Telestroke
Is It Ready for Prime Time?
David Wang, D.O., FAHA, FAAN
Director, OSF/INI Stroke Network
Clinical Associate Professor of Neurology
University of Illinois College of Medicine at Peoria
Disclosure Statement
Dr. Wang is a member of:
•
•
•
•
•
•
•
Illinois Stroke Task Force.
Co-Chair, Illinois Stroke Task Force Telestroke Subcommittee
Executive Committee, American Academy of Neurology-Vascular Section
Quality Measurement and Reporting Subcommittee, AAN
Advisory Committee, American Stroke Association
International Operations Committee, American Heart Association
Speaker Bureau:
Pfizer, Boeringher-Ingelheim,
The Scope of the Problem
• 700,000 a year, third
leading cause of death,
leading cause of adult
disability.
Stroke Incidence: +61%
1,200,000
800,000
• rt-PA needs to be given
within 3 hrs, which
presents an opportunity
to improve patient
outcomes and reduce
overall costs to the US
health system 2.
Sources: Sg2 Analysis, 2006.
400,000
0
2000
2020
Stroke Incidence US Market,
2000-2020
4 Key Elements in the Initial
Evaluation and Treatment of a Stroke
• ER
Emergency room physicians are often reluctant to
administer t-PA without the guidance of a
neurologist.
• Radiology
• Neurology
Few have access to a general neurologist
Even fewer have access to a highly skilled
stroke neurologist
• Stroke Team
Responsible for delivering organized, errorfree quality care
Not Enough Neurologists
• 48 million Americans residing in
counties that contain no neurologist.
• American Academy of Neurology Report:
10,038 U.S. Neurologists registered
83.7% were adult Neurologists
42.3% had stroke as their practice focus
47% strongly agree and feel comfortable in
giving tPA.
Hospital Administrator’s Headache
• We can’t get anyone (neurologist) to take ED
stroke calls.
• We don’t have any neurology coverage. The
closest neurologist is 70 miles away and he has a
waiting period of 6 months.
Not Enough Radiologists
• American College of Radiology:
There are about 25,600 post-training diagnostic
radiologists in the US
73% of these radiologists work full time
Over half of the radiologists surveyed indicated
that they were overworked
• There are not enough Radiologists interpret
imaging studies of the stroke patients 24/7
• There are even fewer Interventionists that can
deliver catheter-based treatment
Sunshine JH, et al. Diagnostic Radiologists in 2000. Basic Characteristics, Practices, and
Issues Related to the Radiologist Shortage. AJR 2002;178:291-301.
What Do We Have?
• According to the Hospital Statistics 2002:
4,856 US hospitals reported
85% have emergency departments
65% have medical or surgical intensive care
78% have CT scanner
48% have MRI
80% have ultrasound services
69% have case management
85% have social workers
27% have inpatient physical rehabilitation services 76%
have outpatient physical rehabilitation services
Facilities and Services in the U.S. Census Divisions and States. Hospital Statistics.
Health Forum LLC, an affiliate of the American Hospital Association. 2002.
Can TeleStroke Help?
Not enough Neurologists and Radiologists,
TOO MANY STROKES!
Telestroke, Hospitals without onsite stroke expertise are provided with
the access to stroke centers (stroke expertise) in real time. No distance
limitation between the site hospital and the stroke center.
• What it takes to set up a telestroke network
• Benefit of telestroke
• Pros and Cons of Telestroke
Telestroke-Technology Involved
• Low tech:
Telephone consultations
• Need some tech:
Incorporate radiology image transmission
• High tech:
Real time audio and video conferencing via wireless encrypted transmission, or
secure landline and transmitting neuro images simultaneously.
Hub and Spoke Model, high tech
Name of System
Description
Stroke-Center Hub Neuro-critical care specialists based in a Academic or Tertiary Care
and Spoke Model Medical Center
Examples: Partner’s Tele-stroke program, Medical College of Georgia
REACH* program
Partners Telestroke Program
Serves 14 hospitals in Massachusetts and provides consultation for
AMCs willing to develop a stroke network.
Distributed cost model where both the hub and the spoke hospitals
share costs associated with tele-stroke.
