Who is Qualified to Interpret Neuromonitoring Data?

There is a great deal of controversy in the field of Intraoperative Neurophysiology regarding what makes one qualified to interpret neuromonitoring data. Must the interpreter be a physician? A neurologist? What about an audiologist? Are you qualified with a PhD in neurophysiology? Does professional board certification matter? If so, which one? In the current state of affairs, do we have enough qualified professionals to interpret the data for the tens of thousands of surgeries that are performed each year? The answer to the last question is NO, not even close. How did we get to where we are now, and where do we go from here? I’ve attempted to answer some of these questions below.

History of Neuromonitoring:

Arguments about the history of neuromonitoring are frequently driven by political agendas. The fact is that intraoperative neurophysiology as a profession evolved slowly over time and without any formal guidance or structure. Certainly there were early studies that paved the way for modern neuromonitoring. The first exploratory stimulation of human cortex was performed by Robers Bartholow (1874). This work paved the way for future advances in localization of cortical function by Horsley (1886, 1909) and Penfield & Boldrey (1937). Likewise, the first description of facial nerve monitoring during posterior fossa tumor resection was reported by Fefor Krause (1898), and this worked paved the way for facial nerve monitoring during parotid surgery as described by Parsons (1966). These early, sporadic reports have contributed to what we now call neuromonitoring, but these reports were highly investigational works performed by surgeons working alone in the OR, attempting to map or monitor the nervous system. If anything, these early, sporadic reports demonstrate a need for neuromonitoring, but medicine lacked the technology and the expertise for neuromonitoring to emerge in the early 20th century.

I think it is fair to say that the first example of modern IONM came in 1977-1979 with the application of spinal cord monitoring in surgery (Nash et al., 1977; Brown & Nash, 1979). Prior to 1977, there were truly very few reports and nearly no one working in neuromonitoring. Indeed, even if you argue that IONM began in the late 1970’s, there were still relative few people performing neuromonitoring until the early 1990’s.

Most would agree that biomedical engineer Richard Brown, PhD of Case Western Reserve University is the founder of modern neuromonitoring, as he implemented the use of SSEPs for monitoring spinal cord function during spine surgery. Following Dr. Brown, in 1979, auditory physiologist Aage Møller, PhD described methodology for monitoring the functional status of the auditory and facial nerves during brainstem surgery. Then, in 1981, audiologist Daniel Schwartz, PhD, director of Audiology at the Hospital of the University of Pennsylvania, introduced IONM as an independent clinical service for neuro-, vascular-, orthopedic- and ENT surgery.

In a document recently presented to the Pennsylvania House of Delegates, the early history of neuromonitoring is eloquently described:

“A review of the limited landscape of IONM during the pioneering 1980s shows that the vast majority of professionals actually providing such a clinical service were audiologists like Dr. Schwartz, not physicians. For example, Paul Kileny, PhD, Director of Audiology at the University of Michigan Medical Center, Gary Jacobson, PhD, Director of Audiology at the University of Cincinnati Medical Center, J. Michael Dennis, PhD, Director of Audiology at the University of Oklahoma Medical Cener, Gayle Hick, PhD, Director of Audiology at the Children’s Hospital of San Diego, Jeffrey Owen, Ph.D. Audiologist, Director of Intraoperative Neurophysiological Monitoring, Barnes Hospital, St. Louis, MO, William Martin, PhD, Director of Audiology, Temple University Hospital, Joseph Danto, PhD, Director of Audiology, Kingsbrook Hospital, Brooklyn, NY all were among the foremost pioneers working to advance the scope of knowledge in this infant clinical neurophysiology specialty field. In fact, with the exception of less than a handful of neurologists and just a few anesthesiologists, audiologists performed the vast majority of intraoperative monitoring during the 1980s and early 1990s in the USA.”

In the days, individuals of all backgrounds worked collaboratively in an effort to develop and/or implement physiologic tests in the operative setting to increase patient safety and improve surgical outcomes. There were no fights about who was qualified to interpret the data. Indeed, from the 1970’s into the early 2000’s, IONM test results were interpreted in the operating room by different types of doctors, all of whom were trained to perform bio-electrical tests and interpret the results. Examples of the different types of doctors include audiologists (AuD), chiropractors (DC), neuroscientists (PhD), biomedical engineers (PhD), physicians (MD/DO), etc. But, as these tests proved effective, the use of IONM exploded in the USA and things began to change.

