Telemedicine: Transforming the Delivery of Stroke Care

1. Telemedicine:Transforming the Delivery of Stroke Care Tzu-Ching (Teddy) Wu, MD Associate Professor of Neurology Director of Teleneurology

2. Disclosure: Tzu-Ching Wu, M.D. • Dr. Tzu-Ching Wu, has no relevant financial interests to disclose

3. Objectives • Identify the functionality and benefits that telemedicine technology can offer to providers and patients • Review the nuts and bolts of a teleneurology/telestroke network • Discuss the keys to success • Discuss the future of teleneurology

4. What is Telemedicine? • “Telemedicine” term coined by Thomas Bird in 1970’s, “healing at a distance” • Telemedicine: the use of telecommunications technologies to provide medical information and services • Telephone • Fax • Email • Mobile devices/apps • Store Forward (Asynchronous) • Interactive real-time audio/video streams • Used for Telestroke/Teleneurology • Synchronous

5. Why is Teleneurology/Telestroke Needed? • Stroke is the fifth leading cause of death in the United States and second leading cause of death worldwide • Stroke is the leading cause of long-term disabilityin the United States • Acute ischemic stroke is a treatable disease • IV t-PA is still the only proven medical therapy for acute ischemic stroke • Narrow time window, risk of hemorrhagic conversion • (NNT 1 in 8 for near normal, 1 in 3 will improve) • Intra-Arterial Thrombectomy (IAT) recently shown to improved outcomes in certain acute ischemic stroke patients. NNT = 1 in 4 • Both treatments need to be delivered fast in order to be effective • IV t-PA under-utilized / Access to IAT

6. Why is Teleneurology/Telestroke Needed? • Currently ~800,000 stroke cases per year and with the aging population, incidence likely to double by 2050 • Shortage of neurologist (11%19% by 2025), including vascular neurologists • Declining number of neurologist taking hospital call and inpatient consultation • Lack to access to acute stroke expertise • Emergency room physician uncertain about administering IV t-PA without guidance from neurologist; rapidly evolving treatments with IA • Disparities in acute stroke care for rural populations • Ten times less likely to receive IV t-PA when compared to urban hospitals • Texas has one of the largest rural populations

7. How? • Neurologists • Technology • Audio/Video • Broadband access • PACS

8. Telestroke Network Model Hub(s) and Spoke • Third Party “doc in box”

9. Telestroke Coverage Model • Provide stroke coverage in remote hospitals that lack neurology presence • More difficult to attract neurologist to smaller markets, even more difficult for vascular trained neurologist • Hard to maintain call schedule with only a few neurologist • Provide adjunctive coverage in remote hospitals with local neurology practices/hospitalists • Enhances call schedule • Offers flexibility • Maintain outpatient practice

10. UT Teleneurology Program Overview Program Goals • Improve overall neurological care in the region • Solidify relationships with existing referral hospitals, increase access to Memorial Hermann System (4-Comprehensive Stroke Centers) • Avoid unnecessary transfers and encourage hospitals to keep patients who do not need a higher level of care in their own community • Educate surrounding hospitals and facilitate the transfer of patients who do need a higher level of care (i.e. Neurosurgery, endovascular or participation in research protocols otherwise not available to patients in the community)  • Benefits patient, family and community hospitals

11. UT Teleneurology Program Overview Program Model • Provide 24/7 acute telestroke coverage • Expanded to acute teleneurology and routine teleneurology (3 spokes) • Hub (4) and Spoke (17) model + 7 Freestanding EDs • Spokes (17): 3 CSCs, 10 PSCs • Mixed Network: 9/17 within Memorial Hermann System, 8/17 outside Memorial Hermann system

12. Role of Teleneurology • To provide acute neurological consultative services 24/7 (Emergency room or in-hospital) to supplement current neurological coverage • Flexible coverage: 24/7 vs after hours and weekends only etc. • Examples: Potential IV-tPA/IAT candidates, cerebral hemorrhage, status epilepticus, etc • Expedite transfers to CSC hubs if needed with pre-acceptance • To provide routine/non-urgent consultations and follow ups, 7 days a week 8am to 5pm where contracted

