On April 6, Michael Harrigan, 58, was driving 70 mph on Interstate 94 from Milwaukee to a business meeting in Madison, WI. He never did make it to his meeting, because he suffered a stroke halfway there. The series of events that occurred following his stroke are nothing short of miraculous.
Harrigan was able to pull over his car and call 9-1-1 despite having palpable stroke symptoms. His face was beginning to slump, he lost control of his left hand, and he was having difficulty speaking.
What Harrigan didn't know at the time was that UW Health Partners Watertown Regional Medical Center, the hospital he was transported to by ambulance, had just implemented a telestroke program connecting them to the University of Washington Hospital and Clinics in Madison on a 24/7 basis.
A stroke specialist in Madison was able to evaluate Harrigan using remote brain imaging technology and videoconferencing tools. As a result, he was given tissue plasminogen activator (tPA), a clot-busting drug which needs to be administered within the first three hours of an ischemic stroke in order for it to be effective.
"I am clearly very, very blessed and lucky that I happened to be able to take advantage of the telestroke program," says Harrigan. "I'm certain that without it I would have had more permanent damage and probably even more serious complications, including life-threatening ones in my opinion. It really could have been very serious."
Instead, Harrigan was transferred to the University of Washington clinic in Madison, where he spent the next week in their ICU before he was transferred to cardiology. He was eventually diagnosed with an atrial fibrillation.
In May, the American Heart Association (AHA) and American Stroke Association (ASA) published groundbreaking statements recommending the use of telemedicine technology on stroke patients. The AHA and ASA cite that the US has a mere 4 neurologists per 100,000 people who need to care for over 780,000 acute strokes per year, many of which occur in parts of the US that do not have access to acute stroke services.
The statement encourages the use of telemedicine technology to bridge the gap by providing medical specialists with the data necessary to assist remotely-located bedside clinicians in stroke-related decision making for patients.
Here are three institutions in the country that have implemented telestroke centers and the benefits and challenges they face.
Reducing the burden of stroke in Wisconsin
Justin Sattin, MD, leads the stroke program at the University of Washington School of Medicine and Public Health, which performed Harrigan's telestroke consultation. He describes the telestroke technology in Watertown as a "glorified IV pole" that can be moved anywhere in the hospital where the tools are needed.
It is equipped with a computer and flat screen monitor, which displays the physician's image. At the top of the pole is a high quality camera. To provide a consultation, the on call physician needs a computer with Internet access, a Web cam, and client software.
"The problem is that there's a lot of stroke out there," he says. "But, there really aren't many neurologists and, certainly, not that many stroke specialists."
As a result, Sattin says that healthcare professionals lean on stroke specialists, requesting consultations for any patient who has an acute change in their neurological function. For Sattin, this means he makes many trips to the emergency room for patients who end up getting diagnosed with everything from infections to seizures.
With the telestroke technology, stroke specialists are able to remotely treat patients who may have otherwise not been able to access care, making better use of their time. Sattin believes that telestroke technology could also become a "game changer" from a public health perspective by reducing some of the barriers of giving tPA to patients.
At first, Sattin said that the hospital in Watertown objected to the telestroke services because they didn't see many stroke patients, and saw even fewer patients who were candidates for tPA. However, now that the telestroke program is in place, Sattin says the hospital calls his facility more frequently than they predicted they would.
"More of their stroke patients have become tPA candidates," which, he says, is the whole point of the program.
In fact, Sattin says they treated six out of the first 12 telestroke patients using tPA. According to Medicare data, he says only a mere 2.5% of patients receive the drug.
When patients experience a stroke in Wisconsin, they are typically transported to the nearest hospital that has a designed stroke center. Sattin believes that offering telestroke services will allow more hospitals to be designated as stroke centers in the future.
"If you can hold yourself out as a stroke center, you can get more patients coming to you instead of the hospitals around you that aren't stroke centers," he says. "We need to get some of the rural hospitals on board, because if you have a fairly sizeable rural population, you should be either developing the structure to become a stroke center yourself or you should do it by virtue of one of these telemedicine arrangements."
In the future, Sattin predicts that, as the telestroke network grows, the remote consultations may pull physicians away from caring for their own patients on site. "You can only get interrupted so many times before it really starts compromising operations," he says. "At some point, the telestroke call schedule might need to be separate from the regular on call schedule."
60:6
In Los Angeles, CA, the ratio of hospitals to stroke specialists just don't add up, says Latisha Ali, MD, director of the University of California Los Angeles Telestroke Network Partner Program. While there are 60 hospitals in the Los Angeles area, there are only about six stroke neurologists.
UCLA officially launched its telestroke program in January and has a current network in the five-to-ten hospitals range. (Ali was unable to comment on exact numbers.) They are currently in negotiations with hospitals and trying to grow their network. For now, UCLA hopes to generate enough money to pay for the technology and keep the program sustainable.
"Our goal is to provide our hospitals with 24/7/365 clinical stroke expertise which has really been lacking in the community here," she says. "One of the advantages of our program is that you get a stroke expert at the bedside whereas if you were at the community hospital you might get someone who has treated stroke patients in the past, but for whom stroke is not an area of expertise."
According to Ali, less than 50% of patients who are admitted with a stroke actually see a non-stroke specialist in neurology. For neurologists in general, she says there are only four available to treat every 100,000 people in the United States and most of them are not trained in stroke or vascular neurology.
She attributes the shortage in the profession to the inability of physicians to quickly heal patients like in other specialties. However, she finds the specialty exciting, saying that it is rewarding to watch a patient improve under her care.
Ali says she wants to share her expertise with all of UCLA's partner hospitals. During consultations, emergency room physicians, medical students, and residents are often present. She uses the opportunity to walk them through a stroke examination and through the process of localizing a patient's symptoms.
Ali can view everything that is being done to the patient at the remote hospital, which does not have to page her every step of the way because she is right there watching events take place with them. The UCLA system uses high definition video conferencing. Ali says the images are "beautiful" and allow her to view such detail as a patient's pupillary response.
"We can actually move the camera around and zoom around the room and talk to everyone as though we were actually there."
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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