February 19–21, 2020
Session: “Widening the Lens of Telestroke: From the ED Across the Stroke Continuum,” Thursday, February 20, 2020
Jennifer Majersik, MD: Physician at the University of Utah – Expansion of Telestroke Networks
Matthew Koenig, MD: Physician at Queens Medical Center – Tele-ICU
Steven Cramer, MD: UCLA, University of California Irvine – Tele-rehabilitation
Christine Holmstedt, DO: Medical University of South Carolina – Outpatient Telestroke Follow-up
Stephanie Lyden, MD, BS
This talk provided multiple examples of varied practice settings that use telemedicine to provide patient care. The talk started with Dr. Jennifer Majersik discussing the Expansion of Telestroke Networks. She initially explained the process of consulting a neurologist via telestroke. This is often being utilized by community hospitals that do not have a local neurologist to consult. She explained that there are different levels of acuity (hyper-acute with telestroke vs acute with emergent teleneurology vs non-urgent with scheduled teleneurology) within teleneurology consults. She noted that with a telestroke consult, the main questions addressed include whether the patient is eligible for tPA or thrombectomy, both of which are time sensitive, and the goal of these consults is for them to be completed within 10-30 minutes.
The next question to be answered is regarding transfer and whether a patient should stay at the spoke site or should be transferred to a higher level of care. Dr. Majersik explained that in order to make this decision, it is important to understand the resources available at the spoke site. For example, one must understand if a hospital has an infrastructure to allow for monitoring of post-tPA patients; access to stroke diagnostic tools to complete the stroke work-up; employment of other trained personnel, such as physical/occupational and speech therapists; and their transfer relationships. She explained that in order to understand these questions, the spoke site and the hub site personnel must work closely together to better understand and then integrate their systems of care. This can take on many forms, such as scheduled in-person site visits that are performed by the hub-site at the spoke site to direct communication with the individual nurse and ER physician on an individual tele-case.
Dr. Majersik further explained that these site visits are comprised of going over stroke protocols, explaining how to use the telemedicine robot and running mock stroke codes with the site. These visits are often very helpful before a site “goes live” with the hub site because they can help identify areas that could be improved to ensure the best, most efficient level of patient care. The importance of a transfer center to help manage high-volume calls was also discussed.
Another important point discussed is that the decision of transfer to a higher level of care is complex. Advantages to transferring include that a patient can be managed by specialists trained in that patient’s specific disease state and will receive care from neuro-trained nurses and therapists. However, this can sometimes be costly to patients and can take them away from a support network that they may have in their local community.
Non-urgent teleneurology consults were also discussed. It was explained that this can sometimes be favorable if a patient does not meet criteria for transfer, but still would like expert consultation. In cases of stroke, the same patient that received urgent telestroke consultation could later receive a routine teleneurology consult, which can allow for effective continuity of care. In regards to a non-urgent, scheduled telestroke consultation, Dr. Majersik explained that these consults allow a stroke neurologist to provide recommendations after the stroke-work-up is completed, including determination of stroke subtype, initiation of targeted secondary preventative therapies, and decisions regarding rehabilitation and recovery. These consults also can help provide neurology consultation for other in-hospital neurologic questions. It was noted that in order to develop this type of network, a lot of groundwork needs to be put in place. This involves creative methods for scheduling, working with the patients’ hospitalists’ schedules, communication with administration for a payment model, training of nursing to help complete a neurologic exam over the camera, and an ability to view a patient’s records to understand the results of their work-up (using an integrative EMR or having someone that helps to obtain these records prior to the consultation).
The importance of trust and developing relationships with spoke sites was emphasized. Dr. Majersik explained that the University of Utah has also set up a bi-directional quality improvement program that occurs every two months with the goal of discussing cases that have an opportunity for system and patient care improvement and education. Cases are reviewed by providers and quality experts by both hospitals. It was noted that this program allows a safe place to discuss difficult cases and allows for sharing of best practices.
Dr. Majersik’s talk ended with the following conclusions: Teleneurology is possible, requires a lot of planning and coordination, can be very rewarding, reduces transfer costs and may be an efficient method of extending a neurologist’s reach. However, the effects on patient outcomes are unknown.
