Remote Consultation Offers a Valuable Alternative to Face-to-Face Medical Treatment

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Published on May 7, 2008

By Bruce H. Cohen, MD, FAAN
Author disclosure

The standard face-to-face method for the delivery of medical care provides the best means of evaluation and treatment. Nevertheless, there are various times when this type of interaction may not be necessary or possible. In these circumstances, "remote consultation" has served as an alternative in recent years.

For the scope of this discussion, the use of the term remote consultation will refer to all methods (not restricted to the use of the Internet but also to include traditional technologies of information transfer such as mail or fax) where:

1. There is an exchange of medical information
2. A formal report is issued
3. A fee is charged for the consutative service

There are several reasons that a remote consultation may be requested. It may be initiated by the patient (or patient's family), a primary care doctor seeking another opinion for their patient, or by a specialist' requesting additional expert assistance. In these select instances, the use of remote consultation is a "win-win-win-win" concept for the patient, their primary doctor, their neurologist, and the remote consultant. In the setting in which a treating physician is willing to take responsibility to assist in the process, appropriate reasons for remote consultation could include:

• The patient lives in a remote region where travel would be financially difficult
• The patient is hospitalized or otherwise too ill to travel
• The history and examination are well-established: there is simply a need for more diagnostic or therapeutic suggestions
• The diagnosis is known and specific treatment options are requested

A number of issues thwarted the implementation of remote consultation when the concept arose several years ago. To avoid the suggestion that they were practicing medicine without a license, consulting physicians were advised that they should have a medical license in the state where the patient lived. Secondly, there was the concern that the patient or patient's family would not have the background necessary to formulate the reason for consultation, ask critical questions, or have the resources to acquire and deliver only the pertinent parts of the medical record. Finally, the physicians providing the remote consultation were not part of the patient's medical team never having met the patient in person and suddenly found themselves at the receiving end of seemingly endless phone calls and questions, without the ability to get reimbursed for their additional time.

These issues resolve when the request for the service comes specifically from the physician caring for the patient. Even if the patient initiated the remote consultation (and would usually receive a copy of the opinion), the official reporting relationship was physician-to-physician without the consultant physician ever establishing a direct patient-physician relationship. Under this stipulation, the consulting physician is providing, in effect, a professional service outside of a patient-physician interaction. As such, the service has a defined beginning and end.

The key components of such a consultation require that:

1. The request for service may be initiated by the patient, patient's health care power of attorney or legal guardian, or any member of the patient's physician team.
2. The patient is responsible for the cost of the service. In some circumstances, the patient's insurance company may pay for some or all of this service.
3. The official request for consultation needs to come from a physician. This physician requesting the opinion is responsible for:
1. Preparing a clinical summary, which should include the pertinent history, a detailed current physical examination, a listing of all pertinent laboratory tests, their impression, and the clinical course. This letter should also contain specific questions that are to be addressed by the consultant. The purpose of the letter is not only to provide a summary statement to assist the consultant, but to verify that all relevant material is being submitted for review.
2. Providing copies of pertinent lab reports, pertinent imaging studies (reports and films).
3. Other consultations.
4. Any other relevant data, including pathology slides.
4. A scale of services provided and method of payment is pre-determined. For example, if the request will require additional time to review data (a series of MRIs or pathology slides) there may be additional fees.
5. The consultant physician generally has the opportunity to review the request and agree to accept the request for consultation, or decline it (in which case the fee is returned immediately).
6. The consultant physician will review the data and issue a written report within a specified period of time (generally 2–7 days).
This can take on different formats. In general, the consultant will not repeat the entire history and physical examination, but will review the critical elements of the history, physical examination and laboratory data to formulate an opinion, and make diagnostic and therapeutic recommendations.

Remote consultations have limited applications but, when used appropriately, can be of value to all parties involved. Importantly, the patient must understand the limitations of the consultation and the consulting physicians should prepare a summary letter, also making sure the consultant has all the pertinent data. However, the value of this service is ultimately the responsibility of the remote expert.

Case Study #1
Case Study #2
Table of Remote Consultation Expectations & Obligations

Read a related article from Neurology Now®.

Author disclosure

Within the past 24 months, the author received personal compensation from Transgenomic, Inc., for speaking and serving on a scientific advisory board. Dr. Cohen has also served as an expert witness and given depositions on several legal cases, and has received 15% salary support over the last five years from a Chairman's Grant, Children's Oncology Group, for his participation as chairman of this committee.

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