- Email: [email protected]
Overcoming Challenges to Sustain a Telestroke Network
Review Article
Overcoming Challenges to Sustain a Telestroke Network Jeffrey A. Switzer, DO, MCTS,* and Bart M. Demaerschalk, MD, MSc, FRCP(C)†
Our objectives are to identify and help overcome obstacles to telestroke practice, to present tips for sustaining a telestroke network, to suggest strategies for obtaining buy-in from clinicians and administrative leadership and providers, and to identify and engage champions and stakeholders of telestroke. Key Words: Stroke— telemedicine—telestroke. Ó 2012 by National Stroke Association
Please access related webinars at www.stroke.org/ telestroke_main. Please note that these webinars may be removed by the NSA in the future if the information is determined to be out of date or no longer valid.
Learning Objectives Identify and address existing obstacles to telestroke network implementation Discuss key components to maintaining the logistic and/or operational sustainability of a telestroke network From the *Departments of Neurology at Georgia Health Sciences University, Augusta, Georgia; and †Mayo Clinic, Phoenix, Arizona. Received June 20, 2012; accepted June 26, 2012. Supported by an educational grant from Genentech. This activity was jointly sponsored by the National Stroke Association and Medical Education Resources. Dr. Switzer receives research support from Genentech and Lundbeck and is a local primary investigator on a National Institutes of Health National Institutes of Neurological Disorders and Stroke grant. Dr. Demaerschalk is an investigator on a National Stroke Association–sponsored study on telestroke. The study is funded by Genentech. Address correspondence to Bart M. Demaerschalk, MD, MSc, FRCP(C), Cerebrovascular Diseases Center, Teleneurology and Telestroke Program, Divisions of Vascular, Hospital, and Critical Care Neurology, Department of Neurology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2012 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2012.06.014
Summarize methods to acquire, educate, and maintain telestroke team members Discuss telestroke technology and its issues
Section 1: Identifying and Overcoming Obstacles (Licensing, Credentialing, Privileging, Medicolegal, Financial, and Reimbursement Issues) Multiple regulatory issues have been identified as barriers to implementing and sustaining telemedicine programs. Survey research results revealed an overall consensus that licensing out-of-state physicians, concern over malpractice liability, credentialing for medical staff privileges at individual facilities, and reimbursement limitations are all significant impediments for telemedicine networks.1 Most states have specific licensing provisions for telemedicine. The physical location of the patient is generally accepted as the location at which medicine is being practiced, as opposed to the physical location of the telemedicine physician provider. In most instances, individual states require a full, unrestricted medical license before telemedicine practice is authorized. For practical purposes, an individual telestroke provider would require a medical license for each state of network practice. The requirement of a license for every state poses a significant administrative burden upon telestroke network providers and their managers.2 The creation of a national (or even multistate) telemedicine license would be a logical solution to encourage telestroke network expansion.1 Licensing rules currently vary by state. Some states have introduced specific
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telemedicine licenses (e.g., Alabama, Montana, Minnesota, Ohio, Oklahoma, Oregon, Texas, and Tennessee) or special purpose telemedicine licenses (Nevada), some states require full licenses to conduct telemedicine care (e.g., California, Florida, and New York) with exceptions for consultation only, and other states are still exploring the regulation of telemedicine.1 Mutual interstate recognition of telemedicine licenses would be highly desirable. Traditionally, the requirement for every telestroke provider to undergo independent credentialing and privileging at a hub hospital and at every spoke hospital placed a very high administrative burden upon hospital staff. Fortunately, Centers for Medicare and Medicaid Services (CMS) have introduced a new rule for the credentialing and privileging of telemedicine physicians and practitioners that went into effect on July 5th, 2011.1 The Medicare conditions of participation previously required the governing body of a hospital to make all privileging decisions based on the recommendation of its medical staff after thoroughly reviewing the credentials of the practitioners applying for privileges. This requirement was applied regardless of whether the services were to be provided on-site at the hospital or through a telecommunications system. The new CMS rule allows small and critical access hospitals receiving telemedicine services to rely upon credentialing and privileging information from the hospital providing the telemedicine services (credentialing and privileging by proxy). The new rule has effectively reduced the administrative burden, at hub and spoke, associated with telestroke provider credentialing and privileging.1 Legal barriers to telestroke practice also exist. The federal antikickback statute makes illegal any arrangement where one purpose is to offer, solicit, or pay anything of value in return for a referral for treatment. Whether or not the provision of subsidized or free telemedicine equipment or services violates the statute has been an issue under review and debate. An incentive for telestroke network affiliate hospitals to refer to one another may exist, inherent to their regional connectedness. To the degree that a hub hospital bears the majority of the costs, and to the extent that access to the hub hospital by remote physicians results in referrals, an antikickback remuneration potential may exist.3 Fortunately, the Department of Health and Human Services4 believes that it is unlikely that the Office of the Inspector General would impose antikickback sanctions upon hub and spoke telestroke network work arrangements given that the following conditions are met: there are no prespecified requirements to refer or transfer patients; there is no emergency medicine physician compensation; the overall telestroke network goal is to reduce spoke to hub transfers; the spoke patients benefit from expert assessment and treatment that might not otherwise be provided; the participating spoke hospitals benefit from enhanced health education and training; and that the telestroke network is unlikely to increase the overall cost to federal health care programs.
