1. Telestroke Is It Ready for Prime Time?
David Wang, D.O., FAHA, FAAN
Director, OSF/INI Stroke Network
Clinical Associate Professor of Neurology
University of Illinois College of Medicine at Peoria

2. Disclosure Statement Dr. Wang is a member of:
Illinois Stroke Task Force.
Co-Chair, Illinois Stroke Task Force Telestroke Subcommittee
Executive Committee, American Academy of Neurology-Vascular Section
Quality Measurement and Reporting Subcommittee, AAN
Advisory Committee, American Stroke Association
International Operations Committee, American Heart Association
Speaker Bureau: Pfizer, Boeringher-Ingelheim,

3. The Scope of the Problem
Stroke Incidence: +61%
700,000 a year, third leading cause of death, leading cause of adult disability.
rt-PA needs to be given within 3 hrs, which presents an opportunity to improve patient outcomes and reduce overall costs to the US health system 2.
Stroke Incidence US Market,
Sources: Sg2 Analysis, 2006.

4. 4 Key Elements in the Initial Evaluation and Treatment of a Stroke
ER Emergency room physicians are often reluctant to administer t-PA without the guidance of a neurologist.
Radiology
Neurology Few have access to a general neurologist Even fewer have access to a highly skilled stroke neurologist
Stroke Team Responsible for delivering organized, error-free quality care

5. Not Enough Neurologists
48 million Americans residing in counties that contain no neurologist.
American Academy of Neurology Report: 10,038 U.S. Neurologists registered 83.7% were adult Neurologists % had stroke as their practice focus 47% strongly agree and feel comfortable in giving tPA.

6. Hospital Administrator’s Headache
We can’t get anyone (neurologist) to take ED stroke calls.
We don’t have any neurology coverage. The closest neurologist is 70 miles away and he has a waiting period of 6 months.

7. Not Enough Radiologists
American College of Radiology: There are about 25,600 post-training diagnostic radiologists in the US 73% of these radiologists work full time Over half of the radiologists surveyed indicated that they were overworked
There are not enough Radiologists interpret imaging studies of the stroke patients 24/7
There are even fewer Interventionists that can deliver catheter-based treatment
Sunshine JH, et al. Diagnostic Radiologists in Basic Characteristics, Practices, and Issues Related to the Radiologist Shortage. AJR 2002;178:

8. What Do We Have?
According to the Hospital Statistics 2002: 4,856 US hospitals reported 85% have emergency departments 65% have medical or surgical intensive care 78% have CT scanner 48% have MRI 80% have ultrasound services 69% have case management 85% have social workers 27% have inpatient physical rehabilitation services 76% have outpatient physical rehabilitation services
Facilities and Services in the U.S. Census Divisions and States. Hospital Statistics. Health Forum LLC, an affiliate of the American Hospital Association

9. Can TeleStroke Help? Not enough Neurologists and Radiologists,
TOO MANY STROKES! Telestroke, Hospitals without onsite stroke expertise are provided with the access to stroke centers (stroke expertise) in real time. No distance limitation between the site hospital and the stroke center.
What it takes to set up a telestroke network
Benefit of telestroke
Pros and Cons of Telestroke

10. Telestroke-Technology Involved
Low tech: Telephone consultations
Need some tech: Incorporate radiology image transmission
High tech: Real time audio and video conferencing via wireless encrypted transmission, or secure landline and transmitting neuro images simultaneously.

11. Hub and Spoke Model, high tech

12. Sources: Sg2 Analysis, 2006. Name of System Description
Stroke-Center Hub and Spoke Model
Neuro-critical care specialists based in a Academic or Tertiary Care Medical Center
Examples: Partner’s Tele-stroke program, Medical College of Georgia REACH* program
Partners Tele-stroke Program
Serves 14 hospitals in Massachusetts and provides consultation for AMCs willing to develop a stroke network.
Distributed cost model where both the hub and the spoke hospitals share costs associated with tele-stroke.
Spoke hospitals pay for videoconferencing equipment ($5,000 to $20,000), annual maintenance fees and a fee per Tele-Stroke Consult ($1,000 each).
Hub hospital provides on-site and continuing stroke education, and necessary implementation steps and training sessions for staff.
Advantage: Spokes aligning with major stroke center hubs are aligned to provide advanced neurovascular services their patients may need and can market their affiliation to draw patients as referrals.
Sources: Sg2 Analysis, 2006.

