1. Maryland Stroke Telemedicine Project RMC Maryland Health Roundtable 9/23/08 Eric Aldrich, M.D. (with minor adaptations by Dr. Stern, 10/2/08)

2. Background 1996: tPA approved by the FDA, 0 – 3 hour window 1996: tPA approved by the FDA, 0 – 3 hour window 2000 – 2002: “Operation Stroke” 2000 – 2002: “Operation Stroke” 2005: “Strike Out Stroke” Maryland State Plan 2005: “Strike Out Stroke” Maryland State Plan 2005: Plan approved by State Advisory Council on Heart Disease and Stroke, included in 2005 Annual Report 2005: Plan approved by State Advisory Council on Heart Disease and Stroke, included in 2005 Annual Report 2007: MIEMSS State Stroke System 2007: MIEMSS State Stroke System 2007: State Advisory Council on Heart Disease and Stroke 2007 Annual Report includes telemedicine as a “future goal” 2007: State Advisory Council on Heart Disease and Stroke 2007 Annual Report includes telemedicine as a “future goal” 9/25/08: tPA effective and safe, 3 – 4.5 hour window (Hacke, et al. N Engl J Med 2008:359;1317-29 9/25/08: tPA effective and safe, 3 – 4.5 hour window (Hacke, et al. N Engl J Med 2008:359;1317-29

3. Current Situation Pre-hospital provider training has been developed and is ongoing Pre-hospital provider training has been developed and is ongoing Over 30 hospitals have become MIEMSS certified stroke centers Over 30 hospitals have become MIEMSS certified stroke centers Emergency Medicine physicians have completed training Emergency Medicine physicians have completed training CHALLENGE = Neurology Coverage CHALLENGE = Neurology Coverage

4. Telemedicine: Past Experience 1990’s: University of Maryland – St. Mary’s Hospital Project 1990’s: University of Maryland – St. Mary’s Hospital Project Other States: Georgia, Massachusetts, Michigan, California, New York Other States: Georgia, Massachusetts, Michigan, California, New York Telestroke Companies: REACH MD, InTouch Telestroke Companies: REACH MD, InTouch Johns Hopkins Hospital – Howard County General Hospital Pilot Project (PACS + telephone) Johns Hopkins Hospital – Howard County General Hospital Pilot Project (PACS + telephone)

5. Telemedicine: Costs Hub and Spoke model – dedicated stroke care Hub and Spoke model – dedicated stroke care Hub: $ 3,500 - $4,500 per month Hub: $ 3,500 - $4,500 per month Spoke: Hardware - $ 3,300 per year Spoke: Hardware - $ 3,300 per year Support - $ 2,000 - $ 3,000 per month Support - $ 2,000 - $ 3,000 per month 1 Hub + 10 Spokes = $ 447,000 per year 1 Hub + 10 Spokes = $ 447,000 per year 24 / 7 remote system maintenance 24 / 7 remote system maintenance REACH MD

6. Telemedicine: Costs Hub and Spoke model Hub and Spoke model Hub: Maintains the system Hub: Maintains the system Spoke: Hardware - $ 10,000 one time cost Spoke: Hardware - $ 10,000 one time cost Support – Annual Fee to the Hub Support – Annual Fee to the Hub MGH

7. Telemedicine: Costs MGH: Part of the annual fee MGH: Part of the annual fee REACH MD: T.B.D. by the Hub REACH MD: T.B.D. by the Hub Canada: $ 250 for 24 hours, $ 500 if have to come in Canada: $ 250 for 24 hours, $ 500 if have to come in U.S. Hospitals: varies from $ 0 and up U.S. Hospitals: varies from $ 0 and up Note: State support for in house trauma surgeon coverage Note: State support for in house trauma surgeon coverage Note: Possibility of 3 rd party payer coverage Note: Possibility of 3 rd party payer coverage Neurology Coverage

8. Telemedicine: Future Benefits Benefits community hospitals with neurology coverage problems Benefits community hospitals with neurology coverage problems Could be used for other specialties in demand such as otolaryngology, orthopedic surgery, plastic surgery Could be used for other specialties in demand such as otolaryngology, orthopedic surgery, plastic surgery Could be used for emergency preparedness Could be used for emergency preparedness

9. Telemedicine: Future Options Centralized state supported system Centralized state supported system De-centralized private systems De-centralized private systems Cooperative venture Cooperative venture State / private / hospital blend State / private / hospital blend

10. Telemedicine: Recent Efforts May, 2007: REACH MD presentation at U. of Maryland May, 2007: REACH MD presentation at U. of Maryland InTouch presentation in summer, 2007 InTouch presentation in summer, 2007 December, 2007: Conference call with New York system December, 2007: Conference call with New York system April, 2008: DHMH “brain storming” meeting April, 2008: DHMH “brain storming” meeting May, 2008: JHH Grand Rounds: Massachusetts system May, 2008: JHH Grand Rounds: Massachusetts system July, 2008: DHMH follow-up meeting July, 2008: DHMH follow-up meeting September, 2008: State Advisory Council resolution to develop a telemedicine proposal September, 2008: State Advisory Council resolution to develop a telemedicine proposal

11. Telemedicine: Next Steps State Advisory Council on Heart Disease and Stroke State Advisory Council on Heart Disease and Stroke DHMH DHMH MIEMSS MIEMSS MIEMSS State Stroke System QIC MIEMSS State Stroke System QIC Comprehensive Stroke Centers (possible hubs) Comprehensive Stroke Centers (possible hubs) Maryland Hospital Association Maryland Hospital Association Maryland Stroke Alliance Maryland Stroke Alliance American Stroke Association American Stroke Association Other? Other? health insurance providers health insurance providers Discussion Amongst Key Stakeholders