Dr. Matthew Koenig later discussed a model of Tele-ICU based on his experience at Queens Medical Center in Hawaii. He highlighted the importance of nurse training at spoke sites to recognize neurologic decline, integrated EMRs and pre-planning the roles and responsibilities of each provider (the teleneurologist vs the teleintensivists vs the on-site physician). He explained that completing a neurologic ICU exam can be difficult via telemedicine, but additional use of devices, such as pupilometers and limited montage EEG, can be helpful, as well as specific training of nurses in neurologic assessment of ICU patients who will assist in completing the exam during the teleconsultation. The importance of developing a system in which the note of the telephysician can be documented and viewable by the on-site physician to help direct care was emphasized. Dr. Koenig explained different payment models for tele-ICU, including subscription, volume-based pro-rated subscription, per-click, hybrid, fee-for-service and RVU-based. At the conclusion of Dr. Koenig’s talk, he noted that discussions with patients have shown that a majority appreciated the two-way video interaction that telemedicine allows because it helped the patient know that they saw a specialist vs their on-site physician completing a phone consult.
Following Dr. Koenig’s talk, Dr. Steven Cramer discussed implications for Tele-rehabilitation. He started his presentation off by noting that telerehab is a very broad term that encompasses a range of rehab and habituation services that include assessment, monitoring, intervention, supervision, education, consultation and counseling. He explained that there have been various trials and meta-analyses investigating whether there is any benefit using telerehab vs in-person rehab. He explained that an analysis by Laver et al. reviewed 10 trials of stroke telerehab in which many of the reviewed trials were small, the interventions were variable and there was no effect on ADL or arm function. Furthermore, an analysis by Agostini et al. reviewed 12 studies of motor telerehab that found favorable results for patients with cardiac and orthopedic diagnoses, but there were inconclusive results for neurologic diagnoses. He noted that an analysis by Chen et al. reviewed 11 randomized controlled trials of telerehab in stroke survivors at home and found that there were similar ADL gains in the telerehab group compared to usual therapy. He explained that there were various criticisms about these meta-analyses as many studies had inadequate reporting quality and there was selective outcome reporting and incomplete outcome data. Additionally, the targeted therapy (discharge support program vs upper limb training vs mobility training vs communication therapy) and technology used (telephone vs videoconferencing vs email vs online chat program vs video recordings, etc.) varied.
Dr. Cramer explained that there was a trial, with better study design, looking at Telerehabilitation in the Home vs Therapy in-Clinic for Patients with Stroke that enrolled 124 subjects with stroke 4-36 weeks prior and arm motor deficits. The trial involved 11 U.S. sites where patients were randomized to intensive arm motor therapy in-clinic vs in-home telerehabilitation. It was a non-inferiority design in which patients were randomized and the assessors were blinded to the treatment group allocation of the patients. The primary outcome was change in arm motor recovery using the Fugl-Meyer assessment from baseline to 30 days post-therapy. It ultimately found that telerehab was non-inferior and showed comparable efficacy for improving arm function as compared to in-clinic therapy. It was noted that this can be interpreted that telerehab can, therefore, be an adequate alternative to in-person rehabilitation.
Dr. Cramer then explained that various animal studies have shown favorable plasticity with high use rehab doses, and in humans, higher rehab therapy doses are felt to possibly improve outcomes. However, he noted that there are various barriers to completing a high quantity of rehab due to financial constraints, limitations of patient travel, shortage of rehabilitation care in some regions, poor patient compliance with assignments and limited doses allowed during stroke rehabilitation.
He gave an example that an effective telerehab model may include an initial teleconsult with a patient in which a rehab strategy is defined, which can include a regimen of computerized games and telerehab that provides oversight/coaching of specific exercises multiple times a week. He noted that future considerations for telerehab include needing to validate successful results with a late phase trial, possibly pairing telerehab with a drug, needing to obtain detailed remote measurements, treating multiple neurological domains in parallel, improving access and lowering cost of post stroke rehab, providing very high doses of activity-based therapies, assessing very long term treatment in the prevention of functional decline, working on inner-connectedness of the electronic health record, generating actionable reports to health-care professionals and easing transitions of care.
Lastly, Dr. Christine Holmstedt spoke about her experience at the Medical University of South Carolina on Outpatient Telestroke Follow-up. She noted that their telestroke program started in 2008 and now has 37 sites with about 5,900 consults/year. Later, she explained that they started a teleneuroscience clinic that is staffed by NPs. She noted that these patients are scheduled in the provider’s clinic template in EPIC, are checked in by a clinic nurse and are connected via telemedicine. She provided data regarding cost-saving by the patient due to reduced transportation costs and reduced time off from work. Dr. Holmstedt also explained that they measured patient satisfaction with telemedicine for clinic visits and found that about 65% preferred to be seen by telemedicine, but found both telemedicine and in-person visits acceptable, and about 30% preferred only to be seen by telemedicine.
Overall, this talk was an excellent overview of the expanding reach of telemedicine. It explained the various advantages, disadvantages and future goals/possibilities of this technology in a wide range of practice settings.