Spoke hospitals pay for videoconferencing equipment ($5,000 to
$20,000), annual maintenance fees and a fee per Tele-Stroke Consult
($1,000 each).
Hub hospital provides on-site and continuing stroke education, and
necessary implementation steps and training sessions for staff.
Advantage: Spokes aligning with major stroke center hubs are aligned to provide advanced neurovascular services their
patients may need and can market their affiliation to draw patients as referrals.
Sources: Sg2 Analysis, 2006.
Name of System
Description
Physician Hub
and Spoke
Model
Network or center of independent neuro-care specialists,
independent of tertiary or Academic Medical Centers provide
consultations to surrounding hospitals.
Brain Saving
Technologies
Establishes Neuro-critical Care Centers
First one at UMASS Memorial Medical Center staffed by stroke
specialists.
Currently serves five hospitals in Massachusetts and Virtua
Health System in New Jersey.
Hospitals pay a fixed yearly price.
As an example a 300 bed hospital the fee is around $216K plus
upstream costs for technology.
Advantage: Organizations that do not have the stroke volumes to justify the cost of
the video technology can leverage it for other telemedicine services.
Sources: Sg2 Analysis, 2006.
Tele-Stroke Technology Providors
BF-Technologies
• Sells a bi-directional audio and video
system (AccessVideo™ $24,000)
• Charges a yearly maintenance fee of
$6,000.
• System provides site-independent access
error-free HIPPA compliance encryption,
remote pan/tilt/zoom, and full
audio/video session recording.
• University of California San Diego has
such set-up
Stroke Team Remote Evaluation Using a
Digital Observation (STRokE DOC).
Courtesy of Sg2
InTouch Health®
• Mobile robot (RP-7 Remote Presence Robotic System)
that allows a remote physician to guide the robot to the
patient’s bedside, and evaluate the patient through bidirectional video and audio communications.
• A robot costs $120,000 to buy, or $4,000 a month to rent.
• The Michigan Stroke Network which includes 21 Michigan
hospitals and spearheaded by St. Joseph Mercy Oakland
Hospital is an example of a stroke network using robotic
technology.
Courtesy of Sg2
Where Is the Funding?
• States initiating reimbursement for telemedicine:
NY, CO, GA, FL, OK
• Federal Funding:
Grants more likely, and it is usually one time deal
• Some stroke networks have been funded by tobacco taxes (Colorado
$185,000),or grants from the State’s Stroke Center Act (New Jersey
$390,000)
• Share the cost:
Per use based or flat fee between the hub and spokes
• Others:
Patient revenue, hospital operating budgets, Philanthropy.
• Paying a yearly fee:
Brain Saving Technologies $216K per year
TeleStroke-PROs
•
•
•
•
•
•
•
•
The cost is flexible, depending on the system used
It can be wireless, nearly real time with broad band
Extend stroke care expertise into rural and underserved areas.
It is time saving and efficient. Doc-Doc, Doc-patient interaction
allowed at distance
Multifunctional: films, labs, medical records, pathology report
Provides rapid access to specialized interventions through initiation
of inter-hospital transfers and improve in basic on-site stroke
therapy.
It has demonstrated improved use of rt-PA.
It may improve enrollment in acute stroke trials.
Impact on Stroke Care
• Videoconferencing by off-site stroke neurologist
provides accurate assessment of the patient’s physical
condition and neuroimaging studies
• Tele-stroke can maximize use of life saving therapies:
– A rural hospital that had not used tPA in 2yrs increased tPA
administration to 5.6% with the Partners Tele-Stroke Network
– Houston: 0.8% use of rt-PA improved to 4.3%
• Improves hospital standing in the community by
providing leading treatments.
• Reduces mortality rate by identifying patients who need
to be transferred for advanced care.
Sources: Sg2 Analysis, 2006.
Impact in Rate of Thrombolysis after Implementation
of Telestroke Network
•
•
•
•
•
•
•
•
•
•
The use of telemedicine in stroke makes it possible to bring the expertise of
academic stroke centers to underserved areas, potentially increasing the quality of
stroke care.
Telemedicine support to 12 community hospitals without on-site stroke specialists.
3/2005 - 12/2008. 2,606 entries divided in two phases: pre-telemedicine (N= 933)
and post-telemedicine (N=1,673).
