Making Telestroke the Norm
When Nancy Lowman of Hickory, North Carolina, woke up one morning in February 2014, she knew something was wrong — “I was so dizzy the house was spinning,” she said. “I had a terrible headache, blurred vision and slurred speech and was sick to my stomach.” She called her husband, David, who could tell she needed professional attention, and he immediately called their daughter, Jill, to take her to Catawba Valley Medical Center (CVMC), where Nancy worked as a materials manager.
In less than 30 minutes, she had had blood work, a CT scan and her examination began — by a stroke neurologist at Wake Forest Baptist Medical Center more than 60 miles away. He was able to do that because Lowman was hooked up to Webster, CVMC’s telemedicine robot. Danielle Thurman, R.N., B.S.N., C.P.E.N., dialed an 800 number and then helped with the examination.
Telemedicine robots are quite simple — much like Facetime or Skype. “Telemedicine robots use a similar format of audio-visual conferencing, but through approved vendors and systems to ensure patient privacy and compliance with laws.” said Shyam Prabhakaran, M.D., associate professor of neurology at the Feinberg School of Medicine in Chicago.
On the hospital side, the robot has a camera or a couple of cameras to give different views of the environment and the patient. There is also a large teleprompter screen that the patients and healthcare providers can see, which usually shows the doctor, who is remotely logged in. Usually the doctor is using a desktop computer, but the examination can now also be done on smaller handheld devices like smartphones or tablets.
Depending on the model, the doctor can also get other biometric information, such as vital signs. “Some robots have stethoscopes that you can have nurses place on the patient, and you can listen to the heart and other sounds,” Prabhakaran said.
What happened next
Lowman’s doctor flashed a picture of a glass of water on Webster’s screen — was it completely full or just half full? Lowman couldn’t see it. Could she read the sentence on the screen? Her speech was slurred. When the doctor asked her to lift both arms, he could see that her left arm drifted. With this information and the results of her blood work and CT scan, he diagnosed a right-hemisphere ischemic stroke and approved her for tPA, the clot-buster.
The impact was dramatic. “I felt the result within five or 10 minutes because my eyesight started coming back,” Lowman said. In fact, all of her symptoms resolved. “I was so happy that I wasn’t paralyzed,” she said. “I guess I got there just in time.”
Time is brain
According to the American Stroke Association, 1.9 million neurons die every minute when a stroke is happening. In the time it would have taken Lowman to get to the nearest comprehensive stroke center in Winston-Salem and then get examined, she would have lost tens of millions of neurons and her deficits may have been severe and permanent.
Dr. Shyam Prabhakaran
Lowman’s outcome shows the immense promise of telestroke. But it remains just a promise, as telemedicine has not been widely adopted. Barriers exist, such as the initial cost of the machine. But the greater challenge is that it is not typically reimbursed by Medicare. Two politicians who are also stroke survivors, Illinois Senator Mark Kirk and Ohio Representative Joyce Beatty, are working on the FAST (Furthering Access to Stroke Telemedicine) Act –– legislation to help make telemedicine the norm and not the exception.
“Currently, telemedicine is only covered or reimbursed by Medicare if it’s provided at rural hospitals,” Prabhakaran said. ‘Rural’ hospital has a very strict definition and includes only a small subset of all hospitals. “The majority of people in the U.S. live in urban or suburban areas, and Medicare does not reimburse telestroke services administered at those hospitals.”
Because CVMC is considered a suburban hospital, Lowman’s telestroke evaluation would not have been reimbursable. As a result, she and nurse Thurman were asked to testify before Kirk’s subcommittee in May 2015. At this time, 94 percent of strokes happen in urban and suburban areas, but only 4 percent of those patients receive tPA, a number that has barely changed since tPA was introduced and approved more than 20 years ago.
TPA can only be used within 4.5 hours of onset of symptoms and only with ischemic strokes. Those two requirements mean that stroke patients who arrive within the time window must receive a CT scan and urgent evaluation by a stroke expert, but according to the American Academy of Neurology there are only four stroke neurologists for every 100,000 Americans. “There are simply not enough experts to travel to every stroke patient in the U.S.,” Prabhakaran said. “However, if connected through the Internet, there are enough doctors who could remotely assist in the evaluation of patients wherever they are.”
Thurman has witnessed an increase in the number of stroke patients who are evaluated by Webster, CVMC’s telestroke robot. “We used it 39 times in 2012, and we used it 80 times in 2014,” she said. They were on track to match that number when we talked last year. “Telemedicine has been instrumental in expediting the care of stroke patients here at Catawba Valley Medical Center,” Thurman said. “We have been able to decrease our door-to-needle time (the time from the moment the patient arrives to the time they receive tPA) dramatically since the implementation of the telestroke network.”
The Wake Forest Baptist network that CVMC is a part of has used telestroke more than 1,600 times since it was implemented in 2010, increasing the use of tPA so that over 40 percent of those who have had telestroke evaluations received it.
“Most applications of telemedicine for neurology are for telestroke and the most common use is for tPA decision making,” Prabhakaran said. “But now we’re also using it in other instances to look at eligibility for interventional treatment such as mechanical clot removal for acute stroke. There have been multiple trials showing major benefits with these interventions.” In some places they are also using the robots for ICU care and to follow up with patients who are initially seen in the emergency room and then are admitted to the hospital. There are currently trials underway to evaluate its use with rehabilitation. “Telemedicine has broadened its applications since its original use for tPA decision making in acute stroke,” Prabhakaran said.
Expanding Medicare reimbursement for telestroke care could save federal health programs $119 million each year, according to an AHA/ASA analysis prepared for the Congressional Budget Office. Despite an initial increase in Medicare spending to cover the costs of the telestroke consultation and the increased utilization of tPA, telestroke care can reduce costs for stroke rehabilitation and long-term care, the report said.
Interventional treatments and tPA prevent or lessen disability. Lowman testified that her doctors told her that if her treatment had been delayed 30 minutes her arm could have been permanently paralyzed. “We know tPA and interventional treatments improve outcomes, reducing disability and death from stroke,” Prabhakaran said. “Increasing the number of people who could receive treatments that are proven to work is a very important way to reduce healthcare costs from stroke which we expect to continue to climb as the population ages.”
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