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.

Ciji Woodward, RN, BSN (left) and Danielle Thurman, RN, BSN, CPEN (right) use Webster, the telemedicine robot, to facilitate an exam of survivor Nancy Lowman.

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.


(l-r) Danielle Thurman, Nancy Lowman and Kim Hudson, Director of PR at CVMC

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.

Other uses

“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.

The why

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.”

This information is provided as a resource to our readers. The tips, products or resources listed have not been reviewed or endorsed by the American Stroke Association.

- Advertisement -

This link is provided for convenience only and is not an endorsement or recommendation of either the linked-to entity or any product or service.

AD. Amramp Making Life Accessible. 20 years. Be accessible to everyone. Protect your clients & their caregivers from slip and fall accidents. 888-715-7599. Click here for more info.

AD. American Heart Association logo. Know your blood pressure numbers. And what they mean. Gain Control.  Learn more.


Ad: American Heart Association Support Network. Facing recovery after a stroke or heart disease diagnosis can be overwhelming. You are not alone. Our community is here for you. Join us today.


Stroke Connection. Get the app for free.


Edit ModuleShow Tags

Stroke Rehabilitation

Making the Best Decisions at Discharge After Stroke

The type of rehabilitation and support systems a survivor receives at discharge can strongly influence health outcomes and recovery. In this, the first part of a two-part series on stroke rehab, we offer guidance for the decision-making process required when it’s time to leave the hospital.

What to Expect from Outpatient Rehab

After stroke, about two-thirds of survivors receive some type of rehabilitation. Outpatient therapy may consist of Several types of therapy. Whether a patient is referred to inpatient or outpatient therapy depends on the level of medical care required.

What to Expect in Stroke Rehab

Following a stroke, about two-thirds of survivors receive some type rehabilitation. In this second of our two-part series, we want to alleviate some of the mystery, fear and anxiety around the inpatient rehab part of the stroke recovery journey.
Edit ModuleShow Tags Edit ModuleShow Tags

AHA-ASA Resources

The Support Network

When faced with challenges recovering from heart disease or stroke, it’s important to have emotional support. That is why we created a network to connect patients and loved ones with others during their journey.

Caregiver Guide to Stroke

The Caregiver Guide to Stroke is meant to help caregivers better navigate the recovery process and the financial and social implications of a stroke.

Stroke Support Group Finder

To find a group near you, simply enter your ZIP code and a mile radius. If your initial search does not pull up any groups, try

Tips for Daily Living Library

This volunteer-powered library gathers tips and ideas from stroke survivors, caregivers and healthcare professionals all over the country who’ve created or discovered adaptive and often innovative ways to get things done!

Stroke Family Warmline

The Warmline connects stroke survivors and their families with an ASA team member who can provide support, helpful information or just a listening ear.

Let's Talk About Stroke Patient Information Sheets

Let's Talk About Stroke is a series of downloadable patient information sheets, created by the American Stroke Association, that presents information in a question-and-answer format that's brief, easy to follow and easy to read.

Request Free Stroke Information Packets

Fill out this online form to request free information about a variety of post-stroke topics.
Edit ModuleShow Tags

Stroke & Parts of the Brain

When Stroke Affects the Occipital Lobe

Our occipital lobe, the smallest of the four lobes of the cerebral cortex, controls how we visually interpret our world.

When Stroke Affects the Cerebellum

The cerebellum contains 80 percent of our neurons. Its job seems to be to make things better. We talked with neuroscientist Jeremy Schmahmann about how stroke affects the “little brain.”

When Stroke Affects the Parietal Lobe

The parietal lobe helps us make sense of sensory information, like where our bodies and body parts are in space, our sense of touch, and the part of our vision that deals with the location of objects.

When Stroke Affects the Frontal Lobe

Of the four lobes that make up the cerebral cortex, the frontal lobe is the largest. It plays a huge role in many of the functions that make us human — memory, language, movement, judgment, abstract thinking.

When Stroke Affects the Temporal Lobe

The temporal lobe has several functions, mainly involved with memory, perception and language.

When Stroke Affects the Brain Stem

The brain stem serves as a bridge in the nervous system. It sits at the top of the spinal column in the center of the brain. When a stroke happens there, it can cause a few different deficits and, in the most severe cases, can lead to locked-in syndrome.

When Stroke Affects the Thalamus

The thalamus can be thought of as a "relay station," receiving signals from the brain’s outer regions (cerebral cortex), interpreting them, then sending them to other areas of the brain to complete their job.
Edit ModuleShow Tags


Stroke Notes

Stroke-related news you can use about new scientific findings, public policy, programs and resources.

Readers Room

Articles, poems and art submitted by stroke survivors and their loved ones.

Life Is Why

Everyone has a reason to live a longer, healthier life. These stroke survivors, caregivers and others share their 'whys'. We'd love for you to share yours, too!

Everyday Survival

Practical tips and advice for day-to day living after stroke.

Life At The Curb

A unique perspective on survival by comedian and stroke survivor John Kawie.

Simple Cooking

Cooking at home can be a daunting task, but a rewarding one for your diet and lifestyle (and your wallet). Making small changes in your diet is important to your heart health. Here are simple, healthy and affordable recipes and cooking tips.

Helping Others Understand

Stroke affects people differently and many of the effects of stroke can be complicated. Helping friends and family understand how a stroke is affecting a survivor can help everyone involved.

Support Showcase

Our new department highlighting the good work being done by stroke support groups from around the nation. If you are part of a successful support group we should consider featuring, let us know!