J.A. SWITZER AND B.M. DEMAERSCHALK
Ensuring the privacy and security of information transmitted via telemedicine systems are vital legal requirements. When medical information is being transmitted, stored, or retrieved in digitized form, privacy and security threats exist. Unauthorized access and disclosure of electronic medical records must be prevented. Privacy and security can be maintained by Secure Socket Layer conditional access, data encryption, intruder alerts, and access logging and reporting. Virtual private networks can provide encrypted connections over the Internet. Multiple security features integrated into the technology ensures Health Information Portability and Accountability Act (HIPAA) compliance for virtual telestroke consultations.5 In reference to medical liability, there is no specific evidence to suggest that providing telemedicine consultations increases the risk of malpractice claims compared with providing direct face-to-face consultations for the treatment of patients with acute stroke.3 From the perspective of the telestroke consultant, the duties, responsibilities, and obligations are not different from those present during an in-person physician-to-patient relationship. The American Stroke Association (ASA) recommends that medical advice be provided during a telestroke consultation in a manner similar to that which occurs during a face-to-face encounter.3 From the perspective of the referring emergency medicine physician and spoke hospital, the largest cause of malpractice accusations in stroke historically is the failure to consider or to provide thrombolysis. Because telestroke networks within established stroke systems of care increase safe, appropriate, and effective use of thrombolysis in stroke, they are likely to safeguard against malpractice vulnerabilities.3 It is advisable for telestroke providers to carry adequate malpractice coverage, perform timely consultations, communicate effectively, seek consent for the telemedicine consultation and for thrombolysis when applicable, and to document assessment and decisionmaking in an effort to reduce adverse patient outcomes and to minimize the risks and consequences of litigation.3 Financial barriers remain a major obstacle to any telestroke network operation because of both the high initial expenditure of capital and the lack of reimbursement opportunities. While many professional societies lobby to gain support for physician reimbursement for telemedicine, the CMS has only recently established a telemedicine code (effective January 2010). Unfortunately, the code is not broadly applicable to all telestroke network environments. CMS requires that 2-way, real-time, interactive audio/video telemedicine be conducted and that the referring site (the spoke hospital at which the CMS beneficiary is located) must be in either a rural health professional shortage area or a county that is not included in a metropolitan statistical area in order for the work to be eligible for reimbursement. Each state has its own regulations for private payers. Regulation concerning the issue of mandatory telemedicine reimbursement exists only
OVERCOMING CHALLENGES TO SUSTAIN A TELESTROKE NETWORK
for California, Colorado, Hawaii, Kentucky, Louisiana, Maine, New Hampshire, Oregon, Oklahoma, Texas, and Virginia. There is the potential for telestroke spoke hospitals to improve their reimbursement if they become increasingly engaged in the practice of telemedicine-aided thrombolysis and post-thrombolysis care for acute stroke patients (‘‘drip and admit’’ or ‘‘drip and keep’’). Unfortunately, an entirely unresolved reimbursement barrier occurs after a telestroke consultation that results in the provision of thrombolytic therapy in the spoke hospital’s emergency department followed by transfer of the patient to a hub hospital. In these instances (‘‘drip and ship’’), neither the spoke nor hub facility is eligible to bill the higher Medicare diagnosis-related group codes (codes 61-63) that are associated with thrombolytic administration. Telestroke network cost-effectiveness research conducted from the hub and spoke perspective and presented at 2012 64th Annual Meeting of the American Academy of Neurology revealed that compared to no network, a single hub and 7 spoke hospital set-up resulted in 45 more patients being treated with intravenous thrombolysis, 20 more patients being reated with endovascular stroke therapies, and 5 additional discharges home with independence per 1000 acute ischemic stroke patients per year.6 Across a span of spoke to hub transfer rates from 0% (all telestroke patients admitted to spoke) to 100% (all telestroke patients transferred to hub), incremental cost savings of $550,000 to $6000 for the network as a whole, an incremental cost burden of $1,500,000 to a cost savings of $3,500,000 for the hub hospital, and an incremental cost savings of $300,000 to a cost burden of $500,000 for each spoke hospital. Expressed differently, as the spoke to hub transfer rate increases, the network as a whole faces a reduction in cost savings associated with telestroke activity and the hub hospital benefits with a steady rise in cost savings, but at the expense of the spoke hospital, which faces a reduction in cost savings (and instead bears rising incremental costs). The key factors that influence the telestroke network costeffectiveness exchange are thrombolysis administration, spoke to hub transfer rate, and endovascular interventions for stroke.6 Different dynamics and relationships may exist between hub and spoke hospitals in any given network and even between any 2 facilities within a network. Some smaller and or poorly resourced and staffed hospitals (e.g., facilities with ,100 beds) may be capable of effective drip and ship—that is, thrombolysis under telemedicine guidance followed by transfer to hub hospital stroke center.7,8 The safety and early outcomes of patients treated with thrombolysis for acute ischemic stroke by the ‘‘drip and ship’’ method were compared to patients directly treated at a stroke center.8 Seventy-two percent were treated within 3 hours of symptom onset, the median National Institutes of Health Stroke Scale (NIHSS) score was 9.5, the median door-to-needle time
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was 85 minutes, the in-hospital mortality was 10.7%, the symptomatic intracranial hemorrhage rate was 6%, 30% had an early excellent outcome, and 75% were discharged home or qualified for acute inpatient rehabilitation.8 These outcomes were not statistically different from those for stroke patients thrombolysed directly at a stroke center. In this small retrospective study, the ‘‘drip and ship’’ approach did not appear to compromise safety.8 Other larger and better equipped and staffed hospitals (e.g., facilities with 200 beds) may have the personnel and resources to admit stroke patients after thrombolysis (‘‘drip and admit’’ or ‘‘drip and keep’’).8 Criteria have been proposed to aid in the decision-making regarding the necessity of transferring a stroke patient from spoke to hub, but these decisions are still best made patient by patient, stroke by stroke, and taking into account patient clinical syndrome characteristics, available spoke hospital personnel and resources, necessary diagnostic tests, the medical and surgical management being proposed, proximity of hub hospital, and the hub hospital’s capabilities. Several proposed criteria that may warrant consideration of transfer to a higher level of care may include a high NIHSS score, large hemispheric infarction, intracranial hemorrhage with intraventricular extension, requirement for endovascular revascularization with thrombolysis or mechanical devices, hemicraniectomy for malignant hemispheric infarction with edema, mass effect and herniation, posterior fossa decompression for hemorrhage or infarction, extracranial cervical carotid artery revascularization by endarterectomy or angioplasty and stenting, craniotomy for hematoma evacuation, ventricular drainage for hydrocephalus, clipping or coiling for intracranial aneurysms, or embolization or surgery for arteriovenous malformations.
