Teleneurology - Florida Osteopathic Medical Association · 2Efficacy of site-independent telemedicine in the stroke doc trial: a randomized, blinded, prospective study. Lancet Neurology

Teleneurology

SCOTT PEARLMAN, D.O.

NEUROHEALTH OF SOUTH FLORIDA

TELENEUROLOGIST FOR SPECIALISTS ON CALL

Telemedicine Benefits And

Challenges

2

“It is an amazing invention, but who would ever want to

use one”

Rutherford Hayes, 1882 on the using telephone for the first time

RESISTANCE TO CHANGE

Discovery to implementation in medicine = 15 years

TIME

Ra

te o

f C

ha

ng

e

Society

Business

Technology

Healthcare

The Shortage of Specialty Physicians

Cost, quality, patient satisfaction all suffer in the absence of effective

on-call coverage

Call coverage is increasingly

punitive & undesirable

Specialty physician shortage is

increasing

Underserved no longer means just ‘rural’

Demand for specialty consults

is increasing

Stipends are growing as a

burden to systems

Telemedicine + Stroke

The U.S. has ~4 neurologists per 100,000 persons

800,000 strokes per year

Increasing numbers of stroke neurologists opting out of call coverage Increasing numbers of underserved patients

State/local regulations require emergency call coverage

in order for center to be recognized as stroke-capable

facilities or primary stroke centers

The Rationale

Just-in-time Care

Improved Quality

Enhanced Efficiency

Better Professional Communication

Patient Satisfaction

Enlarged Catchment Area

Cost Savings?

Advantages of telemedicine:

Decreased response time

High patient satisfaction scores for telemedicine consults

Reduced geographic disparity in neurological care

Improved access for remote or underserved areas

Easy recruitment of patients for clinical trials

Decreased travel time and expense for patients and doctors

Telemedicine is Good for

patients

Access to specialists in a timely manner

Increased response time

Quicker treatment plan

TIME IS BRAIN

Acutely ill patients get acute evaluation

Shorter hospital stay as earlier evaluation and thus

test ordered earlier

Teleneurology is Good for

Hospitals

Allows hospitals to treat stroke patients with confidence &

clinical consistency

Eliminates EMS diversions

Reduces unnecessary patient transfers

Satisfies staffing requirement for Primary Stroke Center certification

Supports ER staff & improves department efficiency

Provides a competitive advantage in local marketplace

Relieves the burden of on-call coverage for local neurologists/physicians

Serves as a recruiting advantage for physicians

HISTORY OF TELEMEDICINE

Early History of Telemedicine

1950s and 1960s

Nebraska Psychiatric Institute - UN & state mental hospital & Interact System - Dartmouth and UVM Medical Schools [Microwave]

STARPAHC [Space Technology Applied to Rural Papago Advanced Health Care - Papago Indian Reservation & Public Health Hospital in Arizona

Alaska Satellite Biomedical Demonstration Project used NASA technology to link 26 sites across Alaska.

HISTORY OF TELEMEDICINE Boston Logan Airport to Massachusetts General

Hospital 1967

HISTORY OF TELEMEDICINE STARPAHC – On the Papago Indian Reservation

1975

History & Development

Health care via remote services

Not a new concept

What IS new – technology

Levine & Gorman, 1999

First detailed description of potential use of telemedicine in

acute stroke via video teleconferencing (VTC)

As of 2012 survey, there were 56 confirmed active telestroke

programs in the U.S. (Silva et al, 2012)

16

What the patient sees

17

What I see

Youtube Patient video

https://www.youtube.com/watch?v=nB4joFD7MR

0

Equipment

Minimum quality standards, including transmission rates

and ability to support high resolution and high frame

rates

Teleradiology - Review of imaging at appropriate

resolution using DICOM (digital imaging and

communications in medicine), which is a standardized digital format.

Must be FDA-approved in order to receive Medicare or

Medicaid reimbursement

Equipment

High quality video

teleconferencing (HQ-VTC) –

interactive audiovisual systems, coupled with the use of

teleradiology for remote review

of brain images (Schwamm et

al, 2009)

Pt & provider can see and hear

each other in full color

Cameras have various degrees

of remote control connected to

a display screen

Telemedicine models:

Do it yourself: technology purchase with consults by local physician

Hub – Spoke: consults provided by hub facility physicians

Independent: consults provided by independent telephysicians

Telemedicine Models of Care

GS Silva et al., 2012

Why is Telemdicine

important?

-TIME

-NEED

-TPA WINDOW

Every 3-4 min delay= 1% more

death/complications/lack of

improvement.