Outside of the three-hour-window was the most common contraindication for
thrombolytisis (52.3%).
143 patients received thrombolytics, with 35 interventions prior to starting
telemedicine and 108 after.
Thrombolysis rate prior to telemedicine was 3.8% and after 6.5% (p=0.004).
Incorrect treatment decisions happened 10 times (0.39%), with 4 (0.43%) pre vs. 6
(0.36%) post telemedicine (p=0.78).
There were no statistically significant differences in mortality (15.9% pre vs. 9.2%
post; p=0.23) or good outcome (17.1% pre vs. 15.8% post; p=0.84).
S-ICH happened in six patients (4 [9.8%] pre vs. 2 [1.9%] post telemedicine).
CONCLUSIONS: Telestroke implementation increased rate of thrombolytic use in
remote hospitals within the telemedicine network.
Telestroke-Cons
• Price
• HIPPA, patient confidentiality
• Can be complicated to use and
maintain
• Lack of reimbursement will hinder
widespread adaptation of its use.
• Is a patient's brain scan clearly
readable over the system?
• Are onsite physicians able to
adequately care for the patient
after the medication is given?
• Reimbursement and liability issues
pending resolved
The Ideal Set-up
•
•
•
•
•
•
•
•
Affordable
Portable
User friendly
Can have a mixture of high-tech and low-tech type of
network
Low maintenance
Maintain confidentiality
No one type or size of telestroke system that will fit all
situations.
Type of clinical applications and volume of consultations
determine the characteristics and costs of the
appropriate systems.
Six Current Centers that Function as CSCs and uses
different Telestroke Equipment
Transf
er
hospit
al
Telem
edicin
e
hospit
Our
50 hospit
milesal
Example #1:
Greater Cincinnati/Northern Kentucky Stroke Network
• Acute Team
•
15 local hospitals, including 4
PSCs
Based at Univ of
Cincinnati (UC)
– EMS brings pts to nearest
hospital
– 3 Emergency
physicians
– UC Stroke team MD drives to
– 7 Vascular
all local hospitals
neurologists
– Encourage pre-notification
– 4
(prior to CT completion)
Neurointervention
– Study coordinator comes if
alists
possible trial candidate
– 6 Acute
Coordinators
• Additional ~10 regional
• 15 Hospitals
–
–
–
1 University (TUH
@ UC)
3 Teaching
11 Community
hospitals
– Drip and ship by phone
assessment
2.1 million population for
metropolitan area;
About 30 miles between
farthest hospitals;
Crosses state lines
Example #2:
Saint Luke’s Brain and Stroke Institute –
Kansas City Stroke Referral Network
2009 (n>80)
2002 (n=18)
• Over 80 hospitals, including
4 PSCs
– PSCs refer for IA tx or IV
tPA guidance
– Phone consultations; no
fee for 24/7 support
• Treat ~30% of cases called
in
• Threshold for transfer
– Post IV rtPA care
– For IA therapies
• Weekly education in region
by MDs and RNs
2.1 million KC metro; >100 mile radius
Example #3:
Network
Six UT Dept
of Neurology faculty
• Currently: University of Texas-Houston• Stroke
– About 40 calls/mo; 1-2 per
24 hr period; treat 25%
– 43% daytime, 36% evening,
21% at night
– 60-70% of calls are strokerelated
– About 6 TPA treatments/mo
•
Memorial Herman Hospital (MHH)
•
22+ hospitals via telemedicine
– Two systems
•
Additional regional hospitals by
phone
–
Drip and Ship
• Changing climate
– Increasing # of pts take to
local PSCs rather than MHH
• Decreasing pt access to
research and IA therapies
at MHH
• Concern for decreasing
rates of rtPA use at lowvolume ctrs
Transfer
hospital
Telemedici
Our
ne
hospital
hospital 50 miles
Houston metropolitan population of
5.7 million;
2 IA centers within three blocks of hub
Example #4:
UCSD Stroke Network
STRokE DOC network
(trial on hold)
Based at UC San Diego (UCSD)
– UCSD:
– 6 Vascular neurologists
4 telemedicine
– 4 Coordinators
hospitals 30-350
miles away
– 2 Emergency Physicians
– Mayo Scottsdale:
– 4 NeuroInterventionalists
2 Telemedicine
hospitals
• Acute Team
• 10 Hospitals
–
–
–
1 University (2 Centers)
4 Community
(physical coverage)
3-4 Remote
(phone /telemedicine)
•
15% treatment rate overall
•
6.50 rt-PA treatments per month
•
2.75 rt-PA treatments per month
@ < 2 hours from symptom onset
– 28% telemedicine