Section 2: Tips and Tools for Sustaining a Telestroke Network The major determinants of a successful hub and spoke telestroke network are the health care professionals and their relationships. The personnel and effective interactions between hub and spoke are more important than the telemedicine technology. Effective telestroke relationships successfully fulfill the clinical and economic needs of hub and spoke hospitals and health care institutions, and require ongoing and repeated hub to spoke contact (both in-person and over virtual connections). Key telestroke network representatives, stakeholders, and champions are listed in Table 1.
Section 3: Getting Buy-in from Referring Physicians, Administrative Leadership, and Telemedicine Providers Gaining the attention of prospective spoke hospital leadership is easier with published evidence of telestroke
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Table 1. Telestroke stakeholder representatives and champions at hub and spoke hospitals Hub hospital
Spoke hospital
Director (e.g., vascular neurologist) Program manager Program education coordinator Teleneurologists Teleneurosurgeons Teleneuroradiologists Teleneurointerventionalists
Director (e.g., emergency physician) Program manager Program education coordinator Emergency physicians Hospitalists Intensivists Local neurologist(s), if applicable Information technologists Midlevel providers, emergency medicine Lawyer Radiologist (or teleradiologist) Laboratory Emergency nurses Emergency medical services Contracts advisor Quality representatives Radiology technologists Billing and coding analyst
Information technologists Nurse practitioners or physician assistants Lawyer Administrative assistant Billing and coding analyst Financial analyst Operations administrator
Contracts advisor Marketing analyst Grant writer Health policy and administration advisor Research coordinator Research coordinators Public affairs representative Public affairs representative
safety, efficacy, and cost-effectiveness. Strategies for presenting telestroke opportunities to hospital officials may include letters, e-mails, pamphlets, websites, word-ofmouth, administrator to administrator dialogue, testimonials from satisfied patients, spoke hospitals, doctors, benefactors, community leaders, and politicians. Effective planning before travel and spoke site visits may include gaining a clear understanding of a prospective spoke hospital’s strengths and weakness regarding stroke resources, care, and outcomes, its objectives regarding acute stroke care (stroke patient retention versus transfer), and the perspectives of key stakeholders. Administrative and clinical leaders may be more receptive to considering a telestroke solution if a compelling clinical and economic case is established and presented. Maintaining effective relationships between spoke emergency medicine physicians and hub neurologists is of paramount importance for the operations of a telestroke network. Several strategies to strengthen the consultative relationship include providing a 1-800 telestroke hotline that provides a direct connection to a dedicated available neurology provider 24 hours per day, 7 days per week, and 365 days per year, simple pragmatic telestroke hotline eligibility criteria, a telemedicine algorithm that is easy to
follow, a quick response time (,10 minutes), accepting all referrals without questioning or challenging, working effectively with bedside emergency nursing personnel so as not to unnecessarily hold up the emergency physician from evaluating other patients, evaluating urgently, collaborating with emergency personnel on a diagnosis and treatment plan, communicating effectively with the patient, family, nurse, and physician, documenting, and facilitating transfers whenever indicated. For hub hospital telestroke providers, incentives, salary increase, on-call stipend, time off compensation, access to technology, provision of new skills, participation in research trials and publications, and appearing in media presentations may all assist with fair compensation for any incremental work that may be associated with participating in a telestroke network.
Section 4: Telestroke Staff Education Education and orientation are necessary for new staff at both hub and spoke hospitals. At the hub hospital, each new telestroke provider will require instruction on telemedicine technology, troubleshooting, algorithm for consultation, and on spoke hospital characteristics pertaining to capacity, resources, personnel, and transfer. Educating a new spoke hospital and all of its personnel is as critical but more time consuming. Spoke hospital staff education will likely be targeted to include emergency medical services providers, emergency nurses and physicians, hospitalists, intensivists, nurses, pharmacists, laboratory technologists, and radiology technicians. Short, tailored, focused educational messages targeted to individual provider groups at a spoke hospital are more effective, efficient, and respectful of the providers’ competing responsibilities and duties than a long, one-size-fits-all lecture approach. Examples of commonly used education modules include the NIHSS assessment, the general neurologic examination, central nervous system anatomy, a step-by-step telestroke consultation algorithm, technical troubleshooting, the review of any relevant stroke guidelines, order sets, and pathways.
