As the stroke treatment spectrum continues its rapid evolution, one increasingly clear fact is the significant role telemedicine will play in future systems of care. Once considered a promising concept and still relatively new to healthcare, telemedicine has been with us long enough that its impact can now be measured and evaluated in real, concrete terms. This may be critical as stroke treatment networks continue to grow alongside the technology. Earlier this year, telemedicine took another step toward increased integration in stroke management, as the American Stroke Association (ASA) and American Heart Association (AHA) published the first scientific statement regarding telemedicine quality and outcomes, offering a blueprint for measuring the impact of stroke. Since then, the American Telemedicine Association (ATA) released its first telestroke guidelines, to assist practitioners in providing assessment, diagnosis, management, and/or remote consultative support to patients exhibiting symptoms and signs consistent with an acute stroke syndrome.
It is important to establish networks of communication with local hospitals and providers, as this may expedite transfers when patients need to be routed to another facility. Communication will be key to directing the patient to the right place for best care.
Ahead, lead author and co-author on the ATA guidelines Lawrence Wechsler, MD, Henry B. Higman Professor and Chair of the Department of Neurology and Vice President of Telemedicine at the University of Pittsburgh Medical Center, reflects on the new guidelines and how they will help physicians in harnessing telemedicine to its maximum potential in stroke treatment.
What role does telemedicine play in overall stroke network performance?
“Telemedicine is becoming a integral part of what we do in a stroke network,” says Dr. Wechsler. “We’ve always had the hub and spoke connections, but most of it has been done by phone historically, and that has limitations,” he continues. Often you have an ER doctor on the other end of the line who may not be as knowledgeable about acute stroke and may be uncertain of information, according to Dr. Wechsler, leading to a greater tendency to transfer patients. “With telemedicine we do a much better job of assessing the patient as we would if we were seeing them in person and make a better decision about treatment options,” he explains.
With telemedicine enabling neurologists to feel more confident in their assessments and diagnosis, it is likely that the number of unnecessary transfers will be reduced, Dr. Wechsler notes. “What’s been shown is that we can increase treatment rates for tissue plasminogen activator (tPA), better assess patients for endovascular therapy, and transfer patients who are most appropriate for endovascular treatment.” In general, he says, telemedicine enables the entire system to function more effectively and gets patients to the right place for optimal care.
How is a tele-consult so different than other forms of interaction?
The most notable difference between telemedicine and other forms of interaction, according to Dr. Wechsler, is that physicians can perform their own assessment. “You can ask questions that you feel are most relevant and most important, and you can actually do the exam yourself and get your own primary data as opposed to someone else’s assessment. As physicians, we feel more comfortable when we get our own primary information, particularly when we’re trying to make decisions like giving tPA or transferring a patient for endovascular therapy; these are major decisions for the patient.”
Therefore, telemedicine essentially increases the role of the neurologist in the overall care of the patient. “It extends the expertise of the stroke neurologist outside of their own primary hospitals,” says Dr. Wechsler.
Can you talk about the limitations of telemedicine, both from a technology perspective as well as a clinical one?
From a technology point of view, Dr. Wechsler stresses that there are no limitations. “Basically, we can go anywhere in the world, as long as a broadband connection is available.” The limitations of telemedicine tend to arise more from practical/logistical issues related to the business structures of hospitals and care networks. Licensing and credentialing are limitations in that physicians must be licensed in the state in which the patient resides and often require credentialing at all hospitals served by a telestroke network. “When a patient is undergoing evaluation by neurologist remotely who believes endovascular therapy is appropriate, it is possible the patient may be transferred to a different stroke network with a different group of stroke physicians and interventionalists. This may require repeating the evaluation and sometimes reaching different treatment decisions,” Dr. Wechsler explains. “If you keep it within a single system, the same people who are doing remote evaluations are doing in-person evaluation, and everything flows very seamlessly.”
There will undoubtedly be growing pains as telemedicine expands in stroke care networks. According to Dr. Wechsler, communication will be key to directing the patient to the right place for best care. “It is important for transfer arrangements to be made ahead of time wherever possible,” he says. “That way, providers who aren’t local will know where to transfer patients.” Dr. Wechsler points out that the issue of physicians disagreeing remains, but even in those instances it is always better for the expediency of care when arrangements are made in advance.
