TelestrokeIs It Ready for Prime Time?

David Wang, D.O., FAHA, FAANDirector, OSF/INI Stroke Network

Clinical Associate Professor of NeurologyUniversity of Illinois College of Medicine at Peoria

Disclosure Statement

Dr. Wang is a member of:

• Illinois Stroke Task Force.• Co-Chair, Illinois Stroke Task Force Telestroke Subcommittee• Executive Committee, American Academy of Neurology-Vascular Section• Quality Measurement and Reporting Subcommittee, AAN• Advisory Committee, American Stroke Association• International Operations Committee, American Heart Association• Speaker Bureau:

Pfizer, Boeringher-Ingelheim,

The Scope of the Problem

• 700,000 a year, third leading cause of death, leading cause of adult disability.

• rt-PA needs to be given within 3 hrs, which presents an opportunity to improve patient outcomes and reduce overall costs to the US health system 2. 0

400,000

800,000

1,200,000

2000 2020

Sources: Sg2 Analysis, 2006.

Stroke Incidence US Market, 2000-2020

Stroke Incidence: +61%

4 Key Elements in the Initial Evaluation and Treatment of a Stroke

• EREmergency room physicians are often reluctant to administer t-PA without the guidance of a neurologist.

• Radiology• Neurology

Few have access to a general neurologistEven fewer have access to a highly skilled stroke neurologist

• Stroke TeamResponsible for delivering organized, error-free quality care

Not Enough Neurologists

• 48 million Americans residing in counties that contain no neurologist.

• American Academy of Neurology Report:10,038 U.S. Neurologists registered 83.7% were adult Neurologists 42.3% had stroke as their practice focus47% strongly agree and feel comfortable in giving tPA.

Hospital Administrator’s Headache

• We can’t get anyone (neurologist) to take ED stroke calls.

• We don’t have any neurology coverage. The closest neurologist is 70 miles away and he has a waiting period of 6 months.

Not Enough Radiologists

• American College of Radiology:There are about 25,600 post-training diagnostic radiologists in the US73% of these radiologists work full time Over half of the radiologists surveyed indicated that they were overworked

• There are not enough Radiologists interpret imaging studies of the stroke patients 24/7

• There are even fewer Interventionists that can deliver catheter-based treatment

Sunshine JH, et al. Diagnostic Radiologists in 2000. Basic Characteristics, Practices, and Issues Related to the Radiologist Shortage. AJR 2002;178:291-301.

What Do We Have?

• According to the Hospital Statistics 2002:4,856 US hospitals reported85% have emergency departments65% have medical or surgical intensive care 78% have CT scanner 48% have MRI80% have ultrasound services69% have case management85% have social workers27% have inpatient physical rehabilitation services 76% have outpatient physical rehabilitation services

Facilities and Services in the U.S. Census Divisions and States. Hospital Statistics. Health Forum LLC, an affiliate of the American Hospital Association.

2002.

Can TeleStroke Help?Not enough Neurologists and Radiologists, TOO MANY STROKES!

Telestroke, Hospitals without onsite stroke expertise are provided with the access to stroke centers (stroke expertise) in real time. No distance limitation between the site hospital and the stroke center.

• What it takes to set up a telestroke network• Benefit of telestroke• Pros and Cons of Telestroke

Telestroke-Technology Involved• Low tech:

Telephone consultations• Need some tech:

Incorporate radiology image transmission• High tech:

Real time audio and video conferencing via wireless encrypted transmission, or

secure landline and transmitting neuro images simultaneously.

Hub and Spoke Model, high tech

Name of System

Description

Stroke-Center Hub and Spoke Model

Neuro-critical care specialists based in a Academic or Tertiary Care Medical CenterExamples: Partner’s Tele-stroke program, Medical College of Georgia REACH* program

Partners Tele-stroke Program

Serves 14 hospitals in Massachusetts and provides consultation for AMCs willing to develop a stroke network. Distributed cost model where both the hub and the spoke hospitals share costs associated with tele-stroke. Spoke hospitals pay for videoconferencing equipment ($5,000 to $20,000), annual maintenance fees and a fee per Tele-Stroke Consult ($1,000 each). Hub hospital provides on-site and continuing stroke education, and necessary implementation steps and training sessions for staff.

