1. Stroke Telemedicine Extending Care in Rural U.S. MONDAY, 3:00 – 3:20PM 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 E-Care

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 20102

3. Equal Opportunity Disease HIMSS 20103

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 20104

5. Barriers to Access – Geography HIMSS 20105

6. Barriers – Lack of Specialists »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 Board-Certified Neurologists in Virginia by Rurality - 2007 HIMSS 20106

7. Stroke Damage Increases with Time HIMSS 20107 “TIME IS BRAIN”

8. Stroke System of Care 1.1. 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 20108

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 30 - 50% »10X increase in brain hemorrhage (requires an emergent head scan) HIMSS 20109

10. What is Telestroke? Evaluation, diagnosis and treatment of stroke patients using telemedicine Multiple technology platforms Mobile (Robotic, Cart) Fixed High Quality Videoconferencing HIMSS 201010

11. National Guidelines May 2009 ASA = American Heart Association Stroke epub May 4 th 2009 HIMSS 201011

12. Critical Teleradiology BRAIN CT SCAN – Normal Vs. Hemorrhage Blood HIMSS 201012

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 Fixed / Mobile VC Unit ED Physician or PA Patient DICOM Image Server HIMSS 201013

14. The TeleStroke “Hub and Spoke” Model HIMSS 201014 MGH TeleStroke 2007 © Tertiary Hospital Community Hospital Community Health Center

15. The TeleStroke “Third Party Consult” Model HIMSS 201015

16. 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 201016

17. 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 201017

18. Post-Stroke Remote Patient Monitoring Mobile Clinical Assistant Health Care Management Suite Medical PeripheralsPatient Educational Content Vital sign measurements Reminders/Surveys Customizable care protocols Video conferencing HIMSS 201018

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 201019

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 201020

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 201021

22. Telecommunications costs Building out Infrastructure FCC Pilot program in Virginia “VAST” Phase 1 Broadband Infrastructure Development Plan for VAST HIMSS 201022

23. Funding Sources »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 HIMSS 201023

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 201024

25. 25 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. Thank You