Section 5: Keeping Hub and Spoke Partners Engaged and Combating Telemedicine Fatigue Telestroke hub hospitals, spoke facilities, and the networks that join them are all vulnerable to fatigue and a resultant drop in consultation rate and results, both clinical and economic. The excitement and satisfaction of new technology, a new mode of neurologic practice, the new professional relationships that develop, and the new extended reach of expertise that all come from initiating a hub and spoke telestroke network may wane and give way to frustration over incremental workload and any of several telestroke barriers that remain. Fatigue amongst telestroke referring doctors and providers is
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Table 2. Videoconferencing and telestroke vendors Telemedicine cart vendor
Location
Web site
BF Technologies/MedAccess Emerge.MD Global Med InTouch Health Lifesize Polycom REACH Remote Meeting Technologies Specialists on Call Tandberg Vidyo
San Diego, CA Phoenix, AZ Scottsdale, AZ Santa Barbara, CA Austin, TX Pleasanton, CA Augusta, GA Melville, NY Westlake Village, CA New York, NY Hackensack, NJ
www.bf-technologies.com www.emergemd.com www.globalmed.com www.intouchhealth.com www.lifesize.com www.polycom.com www.reachhealth.com www.remotemeetingtechnologies.net www.specialistsoncall.com www.tandberg.com www.vidyo.com
Abbreviation: REACH, remote evaluation of acute ischemic stroke.
a reality amongst networks. Strategies that may combat the fatigue element include: telestroke network newsletters, tracking and broadcasting metrics, setting targets, rewarding successful personnel and sites, introducing novel technology, participating in stroke research trials, team celebrations, annual conferences, favorable media attention, conducting mock telestroke alerts, participating in research publications, hub-to-spoke continuing medical education and training, spoke-to-spoke sharing of best practices, using telemedicine for training and mentoring residents and fellows at hub and spoke facilities, expanding telestroke coverage to new spoke sites or expanding telemedicine services to other medical and surgical disciplines, and conducting spoke site visits.
Section 6: Issues with Telestroke Technology There are an increasing number of telemedicine vendors that provide videoconferencing technology, integrated telestroke systems, and network services (Table 2). Further complicating the landscape, minimal technical standards for telestroke consultation have not been formalized. As a result, there is great deal of variation in the technical features of telemedicine systems used in current practice and available from the marketplace. To comply with CMS billing requirements, a high-quality 2-way video connection is recommended whereby the consultant may directly observe the patient and where patient, family, and local staff may view the consultant. At a minimum, a frame rate of at least 20 frames per second is suggested.3 A spoke hospital bandwidth of at least 768 kbps may achieve minimal acceptable video quality; however, higher rates may be desirable.9 Camera controls should allow for point, tilt, and zoom functions that are sufficient to perform a remote NIHSS assessment. Audio may either be integrated into the video transmission or accomplished separately via telephone. In addition, re-
mote neuroimaging (Digital Imaging and Communications in Medicine compatible) should be available for viewing by the consultant either integrated with the video link, or using a separate picture archiving and communication system. Telestroke systems should be easy to use, both from the perspective of the consultant and the spoke staff. More complex systems may be a roadblock to implementation, require frequent retraining, and result in end user frustration. Under the worst circumstances, complicated systems may result in delays in the patient registration and assessment that potentially could delay thrombolytic therapy. Beyond an audiovisual link and teleradiology, other important telestroke features may include integrated documentation and the ability to produce a billable physician note.9 These characteristics may facilitate the tracking of data elements, including the number of consultations, number of tissue plasminogen activator treatments, onset and door-to-treatment times, and transfer rates. In addition, a template-driven physician note can be constructed by co-opting data provided by the spoke staff. The recommendation to administer tissue plasminogen activator may be accompanied by a printout of appropriate dosing information and post-thrombolysis care orders. Alternatively, a note could be produced independently and transmitted to the spoke via fax. A mobile workstation for the consultant is another important feature of some systems. This allows the stroke specialist to perform consults from the office, home, or any other location, reducing the response times and door-to-treatment times for thrombolysis.10 Finally, information technology support is essential for system reliability. Considering the unpredictable nature of acute stroke, available support personnel are recommended to be available 24 hours per day, 7 days per week, and 365 days per year. A loss of video or the inability to view neuroimaging data may delay time-sensitive
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management decisions and lead to physician frustration, equipment disuse, and network failure.
References 1. Rogove HJ, McArthur D, Demaerschalk BM, et al. Barriers to telemedicine: Survey of current users in acute care units. Telemed J E Health 2012;18:48-53. 2. Demaerschalk BM. Telemedicine or telephone consultation in patients with acute stroke. Curr Neurol Neurosci Rep 2011;11:42-51. 3. Schwamm LH, Audebert HJ, Amarenco P, et al. Recommendations for the implementation of telemedicine within stroke systems of care: A policy statement from the American Heart Association/American Stroke Association. Stroke 2009;40:2635-2660. 4. US Department of Health and Human Services web site. Office of the Inspector General. Available from http://oig.hhs.gov/fraud/docs/advisoryopinions/2-11/ AdvOpn11-12.pdf. Accessed July 4, 2012.
J.A. SWITZER AND B.M. DEMAERSCHALK 5. Demaerschalk BM. Telestrokologists: Treating stroke patients here, there, and everywhere with telemedicine. Semin Neurol 2010;30:477-491. 6. Switzer JA, Demaerschalk BM, Xie J, et al. Costeffectiveness of hub-and-spoke telestroke networks for the management of acute ischemic stroke. To be presented in abstract form at the 65th annual meeting of the American Academy of Neurology, San Diego, CA, March 16-13, 2013. 7. Hess DC, Switzer JA. Stroke telepresence: Removing all geographic barriers. Neurology 2011;76:1121-1123. 8. Martin-Schild S, Morales MM, Khaja AM, et al. Is the dripand-ship approach to delivering thrombolysis for acute ischemic stroke safe? J Emerg Med 2011;41:135-141. 9. Switzer JA, Levine SR, Hess DC. Telestroke 10 years later—‘Telestroke 2.0’. Cerebrovasc Dis 2009;28: 323-330. 10. Switzer JA, Hall C, Gross H, et al. A web-based telestroke system facilitates rapid treatment of acute ischemic stroke patients in rural emergency departments. J Emerg Med 2009;36:12-18.