rt-PA during trial
period
– More accurate rtPA
decision-making
with video,
comparable safety
and outcomes by
phone
12 miles to farthest hospital (drive)
150 miles to farthest hospital (telephone)
350 miles to farthest hospital
(telemedicine)
San Diego metropolitan population 3
million
Example #5:
Med Coll of Georgia (MCG) REACH Telestroke Network
• 10 smaller rural hospitals (37-127
miles)
•
– 5 neurologists
– 1 EM physician
– No 24-hr radiology; drip and ship
• 5 larger community hospitals
– Two PSCs, but lack 24/7 stroke
coverage
– Telestroke coverage for a fee
– “Treat and keep” at local hospital
(DRG 559)
– Transfer for higher level of care
• Decreasing 24/7 local neurology
coverage in region and potential for
REACH being at capacity
6 MDs
•
15 hospitals
– 10 rural (<75-bed)
– 5 larger community (100-300 beds)
~200 miles
Example #6: OSF/INI Stroke Network
Telestroke by the JEMS
System, projecting live
video to your cell phone.
4 helicopters for transport
10/09-9/11:
• 875 transfers
• 179 drip and ship cases from 30 hospitals
• TPA administration rate:20%
The Challenges Facing
Telemedicine
• Who regulates the existing telemedicine structure?
• The authority of local and regional providers in
developing telemedicine.
• When it becomes Web-based, what will happen to the
traditional relationships that exist between a doctor and a
patient?
• It may be an investment that may not have clear financial
return.
• Credentialing among spoke hospitals and cross the states
• The Stark law of preventing enticement
JD Linkous, MD Net Guide 11/06
A Look at the Budget for a Telestroke Network
• One new rural spoke hospital needs about $46,000 (
$10,000 -$20,000) per year dependent upon the size of
hospital, volume of stroke consultations, and sophistication
of telemedicine equipment selected.
• The start-up and first year of operation cost for a multi-hub
network serving 35 rural spoke hospitals was $2.5 million.
• Costs include:
neurology, personnel, coordinators, managers, information
technologists, administrators, telemedicine platform
equipment, institute supplies, laptop cameras, headsets
with microphones, broadband wireless cards, efax
subscriptions, travel expenses, training, and overhead.
So, Does Telestroke Save Money?
• Compared two-way audio video technology to usual care
• A decision analytic model was developed for both 90-days and
lifetime horizons. Model inputs included both costs and clinical
consequences.
• Quality adjusted life years (QALYs) gained were combined with
costs to generate incremental cost-effectiveness ratios (ICERs).
• In the base case analysis, compared to usual care, telestroke
resulted in an ICER of $108,363/QALY in the 90-day horizon and
$2,449/QALY in the lifetime horizon.
• Telestroke appeared cost-effective.
REALLY?
So, Does Telestroke Save Money?
• A network model:
-more patients treated with IV thrombolysis
-more patients transferred for endovascular management
-more patients discharged home independently.
• The telestroke network costs less, overall, and was more effective
than no network.
• With increased spoke to hub transfer rates, the hub experiences
greater cost savings while the spokes bear higher costs.
• When reducing spoke to hub transfer rates, the spokes
experience greater cost savings while the hub bears higher costs.
So, Does Telestroke Save Money?
• The answers to this question are:
Patients may get better care at the cost of the
institution that establishes and runs telemedicine
Institutions are not being paid adequately to run
telestroke network
• Health economic research is needed to develop viable
and sustainable business plans.
The Near Future
Conclusion
• Telemedicine Can solve the problem of
access to specialty services
• Currently there is no set rules to regulate
telemedicine
• Telemedicine improves TPA use in stroke
patients in rural and remote ERs
• Technologically it will be cheaper to set it up
in the near future
• To staff and support telemedicine is not
cheap.
• Telemedicine may not have financial benefit
to the institution that runs it