Telemedicine might still be struggling to gain acceptance in healthcare circles, but one particular platform is proving its value.
Five years ago, someone suffering a stroke in the tiny Mississippi community of Kosciusko would face an uphill battle for survival. The town’s 25-bed critical care hospital wasn’t equipped to handle such emergencies, so the patient would have to be transported 80 miles southwest to St Dominic Hospital in Jackson. That’s a long trip - each hour, minute and second on the road cuts into the three-hour window of opportunity for doctors to inject the clot-busting drug tPA before permanent brain damage occurs.
Nowadays, the road race is no longer necessary. Someone showing signs of a stroke can visit Kosciusko’s hospital, Baptist Medical Center Attala, and be seen within minutes by a specialist at St. Dominic who can perform a video consult and prescribe tPA if necessary.
St. Dominic sits in the center of what officials say is the “sickest and saddest state in the country,” with high levels of obesity, diabetes and heart disease and decidedly rural conditions. Yet the state is ranked among the best in the American Telemedicine Association’s annual report cards, and its survival rate for stroke victims is admirable.
Credit goes to health networks like St. Dominic, which launched its telestroke platform four years ago – beginning with Baptist Attala (it was then called Montfort Jones Hospital) – and now sits at the center of a five-hospital network. The hub-and-spoke model used by St. Dominic, in fact, is popular throughout the country, ranging from little two- and three-hospital flowers to multi-site starbursts like the 15-hospital South Carolina Stroke Network and the Southeast Alabama Medical Center’s Stroke Care Network, which spans 240 miles and reaches into three states.
Telemedicine advocates have long championed telestroke as a vital means of getting treatment to stroke victims, whose chances for survival diminish with time. According to the American Stroke Association, American Heart Association and the ATA, telestroke services could save thousands of people each year and cut costs by $1.2 billion over the next decade. Yet only 3 percent to 5 percent of those diagnosed with a stroke are given tPA in time to avoid brain damage.
Wendy Barrilleaux, St. Dominic’s director of stroke services, says a telestroke network has to be built slowly and gradually, with just as much emphasis on education as on the technology. She credits Dr. Ruth Fredericks, a neurologist who hails from Mississippi’s remote delta region, with seeing the value of telemedicine and launching the St. Dominic program in a partnership with Atlanta-based REACH Telemedicine.
“When they first suggested it, it was such a foreign subject – I had to Google it,” Barrilleaux said. “We had to spend about a year studying it and just getting used to it in our own hospital.” That included winning over clinicians who weren’t comfortable with the new technology or who had never used it before.
“We started practicing in our own hospital first,” she said. The doctors and nurses would get used to it during the day, then log on at home at night.
Stroke cases are typically fast-moving and stressful times, “with lots of running around,” said Barrilleaux. With a telestroke feed, however, the doctor sits in one place “and has all the information right in front of him or her.” Vital signs and labs are entered into the medical record, the doctor can examine the patient via high-definition video, even consult with others in the room or talk to family members, and then a diagnosis can be made – often within 15 minutes.
Once that process was established, St. Dominic set its sights on Montfort Jones Hospital, who had no neurologists and had never treated stroke patients. Officials found they not only had to educate the small hospital’s staff, but go into the community and talk with EMS providers, town officials, even the public, many of whom didn’t know how to identify a stroke.
“It was very abstract to them how this could occur,” said Barrilleaux. “We found that we not only had to teach them what a stroke was and how to recognize it, but then we had to show them” that it could be treated at their own hospital.
“This wasn’t just dumping a telemedicine cart in the hospital – this was a partnership,” she said.
Once that program was up and running, St. Dominic officials realized they had the recipe in place for expansion. Barrilleaux said they took that model and presented it to other hospitals, in time establishing four more spokes – one to the north, two to the south and one to the east. She now spends a couple days every other month driving to those hospitals, meeting with clinicians and going over the treatment results.
“We can see how it’s working, how our patients are getting better,” she said. At Baptist-Attala, for instance, a hospital that once had a stroke treatment rate of 0 percent now stands at 22 percent, more than twice the national average.
Barrilleaux says St. Dominic “would definitely like to expand more” and add spokes, but there are challenges. Some hospitals don’t have the technology, or even a Wi-Fi connection. Each hospital needs about $20,000 in start-up costs – not an easy thing at a time when many hospitals are struggling to make ends meet – and is charged a monthly fee to stay in the network. “We want them to have skin in the game,” she pointed out.
There are some grants available, but not many, and reimbursement isn’t always a sure thing.
That may be changing. Last year saw the introduction of the “Furthering Access to Stroke Telemedicine (FAST) Act in the House, with a companion bill in the Senate. Supported by the American Heart Association and the American Stroke Association – who said it could save 22,000 lives each year - the bill would expand the locations where telestroke services could be administered and open more programs to Medicare reimbursement.
"Telestroke has proven to be very effective in increasing the speed with which patients get treatment by a stroke neurologist and also the number of patients who get tPA in both rural and urban areas," U.S. Reps. Joyce Beatty, D-Ohio, and Morgan Griffith, R-Va., said in introducing the House bill.
Telestroke services also figure in the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act, introduced to Congress earlier this month by a host of lawmakers. Among other things, the bill would enable healthcare providers to experiment with telestroke programs in alternative payment models and incentive programs.
While most health systems concentrate their telestroke services on hospitals and clinics, others take the mHealth angle a step further. Two years ago the University of Virginia piloted a unique program that placed a mobile telemedicine kit, called an iTREAT, with first responders. Their idea was to give EMTs an instant link, via a tablet, with UVA neuroogists the moment they reach a patient.
“The longest delay in treating folks is not once they get to the hospital but before they get to the hospital,” stroke neurologist Andrew Southerland, MD, said in a 2014 interview with EHRIntelligence.com. Added David Catell-Gordon, the UVA Office of Telemedicine’s director: “iTREAT is really designed to help support patients from rural communities to get the care they need quickly. Every minute in a stroke matters.”
“This novel approach could substantially reduce stroke onset-to-treatment times largely impacting the lives of individual stroke patients and their families,” UVA officials said. “The prospects of our iTREAT mobile telemedicine toolkit offer a new infrastructure for the way the medical community approaches timely stroke care and other emergency medical conditions going forward. No longer will we wait for the patient to get to the hospital, but now we can bring the hospital to the patient.”
At St. Dominic, meanwhile, Barrilleaux focuses on the spokes in the hub, checking in with each hospital to discuss successful cases as well as the false alerts (called “stroke mimics”) and consults that don’t end in a stroke diagnosis. She’s not only ensuring that the telestrokje platform saves lives, but that its help the clinicians using it to become better.
“Our doctors are actually really enjoying it and have been fulfilled by it,” she said.