Overcoming Challenges to Sustain a Telestroke Network Jeffrey A. Switzer, DO, MCTS,* and Bart M. Demaerschalk, MD, MSc, FRCP(C)†
Our objectives are to identify and help overcome obstacles to telestroke practice, to present tips for sustaining a telestroke network, to suggest strategies for obtaining buy-in from clinicians and administrative leadership and providers, and to identify and engage champions and stakeholders of telestroke. Key Words: Stroke— telemedicine—telestroke. Ó 2012 by National Stroke Association
Please access related webinars at www.stroke.org/ telestroke_main. Please note that these webinars may be removed by the NSA in the future if the information is determined to be out of date or no longer valid.
Learning Objectives Identify and address existing obstacles to telestroke network implementation Discuss key components to maintaining the logistic and/or operational sustainability of a telestroke network From the *Departments of Neurology at Georgia Health Sciences University, Augusta, Georgia; and †Mayo Clinic, Phoenix, Arizona. Received June 20, 2012; accepted June 26, 2012. Supported by an educational grant from Genentech. This activity was jointly sponsored by the National Stroke Association and Medical Education Resources. Dr. Switzer receives research support from Genentech and Lundbeck and is a local primary investigator on a National Institutes of Health National Institutes of Neurological Disorders and Stroke grant. Dr. Demaerschalk is an investigator on a National Stroke Association–sponsored study on telestroke. The study is funded by Genentech. Address correspondence to Bart M. Demaerschalk, MD, MSc, FRCP(C), Cerebrovascular Diseases Center, Teleneurology and Telestroke Program, Divisions of Vascular, Hospital, and Critical Care Neurology, Department of Neurology, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054. E-mail: [email protected]. 1052-3057/$ - see front matter Ó 2012 by National Stroke Association http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2012.06.014
Summarize methods to acquire, educate, and maintain telestroke team members Discuss telestroke technology and its issues
Section 1: Identifying and Overcoming Obstacles (Licensing, Credentialing, Privileging, Medicolegal, Financial, and Reimbursement Issues) Multiple regulatory issues have been identified as barriers to implementing and sustaining telemedicine programs. Survey research results revealed an overall consensus that licensing out-of-state physicians, concern over malpractice liability, credentialing for medical staff privileges at individual facilities, and reimbursement limitations are all significant impediments for telemedicine networks.1 Most states have specific licensing provisions for telemedicine. The physical location of the patient is generally accepted as the location at which medicine is being practiced, as opposed to the physical location of the telemedicine physician provider. In most instances, individual states require a full, unrestricted medical license before telemedicine practice is authorized. For practical purposes, an individual telestroke provider would require a medical license for each state of network practice. The requirement of a license for every state poses a significant administrative burden upon telestroke network providers and their managers.2 The creation of a national (or even multistate) telemedicine license would be a logical solution to encourage telestroke network expansion.1 Licensing rules currently vary by state. Some states have introduced specific
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telemedicine licenses (e.g., Alabama, Montana, Minnesota, Ohio, Oklahoma, Oregon, Texas, and Tennessee) or special purpose telemedicine licenses (Nevada), some states require full licenses to conduct telemedicine care (e.g., California, Florida, and New York) with exceptions for consultation only, and other states are still exploring the regulation of telemedicine.1 Mutual interstate recognition of telemedicine licenses would be highly desirable. Traditionally, the requirement for every telestroke provider to undergo independent credentialing and privileging at a hub hospital and at every spoke hospital placed a very high administrative burden upon hospital staff. Fortunately, Centers for Medicare and Medicaid Services (CMS) have introduced a new rule for the credentialing and privileging of telemedicine physicians and practitioners that went into effect on July 5th, 2011.1 The Medicare conditions of participation previously required the governing body of a hospital to make all privileging decisions based on the recommendation of its medical staff after thoroughly reviewing the credentials of the practitioners applying for privileges. This requirement was applied regardless of whether the services were to be provided on-site at the hospital or through a telecommunications system. The new CMS rule allows small and critical access hospitals receiving telemedicine services to rely upon credentialing and privileging information from the hospital providing the telemedicine services (credentialing and privileging by proxy). The new rule has effectively reduced the administrative burden, at hub and spoke, associated with telestroke provider credentialing and privileging.1 Legal barriers to telestroke practice also exist. The federal antikickback statute makes illegal any arrangement where one purpose is to offer, solicit, or pay anything of value in return for a referral for treatment. Whether or not the provision of subsidized or free telemedicine equipment or services violates the statute has been an issue under review and debate. An incentive for telestroke network affiliate hospitals to refer to one another may exist, inherent to their regional connectedness. To the degree that a hub hospital bears the majority of the costs, and to the extent that access to the hub hospital by remote physicians results in referrals, an antikickback remuneration potential may exist.3 Fortunately, the Department of Health and Human Services4 believes that it is unlikely that the Office of the Inspector General would impose antikickback sanctions upon hub and spoke telestroke network work arrangements given that the following conditions are met: there are no prespecified requirements to refer or transfer patients; there is no emergency medicine physician compensation; the overall telestroke network goal is to reduce spoke to hub transfers; the spoke patients benefit from expert assessment and treatment that might not otherwise be provided; the participating spoke hospitals benefit from enhanced health education and training; and that the telestroke network is unlikely to increase the overall cost to federal health care programs.
