Transcript Stroke Telemedicine Extending Care in Rural US

MONDAY, 3:00 – 3:20PM
E-Care
Stroke Telemedicine
Extending Care in Rural U.S.
Nina J. Solenski, M.D., Associate Professor of Neurology and Co-Chair of
the Virginia State Stroke Systems of Care Task Force, University of Virginia
U.S. Public Health Problem
Many patients impacted by stroke do not receive the
most advanced stroke treatment possible.
» Fragmented systems and processes
» A lack of capital resources for technology, personnel and
dedicated staff
» Shortage of stroke specialists and interventionalists
» A limited number of certified primary stroke centers in the state
» A lack of public awareness related to stroke as a medical
emergency
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Equal Opportunity Disease
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Virginia Stroke Statistics
» Stroke the third leading cause of death in Virginia (2004)
» Mid-Atlantic Stroke Belt - highest national average for
mortality
» IV rt-PA [‘TPA’] use
• Nationally only 2-5% of
ischemic stroke patients
received TPA
• Virginia below national
– 1.7% (2007)
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Barriers to Access – Geography
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Barriers – Lack of Specialists
» Emergency room physicians are often reluctant to
administer t-PA without the guidance of a neurologist
» Many community hospitals do not have access to
important stroke related resources.
• Few have access to a general neurologist
• Even fewer have access to a highly skilled stroke neurologist
Board-Certified Neurologists in Virginia by Rurality - 2007
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Stroke Damage Increases with Time
“TIME IS BRAIN”
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Stroke System of Care
Continuum of Care
1.
2.
3.
4.
Prevention
EMS Notification
& Response
Acute
Treatment
Sub-Acute Care &
Secondary Prevention
5.
Rehabilitation
Continuous Quality Improvement (CQI)
VAST 2008 HRSA Grant #H54RH08675
HIMSS 2010
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Acute Stroke Therapy
» Intravenous “TPA”
• Recombinant Tissue Plasminogen Activator
» Higher dose of a “natural clot buster”
» Time sensitive! ~3 hrs from onset
» Increases your chances of complete
recovery by 30 - 50%
» 10X increase in brain hemorrhage
(requires an emergent head scan)
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What is Telestroke?
Evaluation, diagnosis and treatment of stroke patients
using telemedicine
Multiple technology platforms
• Mobile (Robotic, Cart)
• Fixed High Quality Videoconferencing
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National Guidelines May 2009
ASA = American Heart Association Stroke epub May 4th 2009
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Critical Teleradiology
BRAIN CT SCAN – Normal Vs. Hemorrhage
Blood
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MGH TeleStroke 2007 ©
Acute TeleStroke: Provider-to-Provider Link
DICOM Image Server
Fixed / Mobile VC Unit
CT Scanner
ED Physician or PA
Patient
Fixed / Mobile VC Unit
Hospital or Home Based
TeleStroke Consultant
Desktop PC with
Monitor or integrated
Image Viewer
DICOM Image Server
HIMSS 2010
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The TeleStroke “Hub and Spoke” Model
Community
Health Center
Community Hospital
Community Hospital
Community Hospital
Community Hospital
Community
Health Center
Tertiary Hospital
Community Hospital
Community Hospital
MGH TeleStroke 2007 ©
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The TeleStroke “Third Party Consult” Model
For-Profit TeleStroke
Service Provider
Community Hospital
Community Hospital
Community Hospital
Community Hospital
Tertiary Hospital
Tertiary Hospital
MGH TeleStroke 2007 ©
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Va Acute Stroke Telehealth (VAST) initiative:
VDH, VTN, UVA – Framework for FCC Pilot Program
Clinical Results:
Bath Community Hospital (Critical Access Hospital)
» ~20 CVA per year
» Evaluated 8 acute stroke patients (40 % total)
» 50% qualified for TPA drug; all received <3 hrs and without
complication
» 50% had new medical dx (diabetes, hypertension)
» 100% were “drip & ship” or “ship” transfer
» Excellent patient and provider satisfaction
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Summary
Virginia – Telestroke program (VAST)
» Feasible
» Increased the number of patients eligible for rt-PA therapy
» High patient, referral and provider satisfaction
» Sustainable
» Require dedication of CEO, physician, EMS and hospital staff
» Relationships are the “oil” that makes it run
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Post-Stroke Remote Patient Monitoring
• Vital sign measurements
• Reminders/Surveys
• Customizable care protocols
• Video conferencing
Mobile Clinical
Assistant
Medical Peripherals
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Health Care
Management Suite
Patient Educational Content
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Managing Chronic Disease
Remote monitoring & home telehealth
Need
• Readmission rate within 90 days for Medicare beneficiaries > 30%
• MedPAC - $7,200 dollars per readmission deemed preventable
Remote monitoring/home telehealth can reduce costs
• Congestive heart failure
• Diabetes
• Chronic obstructive pulmonary disease / asthma
VA care coordination/home telehealth
• 19% reduction in hospital readmissions
• 25% reduction in hospital days
HIMSS 2010
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UVA Telemedicine Network
» 60 site telemedicine network
• Hospitals, FQHCs, clinics, prisons, schools, home
» Federal, state, foundation funding
» FCC rural healthcare and pilot program for bandwidth
» Services in more than 35 subspecialties
» Emergency and elective services 24/7
HIMSS 2010
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Telecommunications costs
Vary with mechanism of transport/and bandwidth utilized
1996 Telecommunications Law (FCC/USF)
• T1 to Wise, Virginia: $5800/month (1995)
• “
“
$1000/month (2001)
• “
“ Universal service fund $<200/month (2007)
FCC Pilot program (UVA administering VAST)
• Enhanced broadband access tied to stroke systems of care
• 48 rural hospitals
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Telecommunications costs
Building out Infrastructure
FCC Pilot program in Virginia “VAST”
Phase 1 Broadband Infrastructure Development Plan for VAST
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Funding Sources
» Federal & State Funding
• Grants
» Federal / State Insurance Programs
• Medicare / Medicaid
• Veterans, DoD
• Private pay
» Distributed Cost
• Hub and Spoke Share the Costs
• Sources include Patient Revenue, Hospital Operating
Budgets, Hospital Capital, and Philanthropy
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Future of Telehealth
» Demonstration projects (ARRA)
• Sustainability of federal investment
» Sound federal policies - sustainability
» Integration into mainstream medicine
•
•
•
•
Medicare
Medicaid
National health reform
Private pay
» National Broadband Plan
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Thank You
Acknowledgements:
The participants of the FLEX-HIT CAH VAST initiative wish to thank HRSA for support: Grant #H54RH08675
Participants:
•
Virginia Telehealth Network [Cynthia Barrigan, June Collmer)
•
Bath Co Hospital Staff, Hot Springs, Va [Debbie Lipes, CEO]
•
Virginia Department of Health [Kathy Wibberly, PI]
•
American Stroke Association [Keltcie Delamar]
•
UVA Office of Telemedicine [Karen Rheuban, Gene Sullivan]
•
Today’s Demo: Success Studio, Richard Settimo, David Stewart
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