“You have to have a physician champion who can really convey how it would work, how it would work in the flow of physicians at these small spoke hospitals,” says Mike Schmitt, PBI’s program development and outreach director, and the telestroke administrative lead. “Really communicate to them the value of the program.” To date, the method’s proved fruitful for PBI, the first nationally certified primary stroke center in Oregon. It signed its first community hospital in April 2010. By December of that year, the number increased to seven. Now, just two months later, PBI is working with 11 Oregon facilities, plus one in Washington.
It’s not just physicians who need to be on board to have a successful telestroke program; the administration, too, must be convinced of its merits, says Anand Vaishnav, MD, MPH, associate professor and vice chairman of the University of Louisville School of Medicine’s department of neurology, and one of four board-certified neurologists who rotate call for Louisville’s telestroke program. “The hospital administration needs to see the long-term vision of going out to hospitals and developing a network,” he says.
That could mean shelling out cash up front—to compensate on-call neurologists, for example, or to put toward equipment. Regardless of where the money goes, it pays out dividends in the end, Vaishnav adds. “Our aim is to take care of patients in a good, appropriate way with good standardized medicine. If people get to know that a hospital is delivering good stroke care, your volumes are going to increase.”
Success Key No. 2: Willingness to invest
Like any major project, a telestroke program requires up-front investment in technology and people. Implementing a high-tech system can run up a modest $10,000 bill, or an astronomical price tag reaching into the hundreds of thousands of dollars, according to Shawn Farrell, director of the Partners Telestroke Program, through which MGH is a hub. “It depends on how many bells and whistles you want,” he says. “Do you want a Honda Accord or do you want a Lamborghini?”
In fact, an Accord may work perfectly. (And knowing that ahead of time falls under Success Key No. 3.) St. Luke’s Episcopal Hospital, a 706-staffed-bed facility in Houston, intentionally started with simple technology, says Sarah Livesay, MSN, RN, ACNP, manager of the hospital’s neuroscience clinical programs. “I believe we wouldn’t have been successful at the time with the [spoke] hospitals had we asked them to make large investments in technology,” she says. Currently, St. Luke’s offers telestroke services to six partner facilities, with three more interested in the program. Livesay says St. Luke’s will set aside more capital for technology as its telestroke program expands.
Fortunately and unfortunately, technology moves quickly. To keep up, hospitals improve their systems accordingly—and pay whatever the price tag reads. “We’ve seen three iterations of this technology already in the 10 years we’ve been doing this, from large, expensive video-conferencing systems to inexpensive PC-based, multimedia systems,” says Schwamm of MGH. The advances will keep coming, making it crucial to figure out how to refill the money pot once it empties, Farrell says. “The funding challenges are clearly there,” he adds.
Equipment isn’t the sole fiscal consideration, Louisville’s Vaishnav says. The physicians who participate—particularly those on call for extensive time periods—may need appropriate compensation. “Put yourself in the position of the doctors,” he says. “It’s 24 hours a day.” Couple that with negligible overall reimbursement for telemedicine, and a hospital’s administration would do well to focus on long-term gains rather than short-term challenges.
Success Key No. 3: A solid game plan
For most tertiary facilities offering telestroke, it’s less about bringing in money and more about sending out knowledge from trained neurologists—with the back-of-mind notion that payment will eventually follow.
Some physicians see it as fulfilling part of a hospital’s community outreach mission: “It’s our responsibility that we extend our expertise beyond the boundaries of the four walls of our campus,” says Schwamm, whose telestroke network includes 24 hospitals in New England. Others believe it’s every patient’s right to receive high-quality services. “All hospitals should be capable of treating stroke or directing patients to hospitals that are capable,” Vaishnav says. “Why should stroke treatment not be the standard of care irrespective of hospital?”
A third school of thought says this service brings smaller hospitals into the stroke game. “For us, telestroke is not just about the acute part of it, the golden-hour stuff [administering tPA],” says PBI’s Okon. “It’s also about helping to build infrastructure, improving capacity to take care of patients, and building a relationship between a hub and the small hospitals.” Schwamm compares joining a telestroke network to buying shares of a private jet rather than the whole plane. “Most companies can’t afford a 24/7 stroke center,” he says, “but they can afford a slice of one.”