Advantage: Spokes aligning with major stroke center hubs are aligned to provide advanced neurovascular services their patients may need and can market their affiliation to draw patients as referrals.

Sources: Sg2 Analysis, 2006.

Name of System

Description

Physician Hub and Spoke Model

Network or center of independent neuro-care specialists, independent of tertiary or Academic Medical Centers provide consultations to surrounding hospitals.

Brain Saving Technologies

Establishes Neuro-critical Care Centers First one at UMASS Memorial Medical Center staffed by stroke specialists. Currently serves five hospitals in Massachusetts and Virtua Health System in New Jersey. Hospitals pay a fixed yearly price. As an example a 300 bed hospital the fee is around $216K plus upstream costs for technology.

Advantage: Organizations that do not have the stroke volumes to justify the cost of the video technology can leverage it for other telemedicine services.

Sources: Sg2 Analysis, 2006.

BF-Technologies • Sells a bi-directional audio and video system

(AccessVideo™ $24,000) • Charges a yearly maintenance fee of $6,000. • System provides site-independent access

error-free HIPPA compliance encryption, remote pan/tilt/zoom, and full audio/video session recording.

• University of California San Diego has such set-up

Stroke Team Remote Evaluation Using a Digital Observation (STRokE DOC).

Tele-Stroke Technology Providors

Courtesy of Sg2

InTouch Health®

• Mobile robot (RP-7 Remote Presence Robotic System) that allows a remote physician to guide the robot to the patient’s bedside, and evaluate the patient through bi-directional video and audio communications.

• A robot costs $120,000 to buy, or $4,000 a month to rent. • The Michigan Stroke Network which includes 21 Michigan

hospitals and spearheaded by St. Joseph Mercy Oakland Hospital is an example of a stroke network using robotic technology.

Courtesy of Sg2

Where Is the Funding?• States initiating reimbursement for telemedicine:

NY, CO, GA, FL, OK• Federal Funding:

Grants more likely, and it is usually one time deal• Some stroke networks have been funded by tobacco taxes (Colorado

$185,000),or grants from the State’s Stroke Center Act (New Jersey $390,000)• Share the cost:

Per use based or flat fee between the hub and spokes• Others:

Patient revenue, hospital operating budgets, Philanthropy.• Paying a yearly fee:

Brain Saving Technologies $216K per year

TeleStroke-PROs• The cost is flexible, depending on the system used• It can be wireless, nearly real time with broad band• Extend stroke care expertise into rural and underserved areas.• It is time saving and efficient. Doc-Doc, Doc-patient interaction

allowed at distance• Multifunctional: films, labs, medical records, pathology report• Provides rapid access to specialized interventions through initiation

of inter-hospital transfers and improve in basic on-site stroke therapy.

• It has demonstrated improved use of rt-PA.• It may improve enrollment in acute stroke trials.

Impact on Stroke Care• Videoconferencing by off-site stroke neurologist

provides accurate assessment of the patient’s physical condition and neuroimaging studies

• Tele-stroke can maximize use of life saving therapies: – A rural hospital that had not used tPA in 2yrs increased tPA

administration to 5.6% with the Partners Tele-Stroke Network– Houston: 0.8% use of rt-PA improved to 4.3%

• Improves hospital standing in the community by providing leading treatments.

• Reduces mortality rate by identifying patients who need to be transferred for advanced care.

Sources: Sg2 Analysis, 2006.

Impact in Rate of Thrombolysis after Implementation of Telestroke Network

• The use of telemedicine in stroke makes it possible to bring the expertise of academic stroke centers to underserved areas, potentially increasing the quality of stroke care.

