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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
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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
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Equal Opportunity Disease
HIMSS 2010
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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
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Barriers to Access – Geography
HIMSS 2010
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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
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Stroke Damage Increases with Time
“TIME IS BRAIN” HIMSS 2010
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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
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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
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What is Telestroke? Evaluation, diagnosis and treatment of stroke patients using telemedicine Multiple technology platforms Mobile (Robotic, Cart) Fixed High Quality Videoconferencing HIMSS 2010
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National Guidelines May 2009
ASA = American Heart Association Stroke epub May 4th 2009 HIMSS 2010
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Critical Teleradiology
BRAIN CT SCAN – Normal Vs. Hemorrhage Blood HIMSS 2010
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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
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The TeleStroke “Hub and Spoke” Model
MGH TeleStroke 2007 © Tertiary Hospital Community Hospital Community Health Center HIMSS 2010
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The TeleStroke “Third Party Consult” Model
Tertiary Hospital Community Hospital For-Profit TeleStroke Service Provider MGH TeleStroke 2007 © HIMSS 2010
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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
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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
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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
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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
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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
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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
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Telecommunications costs Building out Infrastructure
FCC Pilot program in Virginia “VAST” Phase 1 Broadband Infrastructure Development Plan for VAST HIMSS 2010
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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
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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
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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.
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