13. How does Teleneurology get Activated? • Acute neurological patient identified • Page UT Teleneurology Team thru call center • Teleneurology protocol activated • TM physician to be on camera if necessary within 10 minutes of page • Evaluate Patient with bedside nurse • Give recommendations • Arrange for transfer if needed

14. Example Case • 20 year old no sig PMH • Citizens Medical Center • Victoria Texas • Just returned from concert • Found in bathroom @ 9:30PM not acting herself • Last seen normal 9pm • Arrived at OSH ED @ 11pm • Has been having headaches for 1 week • VS: BP: 123/74 HR: 82 RR: 16 NSR • FS: 112

15. Example Case

16. Example Case

17. Example Case • NIHSS = 13 • Expressive aphasia, right FD, Right sided hemiparesis and sensory loss • Arrival to ED @ 11:00PM • Paged TM @ 11:19PM • On Cam @ 11:29PM • TPA Bolus @ 11:35PM • Time from page to TPA = 16 minutes

18. Example Case • Arranged for Transfer to MHH-TMC for possible intra-arterial therapy • Angio showed no proximal occlusion • NIHSS @ 24 hrs = 2 for mild dysarthria and sensory loss • NIHSS @ discharge 1 for sensory changes

19. Follow up • Negative hypercoaguable work up • TTE + right to left shunt, likely PFO • TEE + interatrial septal aneurysm small fenestrated spontaneous shunting • Lower extdopplers: negative for DVT • MRV Pelvis: no DVT, severe compression of left common iliac vein by right common iliac artery, with increased left sided deep pelvis venous collateralization, may be associated with increase risk of development of DVT • She under went closure of ASD with amplatz device

20. Example Case • 43 year old no sig PMH • On antibiotics for facial infection • Found @ 7:30PM on the floor of kitchen by daughter “acting strange”, last seen normal at 7pm. • Exam: • Right gaze deviation • Left neglect • Left sided plegia and Left facial droop • Severe dysarthria • NIHSS = 18

23. Example Case • 43 yr old no sig PMH. On antibiotics for facial infection • Found @ 7:30PM on the floor of kitchen by daughter “acting strange”, last seen normal at 7pm. • Arrived at CSC ED @ 8:21PM via EMS • TM paged @ 8:30PM • TM on cam @ 8:36PM (CTH and CTA completed) • tPA bolus given @ 8:48PM (DTN: 27minutes) • IA Team activated @ 8:43PM • TICI 3 Recanalization @ 10:15PM

24. Pre Post

27. Example Case: Outcome and Work up • NIHSS = 0 next day • TEE with PFO/ASA • No DVT; Hypercoagulable labs all unremarkable • PFO closed prior to Discharge home • LOS 5 days

28. Benefits of Telestroke • Accurate decision making • Increase use of IV t-PA • Reduce unnecessary transfers • Comparable outcomes • Financial benefits • Research opportunities

29. Assess whether telemedicine consultation is superior to telephonic consultation for acute stroke treatment. • Primary outcome: Decision of thrombolytic treatment • Secondary outcome: sICH, mRS

31. Conclusion: Telemedicine for acute stroke treatment results in more accurate decisions when compared to telephone consultations.

32. Benefits of Telestroke • Accurate decision making • Increase use of IV t-PA • Reduce unnecessary transfers • Comparable outcomes • Financial benefits • Research opportunities

33. Telemedicine: IV t-PA Rates • Thomas Jefferson • Jan 2011-June 2012 • 1643 consults • IV t-PA rate 14% • Increase of IV t-PA use by ~55% • University of Pittsburg • March 2005-December 2008 • 12 hospital spokes • IV t-PA rate 2.8%6.3% • Choi et al. JtComm J Qual Patient Saf. 2006 Apr;32(4):199-205. • Compared IV t-PA rates in 2 community hospitals in Houston over 13 months • IV t-PA rates increased from 0.8% to 4.3% during telestroke project • TEMPiS project in Bavaria • 12 community hospitals with 2 hubs • IV t-PA volume increased 10x from 10 to 115 over 12 months.

34. Benefits of Telestroke • Accurate decision making • Increase use of IV t-PA • Reduce unnecessary transfers • Comparable outcomes • Financial benefits • Research opportunities

35. Reductionin Transfer • Intravenous Tissue Plasminogen Activator Administration in Community Hospitals Facilitated by Telestroke Service • Chalouhi et al., Neurosurgery 2013 • Thomas Jefferson University Hospital developed a 28 spoke telestroke network • Jan 2011-June 2012: 1643 Total consults • 237 IV t-PA (14%), 82% increase in IV t-PA use, • Transfers decreased from 44% in first two quarter 2011 to 19% in the first two quarters of 2012.

