1. Telestroke in Alberta Dr Thomas Jeerakathil Sharlene Stayberg

2. Page 2 Agenda Alberta Provincial Stroke Strategy Telestroke in Alberta Hyperacute Case Examples

3. Page 3 The Facts About Stroke In Canada Stroke is the number 1 cause of acquired long-term disability Stroke is the 4th leading cause of death Most common neurological condition requiring admission to hospital 20% fatal 75% of survivors live with some level of disability

4. Page 4 Alberta 5,500 new stroke case per year 25,000 stroke survivors Cost $200-$300M per year Stroke incidence increases with age 1-2% increase in the occurrence of stroke per year for the next ten years

5. Page 5 Current State Major advances in stroke care over the past decade Prevention Acute management Rehabilitation Significant gap between what is known about best practice and actual practice

6. Page 6 Alberta Provincial Stroke Strategy Close the gap between best practice and current practice Create systems of care that span geopolitical boundaries Health Regions, Heart and Stroke Foundation and AHW working in partnership to enhance service delivery across the province Alberta Stroke Council reporting to Minister of Health $20M 2 Year Grant Funding

7. Page 7 Stroke System in Action Provincial Network Model Optimal stroke care accessible to residents of all health regions regardless of where they live Enhanced clinical relationships - referrals/information flow/knowledge transfer/consultation support An organized and standardized approach to stroke care through the adoption of best practices, protocols etc. Performance measures to allow continual evolution and improvement in service delivery

8. Page 8 APSS - Opportunity Inter-regional Collaboration - Coordinate service delivery across geopolitical boundaries Develop common provincial strategies to facilitate access to services and optimal evidence based care Regions share information about stroke services (strengths, gaps, best practices)

9. Page 9 Role of the Key Participants Regional Health Authorities (9) Heart & Stroke Foundation of Alberta Department of Alberta Health & Wellness (Gov’t) Together they form the Alberta Stroke Council The Participants :

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11. Page 11 APSS Process Components / Inventory (Current State) Pillars Health Regions Education Gaps /IssuesStroke Plans Best Practices / Recommendations / Protocols / Resources Performance Measures/ Methodology Current State Provincial Model Implementation Stroke Plans Services Best Practice Protocols Education

12. Page 12 Comprehensive Stroke Centres Other Primary Stroke Sites Regional Hospital Primary Stroke Centres

13. Page 13 Comprehensive Stroke Centres Other Primary Stroke Sites Regional Hospital Primary Stroke Centres

14. Page 14 Wetaskiwin Comprehensive Stroke Centres Other Primary Stroke Sites Regional Hospital Primary Stroke Centres Wetaskiwin

15. Page 15 Pillars Span prevention, emergency and acute care, rehabilitation and community reintegration, evaluation and quality improvement Best practices – Define and disseminate Protocols and tools Education Resources Performance Measures

16. Page 16 APSS Initiatives Provincial Health Care Provider Stroke Education Strategy Provincial Telestroke Working Group – facilitate telestroke access to education and clinical consultation Integration of stroke protocols in regional Electronic Health Records systems

17. Page 17 Telestroke Working Group Regional representatives Telehealth DI/ IT Clinicians Stroke Neurologists ER physician Other Pillar Representative Project Manager APSS AB DI IM/IT Representative AHW Telehealth Others as Required Technical Consultant, APSS Evaluation Representative

18. Page 18 Activities Review of compilations of regions service + telehealth plans, discuss implementation issues and requirements Funding applications Technical analysis + recommendations for hyperacute Review of technical requirements Coordination of data collection to minimize duplication

19. Page 19 Telestroke Questionnaire Regional telehealth plans re stroke When plan to migrate to a telehealth model for hyperacute, other planned uses of telehealth re APSS, initial plans for ‘overlay’ applications Technical plans Proposed solution (technology requirements, technical approach for sharing images, integration with regional systems) Implementation issues Barriers, tools that can share, how privacy and security issues are being addressed, clinical workflow Regional funding requirements

20. Page 20 Learnings - Questionnaires Telehealth will support enhance delivery of stroke services, within and between regions Supports all Pillars Variable readiness Telestroke/ Overlay Different telestroke service priorities Different resource requirements Different technical solutions planned The most technically complex service is hyperacute and involves DI and videoconferencing components. Other services use videoconferencing.

21. Page 21 Canada Health Infoway Investment Scope – telehealth components: equipment, planning, implementation, change management, etc Leverages APSS funding and other regional and AHW investments Multiphased provincial scale project reflecting: variable readiness to proceed stroke (e.g. re hyperacute, variable readiness to proceed with overlay applications

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23. Page 23 MilestoneDate Infoway approval (Phase 2) effective dateApr 2007 Implementation team in place: 1 st 6 regions May 2007 Implementation team: remaining regionsDec 2007 Technology for all other applications (rehab, prevention/ promotion, capacity building, other acute) implemented Feb 2008 1 st Consults – hyperacute, first six sites 1 st Consults – hyperacute, next three sites/ other services Aug 1, 2007 Mar 1, 2008 Timelines

24. Page 24 Pillar I: Health Promotion and Disease Prevention Primary prevention sessions focused on established disease risk factors for stroke and other cardiovascular disease Secondary prevention clinic consultations for high risk individuals Pillar 2: Emergency Response and Acute Care Hyperacute stroke triage Hyperacute care follow-up consultations Other acute stroke services Pillar 3: Rehabilitation and Community Reintegration Rehabilitation consultations for assessment and treatment Discharge / transitional planning sessions Telestroke Services

25. Page 25 Telestroke Services Cont’d Other Stroke Services (impacts multiple pillars) Telementoring for staff Public education sessions Patient education sessions Telestroke rounds and other provider education sessions Initial Overlay Services – piloting of the overlay Trauma consultations (1 region) Occupational therapy consultations (1 region)