Growth of Neuromonitoring:

Along with a rapid rise in the use of neuromonitoring technology in the USA, two very different models for delivering patient care emerged. The first model was the original. In this model, an expert versed in both the technical and conceptual aspects of IONM actually worked in the operating room. All of the data were interpreted in the room by this expert, and patient care was delivered in a one-to-one fashion. The second model was a hybrid in which a technician worked in the operating room (setting up the patient and collecting the data), and the interpreter accessed the technician’s computer screen from somewhere else in the world, via an internet connection, and interpreted the data from afar. This allowed the interpreter to watch many surgeries simultaneously. This “technician oversight” approach was highly favored by physicians and quickly became the dominant model.

With the increasing use of telemedicine, IONM quickly moved from a field to an industry as businesses and physician groups, backed by venture capital firms, saw an opportunity to make money by maximizing the number of surgeries that the interpreter could supervise, and by supplying the “tech” to the surgery. Some companies hired independent physicians, who may or may not have had training in IONM, to provide oversight to the technicians. In the early days of telemedicine, before there were any guidelines or regulations, physicians could watch more than a dozen surgeries simultaneously (the most I’ve ever heard of was 60 simultaneous surgeries – and that came directly from the physician). Today, in 2016, the maximum is generally capped at 8-10 simultaneous cases, and the average is probably 4. Anyway, back in the early days, these corporations and physician groups were billing third-party insurance companies a professional fee (for physician compensation), and hospitals a technical fee (for supplies and technologist compensation), and concurrent case monitoring by physicians made a lot of people rich.

Meanwhile, many of the nonphysician practitioners of IONM continued to work in the OR under the original model. Licensed audiologists, neuroscientists, neurophysiologists and licensed chiropractors continued to perform both the technical and interpretive services. In some cases physicians did, too. For many of these pioneers, the landscape changed quite dramatically in 2008 when the American Medical Association House of Delegates, an opinion body, passed Resolution 201.  The resolution stated:

 “…it is the policy of the American Medical Association that supervision and interpretation of intraoperative neurophysiologic monitoring constitutes the practice of medicine, which can be delegated to non-physician personnel who are under the direct or online real time supervision of the operating surgeon or another physician trained in, or who has demonstrated competence, in neurophysiologic techniques and is available to interpret the studies and advise the surgeon during the surgical procedures.”

Supply & Demand for Neuromonitoring

As a result of this resolution, reimbursement from Medicare/Medicaid and some third-party insurance carriers for the interpretation of IONM data became a privilege exclusive to physicians, and all of the other types of doctors were suddenly demoted and placed under the supervision of their physician colleagues. This caused a rift within the IONM community, pitting highly-trained professionals (some but not all of whom had more than 30 years experience in IONM) against their physician counterparts (many but not all of whom were quite new to the field). With a large community of experts suddenly legally unable to interpret IONM data, or at least unable to get paid for their work, many surgeons began to fear that there were not enough qualified professionals to care for all of the patients.

John P. Dormans, MD, a world-renowned pediatric spine surgeon and Chief of Orthopedic Surgery at the Children’s Hospital of Philadelphia (at the time), recently published a paper with the following position:

Availability, training, and experience of IONM personnel may set practical limits on the type and quality of IONM provided in a given setting. Specifically, there are a limited number of trained and certified individuals for technical support and/or professional clinical interpretation of IONM data. Further, there is no single agreed on training or certifying pathway or entity.

Adding to the problem of who is best qualified to perform IONM based on training, education, and experience, is the lack of agreement as to who is best qualified to interpret IONM data. Although some physician specialty groups maintain that interpretation of IONM data represents “the practice of medicine,” this is far from a consensus opinion.

A license to practice medicine does not equate to competency or knowledge in intraoperative neuromonitoring.

Indeed, there is increased recognition that historically, the contributions of PhDs and other nonphysician doctoral level professionals who are well-versed in both the technical and interpretive aspects of IONM have been pivotal in the development of the field and the delivery of high quality IONM services.

Review of the evolution of IONM as a subspecialty shows that most of the pioneers were PhDs with vast experience in evoked potential testing and interpretation. In fact, the first “scope of practice” statement from a professional organization for the practice of broad-based IONM was for licensed audiologists with evidence of specialty experience in IONM.