13. Sources: Sg2 Analysis, 2006. Name of System Description
Physician Hub and Spoke Model
Network or center of independent neuro-care specialists, independent of tertiary or Academic Medical Centers provide consultations to surrounding hospitals.
Brain Saving Technologies
Establishes Neuro-critical Care Centers
First one at UMASS Memorial Medical Center staffed by stroke specialists.
Currently serves five hospitals in Massachusetts and Virtua Health System in New Jersey.
Hospitals pay a fixed yearly price.
As an example a 300 bed hospital the fee is around $216K plus upstream costs for technology.
Advantage: Organizations that do not have the stroke volumes to justify the cost of the video technology can leverage it for other telemedicine services.
Sources: Sg2 Analysis, 2006.

14. Tele-Stroke Technology Providors
BF-Technologies
Sells a bi-directional audio and video system (AccessVideo™ $24,000)
Charges a yearly maintenance fee of $6,000.
System provides site-independent access error-free HIPPA compliance encryption, remote pan/tilt/zoom, and full audio/video session recording.
University of California San Diego has such set-up Stroke Team Remote Evaluation Using a Digital Observation (STRokE DOC).
Courtesy of Sg2

15. InTouch Health®
Mobile robot (RP-7 Remote Presence Robotic System) that allows a remote physician to guide the robot to the patient’s bedside, and evaluate the patient through bi-directional video and audio communications.
A robot costs $120,000 to buy, or $4,000 a month to rent.
The Michigan Stroke Network which includes 21 Michigan hospitals and spearheaded by St. Joseph Mercy Oakland Hospital is an example of a stroke network using robotic technology.
Courtesy of Sg2

17. Where Is the Funding?
States initiating reimbursement for telemedicine: NY, CO, GA, FL, OK
Federal Funding: Grants more likely, and it is usually one time deal
Some stroke networks have been funded by tobacco taxes (Colorado $185,000),or grants from the State’s Stroke Center Act (New Jersey $390,000)
Share the cost: Per use based or flat fee between the hub and spokes
Others: Patient revenue, hospital operating budgets, Philanthropy.
Paying a yearly fee: Brain Saving Technologies $216K per year

18. TeleStroke-PROs The cost is flexible, depending on the system used
It can be wireless, nearly real time with broad band
Extend stroke care expertise into rural and underserved areas.
It is time saving and efficient. Doc-Doc, Doc-patient interaction allowed at distance
Multifunctional: films, labs, medical records, pathology report
Provides rapid access to specialized interventions through initiation of inter-hospital transfers and improve in basic on-site stroke therapy.
It has demonstrated improved use of rt-PA.
It may improve enrollment in acute stroke trials.

19. Impact on Stroke Care
Videoconferencing by off-site stroke neurologist provides accurate assessment of the patient’s physical condition and neuroimaging studies
Tele-stroke can maximize use of life saving therapies:
A rural hospital that had not used tPA in 2yrs increased tPA administration to 5.6% with the Partners Tele-Stroke Network
Houston: 0.8% use of rt-PA improved to 4.3%
Improves hospital standing in the community by providing leading treatments.
Reduces mortality rate by identifying patients who need to be transferred for advanced care.
Sources: Sg2 Analysis, 2006.