How important will outcome measurements be to the success of telemedicine in stroke?
“Telestroke has become mature and widespread enough that it’s now necessary to create recommendations for how to measure quality and to make sure that patients are getting optimal delivery of these services,” says Dr. Wechsler. When telemedicine was just starting up at academic centers, Dr. Wechsler observes that the impetus was more to get it out there, rather than to monitor how it was being done. “Now we need to start to concentrate on making sure it’s being done right, not just being done,” he explains. That’s why Dr. Wechsler and his fellow researchers created the statement that ultimately led to the guidelines. He notes that the statement presents suggestions on how quality should be measured in a telestroke network, divided into three types of recommendations:
2. Process measures
Structural elements include standards, parameters, and failures for technology and how they interfere with care. Process measures look at the time interval from the time patients come into ER to when the consult is placed, and cover everything in between, such as how long does consultation takes, and the time between consultation and tPA, according to Dr. Wechsler. “One of the things we wanted to monitor was whether a telestroke consult reduces or adds to time to treatment—hopefully it reduces it.” Since telestroke is designed to streamline the treatment process for patients, minimizing provider response time is essential, he emphasizes.
Finally, outcomes represent measurements that would be monitored similar to an in-person stroke networks. These include length of stay, in-hospital mortality, 90-day outcomes in terms of functional scales, complications, and hemorrhages.
Dr. Wechsler believes that with guidelines in place, physicians and hospital networks will give more attention to their processes and outcomes. “Just getting providers to monitor what they’re doing in this way is important,” he notes. “Even if they don’t share or report it or do anything with it or nobody’s watching it, just the fact that they as a network are looking at these elements is likely to improve their performance.”
What financial impact, if any, do you foresee if telemedicine becomes more integrated in stroke networks?
While Dr. Wechsler is confident that more widespread use of telemedicine technology will result in better outcomes for patients as quality is maintained or increased, he also believes that broader application of the technology could have significant cost implications. “We know that tPA treatments reduce costs and have better outcomes, but where additional savings can be achieved is in reducing unnecessary transfers,” he says. “To transfer a patient by helicopter can cost $20,000. If patient comes down and we don’t do anything different and don’t treat in a different way, that’s $20,000 we could have avoided,” he explains.
While cost savings are not and should not be the primary driver of telemedicine use, the long-term savings for the healthcare system would be one of its many benefits. “Treating with IV tPA and endovascular therapy is cost effective by improving outcomes, reducing disability and lowering the overall cost of stroke care.
Based on where we are now regarding telemedicine in stroke care, how would you assess where we are going and what do you think that will look like in the future?
Dr. Wechsler notes that we are still in the early adoption phase of telemedicine, and much work remains toward understand the benefit of the technology. “Usually what happens with any new technology, there is a rising curve that reaches some zenith, at which point people discover what it’s really good for and not good for, then it drops off and reaches equilibrium,” says Dr. Wechsler. “We’re still on that curve, and there’s still a lot we need to know about telemedicine interactions. Telestroke is one application of telemedicine for which we have accumulating evidence that it is effective and that the outcomes are just as good when you evaluate patients remotely compared to in person.”
Nevertheless, questions remain about the limitations of the technology, such as identification of stroke mimics. “Are we treating more patients who don’t have strokes if we’re not there in person tapping for reflexes?” he asks. It also is worth exploring levels of satisfaction of patients as well as medical staffs who might prefer someone in person to interact with, according to Dr. Wechsler.
Despite the number of questions and issues that remain to be dealt with, Dr. Wechsler emphasizes that telemedicine in stroke is an evolving science and that it ultimately serves an important need. “The most important thing to me is that there are many hospitals with no stroke expertise, where patients come to ER with stroke and don’t get the standard of care that they would at a stroke center,” says Dr. Wechsler. Telemedicine technology has the potential to increase access to better stroke care for patients regardless of location. “This is probably not perfect and has limitations, but it’s a way of getting that stroke expertise to patients who need it,” he notes. “There aren’t enough vascular neurologists to go to every small hospital in the country, but telemedicine is a way to get our expertise from stroke centers out to these places in an efficient manner with treatment that we know can improve outcomes.”
Lawrence B. Wechsler, MD is the Henry B. Higman Professor and Chair of the Department of Neurology and Vice President of Telemedicine at the University of Pittsburgh Medical Center.