1. Stroke Telemedicine Extending Care in Rural U.S.
MONDAY, 3:00 – 3:20PM
E-Care
Stroke Telemedicine Extending Care in Rural U.S.
Nina J. Solenski, M.D., Associate Professor of Neurology and Co-Chair of the Virginia State Stroke Systems of Care Task Force, University of Virginia

2. U.S. Public Health Problem
Many patients impacted by stroke do not receive the most advanced stroke treatment possible.
Fragmented systems and processes
A lack of capital resources for technology, personnel and dedicated staff
Shortage of stroke specialists and interventionalists
A limited number of certified primary stroke centers in the state
A lack of public awareness related to stroke as a medical emergency
HIMSS 2010

3. Equal Opportunity Disease
HIMSS 2010

4. Virginia Stroke Statistics
Stroke the third leading cause of death in Virginia (2004)
Mid-Atlantic Stroke Belt - highest national average for mortality
IV rt-PA [‘TPA’] use
Nationally only 2-5% of ischemic stroke patients received TPA
Virginia below national – 1.7% (2007)
HIMSS 2010

5. Barriers to Access – Geography
HIMSS 2010

6. Barriers – Lack of Specialists
Board-Certified Neurologists in Virginia by Rurality
Emergency room physicians are often reluctant to administer t-PA without the guidance of a neurologist
Many community hospitals do not have access to important stroke related resources.
Few have access to a general neurologist
Even fewer have access to a highly skilled stroke neurologist
HIMSS 2010

7. Stroke Damage Increases with Time
“TIME IS BRAIN”
HIMSS 2010

8. 1. 2. 3. 4. 5. Stroke System of Care Continuum of Care
Prevention 2.
EMS Notification & Response 3.
Acute Treatment 4.
Sub-Acute Care & Secondary Prevention 5.
Rehabilitation
C o n t i n u o u s Q u a l i t y I m p r o v e m e n t ( C Q I )
Continuum of Care
VAST 2008 HRSA Grant #H54RH08675
HIMSS 2010

9. Acute Stroke Therapy Intravenous “TPA”
Recombinant Tissue Plasminogen Activator
Higher dose of a “natural clot buster”
Time sensitive! ~3 hrs from onset
Increases your chances of complete recovery by %
10X increase in brain hemorrhage (requires an emergent head scan)
HIMSS 2010

10. What is Telestroke?
Evaluation, diagnosis and treatment of stroke patients
using telemedicine
Multiple technology platforms
Mobile (Robotic, Cart)
Fixed High Quality Videoconferencing
HIMSS 2010

11. National Guidelines May 2009
ASA = American Heart Association Stroke epub May 4th 2009
HIMSS 2010

12. Critical Teleradiology
BRAIN CT SCAN – Normal Vs. Hemorrhage
Blood
HIMSS 2010

13. Acute TeleStroke: Provider-to-Provider Link
MGH TeleStroke 2007 ©
Fixed / Mobile VC Unit
Hospital or Home Based
TeleStroke Consultant
Desktop PC with Monitor or integrated Image Viewer
DICOM Image Server
CT Scanner
ED Physician or PA
Patient
Acute TeleStroke: Provider-to-Provider Link
HIMSS 2010

14. The TeleStroke “Hub and Spoke” Model
MGH TeleStroke 2007 ©
Tertiary Hospital
Community Hospital
Community Health Center
HIMSS 2010

15. The TeleStroke “Third Party Consult” Model
Tertiary Hospital
Community Hospital
For-Profit TeleStroke Service Provider
MGH TeleStroke 2007 ©
HIMSS 2010

16. Bath Community Hospital (Critical Access Hospital)
Va Acute Stroke Telehealth (VAST) initiative: VDH, VTN, UVA – Framework for FCC Pilot Program Clinical Results:
Bath Community Hospital (Critical Access Hospital)
~20 CVA per year
Evaluated 8 acute stroke patients (40 % total)
50% qualified for TPA drug; all received <3 hrs and without complication
50% had new medical dx (diabetes, hypertension)
100% were “drip & ship” or “ship” transfer
Excellent patient and provider satisfaction
HIMSS 2010

