Groups Back Telemedicine for Stroke Care

Health care facilities should use high-quality videoconferencing systems connecting expert neurologists for rapid, remote examination and treatment of patients undergoing suspected strokes, says a policy statement from the American Heart Association (AHA).

The statement is meant to spur the stroke care community to overcome barriers limiting the use of such technology—known as telemedicine or telestroke—and to provide optimal treatment to patients having strokes in underserved areas, said Lee H. Schwamm, MD, lead author of the statement and vice chairman of neurology at Massachusetts General Hospital in Boston (Schwamm LH et al. Stroke. doi:10.1161/strokeaha.109.192360 [published online ahead of print May 7, 2009]). “The goal of telemedicine, or any stroke system of care, is to provide the right care to the right patient in the right amount of time—every single time,” Schwamm said. “The advantage of telemedicine is you get a stroke expert at the bedside, whereas in the community, you might get someone who has treated some stroke patients in the past, but for whom it is not an area of expertise.”

The AHA statement reads: “Whenever local or onsite acute stroke expertise or resources are insufficient to provide around-the-clock coverage for a health care facility, telestroke systems should be deployed to supplement resources at participating sites.” The statement also recommends that patients and families be made aware that telestroke consultation will occur and that they should grant permission for the consultation.

About 700 000 strokes occur annually in the United States, causing about 163 000 deaths. However, there are only about 4 neurologists per 100 000 people in the United States, and not all of them work in stroke care. Those who do are distributed unevenly throughout the country, so populations in certain rural or urban settings remain underserved. Adding to the stress on the stroke care system is the increasing number of neurologists opting out of call coverage for acute stroke and other neurological emergencies, the statement says. It adds that in such an environment, the misdiagnosis rate by primary care and emergency physicians may be as high as 30% when compared with stroke team final diagnoses.

“It is important to adopt these recommendations because right now, far too many patients with stroke never see a neurologist and do not have access to urgent treatment,” Schwamm said. “It has been estimated that less than 50% of patients who are admitted with a stroke ever see a neurologist while they are in the hospital.”

Optimal and urgent care for patients with stroke is crucial because the most effective treatment for acute ischemic stroke is rapid reperfusion using intravenous tissue plasminogen activator within 3 hours of the onset of symptoms. One study (Schwab S et al. Neurology. 2007;69[9]:898-903) found that patients who are assessed and treated by a physician receiving consultation via telemedicine show good functional outcome and mortality rates compared with those treated in the conventional manner (although more rigorous research is needed to confirm these findings).

Bolstering the AHA's policy statement was the simultaneous release of a scientific statement by the AHA and the American Stroke Association (ASA) providing evidence-based recommendations for the various uses of telemedicine for stroke care, ranging from general neurological assessment and primary prevention of stroke to acute stroke treatment and rehabilitation (Schwamm LH et al. Stroke. doi:10.1161/strokeaha.109.192360 [published online ahead of print May 7, 2009]). The joint statement from the AHA and the ASA defined telemedicine as the use of dedicated, high-quality, interactive, bidirectional audiovisual systems coupled with teleradiology for remote review of brain images.

Still, obstacles stand in the way of widespread adoption of telemedicine for stroke treatment, as well as for other conditions. “The overriding barrier is acceptance of this new form of care delivery,” Schwamm said. “People first looked at [automated teller machines] with skepticism, but now we can't live without them. I think 10 years from now we’ll see the same thing with telemedicine.”

Obstacles also include a Medicare reimbursement policy that allows payment for telemedicine only in the treatment of patients in specially designated rural counties, a reluctance by some insurers to reimburse for telemedicine services, licensing by state medical boards that restricts the out-of-state use of the technology, and liability concerns. The timing of the release of the AHA's policy statement may be fortuitous, as the debate in Washington, DC, about health care reform offers an opportunity for advocates of telemedicine to eliminate some of these barriers.

