When Every Second Counts

April 10, 2013
Teaching hospitals with neurologists specializing in stroke are creating programs to help clinicians in smaller community hospitals diagnose and treat the condition.
Jim Noga

Teaching hospitals with neurologists specializing in stroke are creating programs to help clinicians in smaller community hospitals diagnose and treat the condition. And as these telestroke programs get off the ground, CIOs are providing support and facilitation, using clinical IT, videoconferencing technology, and other communication devices to make it all happen.

One factor that has played a critical role in the evolution of stroke treatment is the emergence of tissue plasminogen activator (tPA), a clot-busting drug that can save brain function during the early onset of an ischemic stroke - but only if a patient is correctly diagnosed within a narrow window of time.

“I'd get a call from a general physician who would be asking whether he or she should give their patient tPA. And I would say to the referring doctor, ‘If I could see the patient, I could make a determination.’”

The drug, approved for stroke care in 1996 by the FDA (tPA had already been in use for heart attack treatment), must be administered within three hours after the onset of stroke symptoms. But, prior to the establishment of telestroke programs, many patients were being rushed to community hospital EDs or into rural hospitals that were situated too far from neurologists who could approve the administration of tPA.

Now, hospitals like Massachusetts General and Brigham and Women's in Boston, Swedish Medical Center in Seattle, and the UCLA Health System in Los Angeles, are addressing this problem, with the assistance of IT.

One of the earliest innovators in this area has been Massachusetts General Hospital, a 900-bed academic medical center that is a part of the multi-hospital Partners HealthCare system, and whose sister institution, Brigham and Women's Hospital, is a partner in its telestroke program.

At Mass General, Lee Schwamm, M.D., vice chairman of the department of Neurology, and director of TeleStroke and Acute Stroke Services, established the telestroke program in 2000 (it began as a pilot in 1998). Schwamm says it became clear, upon the FDA's approval of tPA for ischemic stroke care, that a stumbling block to its use was connecting patients with experts in brain imaging and brain function in a timely way.

“I'd get a call from a general physician who would be asking whether he or she should give their patient tPA. And I would say to the referring doctor, if I could see the patient, I could make a determination,” says Schwamm.

Initially, he created a QuickCam setup that allowed him to remotely view patients and their referring physicians, and through which he did “some very primitive consults,” he says.

But Schwamm soon realized he needed help, and reached out to Jim Noga, Mass General's vice president and CIO. “I sat down with Jim and an informaticist and developed a browser-based system for evaluating brain function,” he says.

By 2000, Schwamm, Noga, and their colleagues had set up a pilot with Martha's Vineyard Hospital (Oaks Bluff, Mass.). Four years later, Mass General became a formal stroke center.
Bill Likosky

As a result, neurologists on call at Mass General can connect online from anywhere to view patients and their caregivers at referring hospitals. They can also remotely manipulate the video camera to view patient function and symptoms and, at the same time, view digital diagnostic images that have been produced at the referring hospital.

Steve Horsley

Since the program first began, it has steadily expanded. “We now serve 26 hospitals in Massachusetts, southern Maine, and southern New Hampshire, and we've become a model for programs across the country,” Schwamm says.

Noga says, in terms of IT support for a telestroke program, there are a few critical components. “One is really having a robust videoconferencing infrastructure, as well as the ability to externalize that to other sites. And when you do that for telestroke, it obviously has to be reliable and available 24/7, because you never know when one of these patients in the ED might need to be evaluated for stroke.” This, he says, means expanding service into specialists' homes.

Virginia McFerran

And Mass General hopes to grow the program further, according to Noga, who says the hospital now acts as a software-as-a-service provider to other hospitals looking to establish a telestroke program.

In Seattle, Swedish Medical Center's program, which operates out of the multi-hospital system's Cherry Hill campus (where its team of neurologists is based), runs on a similar platform of medical and technical supports. As at Mass General, on-call neurologists are remotely available to ED physicians at referring hospitals that participate in the program.

“From a technical perspective, we wanted to be able to create network connectivity with the referring hospitals in a more easily replicated fashion.”

Bill Likosky, M.D., the vascular neurologist who supervises Swedish's telestroke program, says it represents about half of the volume of remote consults (as not all consults require the use of videoconferencing). And while he credits the health system's IT team for its technical support, the staff at Swedish found that in implementing this type of program, a level of tech support needs to be in place that goes beyond what any IT department can directly provide. That, says Likosky, means engaging a third-party vendor.

And while the costs are considerable, it is essential to avert any real-time problems neurologists might run into, in terms of basics like video camera functioning, he adds.

Says CTO Steve Horsley, “From a technical perspective, we wanted to be able to create network connectivity with the referring hospitals in a more easily replicated fashion.” So Horsley brought on a third-party vendor to assist by providing secure medical-grade networking communications. “The other element is that the clinicians at the referring hospitals have access to PACS, so we basically enable a remote hospital or ED to send us images that our consultative providers can view.”

Currently, the Swedish Medical Center telestroke program services all four of the health system's EDs, plus those at four community hospitals.

UCLA Health System's telestroke program, like those at Mass General/Brigham and Women's and Swedish Medical Center, is rapidly expanding and follows a similar set-up. Unofficially, reports Latisha Ali, M.D., the neurologist who runs the UCLA Medical Center TeleStroke Network Program, the initiative has been running since January, but officially launched in September.

“Our system has two components, the brain imaging review, and the remote management via videoconferencing,” she says, adding that the brain imaging is usually a CT scan. “We're able to download and view the scans from the remote hospital, and we provide the specialist consult.”

In terms of managing some of the practical aspects of running a telestroke program, Virginia McFerran, who stepped in as CIO of the UCLA Health System this summer, notes that UCLA, like Swedish Medical Center, does not create an electronic record for each patient remotely diagnosed by its telestroke neurologists. Instead, that EMR remains at the referring hospital, but UCLA maintains an electronic copy of the neurologist's notes and of whatever teleconferencing video footage is produced.

As for advice to other CIOs, McFerran says, “I think the first thing CIOs should understand is the rationale for a telestroke program and what it does for the patient. The reason this is such a critical application is because of the timeframe involved in the tPA application. If that medication is administered at the wrong time, brain bleeding will occur.”

Another key element, she says, is the importance of the physical exam for the ED doctor, which will inform choices for the technology.

“We have monitors that can display the results of the CT scans, where the on-call neurologist can look at the CTs at the same time, so you want to make sure you have high-definition monitors, and that you meet the bandwidth requirements.”

Thirdly, she says, the quality of the devices put into participating neurologists' homes must be at a level adequate to meet the needs of the program. And because UCLA puts its telestroke monitors on wireless carts, the wireless environment must be robust enough to support the level of activity involved.

In the end, telestroke programs represent a potential win-win for all stakeholders - patients and their families, ED physicians and referring physicians, and most of all, participating stroke-specialist neurologists and the teaching hospitals sponsoring the programs.

Healthcare Informatics 2009 December;26(12):31-33

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