17. Virginia – Telestroke program (VAST)
Summary
Virginia – Telestroke program (VAST)
Feasible
Increased the number of patients eligible for rt-PA therapy
High patient, referral and provider satisfaction
Sustainable
Require dedication of CEO, physician, EMS and hospital staff
Relationships are the “oil” that makes it run
HIMSS 2010

18. Post-Stroke Remote Patient Monitoring
Mobile Clinical Assistant
Health Care Management Suite
Medical Peripherals
Patient Educational Content
Vital sign measurements
Reminders/Surveys
Customizable care protocols
Video conferencing
HIMSS 2010 18

19. Managing Chronic Disease Remote monitoring & home telehealth
Need
Readmission rate within 90 days for Medicare beneficiaries > 30%
MedPAC - $7,200 dollars per readmission deemed preventable
Remote monitoring/home telehealth can reduce costs
Congestive heart failure
Diabetes
Chronic obstructive pulmonary disease / asthma
VA care coordination/home telehealth
19% reduction in hospital readmissions
25% reduction in hospital days
HIMSS 2010

20. UVA Telemedicine Network
60 site telemedicine network
Hospitals, FQHCs, clinics, prisons, schools, home
Federal, state, foundation funding
FCC rural healthcare and pilot program for bandwidth
Services in more than 35 subspecialties
Emergency and elective services 24/7
HIMSS 2010

21. Telecommunications costs
Vary with mechanism of transport/and bandwidth utilized
1996 Telecommunications Law (FCC/USF)
T1 to Wise, Virginia: $5800/month (1995)
“ “ $1000/month (2001)
“ “ Universal service fund $<200/month (2007)
FCC Pilot program (UVA administering VAST)
Enhanced broadband access tied to stroke systems of care
48 rural hospitals
HIMSS 2010

22. Telecommunications costs Building out Infrastructure
FCC Pilot program in Virginia “VAST”
Phase 1 Broadband Infrastructure Development Plan for VAST
HIMSS 2010

23. Funding Sources Grants Medicare / Medicaid Veterans, DoD Private pay
Federal & State Funding
Grants
Federal / State Insurance Programs
Medicare / Medicaid
Veterans, DoD
Private pay
Distributed Cost
Hub and Spoke Share the Costs
Sources include Patient Revenue, Hospital Operating Budgets, Hospital Capital, and Philanthropy
Medicare – must be 2 way video in eligible regions – sa rural health professional shortage areas and “rural”
3rd party payers – slow to adopt – but 5 states with legislation pending for mandatory reimbursement – 2003 ATA survey indicated increase from 4% to 57% of bills were being paid by private insurance
Medicaid – New York does pay, most do not
HIMSS 2010

24. Future of Telehealth Demonstration projects (ARRA)
Sustainability of federal investment
Sound federal policies - sustainability
Integration into mainstream medicine
Medicare
Medicaid
National health reform
Private pay
National Broadband Plan
HIMSS 2010

25. Thank You Acknowledgements:
The participants of the FLEX-HIT CAH VAST initiative wish to thank HRSA for support: Grant #H54RH08675
Participants:
Virginia Telehealth Network [Cynthia Barrigan, June Collmer)
Bath Co Hospital Staff, Hot Springs, Va [Debbie Lipes, CEO]
Virginia Department of Health [Kathy Wibberly, PI]
American Stroke Association [Keltcie Delamar]
UVA Office of Telemedicine [Karen Rheuban, Gene Sullivan]
Today’s Demo: Success Studio, Richard Settimo, David Stewart
The participation of any company or organization in the NHIN and CONNECT area within the HIMSS Interoperability showcase does not represent an endorsement by the Office of the National Coordinator for Health Information Technology, the Federal Health Architecture or the Department of Health and Human Services.