J.A. SWITZER AND B.M. DEMAERSCHALK
Ensuring the privacy and security of information transmitted via telemedicine systems are vital legal requirements. When medical information is being transmitted, stored, or retrieved in digitized form, privacy and security threats exist. Unauthorized access and disclosure of electronic medical records must be prevented. Privacy and security can be maintained by Secure Socket Layer conditional access, data encryption, intruder alerts, and access logging and reporting. Virtual private networks can provide encrypted connections over the Internet. Multiple security features integrated into the technology ensures Health Information Portability and Accountability Act (HIPAA) compliance for virtual telestroke consultations.5 In reference to medical liability, there is no specific evidence to suggest that providing telemedicine consultations increases the risk of malpractice claims compared with providing direct face-to-face consultations for the treatment of patients with acute stroke.3 From the perspective of the telestroke consultant, the duties, responsibilities, and obligations are not different from those present during an in-person physician-to-patient relationship. The American Stroke Association (ASA) recommends that medical advice be provided during a telestroke consultation in a manner similar to that which occurs during a face-to-face encounter.3 From the perspective of the referring emergency medicine physician and spoke hospital, the largest cause of malpractice accusations in stroke historically is the failure to consider or to provide thrombolysis. Because telestroke networks within established stroke systems of care increase safe, appropriate, and effective use of thrombolysis in stroke, they are likely to safeguard against malpractice vulnerabilities.3 It is advisable for telestroke providers to carry adequate malpractice coverage, perform timely consultations, communicate effectively, seek consent for the telemedicine consultation and for thrombolysis when applicable, and to document assessment and decisionmaking in an effort to reduce adverse patient outcomes and to minimize the risks and consequences of litigation.3 Financial barriers remain a major obstacle to any telestroke network operation because of both the high initial expenditure of capital and the lack of reimbursement opportunities. While many professional societies lobby to gain support for physician reimbursement for telemedicine, the CMS has only recently established a telemedicine code (effective January 2010). Unfortunately, the code is not broadly applicable to all telestroke network environments. CMS requires that 2-way, real-time, interactive audio/video telemedicine be conducted and that the referring site (the spoke hospital at which the CMS beneficiary is located) must be in either a rural health professional shortage area or a county that is not included in a metropolitan statistical area in order for the work to be eligible for reimbursement. Each state has its own regulations for private payers. Regulation concerning the issue of mandatory telemedicine reimbursement exists only
OVERCOMING CHALLENGES TO SUSTAIN A TELESTROKE NETWORK
for California, Colorado, Hawaii, Kentucky, Louisiana, Maine, New Hampshire, Oregon, Oklahoma, Texas, and Virginia. There is the potential for telestroke spoke hospitals to improve their reimbursement if they become increasingly engaged in the practice of telemedicine-aided thrombolysis and post-thrombolysis care for acute stroke patients (‘‘drip and admit’’ or ‘‘drip and keep’’). Unfortunately, an entirely unresolved reimbursement barrier occurs after a telestroke consultation that results in the provision of thrombolytic therapy in the spoke hospital’s emergency department followed by transfer of the patient to a hub hospital. In these instances (‘‘drip and ship’’), neither the spoke nor hub facility is eligible to bill the higher Medicare diagnosis-related group codes (codes 61-63) that are associated with thrombolytic administration. Telestroke network cost-effectiveness research conducted from the hub and spoke perspective and presented at 2012 64th Annual Meeting of the American Academy of Neurology revealed that compared to no network, a single hub and 7 spoke hospital set-up resulted in 45 more patients being treated with intravenous thrombolysis, 20 more patients being reated with endovascular stroke therapies, and 5 additional discharges home with independence per 1000 acute ischemic stroke patients per year.6 Across a span of spoke to hub transfer rates from 0% (all telestroke patients admitted to spoke) to 100% (all telestroke patients transferred to hub), incremental cost savings of $550,000 to $6000 for the network as a whole, an incremental cost burden of $1,500,000 to a cost savings of $3,500,000 for the hub hospital, and an incremental cost savings of $300,000 to a cost burden of $500,000 for each spoke hospital. Expressed differently, as the spoke to hub transfer rate increases, the network as a whole faces a reduction in cost savings associated with telestroke activity and the hub hospital benefits with a steady rise in cost savings, but at the expense of the spoke hospital, which faces a reduction in cost savings (and instead bears rising incremental costs). The key factors that influence the telestroke network costeffectiveness exchange are thrombolysis administration, spoke to hub transfer rate, and endovascular interventions for stroke.6 Different dynamics and relationships may exist between hub and spoke hospitals in any given network and even between any 2 facilities within a network. Some smaller and or poorly resourced and staffed hospitals (e.g., facilities with ,100 beds) may be capable of effective drip and ship—that is, thrombolysis under telemedicine guidance followed by transfer to hub hospital stroke center.7,8 The safety and early outcomes of patients treated with thrombolysis for acute ischemic stroke by the ‘‘drip and ship’’ method were compared to patients directly treated at a stroke center.8 Seventy-two percent were treated within 3 hours of symptom onset, the median National Institutes of Health Stroke Scale (NIHSS) score was 9.5, the median door-to-needle time
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was 85 minutes, the in-hospital mortality was 10.7%, the symptomatic intracranial hemorrhage rate was 6%, 30% had an early excellent outcome, and 75% were discharged home or qualified for acute inpatient rehabilitation.8 These outcomes were not statistically different from those for stroke patients thrombolysed directly at a stroke center. In this small retrospective study, the ‘‘drip and ship’’ approach did not appear to compromise safety.8 Other larger and better equipped and staffed hospitals (e.g., facilities with 200 beds) may have the personnel and resources to admit stroke patients after thrombolysis (‘‘drip and admit’’ or ‘‘drip and keep’’).8 Criteria have been proposed to aid in the decision-making regarding the necessity of transferring a stroke patient from spoke to hub, but these decisions are still best made patient by patient, stroke by stroke, and taking into account patient clinical syndrome characteristics, available spoke hospital personnel and resources, necessary diagnostic tests, the medical and surgical management being proposed, proximity of hub hospital, and the hub hospital’s capabilities. Several proposed criteria that may warrant consideration of transfer to a higher level of care may include a high NIHSS score, large hemispheric infarction, intracranial hemorrhage with intraventricular extension, requirement for endovascular revascularization with thrombolysis or mechanical devices, hemicraniectomy for malignant hemispheric infarction with edema, mass effect and herniation, posterior fossa decompression for hemorrhage or infarction, extracranial cervical carotid artery revascularization by endarterectomy or angioplasty and stenting, craniotomy for hematoma evacuation, ventricular drainage for hydrocephalus, clipping or coiling for intracranial aneurysms, or embolization or surgery for arteriovenous malformations.