The American Telemedicine Association (ATA) is pressing Congress and the White House to change Medicare rules and allow for payment beyond the designated counties, said Gary Capistrant, the ATA's senior director of public policy. “About 83% of people live in metropolitan areas, so it is critical that these telehealth services be in urban areas,” Capistrant said. In addition, Rep Mike Thompson (D, Calif) introduced a House bill on April 23 called the Medicare Telehealth Enhancement Act, which would provide $30 million to help health facilities pay for telemedicine equipment and expand Medicare reimbursement to urban and suburban areas (HR 2068 [http://thomas.loc.gov]).

Capistrant said liberalizing licensure is a more difficult task because reform battles must be waged on a state-by-state basis. Drew Carlson, director of public relations with the Federation of State Medical Boards, agrees and said his organization does not anticipate the development of a national telemedicine license. However, Carlson noted, 17 state medical boards are either using or are in the process of adopting a uniform application for physician state licensure that allows a single application form that can be saved electronically and used from state to state.

And similar state-by-state difficulties exist with regard to changing payment policies from various private health insurers. For Capistrant, the key is expanding Medicare reimbursement. “If Medicare covered urban telehealth, there could be enough clamor for the state licensing agencies and insurers to change,” Capistrant said.

As for liability, Schwamm said that the lawsuits decided against physicians typically involve the failure to provide a patient with tissue plasminogen activator—a situation more likely to occur when a neurologist is not present to make clinical decisions. Telemedicine puts the neurologist at the bedside and allows for a visual recording of the clinical decisions made and actions taken. “For the health care workers, having a recording of a video consultation showing you did a good job is better than jotting down a note saying you did a good job,” Schwamm said.

Not all physicians who encounter patients with stroke are jumping on the telemedicine bandwagon. The Clinical Policies Committee of the American College of Emergency Physicians (ACEP) concluded that there was insufficient evidence to support some of the claims made in the joint AHA and ASA statement, said Robert C. Solomon, MD, a member of ACEP's board of directors. “The committee noted a lack of comparative assessment of telemedicine to alternatives that could also improve stroke care,” said Solomon, who is the attending emergency physician at Trinity Health System in Steubenville, Ohio. “And the strong recommendation that hospitals without neurologists acquire telemedicine equipment becomes yet another unfunded mandate that will divert resources in the already overburdened emergency department.”

On a personal level, Solomon said he could see the benefit of telemedicine being used to assist at hospitals that lack stroke care expertise across the board, from the emergency medical service through inpatient care. But not having a neurologist available at the bedside when a patient presents is not enough for him.

“There seems to be an inherent assumption that if the hospital does not have a neurologist available to come to the emergency department to see the patient at the time of initial presentation, that that situation fits the definition of ‘these-people-don’t-know-what-they’re-doing’ and clearly they must have telemedicine with a neurologist,” Solomon said. “That's not the reality; there are lots of hospitals where patients are getting excellent care where the neurologist is nonexistent or cannot see the patient at the time of presentation.”

The recommendations in the AHA policy statement are based on the stroke association's “stroke systems of care” model (Schwamm LH et al. Stroke. 2005;36[3]:690-703), which emphasizes linkages rather than silos in the chain of stroke assessment, treatment, and rehabilitation. To aid in this linking, the model recommends using telemedicine and aeromedical transport to assist health workers caring for patients in underserved areas. The goal of the stroke systems of care model is to create an integrated team of health workers involved with stroke, starting with public health advocacy to reduce stroke risk and continuing all the way to outpatient rehabilitation.

The AHA policy statement uses evidence gathered from hub-and-spoke telemedicine networks in which nonprofit academic medical centers or tertiary hospitals serve as centralized specialty care stroke centers to a network of rural or community hospitals that lack readily available stroke expertise throughout the day. Other telemedicine models also have emerged, including partnerships among individual campuses of a single hospital system and stand-alone vendors not affiliated with larger institutions.

Any debate about the benefits of telemedicine or which model of care delivery works best should center around the patient, said Schwamm. “Telemedicine is just another enabling technology that allows us to do a better job of treating patients with an acute stroke,” he said.