Over what is now 3 decades of IONM during scoliosis and other spinal deformity surgery, nonphysician professionals have proven no less competent or worthy of interpreting IONM data than experienced physicians in general, or neurologists in particular. Because they devote their professional efforts exclusively to IONM and deliver hands-on services in the operating room on a regular basis, these doctoral level nonphysician professionals are often the best qualified, to render meaningful data interpretation.

The evolving opinion among many surgeons is that both nonphysician and physician professionals should be required to receive actual operating room training and be credentialed in monitoring interpretation rather than simply relying on a medical license or academic degree as evidence of competence.

To define the interpretation of IONM data solely as “the practice of medicine” regardless of training, experience, expertise, or credentials, supports the notion that a license to practice medicine equates to competency in any given specialty.

It would also restrict the pool of viable IONM professionals artificially, in many cases barring from practice the most qualified nonphysician doctoral level professionals who not only pioneered the field, but who also continue to provide clinical services and foster development of new knowledge.

Attempts to disqualify nonphysician professionals who have had a large role in pioneering this field [of IONM] and continue to advance its knowledge, or to limit them to a technician role under the direct supervision of a physician who may or may not have equivalent credentials and expertise, raise concern as to the potential for a shortage of truly trained and qualified IONM professionals who are experts both in the technical delivery of the service and interpretation of the data directly to the surgeon in the operating room. (Dormans, 2010).

Clearly Dr. Dormans has a very strong opinion about what qualifies one to interpret IONM data. Other surgeons have expressed similar opinions as reported by Norton et al (2015).

Who is qualified to supervise and interpret neuromonitoring?

Let us begin to answer that question by talking about the law, since so many people in our field talk about liability and legality, and so few actually know what they are talking about. Here are the facts.

Contrary to popular believe, one does not need to be a physician in order to supervise and interpret neuromonitoring.

Anyone with the appropriate qualifications can supervise and interpret neuromonitoring, and there’s absolutely nothing illegal about it. In terms of liability, you’d want to make certain that the person performing these tasks is appropriately qualified. I’ll return to this point in a second.

Of critical importance for getting paid is that one must be a physician (or audiologist in some states) to bill most insurance companies for the professional component of neuromonitoring. The reason is that insurance companies often (not always) have rules about who can bill for certain services. Medicare and Medicaid are crystal clear: physicians only. Indeed, it is a federal crime to bill Medicare or Medicaid for neuromonitoring services that were not performed by a physician. So, the bottom line here is, if you want to get paid, then you need a physician to supervise, interpret and bill.

So, when can non-physicians supervise and interpret? The short answer is, it depends on the state in which the surgery takes place, and it depends on the non-physicians’s qualifications. Regarding qualifications, if you are going to supervise a case, then your credentials have to support your work and they’ll need to hold up in the court of law. You’ll need to have a doctoral degree in the life sciences (PhD, DC, AuD or foreign medical), and you’ll need board certification for the supervision and interpretation of neuromonitoring (D.ABNM or BCS-IOM). Assuming you have the appropriate education and certification, then you’re free to monitor cases in most states, but you’ll go broke because no one will pay you.

In many cases, you’ll also need a physician to formally delegate privileges to you. Some states allow this, some states don’t, and others are unclear. Over the past several year, particularly in light of the increasing number of surgeries and the decreasing availability of physicians, a multi-tier practitioner model has emerged in which supervision and interpretation of IONM falls under the purview of the D.ABNM or the AuD. This is now the dominant practice model across the country. Indeed, every major IONM company in this country employs D.ABNMs for remote supervision in the role of a mid-level practitioner. Biotronic may have started this practice, but everyone else is doing it. There are simply too many IONM cases and not enough physicians, so delegation is a necessary alternative, particularly in light of CMS’s introduction of the G-code. Thus, while the technologist may be 1:1 with the patient, and the neurologist may supervise ~4 cases simultaneously, D.ABNMs frequently cover cases as needed to provide the necessary supervision and interpretation where physicians cannot (and sometimes will not).

Future of Professional Interpretation

The need for neuromonitoring expertise is clear. As the use of neuromonitoring continues to expand, there simply are not enough physicians who are qualified to supervise technologists and interpret the data.

Presently, groups representing physicians and non-physician professionals are working together behind the scenes to formalize the multi-tier practitioner model of supervision and interpretation of neuromonitoring. Everyone is on board with granting D.ABNMs the privilege to supervise and interpret neuromonitoring, as long as it is under physician delegation and the physician is available for consult as needed. It’s already the dominant practice model, we just need to work it into guidelines. It is my hope that non-physician doctors with board-certifications in IONM can once again receive reimbursement from all third-party insurance carriers.