Section 2: Tips and Tools for Sustaining a Telestroke Network The major determinants of a successful hub and spoke telestroke network are the health care professionals and their relationships. The personnel and effective interactions between hub and spoke are more important than the telemedicine technology. Effective telestroke relationships successfully fulfill the clinical and economic needs of hub and spoke hospitals and health care institutions, and require ongoing and repeated hub to spoke contact (both in-person and over virtual connections). Key telestroke network representatives, stakeholders, and champions are listed in Table 1.
Section 3: Getting Buy-in from Referring Physicians, Administrative Leadership, and Telemedicine Providers Gaining the attention of prospective spoke hospital leadership is easier with published evidence of telestroke
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Table 1. Telestroke stakeholder representatives and champions at hub and spoke hospitals Hub hospital
Spoke hospital
Director (e.g., vascular neurologist) Program manager Program education coordinator Teleneurologists Teleneurosurgeons Teleneuroradiologists Teleneurointerventionalists
Director (e.g., emergency physician) Program manager Program education coordinator Emergency physicians Hospitalists Intensivists Local neurologist(s), if applicable Information technologists Midlevel providers, emergency medicine Lawyer Radiologist (or teleradiologist) Laboratory Emergency nurses Emergency medical services Contracts advisor Quality representatives Radiology technologists Billing and coding analyst
Information technologists Nurse practitioners or physician assistants Lawyer Administrative assistant Billing and coding analyst Financial analyst Operations administrator
Contracts advisor Marketing analyst Grant writer Health policy and administration advisor Research coordinator Research coordinators Public affairs representative Public affairs representative
safety, efficacy, and cost-effectiveness. Strategies for presenting telestroke opportunities to hospital officials may include letters, e-mails, pamphlets, websites, word-ofmouth, administrator to administrator dialogue, testimonials from satisfied patients, spoke hospitals, doctors, benefactors, community leaders, and politicians. Effective planning before travel and spoke site visits may include gaining a clear understanding of a prospective spoke hospital’s strengths and weakness regarding stroke resources, care, and outcomes, its objectives regarding acute stroke care (stroke patient retention versus transfer), and the perspectives of key stakeholders. Administrative and clinical leaders may be more receptive to considering a telestroke solution if a compelling clinical and economic case is established and presented. Maintaining effective relationships between spoke emergency medicine physicians and hub neurologists is of paramount importance for the operations of a telestroke network. Several strategies to strengthen the consultative relationship include providing a 1-800 telestroke hotline that provides a direct connection to a dedicated available neurology provider 24 hours per day, 7 days per week, and 365 days per year, simple pragmatic telestroke hotline eligibility criteria, a telemedicine algorithm that is easy to
follow, a quick response time (,10 minutes), accepting all referrals without questioning or challenging, working effectively with bedside emergency nursing personnel so as not to unnecessarily hold up the emergency physician from evaluating other patients, evaluating urgently, collaborating with emergency personnel on a diagnosis and treatment plan, communicating effectively with the patient, family, nurse, and physician, documenting, and facilitating transfers whenever indicated. For hub hospital telestroke providers, incentives, salary increase, on-call stipend, time off compensation, access to technology, provision of new skills, participation in research trials and publications, and appearing in media presentations may all assist with fair compensation for any incremental work that may be associated with participating in a telestroke network.
Section 4: Telestroke Staff Education Education and orientation are necessary for new staff at both hub and spoke hospitals. At the hub hospital, each new telestroke provider will require instruction on telemedicine technology, troubleshooting, algorithm for consultation, and on spoke hospital characteristics pertaining to capacity, resources, personnel, and transfer. Educating a new spoke hospital and all of its personnel is as critical but more time consuming. Spoke hospital staff education will likely be targeted to include emergency medical services providers, emergency nurses and physicians, hospitalists, intensivists, nurses, pharmacists, laboratory technologists, and radiology technicians. Short, tailored, focused educational messages targeted to individual provider groups at a spoke hospital are more effective, efficient, and respectful of the providers’ competing responsibilities and duties than a long, one-size-fits-all lecture approach. Examples of commonly used education modules include the NIHSS assessment, the general neurologic examination, central nervous system anatomy, a step-by-step telestroke consultation algorithm, technical troubleshooting, the review of any relevant stroke guidelines, order sets, and pathways.