• Telemedicine support to 12 community hospitals without on-site stroke specialists. • 3/2005 - 12/2008. 2,606 entries divided in two phases: pre-telemedicine (N= 933) and

post-telemedicine (N=1,673). • Outside of the three-hour-window was the most common contraindication for

thrombolytisis (52.3%). • 143 patients received thrombolytics, with 35 interventions prior to starting

telemedicine and 108 after. • Thrombolysis rate prior to telemedicine was 3.8% and after 6.5% (p=0.004). • Incorrect treatment decisions happened 10 times (0.39%), with 4 (0.43%) pre vs. 6

(0.36%) post telemedicine (p=0.78). • There were no statistically significant differences in mortality (15.9% pre vs. 9.2% post;

p=0.23) or good outcome (17.1% pre vs. 15.8% post; p=0.84). • S-ICH happened in six patients (4 [9.8%] pre vs. 2 [1.9%] post telemedicine). • CONCLUSIONS: Telestroke implementation increased rate of thrombolytic use in

remote hospitals within the telemedicine network.

Telestroke-Cons• Price• HIPPA, patient confidentiality• Can be complicated to use and

maintain• Lack of reimbursement will hinder

widespread adaptation of its use.• Is a patient's brain scan clearly

readable over the system? • Are onsite physicians able to

adequately care for the patient after the medication is given?

• Reimbursement and liability issues pending resolved

The Ideal Set-up• Affordable• Portable• User friendly• Can have a mixture of high-tech and low-tech type of network• Low maintenance• Maintain confidentiality• No one type or size of telestroke system that will fit all

situations.• Type of clinical applications and volume of consultations

determine the characteristics and costs of the appropriate systems.

Six Current Centers that Function as CSCs and uses different Telestroke Equipment

50 miles

Transfer hospital

Telemedicine hospital

Our hospital

Example #1:Greater Cincinnati/Northern Kentucky Stroke Network

• Acute TeamBased at Univ of Cincinnati (UC)

– 3 Emergency physicians

– 7 Vascular neurologists

– 4 Neurointerventionalists

– 6 Acute Coordinators

• 15 Hospitals– 1 University (TUH

@ UC)– 3 Teaching– 11 Community

2.1 million population for metropolitan area;

About 30 miles between farthest hospitals;Crosses state lines

• 15 local hospitals, including 4 PSCs

– EMS brings pts to nearest hospital

– UC Stroke team MD drives to all local hospitals

– Encourage pre-notification (prior to CT completion)

– Study coordinator comes if possible trial candidate

• Additional ~10 regional hospitals– Drip and ship by phone

assessment

Example #2:Saint Luke’s Brain and Stroke Institute –

Kansas City Stroke Referral Network2002 (n=18)

2009 (n>80)

2.1 million KC metro; >100 mile radius

• Over 80 hospitals, including 4 PSCs– PSCs refer for IA tx or IV

tPA guidance– Phone consultations; no

fee for 24/7 support

• Treat ~30% of cases called in

• Threshold for transfer– Post IV rtPA care– For IA therapies

• Weekly education in region by MDs and RNs

Example #3:University of Texas-Houston Stroke Network

• Six UT Dept of Neurology faculty

• Memorial Herman Hospital (MHH)

• 22+ hospitals via telemedicine– Two systems

• Additional regional hospitals by phone

– Drip and Ship

50 miles

Transfer hospital

Telemedicine hospital

Our hospital

Houston metropolitan population of 5.7 million;

2 IA centers within three blocks of hub

• Currently:– About 40 calls/mo; 1-2 per 24 hr

period; treat 25%– 43% daytime, 36% evening, 21% at

night– 60-70% of calls are stroke-related– About 6 TPA treatments/mo

• Changing climate– Increasing # of pts take to local

PSCs rather than MHH• Decreasing pt access to research

and IA therapies at MHH• Concern for decreasing rates of

rtPA use at low-volume ctrs

• Acute TeamBased at UC San Diego (UCSD)

– 6 Vascular neurologists– 4 Coordinators– 2 Emergency Physicians– 4 Neuro-

Interventionalists

• 10 Hospitals– 1 University (2 Centers)– 4 Community

(physical coverage)– 3-4 Remote

(phone /telemedicine) 12 miles to farthest hospital (drive)150 miles to farthest hospital (telephone)350 miles to farthest hospital (telemedicine)San Diego metropolitan population 3 million