Opportunity gone at approx. 4.5 hrs

TIME IS BRAIN- Quantified

Neurons

Lost

Synapses

Lost

Myelinated

Fibers Lost

Accelerated

Aging

Per stroke 1.2 billion 8.3 trillion 4470 miles 36 y

Per hour 120 million 830 billion 447 miles 3.6 y

Per minute 1.9 million 14 billion 7.5 miles 3.1 wks

Per Second 32 000 230 million 218 yards 8.7 h

SAVER JL STROKE 2006:37:263-6.

Relation of onset-to-treatment time (OTT) and excellent final functional outcome (mRS 0–1 at 90 days) for intravenous tissue plasminogen activator (IV TPA).

Saver J L Stroke 2013;44:270-277

Copyright © American Heart Association

Is Telestroke a good idea?

Televideo Stroke care improves patient outcomes1

Televideo: more correct treatment decisions than Telephone2

High Telestroke satisfaction among skeptical ED docs (100%) and demanding patients (86%) 3

American Stroke Association guidelines require Telestroke in most/many cases4

27

1Effects of the implementation of a telemedical stroke network: the Telemedic pilot project for integrative stroke care (TEMPIS) in Bavaria, Germany Lancet Neurology

2006; 5:742-48

2Efficacy of site-independent telemedicine in the stroke doc trial: a randomized, blinded, prospective study. Lancet Neurology 2008; 7 (9):787-795

3 Virtual Telestroke support for the Emergency department evaluation of acute stroke Academic Emergency Med Nov 2004

4 A Review of the evidence for the use of telemedicine within stroke systems of care Stroke. 2009; 40

Telemedicine + Stroke

• By certain estimates the misdiagnosis rate by primary care and ER physicians may be as high as 30% compared with stroke team final diagnoses (Harbison et al, 2003)

• Non-stroke specialists often reluctant to administer tPA in absence of specialist expertise significant delays or withholding of treatment

– In one survey, 40% of ER physicians indicated they would not use IV tPA, usually due to risk of ICH

– However, most lawsuits involving tPA were associated with failure to treat rather than adverse events from tPA

Medical Liability

As of the 2009 review of telestroke (Schwamm et

al.), no specific evidence to suggest that telemedicine consultations increase risk of

malpractice claims, compared to providing local

consultations

In general, physicians are at greater liability risk

whenever tPA is involved (whether it is delivered

or withheld)

Most tPA-related lawsuits arise when tPA is withheld

More thorough stroke care documentation by

telestrokologists may reduce such issues

Feasibility & Effectiveness (IV tPA)

Safety of telestroke-guided tPA administration assessed by major safety outcome of symptomatic ICH and in-hospital mortality

Audebert et al (2006)

Nonsignificantly higher rates of symptomatic ICH (7.8% vs 2.7%, p=0.14)

Similar rates of PH2 parenchymal hemorrhages (4.3% vs 2.7%, p=0.72)

Similar in-hospital mortality (3.5% vs 4.5%, p=0.74)

TEMPiS study (2007)

Compared to patients receiving conventional tPA delivery,

telestroke patients had similar long-term mortality and functional

outcomes (at 3 and 6 months)

Feasibility & Reliability (acute stroke)

Wang et al (2003)

20 patients, NIHSS vs NIHSS-telestroke

No difference of >3 points between the 2 scoring

systems

Handschu et al (2003)

German study

Excellent reliability for all 13 items of the NIHSS in 41

patients examined within 36 hours of onset

AHA/ASA Recommendation

Class I, Level of Evidence A

“The NIHSS-telestroke examination, when

administered by a stroke specialist using HQ-VTC, is

recommended when an NIHSS-bedside assessment

by a stroke specialist is not immediately available

for patients in the acute stroke setting, and this

assessment is comparable to an NIHSS-bedside

assessment.”

AHA/ASA Recommendation

Class I, Level of Evidence A

“HQ-VTC [high quality video teleconference] systems are

recommended for performing an NIHSS-telestroke

examination in nonacute stroke patients, and this is

comparable to an NIHSS-bedside assessment. Similar

recommendations apply for the European and

Scandinavian Stroke scales”

Feasibility studies (non-acute stroke)

• STRokE DOC (UCSD) – Stroke Team Remote Evaluation using a Digital Observation Camera (Meyer et al, 2005)

– Public internet connection, “site independent”

– 25 patients examined both at bedside and via telemedicine by 2 NIHSS-certified neurologists

– Feasibility – all 25 patient exams performed successfully with wireless telemedicine

– Reliability - 67% of NIHSS items and 82% of modified NIHSS items had excellent agreement

• Comparable to in-person assessments

• Wiborg et al, 2005

– European Stroke Scale

– Scandinavian Stroke Scale

Feasibility studies (non-acute stroke)