Section 5: Keeping Hub and Spoke Partners Engaged and Combating Telemedicine Fatigue Telestroke hub hospitals, spoke facilities, and the networks that join them are all vulnerable to fatigue and a resultant drop in consultation rate and results, both clinical and economic. The excitement and satisfaction of new technology, a new mode of neurologic practice, the new professional relationships that develop, and the new extended reach of expertise that all come from initiating a hub and spoke telestroke network may wane and give way to frustration over incremental workload and any of several telestroke barriers that remain. Fatigue amongst telestroke referring doctors and providers is
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Table 2. Videoconferencing and telestroke vendors Telemedicine cart vendor
Location
Web site
BF Technologies/MedAccess Emerge.MD Global Med InTouch Health Lifesize Polycom REACH Remote Meeting Technologies Specialists on Call Tandberg Vidyo
San Diego, CA Phoenix, AZ Scottsdale, AZ Santa Barbara, CA Austin, TX Pleasanton, CA Augusta, GA Melville, NY Westlake Village, CA New York, NY Hackensack, NJ
www.bf-technologies.com www.emergemd.com www.globalmed.com www.intouchhealth.com www.lifesize.com www.polycom.com www.reachhealth.com www.remotemeetingtechnologies.net www.specialistsoncall.com www.tandberg.com www.vidyo.com
Abbreviation: REACH, remote evaluation of acute ischemic stroke.
a reality amongst networks. Strategies that may combat the fatigue element include: telestroke network newsletters, tracking and broadcasting metrics, setting targets, rewarding successful personnel and sites, introducing novel technology, participating in stroke research trials, team celebrations, annual conferences, favorable media attention, conducting mock telestroke alerts, participating in research publications, hub-to-spoke continuing medical education and training, spoke-to-spoke sharing of best practices, using telemedicine for training and mentoring residents and fellows at hub and spoke facilities, expanding telestroke coverage to new spoke sites or expanding telemedicine services to other medical and surgical disciplines, and conducting spoke site visits.
Section 6: Issues with Telestroke Technology There are an increasing number of telemedicine vendors that provide videoconferencing technology, integrated telestroke systems, and network services (Table 2). Further complicating the landscape, minimal technical standards for telestroke consultation have not been formalized. As a result, there is great deal of variation in the technical features of telemedicine systems used in current practice and available from the marketplace. To comply with CMS billing requirements, a high-quality 2-way video connection is recommended whereby the consultant may directly observe the patient and where patient, family, and local staff may view the consultant. At a minimum, a frame rate of at least 20 frames per second is suggested.3 A spoke hospital bandwidth of at least 768 kbps may achieve minimal acceptable video quality; however, higher rates may be desirable.9 Camera controls should allow for point, tilt, and zoom functions that are sufficient to perform a remote NIHSS assessment. Audio may either be integrated into the video transmission or accomplished separately via telephone. In addition, re-
mote neuroimaging (Digital Imaging and Communications in Medicine compatible) should be available for viewing by the consultant either integrated with the video link, or using a separate picture archiving and communication system. Telestroke systems should be easy to use, both from the perspective of the consultant and the spoke staff. More complex systems may be a roadblock to implementation, require frequent retraining, and result in end user frustration. Under the worst circumstances, complicated systems may result in delays in the patient registration and assessment that potentially could delay thrombolytic therapy. Beyond an audiovisual link and teleradiology, other important telestroke features may include integrated documentation and the ability to produce a billable physician note.9 These characteristics may facilitate the tracking of data elements, including the number of consultations, number of tissue plasminogen activator treatments, onset and door-to-treatment times, and transfer rates. In addition, a template-driven physician note can be constructed by co-opting data provided by the spoke staff. The recommendation to administer tissue plasminogen activator may be accompanied by a printout of appropriate dosing information and post-thrombolysis care orders. Alternatively, a note could be produced independently and transmitted to the spoke via fax. A mobile workstation for the consultant is another important feature of some systems. This allows the stroke specialist to perform consults from the office, home, or any other location, reducing the response times and door-to-treatment times for thrombolysis.10 Finally, information technology support is essential for system reliability. Considering the unpredictable nature of acute stroke, available support personnel are recommended to be available 24 hours per day, 7 days per week, and 365 days per year. A loss of video or the inability to view neuroimaging data may delay time-sensitive
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management decisions and lead to physician frustration, equipment disuse, and network failure.
References 1. Rogove HJ, McArthur D, Demaerschalk BM, et al. Barriers to telemedicine: Survey of current users in acute care units. Telemed J E Health 2012;18:48-53. 2. Demaerschalk BM. Telemedicine or telephone consultation in patients with acute stroke. Curr Neurol Neurosci Rep 2011;11:42-51. 3. Schwamm LH, Audebert HJ, Amarenco P, et al. Recommendations for the implementation of telemedicine within stroke systems of care: A policy statement from the American Heart Association/American Stroke Association. Stroke 2009;40:2635-2660. 4. US Department of Health and Human Services web site. Office of the Inspector General. Available from http://oig.hhs.gov/fraud/docs/advisoryopinions/2-11/ AdvOpn11-12.pdf. Accessed July 4, 2012.
J.A. SWITZER AND B.M. DEMAERSCHALK 5. Demaerschalk BM. Telestrokologists: Treating stroke patients here, there, and everywhere with telemedicine. Semin Neurol 2010;30:477-491. 6. Switzer JA, Demaerschalk BM, Xie J, et al. Costeffectiveness of hub-and-spoke telestroke networks for the management of acute ischemic stroke. To be presented in abstract form at the 65th annual meeting of the American Academy of Neurology, San Diego, CA, March 16-13, 2013. 7. Hess DC, Switzer JA. Stroke telepresence: Removing all geographic barriers. Neurology 2011;76:1121-1123. 8. Martin-Schild S, Morales MM, Khaja AM, et al. Is the dripand-ship approach to delivering thrombolysis for acute ischemic stroke safe? J Emerg Med 2011;41:135-141. 9. Switzer JA, Levine SR, Hess DC. Telestroke 10 years later—‘Telestroke 2.0’. Cerebrovasc Dis 2009;28: 323-330. 10. Switzer JA, Hall C, Gross H, et al. A web-based telestroke system facilitates rapid treatment of acute ischemic stroke patients in rural emergency departments. J Emerg Med 2009;36:12-18.