefactual and no true monitoring had ever been achieved in this instance.
  18. I fired a group of physicians for bothering my IOM professionals with such useless information as “clean up those baselines” during a wake up test; they were not relevant or in context. I once saw a remote physician and a poorly trained IOM professional chat via text about TcMEP changes for 30+ minutes, ultimately never intervening, while a young woman was paralyzed during a routine surgery; the model fails patients.
  19. I think we have a good system. There are not enough professional trained to allow in OR supervision and one could not make a decent living with one case at a time.
  20. Emphasis should be on patient care and that is achievable only by having a trained neurophysiologist onsite.
  21. When I worked for agency in my early days, my remote physicians were often unavailable on late and overnight cases. As I was still relatively inexperienced, this was often terrifying. I now work in-house with a reliable group of reading physicians with whom we enjoy a collegial relationship which also includes our surgeons. A much safer model.
  22. Oversight physician not making themselves available or when informed of changes is unable or unwilling to help in the differential diagnosis.
  23. It is very often that one of our main remote monitoring physicians gives no direction or information to pass on to the surgeon when something comes up i.e. Loss of signals or a decrease. The tech will ask what would he like us to do and we can nothing. I have been in on a carotid where I saw a very distinct change and they did not. It puts the tech in a bad spot when the surgeon wants our opinion over the physicians.
  24. The precedent of remote monitoring had stripped the profession of qualified personnel actually doing the monitoring, allowed techs to be stupid and remote physicians to be inexperienced and unqualified. Patient care is no longer part of the profession–it has been replaced by greed and unethical practices.
  25. I’ve been in the field for 6 years and have worked for all of the major IOM companies and some small ones as well. I can honestly say I love what I do but I hate the logistics of this profession. I have met “techs” who have been working without a CNIM for 10 plus years, “techs” with high school diplomas that couldn’t tell me what the neuro muscular junction is, “techs” who haven’t even heard of the 10/20 system…. I can’t even share my worst horror story anonymously because if I write it …it will just be that much more real to me and I just can’t. If I could hope for one thing it’s better regulation of the people we allow in and better observation of “over site” practices and credentials. We find bad people and bad companies AFTER they do something negligent. Why can’t we be more proactive than reactive?
  26. I believe my previous answers suffice for this. The quality and attentiveness of readers can vary dramatically, just as the quality and attentiveness of neurophysiologists can vary. In my experience, once a reader works with me and grasps the depth and scope of my competence, they become little more than someone to sign off on my documentation for a great deal more money than I myself get paid for actually running the case and performing the physical and intellectual labor. I feel much of the current model is driven by liability. I am fortunate to work with some excellent readers, and I am sure they fill a greater role with some other neurophysiologists.
  27. Sometimes the neurophysiologist knows what the mood of the surgeon is in the OR and on a particular day and if constantly bothering him about running motors or doing something else is going to make his mood worse and if he is getting annoyed and it is easier to see how to maneuver in that scenario from within and sometimes that’s hard to explain.
  28. Inattentive monitoring physician and or the neurophysiologist. Surgeon and the anesthesiologist not communicative or co-operative essentially blinding the neurophysiologist. Subjective selection of modalities and how frequently certain modalities are run. Lack of understanding that not acting on genuine changes in the neurophysiological data can potentially cause major neurological deficits or worse.
  29. I’d rather not. I get that there are political and financial reasons why medicine got more formally involved with IONM, and it seems as if we are stuck with this model. I’m sure most of your audience could include countless embarrassing or unsafe anecdotes where remote people got involved with the case. All we can do is continue to educate everyone involved (including the remote doctors) about what quality means.
  30. During a CEA upon clamping the ipsilateral cortical waveforms showed immediate reduction in amplitudes, the Telemonitoring physician advised to reposition the arm. In a different CEA, The same situation happened with clear signs of ischemia while the NP alerted the surgeon the telemonitoring physician commented that everything was stable and when the technician arrgued differently she blaimed it on the slow internet signal.[/toggle] [/accordion]

Survey Summary:

This is the second survey in a series that I hope to use to get opinions on a wide variety of topics. If you have something that you’d like me ask in a future survey, feel free to ask!! Just drop me an e-mail. Rich Vogel

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