20. Impact in Rate of Thrombolysis after Implementation of Telestroke Network
The use of telemedicine in stroke makes it possible to bring the expertise of academic stroke centers to underserved areas, potentially increasing the quality of stroke care.
Telemedicine support to 12 community hospitals without on-site stroke specialists.
3/ / ,606 entries divided in two phases: pre-telemedicine (N= 933) and post-telemedicine (N=1,673).
Outside of the three-hour-window was the most common contraindication for thrombolytisis (52.3%).
143 patients received thrombolytics, with 35 interventions prior to starting telemedicine and 108 after.
Thrombolysis rate prior to telemedicine was 3.8% and after 6.5% (p=0.004).
Incorrect treatment decisions happened 10 times (0.39%), with 4 (0.43%) pre vs. 6 (0.36%) post telemedicine (p=0.78).
There were no statistically significant differences in mortality (15.9% pre vs. 9.2% post; p=0.23) or good outcome (17.1% pre vs. 15.8% post; p=0.84).
S-ICH happened in six patients (4 [9.8%] pre vs. 2 [1.9%] post telemedicine).
CONCLUSIONS: Telestroke implementation increased rate of thrombolytic use in remote hospitals within the telemedicine network.

22. Telestroke-Cons Price HIPPA, patient confidentiality
Can be complicated to use and maintain
Lack of reimbursement will hinder widespread adaptation of its use.
Is a patient's brain scan clearly readable over the system?
Are onsite physicians able to adequately care for the patient after the medication is given?
Reimbursement and liability issues pending resolved

23. The Ideal Set-up Affordable Portable User friendly
Can have a mixture of high-tech and low-tech type of network
Low maintenance
Maintain confidentiality
No one type or size of telestroke system that will fit all situations.
Type of clinical applications and volume of consultations determine the characteristics and costs of the appropriate systems.

25. Six Current Centers that Function as CSCs and uses different Telestroke Equipment
How does this currently play out in reality? I’m going to go through a whirlwind tour of six centers in a diversity of settings – large cities, smaller cities, and rural communities and share their systems of care for acute tPA delivery. I am focusing on acute reperfusion treatment delivery as this is where we see a particularly diverse and complex set of relationships between CSCs, PSCs, and community centers.
50 miles
Transfer hospital
Telemedicine hospital
Our hospital 25

26. Example #1: Greater Cincinnati/Northern Kentucky Stroke Network
Acute Team
Based at Univ of Cincinnati (UC)
3 Emergency physicians
7 Vascular neurologists
4 Neurointerventionalists
6 Acute Coordinators
15 Hospitals
1 University UC)
3 Teaching
11 Community
15 local hospitals, including 4 PSCs
EMS brings pts to nearest hospital
UC Stroke team MD drives to all local hospitals
Encourage pre-notification (prior to CT completion)
Study coordinator comes if possible trial candidate
Additional ~10 regional hospitals
Drip and ship by phone assessment
Starting with the example I know best….
2.1 million population for metropolitan area;
About 30 miles between farthest hospitals;
Crosses state lines 26

27. Example #2: Saint Luke’s Brain and Stroke Institute – Kansas City Stroke Referral Network
Over 80 hospitals, including 4 PSCs
PSCs refer for IA tx or IV tPA guidance
Phone consultations; no fee for 24/7 support
Treat ~30% of cases called in
Threshold for transfer
Post IV rtPA care
For IA therapies
Weekly education in region by MDs and RNs
2.1 million KC metro; >100 mile radius

28. Example #3: University of Texas-Houston Stroke Network
Currently:
About 40 calls/mo; 1-2 per 24 hr period; treat 25%
43% daytime, 36% evening, 21% at night
60-70% of calls are stroke-related
About 6 TPA treatments/mo
Changing climate
Increasing # of pts take to local PSCs rather than MHH
Decreasing pt access to research and IA therapies at MHH
Concern for decreasing rates of rtPA use at low-volume ctrs
Six UT Dept of Neurology faculty
Memorial Herman Hospital (MHH)
22+ hospitals via telemedicine
Two systems
Additional regional hospitals by phone
Drip and Ship
50 miles
Transfer hospital
Telemedicine hospital
Our hospital
Houston metropolitan population of 5.7 million;
2 IA centers within three blocks of hub

