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Telemedicine Case Report: University of Virginia Health System

For acute stroke patients, any delay in receiving care increases the risk of damage and disability. Vascular neurologists Nina Solenski, MD, and Andy Southerland, MD, at the University of Virginia (UVA) Health System understand the “need for speed” when providing tissue plasminogen activator (tPA) or endovascular procedures to these patients. Both experienced the frustration of having no treatment options for patients who arrived in the Emergency Department (ED) past time-sensitive treatment windows, so they designed a streamlined telemedicine system of care for their patients. This telestroke approach encompasses a prehospital and a hospital ED-based model.

Dr. Southerland's mobile telestroke model, iTREAT, allows emergency medical service (EMS) providers to rapidly videoconference with the remote on-call neurologist during prehospital transport. This is done using low-cost, “off the shelf” technology: a mobile device, 4G commercial broadband and HIPAA-compliant encrypted software. The portable system is deployed in the ambulance to facilitate a livestream neurological exam conducted by the remote neurologist prior to the patient's arrival to the ED. This consult saves valuable time and enables faster treatment. The technology is still in the live-testing phase but has shown promise in feasibility and simulation models. Deployment for widespread clinical care is anticipated later this year. Prehospital telestroke models would be particularly beneficial for rural health systems where EMS ground transport times are longer and a geographic disparity exists in accessible primary stroke centers.

David Cattell-Gordon, Director of the UVA Telemedicine Office, reflects that these innovative systems are, “really designed to help support patients from rural communities to get the care they need quickly. With a stroke, every minute matters. With this telestroke model, we're applying the blazing speed of the internet to life-saving decisions about therapy while patients are en route to the hospital.”

Dr. Southerland adds, “We are in a golden age of mobile telecommunications that is revolutionizing the way we do business, learn and interact as a society. We can take advantage of these rapidly evolving media to effect change in medicine as well. In our case, we are able to reach out more rapidly to acute stroke patients in low-access areas, and in some cases, before they ever reach the hospital.”

As the patient arrives at the ED, pulling a Stat-Pak® envelope rapidly activates an acute stroke alert. The envelope contains a pilot list of instructions for each member of the care team (e.g., physician, nurse, EMS and/or radiologist). A single toll-free phone call alerts the remote telestroke neurologist so that live videoconferencing with the patient and family can start within minutes of arrival at the ED. Telemedicine technicians in the background continuously monitor the audio-video quality and facilitate the transmission of vital brain CT scan images.

Dr. Solenski comments, “I often say to my patients that stroke is an ‘equal opportunity disease’ and similarly as a society we should be providing ‘equal opportunity treatment.’ Reversing geographic and economic barriers and specialist shortages using telestroke technology is a valuable tour de force whose future is now.”

The two-pronged telestroke approach also includes onsite education and training for the emergency providers, the community and healthcare practitioners. With education, the full continuum of stroke care is addressed, from risk factors to symptom identification to appropriate treatment. Each telestroke consult is reviewed quarterly for quality metrics and the data, along with any interesting case reviews, is presented to the originating hospital.

Another emerging telestroke model relies on collaborative partnerships between stroke neurologists and forprofit telemedicine services companies. Dr. Solenski comments that “specialists-on-call” (SOC), one of largest teleneurology consulting companies, curated an extensive database that can be analyzed to further refine the telestroke model. SOC hires highly experienced academic and practicing neurologists (and the scarce subspecialists) to provide on-demand teleneurology consultations on a flexible schedule. In this model, specialty providers of acute stroke and other neurology services give consultations from their home or office, mitigating serious disparities in access to specialty neurologic care.

Drs. Solenski and Southerland have found that these models of telestroke care increase access to therapy, reduce the time to treatment and connect a growing network of stroke providers with low-access hospitals. The ability to screen out unnecessary transfers, such as stroke mimics, mild strokes, etc., results in higher patient retention in their own communities closer to family, and supports the local health care economy (e.g., nursing homes, physical therapy services, etc.). In addition, fully engaging the community, EMS and remote health care providers in regular stroke-related education results in strong, trusting partnerships among all stakeholders in the health care system.

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