Example #4:UCSD Stroke Network

• 15% treatment rate overall

• 6.50 rt-PA treatments per month

• 2.75 rt-PA treatments per month @ < 2 hours from symptom onset

STRokE DOC network (trial on hold)

– UCSD: 4 telemedicine hospitals 30-350 miles away

– Mayo Scottsdale:2 Telemedicine hospitals

– 28% telemedicine rt-PA during trial period

– More accurate rtPA decision-making with video, comparable safety and outcomes by phone

Example #5:Med Coll of Georgia (MCG) REACH Telestroke Network

• 6 MDs– 5 neurologists– 1 EM physician

• 15 hospitals– 10 rural (<75-bed)

– 5 larger community (100-300 beds)

~200 miles

• 10 smaller rural hospitals (37-127 miles)– No 24-hr radiology; drip and ship

• 5 larger community hospitals– Two PSCs, but lack 24/7 stroke

coverage– Telestroke coverage for a fee– “Treat and keep” at local hospital

(DRG 559)– Transfer for higher level of care

• Decreasing 24/7 local neurology coverage in region and potential for REACH being at capacity

Example #6: OSF/INI Stroke Network

10/09-9/11: • 875 transfers• 179 drip and ship cases from 30 hospitals• TPA administration rate:20%

Telestroke by the JEMS System, projecting live video to your cell phone. 4 helicopters for transport

The Challenges Facing Telemedicine

• Who regulates the existing telemedicine structure?• The authority of local and regional providers in developing

telemedicine.• When it becomes Web-based, what will happen to the

traditional relationships that exist between a doctor and a patient?

• It may be an investment that may not have clear financial return.• Credentialing among spoke hospitals and cross the states• The Stark law of preventing enticement

JD Linkous, MD Net Guide 11/06

A Look at the Budget for a Telestroke Network

• One new rural spoke hospital needs about $46,000 ( $10,000 -$20,000) per year dependent upon the size of hospital, volume of stroke consultations, and sophistication of telemedicine equipment selected.

• The start-up and first year of operation cost for a multi-hub network serving 35 rural spoke hospitals was $2.5 million.

• Costs include:neurology, personnel, coordinators, managers, information technologists, administrators, telemedicine platform equipment, institute supplies, laptop cameras, headsets with microphones, broadband wireless cards, efax subscriptions, travel expenses, training, and overhead.

So, Does Telestroke Save Money?

• Compared two-way audio video technology to usual care • A decision analytic model was developed for both 90-days and

lifetime horizons. Model inputs included both costs and clinical consequences.

• Quality adjusted life years (QALYs) gained were combined with costs to generate incremental cost-effectiveness ratios (ICERs).

• In the base case analysis, compared to usual care, telestroke resulted in an ICER of $108,363/QALY in the 90-day horizon and $2,449/QALY in the lifetime horizon.

• Telestroke appeared cost-effective.

REALLY?

So, Does Telestroke Save Money?• A network model:

-more patients treated with IV thrombolysis-more patients transferred for endovascular management-more patients discharged home independently.

• The telestroke network costs less, overall, and was more effective than no network.

• With increased spoke to hub transfer rates, the hub experiences greater cost savings while the spokes bear higher costs.

• When reducing spoke to hub transfer rates, the spokes experience greater cost savings while the hub bears higher costs.

So, Does Telestroke Save Money?• The answers to this question are:

Patients may get better care at the cost of the institution that establishes and runs telemedicine

Institutions are not being paid adequately to run telestroke network

• Health economic research is needed to develop viable and sustainable business plans.

The Near Future

Conclusion• Telemedicine Can solve the problem of

access to specialty services• Currently there is no set rules to regulate

telemedicine• Telemedicine improves TPA use in stroke

patients in rural and remote ERs• Technologically it will be cheaper to set it up

in the near future• To staff and support telemedicine is not

cheap.• Telemedicine may not have financial benefit

to the institution that runs it