29. Example #4: UCSD Stroke Network
STRokE DOC network (trial on hold)
UCSD:
4 telemedicine hospitals miles away
Mayo Scottsdale:
2 Telemedicine hospitals
28% telemedicine rt-PA during trial period
More accurate rtPA decision-making with video, comparable safety and outcomes by phone
Acute Team
Based at UC San Diego (UCSD)
6 Vascular neurologists
4 Coordinators
2 Emergency Physicians
4 Neuro-Interventionalists
10 Hospitals
1 University (2 Centers)
4 Community
(physical coverage)
3-4 Remote
(phone /telemedicine)
15% treatment rate overall
6.50 rt-PA treatments per month
2.75 rt-PA treatments per < 2 hours from symptom onset
How many of you are from the Cincinnati Metropolitan Region, if ANY?
>100
My utopia of stroke care, vs reality in mos of country
Neurologists didn’t sign up to wake up at night
12 miles to farthest hospital (drive)
150 miles to farthest hospital (telephone)
350 miles to farthest hospital (telemedicine)
San Diego metropolitan population 3 million 29

30. Example #5: Med Coll of Georgia (MCG) REACH Telestroke Network
6 MDs
5 neurologists
1 EM physician
15 hospitals
10 rural (<75-bed)
5 larger community ( beds)
10 smaller rural hospitals ( miles)
No 24-hr radiology; drip and ship
5 larger community hospitals
Two PSCs, but lack 24/7 stroke coverage
Telestroke coverage for a fee
“Treat and keep” at local hospital (DRG 559)
Transfer for higher level of care
Decreasing 24/7 local neurology coverage in region and potential for REACH being at capacity
~200 miles

31. Example #6: OSF/INI Stroke Network
Telestroke by the JEMS System, projecting live video to your cell phone. 4 helicopters for transport
10/09-9/11:
875 transfers
179 drip and ship cases from 30 hospitals
TPA administration rate:20%

32. The Challenges Facing Telemedicine
Who regulates the existing telemedicine structure?
The authority of local and regional providers in developing telemedicine.
When it becomes Web-based, what will happen to the traditional relationships that exist between a doctor and a patient?
It may be an investment that may not have clear financial return.
Credentialing among spoke hospitals and cross the states
The Stark law of preventing enticement
JD Linkous, MD Net Guide 11/06

33. A Look at the Budget for a Telestroke Network
One new rural spoke hospital needs about $46,000 ( $10,000 -$20,000) per year dependent upon the size of hospital, volume of stroke consultations, and sophistication of telemedicine equipment selected.
The start-up and first year of operation cost for a multi-hub network serving 35 rural spoke hospitals was $2.5 million.
Costs include: neurology, personnel, coordinators, managers, information technologists, administrators, telemedicine platform equipment, institute supplies, laptop cameras, headsets with microphones, broadband wireless cards, efax subscriptions, travel expenses, training, and overhead.

34. So, Does Telestroke Save Money?
Compared two-way audio video technology to usual care
A decision analytic model was developed for both 90-days and lifetime horizons. Model inputs included both costs and clinical consequences.
Quality adjusted life years (QALYs) gained were combined with costs to generate incremental cost-effectiveness ratios (ICERs).
In the base case analysis, compared to usual care, telestroke resulted in an ICER of $108,363/QALY in the 90-day horizon and $2,449/QALY in the lifetime horizon.
Telestroke appeared cost-effective REALLY?

35. So, Does Telestroke Save Money?
A network model: -more patients treated with IV thrombolysis -more patients transferred for endovascular management -more patients discharged home independently.
The telestroke network costs less, overall, and was more effective than no network.
With increased spoke to hub transfer rates, the hub experiences greater cost savings while the spokes bear higher costs.
When reducing spoke to hub transfer rates, the spokes experience greater cost savings while the hub bears higher costs.

36. So, Does Telestroke Save Money?
The answers to this question are: Patients may get better care at the cost of the institution that establishes and runs telemedicine Institutions are not being paid adequately to run telestroke network
Health economic research is needed to develop viable and sustainable business plans.

38. The Near Future

39. Conclusion
Telemedicine Can solve the problem of access to specialty services
Currently there is no set rules to regulate telemedicine
Telemedicine improves TPA use in stroke patients in rural and remote ERs
Technologically it will be cheaper to set it up in the near future
To staff and support telemedicine is not cheap.
Telemedicine may not have financial benefit to the institution that runs it