36. Benefits of Telestroke • Accurate decision making • Increase use of IV t-PA • Reduce unnecessary transfers • Comparable outcomes • Financial benefits • Research opportunities

37. Compared outcomes for Drip and Ship vs Drip and Stay • 9/2015 to 12/2016: Total of 430 tPA-treated • 232 Drip and Ship (NIHSS = 10) • 192 Drip and Stay (NIHSS = 6) • No difference in LOS, hospital mortality, discharge disposition, 90 day mRS

38. Stroke outcomes worse when presenting overnight or weekends • We compared outcomes and metrics in our TM network • 9/15 to 12/16: Total 424 patients that received tPA • 268 after hours and 156 on-hours • Results: no difference in tPA administration times, complications, and 90 day outcomes • Access to stroke specialist 24/7 via TM can ensure dependable and timely clinical care regardless of time of day or day or week

39. Benefits of Telestroke • Accurate decision making • Increase use of IV t-PA • Reduce unnecessary transfers • Comparable outcomes • Financial benefits • Research opportunities

40. Financial Perspective • Hubs: increase in procedures, complex hospital admissions • Spokes: increase in reimbursement for tPA patients that stay at spoke; downstream revenue • Healthcare system: reduction in unnecessary transfers • Patients and Families: reduce unnecessary transfers (driving, parking, accommodations) • TeleStroke Network: Financial stability

41. Reimbursement Model • Fee-for-service models prevail for metropolitan service areas • Hospitals will pay professional fees for telemedicine coverage • Flat fee per month • “Per Click” • The professional fee model allows for “on the ground” physicians to still bill for services • Telemedicine physician does not bill patient* • Neurologists can focus on their out-patient practice • Alleviates burdensome call

42. Benefits of Telestroke • Accurate decision making • Increase use of IV t-PA • Reduce unnecessary transfers • Comparable outcomes • Financial benefits • Research opportunities

43. Telemedicine and Clinical Trials • Clinical trials completion  advances in stroke treatment • Recruitment is inefficient • Barriers • Access to tertiary centers • Transfer delays • Time sensitive • Patients in rural areas excluded

44. Remote enrollment by TM

45. Results • Between May 2013 and July 2014, 65 patients screened at the two spokes • 10 identified via TM as eligible • 1 case, insufficient time (<5 mins) for consent • Delay in study team notification • 6 of the remaining 9 (56%) agreed to participate

46. 3 of the 6 patient received t-PA within 60 minutes of arrival • Significant t-PA and US/Sham overlap time • No SAE or major protocol deviation • One minor protocol violation • Comparable to 4 patients enrolled at hub hospital during same period of time

47. Barriers to Telemedicine • Technology is no longer a barrier to telemedicine • Widely available broadband internet • Reduced cost of equipment • I-Phones, IPADS, Laptops, carts • Facetime/ Skype/ Other video conferencing platforms • Competition • Healthcare market is competitive • For-Profit national providers • Financial Costs • Equipment • Physician coverage • Other resources • Credentialing • Can delay start-up by months • Buy-in by local practitioners • Emergency room physicians and nurses • Hospitalists • Neurologists

48. Keys To Success

49. Defining the Role and Goals of the Program • Meet with stake-holders to define • Hub hospitals, program managers, physicians, department/division chair • Telestroke or Teleneurology? • Who will provide the consultative services? • UT Stroke Attendings, General Neurologist, fellows? • Community Neurologist?? • Only Emergency room or including medical floors? • Will you provide follow up consultative services? • Facilitate with transfer process? • What network model do we use?

50. Importance of Training (Spoke) • Pre-launch: Day long training sessions • Mock emergency stroke codes • Mock inpatient stroke codes • Nurses, physicians, techs, unit secretaries • On-going inservicing at spoke sites • IV t-PA time metrics • Intra-Arterial Thrombectomy protocols • Review recognition of stroke signs and symptoms • Educated on large vessel stroke screening tools • Review transfer process