References:

  1. Brown RH, Nash CL Jr. Current status of spinal cord monitoring. Spine (Phila Pa 1976). 1979 Nov-Dec;4(6):466-70.
  2. Dormans JP. Establishing a standard of care for neuromonitoring during spinal deformity surgery. Spine (Phila Pa 1976). 2010 Dec 1;35(25):2180-5.
  3. Horsley V. The Linacre Lecture ON THE FUNCTION OF THE SO-CALLED MOTOR AREA OF THE BRAIN: Delivered to the Master and Fellows of St. John’s College, Cambridge, May 6th, 1909. Br Med J. 1909 Jul 17;2(2533):121-32.
  4. Horsley V, Schäfer EA. Experiments on the character of the Muscular Contractions which are evoked by Excitation of the various parts of the Motor Tract. J Physiol. 1886 Apr;7(2):96-110.
  5. Nash CL Jr, Lorig RA, Schatzinger LA, Brown RH. Spinal cord monitoring during operative treatment of the spine. Clin Orthop Relat Res. 1977 Jul-Aug;(126):100-5.
  6. Norton JA, Aronyk KE, Hedden DM. Interpretation of surgical neuromonitoring data in Canada: a survey of practising surgeons. Can J Surg. 2015a Jun;58(3):206-8.
  7. Norton JA, Aronyk KE, Hedden DM. Interpretation of surgical neuromonitoring data in Canada: a survey of practising surgeons. Can J Surg. 2015b Jun;58(3): Appendix.
  8. Parsons RC. Electrical stimulation of the facial nerve. The Laryngoscope 1966; 76(3):391-406.
  9. Penfield W, Boldrey E. Somatic motor and sensory representation in the cerebral cortex of man as studied by electrical stimulation. Brain 1937; 60:389-443.

Dr. Rich Vogel is board-certified intraoperative neurophysiologist working for Safe Passage Neuromonitoring. He started the Neurologiclabs website and blog to connect with others in the field of neuromonitoring.

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7 thoughts on “Who is Qualified to Interpret Neuromonitoring Data?

  • Reply Navigating the Neuromonitoring Job SearchNeurologicLabs August 12, 2015 at 10:58

    […] all decisions about IONM are made by the clinician. If you’d like, you can learn more about qualifications for […]

  • Reply Transitioning from Academia to a Career in NeuromonitoringNeurologicLabs August 12, 2015 at 11:10

    […] both of whom worked together to develop this field. I have described the situation more completely elsewhere. In the not-too-distant past, neurologists finally convinced the AMA to declare IONM to be […]

  • Reply 2015 at NeuroLogicLabsNeurologicLabs August 12, 2015 at 13:05

    […] While I get soooo many nice e-mails and comments from my readers (thanks!!), you may be surprise to hear that I get some pretty nasty and threatening e-mails. Indeed, very few readers are ready for me to address topics like “quality IONM“, and no one wants me to talk about what makes one “sufficiently knowledgeable and competent to interpret IONM“. […]

  • Reply Neuro-what...?NeurologicLabs January 20, 2016 at 19:19

    […] or better understand monitoring personnel, types of certifications and the vast range of clinician qualifications, check out the IONM menu […]

  • Reply Where does Intraoperative Neurophysiological Monitoring stand in Canada in 2016? – Neurologic Labs December 26, 2016 at 18:19

    […] Who is Qualified to Interpret Neuromonitoring Data? […]

  • Reply Sarita January 11, 2017 at 10:46

    I worked hard to get DABNM certification with the thought that this will give me some extra opportunities and responsibilities, but when I go out to look for a job I am not treated any differently than high school passed or undergraduate college student with CNIM degree. It is very frustrating!

    • Reply Richard Vogel January 11, 2017 at 21:02

      Hi Sarita. I understand your frustrations. That happens because a lot of people out there are ignorant and need to be educated. It will take a little time, but we can change things. We are working with various states on advanced licensure, working with societies to write guidelines, and working with hospitals to support credentialing/privileging for DABNMs. We are also working with CMS and private insurance companies to educate them because they’ve been heavily lobbied by physicians for the last decade, and now all those physicians have left the field because the money dried up. Not to worry. Keep your head up. We will make progress. It takes a village to lead the change. Consider joining a committee in the ASNM, or running for office. Your voice matters!

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