Telemedicine for Stroke: A Welcomed Tsunami during a Perfect Storm?
Pub Date: Friday, May 22, 2009
Author: Nina J. Solenski, MD
Schwamm LH, Audebert HJ, Amarenco P, et al, on behalf of the American Heart Association Stroke Council; Council on Epidemiology and Prevention; Interdisciplinary Council on Peripheral Vascular Disease; and the Council on Cardiovascular Radiology and Intervention. Recommendations for the implementation of telemedicine within stroke systems of care: a policy statement from the American Heart Association. Stroke 2009. Published online before print May 7, 2009. 10.1161/STROKEAHA.109.192361.
Necessity, who is the mother of invention.
--Plato, The Republic
Greek author & philosopher in Athens (427 BC-347 BC)
Even the most entrenched "technophobes" cannot ignore the explosion of information and heightened awareness of telemedicine applications over the last 5 to 10 years. Surprisingly, the history of telemedicine covers 50 years or more of development and innovation.[1,2] For example in the early 1960s, the National Aeronautics and Space Administration (NASA) began physiologic telemonitoring from spacecrafts and space suits during missions that most of us marveled at and considered to be the height of human achievement.
Back on earth, equally marvelous technologic advances were taking place, even if they were not as noticeable. Psychiatry teleconsulting was being conducted in Nebraska, and satellite videoconsultation was being provided from Anchorage to improve the quality of health care in rural Alaska. In Boston, in 1967, the "Massachusetts General Hospital/Logan International Airport Medical Station" allowed physicians at the hospital to provide medical care to patients at the airport using a two-way audiovisual microwave circuit.
Now, 50 years later in 2009, we are on the verge of a tsunami-sized wave of telehealth innovation and deployment. For stroke telemedicine services, this has been a slow and arduous, but productive, process. The culmination of recent years of pioneering work is keenly demonstrated in this current issue of Stroke that reviews stroke telemedicine recommendations for implementation and the evidence supporting these systems.[3,4] Dr. Lee Schwamm and the entire writing committee are to be congratulated on their seminal work. It will provide the foundation for continuing growth by allowing physicians and hospital systems to critically analyze their own institutional capacity for either providing or receiving telestroke services.
In many ways, telemedicine has been held to a higher standard of proof of efficacy than other therapies. Therefore, this evidence is critically needed to validate and promote more universal adoption of integrating technology into each component of the stroke systems of care. Some components are advancing quickly, such as acute stroke and the use of headquarters-videoteleconferences (HQ-VTC), while other critical components have little to no applications to date, such as primary stroke prevention. Although each investigation that is cited represents an important contribution to the field, some studies stand out. Those include proof of efficacy of remote interactions compared to face-to-face interactions for the treatment of acute stroke. Multiple studies now validate the use of HQ-VTC for performing a National Institutes of Health Stroke Scale (NIHSS)-telestroke examination both on nonacute and acute stroke patients (the latter by a stroke neurologist). Both are Class I, Level of Evidence A recommendations. Studies comparing telephone consultation versus the use of HQ-VTC [including review of head computed tomography (CT)] for thrombolytic eligibility for acute stroke have been conducted and conclude that treatment decisions were made more accurately using HQ-VTC than using telephone consultation with the referring physician.[5,6] These findings should prompt neurologists, who are frequently asked to provide telephone consultation in this setting, to pause and take notice. As aptly stated by one reviewer, "The status of 'telestroke' for acute stroke is presently passing from feasibility to routine use."
Notably, there are less data on how well the "art" of medicine is being rendered during stroke telemedicine services. Patient satisfaction has been very high in most forms of telemedicine and was equally high in at least one stroke telemedicine program that measured it. One wonders if a reason for slow physician adoption of HQ-VTC for stroke care stems from a misconception of having a poorer patient-physician rapport and that the technology is "getting in the way" of the traditional bedside relationship. This topic requires more study.
For those investigators that led the way, especially those developing acute stroke telemedicine applications, one can imagine that it was not easy. Monitoring vital signs or evaluating a skin wound teleremotely is significantly less complex, than rendering an acute diagnosis (within minutes), and treating a critically ill patient in the chaotic emergency room (ER) setting. Mastering the skill of a remote evaluation of an acute stroke patient, including rapidly and accurately reviewing the head CT scan, performing a challenging neurology examination (for example, on an uncooperative, neglectful, or aphasic patient) to the point of feeling confident with medical decisions is a remarkable achievement. In the United States, with a fairly aggressive medicolegal system, it took "guts" to take these risks, albeit well-calculated, to treat patients remotely. Many in Europe were equally progressive.