26. Page 26 Integration/ Coordination Clinicians delivering hyperacute consultation services will depend on technologies that fall within the domain of the Alberta DI Information Management/ Information Technology (AB DI IM/IT) project (e.g. digitally moving CT images). APSS Telestroke Working Group will retain a close association and awareness of progress in the AB DI IM/IT project. Manager of the AB DI IM/IT project is a member of the Telestroke Working Group. PACS specialist also a member of Working Group Technical consultant works with RSHIP project

27. Page 27 Hyperacute Services Clinical Needs The first is a CT head scan (and image review by a stroke neurologist or a radiologist) to rule out other possible causes for the patient’s condition and/or maintain the patient’s eligibility for tPA. The second is an interactive visual request/response session between a trained clinician (casualty officer and/or stroke neurologist) and the patient; that adheres to an internationally recognized protocol and degree of stroke scale (National Institutes of Health Stroke Scale).

28. Page 28 Remote/Local Requirements - Hyperacute Multiple ways to complete clinical assessment: Completely locally, using local expertise, (telehealth not required) Completely remotely, using an on-call stroke neurologist and possibly radiologist; A mixture of local and remote expertise (e.g. remote review of the CT head images by either a stroke neurologist or radiologist, combined with on-site neurological assessment by trained clinician), Approach varies dependant on local staffing. Recommended approach for regional centers: accommodate all options. This doesn’t preclude implementation of PACS component first.

29. Page 29 Requirements - Hyperacute Both technologies will require, (and potentially use), the same high bandwidth wide area network infrastructure that connects the remote trauma site (PSC) to the Edmonton or Calgary Stroke Center (CSC). The devices and components that enable the telehealth connection and the devices and components that enable the PACS connectivity are vastly different, and totally incompatible. The only possible common component would be the display station at the CSC that the stroke neurologist would use.

30. Page 30 Computed Tomography - Hyperacute Basic CT technology is adequate; CT angiogram may have future benefit but not necessary for hyperacute telestroke intervention Display monitor with 8 bits (256 levels) of gray scale. 1.3 or 2 mega-pixel resolution Scroll feature. Gray scale windowing (dynamic display range) and leveling (central display intensity). Magnification of selected parts of an image and/or Zoom plus Panning of the entire displayed image. Distance measurement, angle measurement.

31. Page 31 TeleHealth Components – Hyperacute Either mobile or fixed configuration can work. Multiple vendors meet criteria; AB - multivendor environment High quality video camera, positioned at face level (patient sitting or supine). Camera needs to have remotely operated zoom as well as remote panning and tilting capability. Adequate room lighting, particularly for the facial area. There should be local (room) control of the individual light sources, including dimming capabilities. High quality (directional?) microphone and speakers for good sound quality. Background noise suppression (if possible). Within 2 years, HD (high definition) video systems will be standard, and will necessitate the use of higher network bandwidth (likely > 1 Mbps).

32. Page 32 Approaches for Sharing of CT Images Tactical Solutions dependant on availability Timelines of AB IM/IT DI project do not align with APSS Creativity (existing networks, abandoned networks, SuperNet) Med-term Tactical Recommendation is use of AB IM/IT DI project infrastructure with images sent from local PACS station to telestroke/ unverified folder at RSHIP Shared Data Center Long-term AB IM/IT DI project will have full data concurrency for PACS images by approximately 2009

33. Page 33 CH PACS Hub CHR PACS Hub NLHR PCHR AHR ECHR CHR CSC PHR ChinHR SuperNet and Other Networks Current Configurations, Protocols Web Server CH UnV Folder SARP DTHR

34. Page 34 CH PACS Hub CHR PACS Hub RSHIP PACS Hub NLHR PCHR AHR ECHR DTHR PHR Chinook HR Supernet Proposed Configurations, Protocols

35. Page 35 Some Next Steps Finalize all funding agreements Regions continue to implement telehealth services Finalize technical analysis/ recommendations Provincial DI architecture group June discussion of technical options Establish new network connections Confirmation/ address network, NAT issues Finalize data collection processes identify training requirements Identification of additional ‘overlay’ services

36. Page 36 CLINICAL EXAMPLES

37. Page 37 Patient 1 70ish male enjoying his coffee at a local restaurant in rural Alberta– fell off of his chair Unable to rise EMS transported patient to a non-tPA hospital ED physician noted right sided weakness, visual loss, inability to speak – acute stroke Transfer to a Telestroke Centre hospital Contact with UAH telestroke physician

38. Page 38 Patient 1 (cont.) Patient assessed via videoconference and PACS images reviewed by stroke physician NIHSS 14 Decision for intravenous tPA Clinical improvement At 1 month NIHSS 3

39. Page 39 Wetaskiwin Comprehensive Stroke Centres Other Primary Stroke Sites Regional Hospital Primary Stroke Centres Wetaskiwin

40. Page 40 Patient 2 70ish male resident of a lodge Family unavailable for history or PMH Witnessed to have speech problems (?sudden); using one side less than the other; Confused behaviour, deficits fluctuating ? Stroke related language disturbance Assessed at Telestroke Hospital simultaneously by stroke neurologist and ED physician CT reviewed by PACS

41. Page 41 Patient 2 On videoconferencing the visual appearance suggested delirium and not stroke Delirium-related speech confusion without neologisms or paraphasic errors No other focal neurological features The appearance would be difficult to describe over the phone and distinguish from isolated aphasia Decision – stroke mimic; Final diagnosis – kidney infection.

42. Page 42 Phone + Local Radiology Expertise +/- Local Radiology expertise Information for decision making Technology Phone Videoconferencing PACS/CT Transmission & Phone PACS/CT Transmission Technology and information for decision-making