Virtual Delivery of Stroke Care: Telemedicine Networks Have Arrived
Pub Date: Wednesday, May 27, 2009
Author: Andrew D. Barreto, MD
Schwamm LH, Audebert HJ, Amarenco P, et al. Recommendations for the implementation of telemedicine within stroke systems of care. A policy statement from the American Heart Association. Stroke 2009. [Epub ahead of print]
Many rural territories in the United States continue to experience a shortage of neurologists. Further, each year fewer neurologists have opted to provide 24/7 emergency room coverage for acute stroke care. Although this growing problem has led to a disparity of access to appropriate emergent neurologic care, it has opened the door for physicians who can offer evaluation and treatment remotely through telemedicine.
In the broad sense of the word, telemedicine encompasses any digital form (e-mail, fax, telephone, videoconferencing, etc.) of bringing together patients and physicians. However, with the arrival of less expensive broad-band internet access and digital imaging, telemedicine currently refers to interactive, full motion, two-way video and audio over high-speed data networks. Patients and physicians are connected through secure web camera video that also allows rapid assessment of the patient. In stroke telemedicine (telestroke), patients can provide a medical history and be examined remotely. Neuroimaging is displayed on the physician's local computer and quickly interpreted. Finally, treatment including thrombolysis for eligible patients is ordered and can be monitored. In addition to providing access to specialized providers, telemedicine can improve diagnostic accuracy. For instance, when compared with using the telephone, neurologists were 10 times more likely to make the correct treatment decision using telemedicine consultation for acute ischemic stroke.
In 2005 a task force appointed by the American Stroke Association recommended that neurologically underserved areas implement telemedicine to increase access to acute stroke care. The current manuscript by Schwamm and colleagues was commissioned by the American Heart Association to provide specific recommendations for how telemedicine can provide a means of improving stroke care delivery in the United States.
The authors identify and offer solutions to six major barriers that limit effective widespread use of telemedicine not just in stroke neurology but, also, general medical care: (1) Defining medical specialties suitable for telemedicine, (2) Medical licensure and liability laws, (3) Securing the health information being shared, (4) Creating simple processes for requesting and performing the consultation, (5) Developing financial models for reimbursement of telestroke services, (6) Gaining acceptance of remote consultation from patients, physicians, and payers.
The most daunting barrier, as correctly pointed out by the authors, currently results from medical licensure and liability law. State medical boards have traditionally only allowed the patient-physician interaction to take place "face-to-face" and within the state's borders. Similarly, most payers have only reimbursed for "in-person" consultation. Slowly, through efforts of individual physicians, newly created corporations, and the American Telemedicine Association, telemedicine has become more accepted, and these barriers are beginning to appear surmountable. For example, effective in September 2006, the Medicaid program of New York state began reimbursing the same for telemedicine consultation as it does for in-person care.
In the recommendations, the authors share valuable historical experiences and lessons learned from their own process of implementing telemedicine systems for acute ischemic stroke. Interestingly, and not surprisingly, the most successful telestroke centers have worked closely with their state's department of public health. After states such as Massachusetts required designation of primary stroke centers and required emergency medical services to deliver patients suffering from stroke to these hospitals, a strong demand began for telemedicine coverage from smaller community hospitals. These lower-volume hospitals are referred to as "spokes" in the "hub-and-spoke" telemedicine model that is the predominant form of telestroke consultation. Impressively, after the institution of telestroke in the spoke hospitals, two very important clinical changes were noticed: the rates of intravenous tissue plasminogen activator (tPA) treatment increased, and there was a reduction in onset-to-treatment time.
In my opinion as a vascular neurologist who participates in the delivery of telestroke consultations, telemedicine stroke networks represent the most ideal mode of providing acute neurologic care in the setting of small to medium-sized community hospitals that cannot employ 24/7 stroke coverage. If this manuscript's recommendations are followed, we can be assured that there will be an increased availability of vascular neurologists to ease the disparity of stroke care that exists in rural communities. In turn, more patients will receive rapid access to treatments that reduce both individual disability and the overall burden of cerebrovascular disease.
- Meyer BC, Raman R, Hemmen T, et al. Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded, prospective study. Lancet Neurol 2008;7:787-795.
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --