Telestroke and Teleneurology - AUPNStroke neurology evaluation by telemedicine: Initial hospital...
Transcript of Telestroke and Teleneurology - AUPNStroke neurology evaluation by telemedicine: Initial hospital...
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Telestroke and Teleneurology
Lawrence R. Wechsler, M.D.
Chairman, Department of Neurology Vice President, Telemedicine
University of Pittsburgh Medical Center
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Outline
Telestroke Teleneurology Challenges Compensation
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Estimated Demand for Neurology 2025
Dall et al. Neurology 2013
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Demand for Vascular Neurology
Number of new strokes per year in US 795,000
Number of vascular neurologists 1100
Primary stroke centers 1092
Comprehensive stroke centers 110
Stroke Fellowship programs (2016) 74
Stroke fellowship positions 123
% Fellowship positions unfilled 34%
Culebras A. Neurology Today 2015
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Teleneurology
IP over Internet Remote control of PTZ camera – Hx, PE
History, exam, recommendations, documentation
Imaging
Consult
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Teleneurology Anywhere
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International Teleneurology
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Advantages of Teleneurology
Direct history by neurological provider
Observe critical elements of examination
Order specific tests – done locally Review results Speak directly to patient regarding
assessment and plan Team based care
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Why Teleneurology in an Academic Dept?
Better care for patients Protect referral relationships Endovascular transfers Income for faculty Alternative work models Research potential Clinical trials
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Components of Teleneurology Program
Bidirectional real time video and audio
Protocols / order sets In service training Stroke/neurology team Community education EMS awareness
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Reliability of Telestroke Exam - NIHSS
Craig J Telemed Telecare
1999
Shafqat Stroke 1999
Meyer Neurology
2005
Anderson JSCVD 2011
Wang Stroke 2003
Handschu Stroke 2003
Lamonte JSCVD 2004
Pts 17 20 25 20 20 41 2 actor pts / 12 scenarios
Setting General Neuro exam Non-acute
stroke Non-acute
stroke Non-acute
stroke Acute stroke
Acute stroke Ambulance
Comparison ISDN v. bedside ISDN v. bedside
Web based v. bedside
iPhone 4 v. bedside
Web based v. bedside
Web based v. bedside
Ambulance v. NIHSS training
Result Kappa r=.21-1.00 Kappa r=.97
Kappa r=.94
Corr coef r=.98
Pearson r=.95
Kappa r=.85-.92
Kappa r >.5
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Teleneurology Examination - Limitations
Visual fields Strength gradation Tone / rigidity Sensory examination Reflexes Stethoscope Ophthalmoscope
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Teleneurology – IT and technology
Purchased services REACH InTouch $$$
Self supported Vidyo Polycom 24/7 coverage Response time $
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Why Telestroke?
Only 2-8% of stroke patients receive IV tPA
Many hospitals don’t have stroke protocols and have never treated a patient with tPA
64% of hospitals in US did not give IV tPA *
Lack of available stroke specialist in rural hospitals major impediment to emergent treatment
* Kleindorfer et al Stroke 2009
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UPMC Telestroke
0
100
200
300
400
500
600
ME PS WS SM MK JR MV BV NW HR JM AR EA CR WM LT UN MG BD FR
Consults - 3525 tPA -1078
• 23 hospitals – 12 UPMC, 11 non-UPMC • tPA treatment rate: 31% • Transfers: 24% • 6 hospitals teleneurology coverage
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Telestroke Before and After: All UPMC Hospitals
2.9%
5.5%5.4%
7.2%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
% strokes Rx with tPA % strokes within 3 hrs
Before
After
1235 Pts Before 2175 Pts After
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Telestroke v. SC Patients Treated with IV tPA 90 day Outcomes
90-Day Clinical Outcomes
8.9
17.1
14.3
21.1
14.3
4
8.9
11.8
14.3
7.9
8.9
6.6
30.4
31.6
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
STROKE CENTER(N=56)
TELESTROKE (N=76)
90 Day Modified Rankin Scores
mRS 0 mRS 1 mRS 2 mRS 3 mRS 4 mRS 5 mRS 6
Zaidi et al. Stroke 2011
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Telestroke: Post tPA care tPA Treated Pts – Hub v. Spoke
Hub Drip and ship Drip and stay P value
Patients 272 73 134
Median NIHSS 11 11 8 >0.001
Mean age 72 71 76 0.008
Onset to needle 156 min 134 148 min 0.072
Door to needle 72 min 75 77 min 0.151
Sx ICH 5% 7% 2% 0.79
LVO 36% 33% 12% >0.001
LOS (days) 6.2 4,6 7.2 0.56
Pneumonia 14% 10% 8% 0.077
Intubation 19% 19% 2% >0.001
In-hosp death 11% 11% 10% 0.859
Heffner et al. Stroke 2015
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Reorganization of System Stroke Care
Stroke neurology evaluation by telemedicine: Initial hospital evaluation 2 day follow-up Hospital pre-discharge visit Outpatient follow-up
Outcomes to be monitored Mortality Readmissions LOS Patient Transfers
19
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Telestroke Workflow
Portal for calls from originating site Receiving calls and response time Time of onset, stroke severity, tPA exclusions Telephone discussion and triage Activation of video Confirmation of history NIHSS exam Consent tPA orders Transfer decision CTA
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Teleneurology
Stroke TIA Seizures Confusion Dizziness
General Neurology
Follow-ups
Inpatient Daily
rounds Acute Care
Stroke
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Teleneurology Issues EMR access Immediate v. scheduled Imaging review Documentation Guidelines for acute stroke calls Telepresenter Follow-up: new v. same problem Communication with originating
team Transfer agreements
(stroke, non-stroke)
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Staffing Models
On call physician Dedicated physician Stroke v. general neuro Triage by fellow/NP Call center Urgent v. Non urgent Backup and surge coverage
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Imaging Access
Direct spoke PACS signin Push imaging studies to central
hub PACS Push imaging to teleneurology
software 3rd party cloud based imaging
solutions
http://www.bing.com/images/search?q=nuro+surgery&view=detailv2&&id=2014701C9BEE3BE4A2738B2C9E6D573AFE865B2D&selectedIndex=97&ccid=bC4Muifm&simid=608011754808017629&thid=OIP.M6c2e0cba27e6b40f9484fd56f42d6afeo0
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Reimbursement for Teleneurology
E&M codes with GT modifier
Most require real time video conferencing
Medicare – rural areas only Medicaid – state mandates
with variable definitions National insurers - limited Other private insurers 32 states with parity laws
States with Parity Laws
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Billing Models
Flat monthly fee – unlimited consults
Tokens Monthly fee plus per case fee Tiered charges based on ED
volume Who pays for equipment and
software Hub hospital support
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Compensation
Physician Salary Per case fee Coverage fee per day,
per night or per shift Combinations
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Reporting: Process Measures 849 tPA Treatments
0 20 40 60 80 100 120 140 160
Sx Hem
OTT < 90 Min
OTT < 2 Hrs
DTN < 60 Min
Door to Rx
Onset to Rx
Mean NIHSS 12
140 min
77 min
37%
11%
4%
62% (2015)
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Reporting: 90 Day Outcomes 711 tPA Treatments
0 10 20 30 40 50 60
Sx Hem
Asx Hem
mRS 0-2
mRS 0-1
Mean NIHSS
UPMC NINDS (benchmark)
11 14
39% 39%
47% 48%
6% 5%
4% 6%
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ROI of Teleneurology: Hub and Spoke
Hub Hospital Spoke Hospital Societal
+ Neurology transfers + Avoid transfers + Improved outcomes: tPA
+ Endovascular and surgery + No EMS bypass + Reduced disability
- Network support + High quality patient care + Return to work
- Neurology support - Greater cost of care + Less caregiver burden
- IT costs - Quality monitoring - Higher upfront costs
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Summary Telestroke and teleneurology
bring expertise to areas without stroke and neurology coverage
Network models vary and several technologies available
Staffing and compensation are challenging issues
Insurance reimbursement limited
Telemedicine now routine component of systems of care
http://www.bing.com/images/search?q=telemedicine+challenges+&view=detailv2&&id=25AF58734E65B857C85479267466D483CA841CC2&selectedIndex=32&ccid=8ciCIV77&simid=608005655959111334&thid=OIP.Mf1c882215efbac1f5e3ac0e7d208f9c4o0
Telestroke and Teleneurology��Lawrence R. Wechsler, M.D.�Chairman, Department of Neurology�Vice President, Telemedicine�University of Pittsburgh Medical CenterOutlineEstimated Demand for Neurology 2025Demand for Vascular NeurologyTeleneurologyTeleneurology AnywhereInternational TeleneurologyAdvantages of TeleneurologyWhy Teleneurology in an Academic Dept?Components of Teleneurology ProgramReliability of Telestroke Exam - NIHSSTeleneurology Examination - LimitationsTeleneurology – IT and technologyWhy Telestroke?UPMC TelestrokeTelestroke Before and After:� All UPMC HospitalsTelestroke v. SC Patients Treated with IV tPA �90 day OutcomesTelestroke: Post tPA care�tPA Treated Pts – Hub v. SpokeReorganization of System Stroke CareTelestroke WorkflowTeleneurologyTeleneurology IssuesStaffing ModelsImaging AccessReimbursement for TeleneurologyBilling ModelsCompensationReporting: Process Measures�849 tPA TreatmentsReporting: 90 Day Outcomes�711 tPA TreatmentsROI of Teleneurology: Hub and SpokeSummary