NIHSS – 13-item neurological exam

Demonstrated to be reliable amongst neurologists, non-

neurologists physicians, nonphysician staff

Shafqat et al. (1999)

First assessment of interrater agreement between NIHSS-

bedside and NIHSS-telestroke

Stroke neurologists, assisted by bedside nurse during telestroke

assessment

NIHSS-bedside and NIHSS-telestroke scores were strongly

correlated (r=0.97, p<0.001)

Telestroke examination times were longer (9.70 vs 6.55

minutes, p<0.001)

NIHSS Reliability (non-acute stroke)

Items with highest interrater reliability:

Level of consciousness

Motor function

Items with lowest interrater reliability:

Facial palsy

Ataxia

Dysarthria

Analogous to bedside exams

Barriers to telemedicine:

Limited neurological evaluation: cannot evaluate muscle tone, strength, sensation, reflexes, funduscopic exam

Physician reluctance to accept novel technology

Licensing and credentialing issues

Limited billing and reimbursement

Malpractice concerns

Licensure & Credentialing • Each state has own rules regarding medical practice

– A physician in state A providing telemedicine services to a patient in state B is considered to be practicing in state B telestroke

specialist must be licensed in all states in which potential patients

are located

• Physicians must be credentialed at sites where they provide

telemedicine services

Case Study #1: small/CAH

• Small community hospital

– <100 beds

– 1 private practice neurologist

– System standard is PSC status for acute facilities

• Barriers

– 24/7 neurology coverage for ED

– Consistent response to ED

– CT & lab services

Case Study #2: limited neurology

• Community hospital

– 220 beds

– Stipend to private practice neurology

– Large stroke volume/current PSC status

• Barriers

– Limited utilization of rt-PA for acute stroke

– Significant variability in ED response to stroke

– Difficulty employing dedicated neurology practice

Case Study #2: limited neurology

• Actions

– Termed private practice stipends

– Implemented TN for 24/7/365 ED coverage

• Results

– Reduced variability in ED response to acute stroke

– Easily acquire new neurologists for out-patient practice and in-patient consultation

– Rt-PA utilization increased immediately

– Continued PSC certification

Case Study #3

Large county hospital

>500 bed

Staff neurologists

Active Neurointerventionalists

Results

Improved door to need time- aim <60 minutes

Improved communication between interventional

and teleneurologist

-still comes down to if no neurologist in house, takes

extended period of time to get to the patient

“Connect to Quality”

Case 3: IV Tpa &Thrombectomy

55 year old man presented to hospital with an acute onset of left sided hemiplegia, right gaze preference and neglect, global aphasic

He was last known normal at 4:30 pm, and his wife attempted to wake him up at 5:15 pm and contacted EMS

He was brought to hospital at 5:30 and a CT of the brain was negative for hemorrhage

I saw the patient on camera at 5:45, reviewed films, lab results and reviewed tpa criteria. NIH 19

Tpa administered at 5:55

Partial improvement, but still with significant aphasia, 30 min into tpa disdcussed case with NIR, pt went for intervention

Connect to Quality 43

Lateral projection pre-

treatment Collaterals noted in delayed

manner

“Connect to Quality”

No Right Middle Cerebral Artery Flow

44

At 24 hours, the patient noted to have a

NIHSS of 0; Discharged to home at 48 hours “Connect to Quality” 45

The Future of Stroke Care

The Mobile Stroke unit

CT scanner capable of advanced vascular imaging (CTA/CTP)

Teleneurology

Point of care labs

Being done in Houston and Germany

Cost: $400,000

PATIENTS SERVED (2012)

Civilian Network Consults

Federal Network Consults

Remote Monitoring Implanted Devices

Cardiac Monitoring

Internet-Pharmacy Services

Internet Clinical Consults

Teleradiology

Outsourced Specialists

Anoxic Brain Injury, 42 Bell Palsy, 389

Demyelinating Disease, 238

Encephalopathy,

3,021

Hypertensive

Encephalopathy, 177

ICH, 832

Migraine/Headache, 1,773

Other, 4,675

Psychogenic, 752

SAH, 106

Seizure, 3,014

Stroke, 16,611

Syncope, 824

TIA, 7,173

tPA/Stroke,

2,702

Transient Global Amnesia,

344

Trauma/TBI, 97

Tumor, 221 Vestibulopathy, 811

2014 Consult Summary

Specialists On Call, Inc.

Specialists On Call’s

tPA Administration Rate

tPA / tPA + ischemic stroke = tPA administration rate

2,702 / 19,313 = 14%

When do we ‘NOT’ use

telemedicine?

51