So why would one pursue this? "Necessity, who is the mother of invention." In 1995, the emergence of a proven, time-sensitive therapy for acute stroke, recombinant tissue plasminogen activator (rt-PA), was quickly followed by the reality in the United States that millions did not have access to it. This experience was mirrored in Europe. But why did it take an additional 15 years to exploit telemedicine use for acute stroke therapy? Perhaps the time was not right, in addition to the stringency for proof of efficacy. A decade ago, reimbursement was even more dismal than it is currently for telemedicine services; broad-band and other high-speed telecommunication services were still growing. In addition in the United States, although health care disparity was growing exponentially, it received less attention. The turning point may also have been the development of American Stroke Association (ASA) guidelines in 2005 for the establishment of stroke systems of care. In the United States, there are multiple examples of strong statewide advocacy for this concept. One example is in the state of Virginia. The Virginia Stroke Systems is a successful collaboration between the Virginia Department of Health, the ASA, and nonprofit organizations such as the Virginia Telehealth Network (http://virginiastrokesystems.org). This partnership led to the Virginia Acute Stroke Telehealth initiative and procurement of federal funding [U.S. Dept. of Health and Human Services Health Resources and Services Administration (HRSA)] to test a robotic telemedicine program in rural Appalachian critical access hospitals (http://ehealthvirginia.org). Similarly in Europe, the 2006 World Health Organization (WHO) Helsingborg Declaration on European Stroke Strategies  and the European Stroke Organization, continue to plant the seeds for the development of stroke systems of care that integrate telemedicine applications.
Lastly, perhaps relationships have made a difference. Telemedicine represents a unique relationship between medicine and technology, each highly dependent on the other. The telecommunication, videoconferencing, and telehealth industry must have the endorsement of the physician to embrace and use the technology. The physicians equally need clinically tailored and pioneering technologies to provide remote care that mimics the same quality as onsite care. This synergistic relationship is critical and currently thriving in the United States as serious health care reform is looming. Interestingly, this comes at a time of heightened awareness of conflict of interest in academic institutions and large sweeping regulatory changes in the pharmaceutical industry. The free junkets, meals, and cheap pens are gone. But in the realm of telemedicine, a strong and principled working relationship is essential. Perhaps it's worth reflecting on new rules of partnership rather than rules of separation, particularly when it comes to research and discovery and the evidence-based role that academics can play.
So perhaps in 2009, the perfect storm was created by the increasing need to bring treatment to where the stroke patients reside, coupled with the growth of the telehealth industry, and re-examination of hospital and physician reimbursement issues. Finally, add to this mix the persistence of the pioneers in stroke telemedicine in Europe and the United States and their willingness to take risks to create evidence-based remote clinical protocols and models for stroke telemedicine services. The results are indicating improved acute and long-term stroke outcome.
However, challenges with implementation remain. Some are formidable, such as funding of the infrastructure, especially if federal or state funding is lacking, sizable inequitable hospital and professional reimbursement, and poor physician adoption. Undoubtedly, these two Stroke publications will propel the adoption of telestroke to overcome these challenges in the near future. It is hoped that readers will identify a clinical knowledge gap and pursue more studies, that they re-examine their own state regional stroke systems of care and consider how telestroke services can rectify therapeutic and educational disparity in each component of the stroke continuum of care. It is hoped that this aids in the creation of viable telestroke business models for diverse hospital systems, and productive principled partnerships between the telehealth industry and academics. It is hoped that this tsunami event, in contrast to wreaking damage and terror, brings sustainable health care relief within the entire spectrum of stroke care, with the ultimate goal of diminishing the all too frequently witnessed suffering in stroke patients and their families globally.
- Allen A, Allen D. Telemedicine programs: 2nd annual review reveals doubling of programs in a year. Telemedicine Today 1995;3:10-14.
- Nancy Brown. A brief history of telemedicine. Telemedicine Information Exchange. May 30, 1995. http://tie.telemed.org/default.asp. [Accessed May 14, 2009.]
- Schwamm LH, Holloway RG, Amarenco P, et al, on behalf of the American Heart Association Stroke Council and the Interdisciplinary Council on Peripheral Vascular Disease. A review of the evidence for the use of telemedicine within stroke systems of care: a scientific statement from the American Heart Association/American Stroke Association. Stroke 2009. Published online before print May 7, 2009. 10.1161/STROKEAHA.109.192360.
- Schwamm LH, Audebert HJ, Amarenco P, et al, on behalf of the American Heart Association Stroke Council; Council on Epidemiology and Prevention; Interdisciplinary Council on Peripheral Vascular Disease; and the Council on Cardiovascular Radiology and Intervention. Recommendations for the implementation of telemedicine within stroke systems of care: a policy statement from the American Heart Association. Stroke 2009. Published online before print May 7, 2009. 10.1161/STROKEAHA.109.192361.
- Meyer BC, Raman R, Hemmen T, et al. Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomized, blinded, prospective study. The Lancet Neurology 2008;9:787-795.
- Handschu R, Scibor M, Willaczek B, et al. Telemedicine in acute stroke: remote video-examination compared to simple telephone consultation. J Neurol 2008;255:1792-1797.
- Audebert H. Telestroke: effective networking. The Lancet Neurology 2006;5:279-282.
- Wiborg A, Widder B. Teleneurology to improve stroke care in rural areas: The Telemedicine in Stroke in Swabia (TESS) Project. Stroke 2003;34:2951-2956.
- AHA Scientific Statement. Recommendations for the Establishment of Stroke Systems of Care Stroke. Stroke 2005;36:690-703.
- Norrving B et al. The 2006 WHO Helsingborg Declaration of Specialized Stroke Care. Int J Stroke 2007;2:139-143.
- Audebert HJ, Schultes K, Tietz V, et al. Long-term effects of specialized stroke care with telemedicine support in community hospitals on behalf of the Telemedical Project for Integrative Stroke Care (TEMPiS). Stroke 2009;40:902-908.
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --