Role of TeleStroke in Healthcare

Memorial University Medical CenterJoel Greenberg, MD, FAAN

Jessica Barker, RN

Memorial University Medical Center

• Memorial University Medical Center (MUMC) is a non-profit, 530-bed academic medical center in Savannah, GA (1955). • MUMC is a regional referral center, serving a 35-county area in southeast Georgia and southern South Carolina. MUMC is proud to house the region’s only Level 1 Trauma Center, Children’s Hospital, Level III Neonatal Intensive Care, and Cancer Research Laboratory. • MUMC employees more that 4000 people and has 645 physicians on the medical staff. Our medical education program includes 6 physician residency programs and the Savannah campus of Mercer University School of Medicine.

Our mission: With compassion, we heal, teach, and discover.Our vision: We will be the healthcare system of choice by demonstrating excellence in everything we do.Our values: Safety, trust, respect, world-class, enjoyment, and my Memorial.

Memorial Stroke Program Overview

• Mission: To provide comprehensive stroke care, that is patient and family centered, outcome driven, evidence based, multi-disciplinary, cost effective, and easily accessible to patients with complex neurological conditions.

• Vision: To provide world-class, patient and family centered stroke care with quality outcomes in an environment of education and research.

Stroke Facts

• Stroke is a “brain attack,” cutting off vital blood flow and oxygen to the brain

• Fourth leading cause of death (killing over 133,000 people each year) and the # 1 cause of serious, long-term adult disability

• Approximately 795,000 strokes occur each year• One occurring every 40 seconds & taking a life approximately every 4 minutes

• 87% Ischemic &13% Hemorrhagic • Two million brain cells die every minute during stroke• Women are TWICE as likely to die from stroke than breast cancer

annually• Time Is Brain.

Georgians at Risk!

18% Smoke

23% Lack of Physical Activity

75% Poor Eating Habits

27% Obese

30% High Blood Pressure

37% Hyperlipidemia

10% Diabetes

Age-adjusted Stroke Death Rates by County, Georgia, 2003-2007

Georgia Department of Community Health, 2009

Mortality & Risk Factors

What Is TeleStroke?

• TeleStroke is the use of telemedicine specifically for stroke care. Telemedicine is the use of electronic communication methods, such as telephone, Internet, and videoconferencing, to exchange medical information from one geographic site to another.• Worldwide, people living in rural and remote areas struggle to access timely, quality

specialty medical care, primarily because specialist physicians are more likely to be located in the urban areas.

• Only 2% to 4% of patients with stroke receive tPA (only FDA approved treatment for acute ischemic stroke) within the first 3 to 4.5 hours of symptom onset. This lowest percentage of tPA administration is in rural areas because of the lack of stroke experts with experience in administering tPA.

TeleStroke at Memorial University Medical Center

•TeleStroke at MUMC is a web-based, telemedicine system

•Utilizing real-time audio/video conferencing between hospitals• Neurologists have a high-speed Internet connection and videoconferencing capabilities on a laptop, tablet or desktop computer. • This allows the neurologist to evaluate the patient, perform a neurological assessment, view the computed tomography (CT) scan, lab values, make a diagnosis and initiate treatment from virtually anywhere.

•Secure network•HIPPA compliant

•Data is collected and stored

Hub & Spoke Model

Hub and spoke models connect spoke hospitals to 1 hub hospital via formal agreements to engage in stroke consultation.

• Hub hospitals typically large, academic centers with the ability to provide advanced specialties 24/7 • Spoke hospitals are typically smaller, community hospitals located in underserved rural or suburban areas.

Scientific validation studies have demonstrated:

1. The NIH Stroke Scale (NIHSS) via telestroke is reliably performed by physicians and non-physicians

2. Neurologists can reliably interpret brain CT images for the purpose of confirming the diagnosis of acute ischemic stroke and establishing eligibility for IV-tPA

3. IV -tPA can be administered safely through telemedicine and with outcomes comparable to those observed in patients being treated at tertiary care facilities.

4. Audio-video telemedicine evaluation of an acute stroke patient leads to better decision-making and safety than telephone-only consultations.

5. Telestroke networks have proven cost-effective.

Benefits of TeleStroke Implementation

• Builds regional relationships

• Decreased travel time and expenses for doctors and patients (decrease unnecessary transfers)

• Improvement of access to neurological expertise for remote or underserviced areas• Reduction in geographical disparity for neurologic care

• Decreased response time in acute stroke• Increase the number of eligible patients who receive IV-tPA

or other time sensitive interventions• Improve patient outcomes, decrease stroke related

disability, and reduce health care cost

• High patient and family satisfaction survey scores

Barriers to TeleStroke Implementation

• Disruption of traditional doctor–patient relationship

• Physician reluctance to adopt novel technology in practice

• Limitations to billing and reimbursement for time spent

• Additional costs for technology

• Licensing, credentialing issues for out-of-state physicians

• Concern for malpractice liability

• Performing complete neurological examination via telemedicine

MUMC’s Telestroke Program

Developed & implemented telestroke portal (2010-2011)

• Memorial Stroke, Savannah Neurology Specialist, Georgia Partnership for TeleHealth, Second Opinion

• “Go-Live” April, 2011 • Bacon County Hospital Alma, GA (4/11)• Jeff Davis Hospital Hazlehurst, GA (7/11)• MUMC’s Emergency Department (8/11)• Lower Oconee Community Hospital Glenville, GA (6/12)• Meadows Regional Medical Center Vidalia, GA (7/12)

TeleStroke Utilization

Per the American Academy of Neurology, teleneurology has demonstrated clinical effectiveness in increasing access to neurological expertise, reducing patient and physician travel time, fostering communication and coordinated care, and improving physician productivity.

Year Number of Regional

Spoke Sites

Number of Neurological Consultations

Number of Patients

Treated with IV-tPA

Percentage of Patients

Treated with IV-tPA via

Telemedicine

Total Number of Patients

Treated with IV-tPA at MUMC

2011 3 14 2 14.3% 31

2012 5 33 19 57.6% 65

2013 (YTD)

5 8 4 50% 10

WJCL News Segment….

Future Use of TeleNeurology

Although teleneurology is most commonly used in treating acute stroke and neurocritical care, in the future teleneurology could potentially have a role in managing patients with:

• Neurologic consultation is diseases such as epilepsy, dementia, Parkinson’s disease and other movement disorders

• Neurologic outpatient referrals or consultations• Rehabilitation referrals• Potential consultations with regional experts

Questions?