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Telestroke Programs Link Stroke Specialists to Patients Unable to Access Care

Cynthia Johnson, October 30, 2009

Ali says that the family members present for the consultations have been appreciative of the services they are able to provide using the technology. They understand that if the technology weren't available, then their loved one might not have gotten much by way of treatment options.

Telestroke roots run deep in the Vineyard
Massachusetts General Hospital is no newcomer to the field of telestroke medicine. According to Shawn Farrell, the director of the Partners Telestroke Program, MGH began offering consultations 13 years ago as part of a pilot program with Martha's Vineyard Hospital. The island had stroke patients who were not able to access care because of their proximity to the mainland. Today, MGH has 27 hospitals in Massachusetts, Maine, and New Hampshire in its program.

Farrell says Massachusetts is unique in that it has a stroke center designation program at the state level with the Department of Public Health. As part of that program, if a hospital is not a designated stroke center by the department, then an ambulance will bypass that facility and go to the next closest hospital that is. While other states may have stroke center certification programs, they may not have emergency medical services rerouting, so there isn't motivation to fulfill that requirement.

"Hospitals feel that stroke center designation is very important, so they do whatever they can to meet that," he says. "Telemedicine is an acceptable form of meeting that requirement.

A unique aspect of the MGH system, which was developed in house, is that it has workflow support, clinical decision making tools, algorithms, calculators, reminders, and alerts built into it. If there are contraindications to administer tPA, the system will display alerts and warnings prompting the user to take action.

According to Farrell, 2 to 4% of patients receive the medication. The MGH telestroke program rates are 20 to 30%. One of their partner hospitals averaged four tPA administrations in four years. After joining the network, the hospital had 10 tPA administrations in the first year.

"They feel much more comfortable about administering the drug to the right patients with the right support of the neurologist with the video screen," he says.

Farrell says stroke specialists are able to do so much more when they are able to visually interact with a patient, the emergency room physician, and the patient's family. "The two-way interactive communication that occurs over a videoconferencing device really helps to make a much higher quality interaction," he says.

Reimbursement overhaul needed
Reimbursement is a clear barrier for hospitals interested in providing these life-saving services. Currently, Medicare only pays for telestroke services in geographic locations that meet narrow criteria. Overall, payers are reluctant to reimburse for telemedicine services in general. As a result, only one of the hospitals in the Partners network meets that profile, so they do not bill any insurance companies for services.

Farrell hopes that, as the American Reinvestment and Recovery Act funding begins to flow, there will be an opportunity for healthcare technology to tap into the available funds to keep telestroke programs up and running.

Sattin does not believe that changing Medicare rules or private insurer rules to allow you to bill for the services is the answer. He says telestroke programs require that physicians be tethered to an Internet connection when they are on call in order to provide consultations—no small task.

"That's a big barrier," he says. "And, being able to bill $100 or $200 for an individual consult isn't going to compensate somebody for being on duty. The billing per click doesn't really capture the costs involved in signing on to this."

Instead, Sattin advocates for hub hospitals to negotiate contractual agreements with spoke hospitals, such as Watertown. Some of the financial benefits Watertown Hospital gains include a fairly sizeable reimbursement for administering tPA, which Medicare recently increased.

Licensing also becomes an issue if providers need to become licensed in neighboring states in order to provide telemedicine services—a time-consuming and expensive process.

Ali is in favor of uniform, national telemedicine licensure by state medical boards for telestroke providers. She says the American Telemedicine Association is working on this and other issues. The AHA/ASA statements will also go a long way in helping to promote change.

Making the most of unhappy ending
Not all strokes end like Harrigan's, who is now in the process of rehabilitation and making changes to his lifestyle. Sattin says that he once saw an elderly, sick patient who had experienced a stroke. He says it was a confusing case in terms of reporting neurological findings.

"That's somebody who I probably would have asked to be transported to our facility," he says. "I was able to conclude remotely that there was nothing that anyone was able to do for this person and what she really needed was palliative care. It's a heavy topic and you prefer to do that in person, but, on the other hand, we saved the family an unnecessary transfer to the big city with the whole big family having to drive over. Why should mom die in a big city hospital when she can die in her own community with her family there and the doctors who know her?"


Cynthia Johnson is the editor of Medicine On The 'Net, a monthly newsletter from HealthLeaders Media.

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