Part of the problem, experts say, lies with neurologists’ hesitance to join telestroke networks because reimbursement for telestroke is less straightforward than for a traditional stroke call, and many consider it to be inadequate under current Medicare and Medicaid guidelines.
Dr. Ramesh Madhavan, director of telemedicine for Wayne State University, Detroit, and the Michigan Stroke Network, one of the largest telestroke programs in the country with 36 affiliated hospitals, said in an interview that his program’s eight neurologists – including himself – take stroke calls over 12-hour shifts.
Courtesy Dr. Ramesh Madhavan and Dr. Kumar Rajamani
Dr. Ramesh Madhavan (on the video monitor) works with Dr. Kumar Rajamani to perform a neurological exam for stroke on a patient during a telestroke consult.
"We take shifts because there is no direct reimbursement, and we have to do other things during the course of that time. We have to multitask," Dr. Madhavan said, adding that this can make some neurologists feel burned out.
Dr. Tegeler said that, by contrast, the five vascular neurologists in Wake Forest Baptist’s smaller program have incorporated the telestroke coverage as part of their regular stroke attending call duties. Now, neurologists at some of the network hospitals "may not have to disrupt their office schedule for an hour or more to go over to the hospital to see an acute stroke patient," he said.
The presence of telestroke coverage also was used by one network hospital to help recruit a neurologist to a community where there had not been one, since the local neurologist would "not have to take stroke calls 24-7," Dr. Tegeler said.
In addition to the reimbursement issue, Dr. Levine said that telestroke has been hampered by "fears that the technology won’t work or may break down, or of lawsuits, and also doctors’ fear of something more technologically advanced than some are used to doing." Unlike their counterparts in emergency departments, Dr. Levine said, "neurologists aren’t techies, as a rule." However, telestroke experts are increasingly exploring cheaper and more portable options for videoconferencing, which could prove less imposing in terms of both startup costs to networks and in ease of use.
Most telestroke programs currently employ videoconferencing technology using equipment mounted on a mobile cart or purpose-built robots that can be driven to a patient’s bedside.
The robots, Dr. Schwamm said, "are a luxury. You can put a laptop with a specialized camera on top of a cart and roll it to a patient and get everything you need. Technology should not be where the costs are."
One team of researchers recently demonstrated that iPhones could be used in telestroke networks for patient assessment (J. Stroke Cerebrovasc. Dis. 2011 Oct. 24 [doi:10.1016/j.jstrokecerebrovasdis.2011.09.013]).
Dr. Madhavan said that he has been working with several technology companies on applications that would allow more telestroke consults to be carried out on portable devices using 3G or 4G networks. A migration to mobile platforms might help improve door-to-needle times in addition to reducing costs, he said.
Research Priorities
When Dr. Levine and Dr. Gorman first proposed telestroke networks in 1999, they envisioned them not solely as a way to increase TPA uptake but also as a way to facilitate patient entry into clinical trials of new stroke treatments.
This has yet to happen directly, Dr. Levine noted, but it may soon. "Community hospitals are not used to dealing with experimental medicines, or the logistics of randomization, and working with trial coordinators, IRBs, and rigorous and extensive data collection. But now that the systems are being built and there’s some infrastructure over the last 10 years, hospitals will hopefully start to see what clinical trials can bring them in terms of recruitment, state-of-the-art care while testing the most novel and promising treatments, and financially," he said.
Dr. Schwamm, whose program is among the few actively seeking to design clinical trials using telestroke, said that enrolling patients through telemedicine – and obtaining consent through video – is a challenge that, if met, will help broaden trial populations to reach more people living in rural and resource-poor areas. "The big studies tend to be done at the teaching hospitals, in urban areas. Telestroke can help allow people in the community to be enrolled," he said, leading to better representation of the population at large.
More telestroke programs are collecting at least short-term outcome or discharge data, measured in National Institutes of Health Stroke Scale (NIHSS) scores at admission and discharge. Dr. Madhavan’s team recently reported that, over 4 years, patients receiving intravenous TPA through the Michigan Stroke Network experienced a greater than seven-point reduction in NIHSS score by the end of their hospital stay (Stroke 2012;43:A2991).