Maryland Stroke Telemedicine ProjectMaryland Stroke Telemedicine Project

RMC Maryland Health RoundtableRMC Maryland Health Roundtable

9/23/089/23/08

Eric Aldrich, M.D.Eric Aldrich, M.D.

(with minor adaptations by Dr. Stern, 10/2/08)(with minor adaptations by Dr. Stern, 10/2/08)

BackgroundBackground

1996: tPA approved by the FDA, 0 – 3 hour window1996: tPA approved by the FDA, 0 – 3 hour window 2000 – 2002: “Operation Stroke”2000 – 2002: “Operation Stroke” 2005: “Strike Out Stroke” Maryland State Plan2005: “Strike Out Stroke” Maryland State Plan 2005: Plan approved by State Advisory Council on Heart 2005: Plan approved by State Advisory Council on Heart

Disease and Stroke, included in 2005 Annual ReportDisease and Stroke, included in 2005 Annual Report 2007: MIEMSS State Stroke System2007: MIEMSS State Stroke System 2007: State Advisory Council on Heart Disease and Stroke 2007: State Advisory Council on Heart Disease and Stroke

2007 Annual Report includes telemedicine as a “future goal”2007 Annual Report includes telemedicine as a “future goal” 9/25/08: tPA effective and safe, 3 – 4.5 hour window (Hacke, 9/25/08: tPA effective and safe, 3 – 4.5 hour window (Hacke,

et al. N Engl J Med 2008:359;1317-29et al. N Engl J Med 2008:359;1317-29

Current SituationCurrent Situation

Pre-hospital provider training has been developed and is Pre-hospital provider training has been developed and is ongoingongoing

Over 30 hospitals have become MIEMSS certified stroke Over 30 hospitals have become MIEMSS certified stroke centerscenters

Emergency Medicine physicians have completed trainingEmergency Medicine physicians have completed training CHALLENGECHALLENGE = = Neurology CoverageNeurology Coverage

Telemedicine: Past ExperienceTelemedicine: Past Experience

1990’s: University of Maryland – St. Mary’s Hospital Project1990’s: University of Maryland – St. Mary’s Hospital Project Other States: Georgia, Massachusetts, Michigan, California, Other States: Georgia, Massachusetts, Michigan, California,

New YorkNew York Telestroke Companies: REACH MD, InTouchTelestroke Companies: REACH MD, InTouch Johns Hopkins Hospital – Howard County General Hospital Johns Hopkins Hospital – Howard County General Hospital

Pilot Project (PACS + telephone)Pilot Project (PACS + telephone)

Telemedicine: CostsTelemedicine: Costs

Hub and Spoke model – dedicated stroke careHub and Spoke model – dedicated stroke care Hub: $ 3,500 - $4,500 per monthHub: $ 3,500 - $4,500 per month Spoke: Hardware - $ 3,300 per yearSpoke: Hardware - $ 3,300 per year

Support - $ 2,000 - $ 3,000 per monthSupport - $ 2,000 - $ 3,000 per month 1 Hub + 10 Spokes = $ 447,000 per year1 Hub + 10 Spokes = $ 447,000 per year 24 / 7 remote system maintenance24 / 7 remote system maintenance

REACH MD

Telemedicine: CostsTelemedicine: Costs

Hub and Spoke modelHub and Spoke model Hub: Maintains the systemHub: Maintains the system Spoke: Hardware - $ 10,000 one time costSpoke: Hardware - $ 10,000 one time cost

Support – Annual Fee to the HubSupport – Annual Fee to the Hub

MGH

Telemedicine: CostsTelemedicine: Costs

MGH: Part of the annual feeMGH: Part of the annual fee REACH MD: T.B.D. by the HubREACH MD: T.B.D. by the Hub Canada: $ 250 for 24 hours, $ 500 if have to come inCanada: $ 250 for 24 hours, $ 500 if have to come in U.S. Hospitals: varies from $ 0 and upU.S. Hospitals: varies from $ 0 and up Note: State support for in house trauma surgeon coverageNote: State support for in house trauma surgeon coverage Note: Possibility of 3Note: Possibility of 3rdrd party payer coverage party payer coverage

Neurology Coverage

Telemedicine: Future BenefitsTelemedicine: Future Benefits

Benefits community hospitals with neurology coverage Benefits community hospitals with neurology coverage problemsproblems

Could be used for other specialties in demand such as Could be used for other specialties in demand such as otolaryngology, orthopedic surgery, plastic surgeryotolaryngology, orthopedic surgery, plastic surgery

Could be used for emergency preparednessCould be used for emergency preparedness

Telemedicine: Future OptionsTelemedicine: Future Options

Centralized state supported systemCentralized state supported system De-centralized private systemsDe-centralized private systems Cooperative ventureCooperative venture

State / private / hospital blend State / private / hospital blend

Telemedicine: Recent EffortsTelemedicine: Recent Efforts

May, 2007: REACH MD presentation at U. of MarylandMay, 2007: REACH MD presentation at U. of Maryland InTouch presentation in summer, 2007InTouch presentation in summer, 2007

December, 2007: Conference call with New York systemDecember, 2007: Conference call with New York system April, 2008: DHMH “brain storming” meetingApril, 2008: DHMH “brain storming” meeting May, 2008: JHH Grand Rounds: Massachusetts systemMay, 2008: JHH Grand Rounds: Massachusetts system July, 2008: DHMH follow-up meetingJuly, 2008: DHMH follow-up meeting September, 2008: State Advisory Council resolution to September, 2008: State Advisory Council resolution to

develop a telemedicine proposaldevelop a telemedicine proposal

Telemedicine: Next StepsTelemedicine: Next Steps

State Advisory Council on Heart Disease and StrokeState Advisory Council on Heart Disease and Stroke DHMHDHMH MIEMSSMIEMSS MIEMSS State Stroke System QICMIEMSS State Stroke System QIC Comprehensive Stroke Centers (possible hubs)Comprehensive Stroke Centers (possible hubs) Maryland Hospital AssociationMaryland Hospital Association Maryland Stroke AllianceMaryland Stroke Alliance American Stroke AssociationAmerican Stroke Association Other?Other?

health insurance providershealth insurance providers

Discussion Amongst Key Stakeholders