The term telestroke, first used in a 1999 article in the American Heart Association (AHA) Journals, refers to the...
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use of telemedicine technology in the treatment of strokes, the third leading cause of death in the United States. These services are increasingly valuable to small, often rural community hospitals that do not have a neurologist on-site 24 hours a day, seven days a week.
- Why are telestroke services important?
- What are the benefits of telestroke?
- What are the technical requirements for deploying telestroke services?
- How does telestroke work?
- What challenges can hinder the development of telestroke networks?
As the American Academy of Neurology (AAN) points out, telestroke marks an important advancement. Issuing intravenous tissue plasminogen activator, or IV tPA, within three hours of the onset of stroke has been proven to better a patient's chances to survive. However, tPA is given to fewer than 5% of patients. In many cases, emergency room physicians lack the expertise to make decisions about stroke treatment without input from vascular neurologists, who in turn are often stretched thin among several hospitals and their own practices.
Telestroke services increase the odds that a stroke patient will be seen by a neurologist within that three-hour window. In fact, remote neurologists are often able to see stroke patients within minutes.
Several studies aggregated by the National Center for Biotechnology Information have reached the following conclusions about telestroke services:
- It can improve acute stroke management through "rapid access to specialised interventions through initiation of interhospital transfers" as well as improvements to on-site stroke services.
- Teleconferencing can effectively support emergency room stroke evaluation, particularly when it comes to deciding whether to administer tPA.
- According to a study conducted by the Medical College of Georgia, Web-based telestroke services can expedite the administration of tPA by as much as 20 minutes for stroke patients in emergency rural departments.
- Telestroke consultations can result in more accurate diagnosis and analysis than telephone conversations with off-site neurologists. This analysis can include triage for "patients who might benefit from interventional treatments not available at the referring hospital."
In its most basic form, a telestroke system requires the consulting neurologist and the attending nurse to use video conferencing equipment, which requires a laptop or personal computer, a camera and a high-speed Internet connection -- the Wake Forest Baptist Telestroke Network suggests an 802.11 wireless Internet connection that is 600 kilobits per second (kbps) or faster. A 24-hour CT scanner should also be in place.
The remote neurologist may be located at an urban hub hospital or a third-party location such as a stroke center or home office. Some telestroke networks, such as the service developed by Georgia Health Sciences University, connect rural hospitals to the hub as well as third-party sites such as the referring physician's office.
Seattle-based Swedish Medical Center identifies five steps in the process of how telestroke works:
- Assessment begins in the ambulance en route to the hospital.
- Assessment continues when the patient arrives at the emergency room.
- The ER physician initiates a secure Web conference with a remote neurologist.
- The neurologist conducts an exam, reviews brain images and test results, and speaks to the ER physician, patient's family and the patient. (Hospitals in Louisiana and North Carolina have begun using robots to help remote neurologists examine acute stroke patients.)
- The neurologist orders a treatment, such as the administration of tPA or the transfer of the patient to a more specialized care facility.
A video demonstration of telestroke by PeaceHealth Oregon shows how such an interaction takes place. The neurologist is able to talk to the patient about what happened that day, evaluate the patient's motor skills, view a CT scan and make a diagnosis.
In its acute stroke management protocol, the University of Utah Stroke Center notes that "telestroke can be initiated any time during the assessment / treatment process" -- and, further, will be initiated if patients have exhibited certain symptoms in the six hours prior to arriving in the ER.
Genentech Inc., a biotechnology firm that develops tPA and other medications, has identified more than two dozen telestroke networks in the United States. Most are based in large cities and/or university medical centers. That said, several challenges confront health care organizations aiming to use telestroke services. Fortunately, many solutions are available now or on the horizon.
- As with all telemedicine technology, reimbursement remains a concern, though a recent rule from the Centers for Medicare & Medicaid Services (CMS) aims to ease the burden of telemedicine credentialing.
- Licensing is also an issue, since in many cases the remote radiologist is not in located in the same state as the patient. To address this, hub hospitals typically assume all responsibility for licensure, according to Genentech.
- To address the security of protected health information, the University of Wisconsin Telestroke Network encrypts all Web-based messaging that occurs during a consultation and makes no recordings from the Web camera or microphone.
- Funding, of course, can be an issue. Many federal programs issue grants to help cover network infrastructure costs; these include the Telehealth Network Grant Program, the Rural Health Care Pilot Program and the Distance Learning and Telemedicine Loan and Grant Program, Genentech notes.
Above all, telestroke initiatives succeed when a symbiotic relationship among the hub hospital, spoke facilities and other third parties can be cultivated. As with many health care IT projects, this requires little more than a single "physician champion" who touts the benefits of the technology and convinces others to make the investment.
Plus, as the case of Christus St. Michael Health System in Texarkana, Texas demonstrates, there's always a slight chance that a telestroke advocate can become a patient.
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