Seminars in Neurology最新文献

This article explores Canada's healthcare system, focusing on neurological care delivery and available national population-based data for research. Canada's publicly funded, provincially administered healthcare ensures universal access to medically necessary services, with provincial variations in coverage. Neurological care is predominantly hospital-centered, with support from advocacy groups promoting equity and research. In Quebec, stroke care is structured through regional service corridors, integrating telemedicine and geolocation-based transfer models to mitigate urban-rural disparities. British Columbia confronts challenges in providing neurological care to rural populations, utilizing outreach clinics, tele-neurology, and subsidized transportation. The First Nations Health Authority addresses unique healthcare access and governance needs for Indigenous populations. Canada's healthcare infrastructure supports population-level research via linked administrative and electronic health records, enabling comprehensive evaluations of healthcare utilization, outcomes, and quality metrics. Despite interprovincial differences and coverage limitations, advancements in data interoperability and standardization have propelled neurologic health services research.

The term "funds flow" refers to the financial relationships between the schools or colleges of medicine and its parent university, the hospital/health system, and clinical departments. Funds flow arrangements vary greatly among organizations based on the relationships between these entities, their financial status, levels of extramural research support, and size of endowments and philanthropic activities. We review four general funds flow models: the "Make Whole" Model, the "Pay for Production" Model, the "Value-Based" Model, and the "Contribution Margin" Model. We also discuss issues that can affect how these models operate and the reasons they differ depending on organizational structures and financial postures.

Value-based care has been impactful in primary care, but specialty care has not been a large focus area. This manuscript provides neurologists with an overview of value-based payment (VBP) models and offers practical suggestions for engaging in these models using example conditions of migraine and dementia. The article discusses various VBP models, from low-risk pay-for-performance to high-risk shared risk models, and emphasizes the importance of data infrastructure, patient outcomes, quality improvement, and cost reduction for success in value. By adopting a value-based approach, neurologists can improve care for complex neurological conditions, enhance patient satisfaction, and achieve sustainable health care excellence. The conclusions highlight the transformative potential of VBP models in neurology, encouraging neurologists to take small steps toward value-based care to achieve quadruple aim benefits.

This article provides a comprehensive examination of legal liability in neurology, encompassing both malpractice litigation and compliance with federal regulations. The article highlights how legal accountability hinges on adherence to the standard of care, the adequacy of informed consent, and accurate documentation of decision-making capacity. Special attention is given to legal and ethical challenges in treating vulnerable populations, including children, pregnant women, and cognitively impaired individuals, for whom neurologists must navigate consent, reporting mandates, and surrogate decision-making. The article also explores driving restrictions for individuals with epilepsy or dementia, where state-specific laws and evolving tort doctrines influence physician liability. The assessment of decision-making capacity and testamentary competency is addressed, emphasizing the role of the neurologist in legal proceedings and estate planning. Brain death determination is discussed as a particularly contentious area with significant implications for organ donation and family disputes. On the regulatory side, the article reviews key statutes such as HIPAA, the 21st Century Cures Act, the False Claims Act, and the Stark Law, identifying the implications for privacy, billing practices, and physician referral behavior. Risk management strategies are offered to help neurologists navigate legal uncertainty, strengthen patient relationships, and comply with federal mandates. This article aims to serve as both a practical guide and a legal primer for neurologists practicing in an increasingly litigious and regulated environment.

Clinical informatics (CI) is an emerging field within biomedical informatics that sits at the intersection of clinical care, health systems, and health information technology (IT). CI emphasizes how individuals (neurologists, patients, staff) interact with health IT (HIT), with a focus on designing systems that support optimal neurologic care. As neurology becomes more complex-expanding diagnostics, treatments, and subspecialties-there is a growing need for usable, efficient electronic health record systems that enhance, rather than burden, care delivery. This paper reviews roles CI neurologists can play, as translators, architects, advocates, and leaders across clinical, operational, and strategic domains. We highlight examples where CI expertise addresses challenges in neurology, including access to care, documentation burden, burnout, quality improvement, patient engagement, artificial intelligence, research registries, and precision health. With projected workforce shortages in neurology and CI, neurologists with CI expertise will ensure that HIT will effectively support high-quality neurologist-led care.

Neurologists engaged in meaningful and satisfying work are positioned to advance the field through research, education, and patient care. On the other hand, neurologists are at elevated risk for burnout and career dissatisfaction, influenced by personal characteristics but driven primarily by external factors at work unit, organizational, and systemic/societal levels. Recognizing and attending to the full range of factors that influence neurologist well-being is necessary to avoid detrimental consequences on patients, clinicians, organizations, and public health. This discussion will review the current state of well-being in neurology, explore drivers and outcomes, and present strategies for improving career satisfaction.

Neurologists in ambulatory settings struggle with low appointment availability and increased work related to patient care outside of clinic visits. Neurologists can better meet these demands using asynchronous or non-face-to-face care options. Specific billing codes allow reimbursement for work neurologists are already doing to care for their patients between visits. This includes care delivery over patient portal messages (e-visits), asynchronous consultations through the electronic health record (EHR) system requested by providers for their patients with neurologic issues (eConsults), care coordination and record review outside of clinic visits (prolonged service for non-face-to-face care outside of the date of service and transitional care management), and analyzing data from new technologies and devices for patient diagnosis and therapeutic monitoring (remote patient monitoring). Artificial intelligence shows promise to improve how neurologists deliver asynchronous care. More seamless incorporation of asynchronous care options in the EHR and clinic templates will ultimately be necessary to improve neurologists' efficiency and work-life balance.

Artificial intelligence (AI) has emerged as a transformative force in the management of movement disorders. This review explores the various applications of AI across the spectrum of care, from diagnosis to clinical workflows, treatment, and monitoring. Recent advancements include deep phenotyping tools like the Next Move in Movement Disorders (NEMO) project for hyperkinetic disorders, diagnostic platforms such as DystoniaNet, and biomarker identification systems for early Parkinson's disease detection. AI may revolutionize treatment selection through technologies like DystoniaBoTXNet and adaptive deep brain stimulation systems. For symptom monitoring, innovations like the Emerald device and smartphone-based assessment tools enable continuous, objective evaluation. AI may also enhance patient care through improved telemedicine capabilities and ambient listening. Despite these promising developments, recent critiques highlight methodological concerns in AI research, emphasizing the need for rigorous validation and transparency. The future of AI in movement disorders requires balancing technological innovation with clinical expertise to improve patient outcomes.

Insomnia is highly prevalent in clinical practice and can present independently or alongside other medical and mental health disorders. Insomnia is a risk factor for the development and exacerbation of medical and mental health conditions. Behavioral and pharmacological treatments for insomnia are available. In this article, we review important mechanisms associated with insomnia including the hyperarousal model of insomnia and the neurobiology of insomnia. We then review the treatment approaches and management strategies for insomnia including cognitive behavioral therapy for insomnia, transcranial magnetic stimulation, pharmacologic treatment, and adjunctive treatments for insomnia.