It’s National EMS Week and Specialists On Call would like to take this opportunity to thank all Emergency Medical Services personnel for their vital public service and positive impact they have on the survival of anyone who experiences sudden injury or illness. We’d like to especially say thank you for their contributions to early recognition of stroke. For more than half of all stroke patients EMS is the first medical contact they have. These patients are dependent upon EMS personnel’s ability to accurately and quickly recognize the signs of stroke and get them to a neurology specialist who can prescribe life-saving treatment.
Due to the short eligibility window for administering tPA, EMS responders and SOC’s TeleNeurology service are essential to the quality of stroke care. Since there’s almost no way for EMS personnel to know precisely when the symptoms started, it’s even more critical that they transport the patient to a hospital that can guarantee a neurologist available for consult. SOC provides board certified vascular neurologists within 15 minutes to patients in more than 250 hospitals in 26 states and our rapid response time has allowed us to consult, diagnose and treat more than 5,000 stroke patients this year alone. In many instances, even with a 15 minute response time, we still wouldn’t have had the opportunity to see and save a patient were it not for the expertise and fast thinking of the EMS responder.
To all Emergency Medical Services personnel: thank you. We recognize and honor you during National EMS week as well as the remaining 51 weeks a year. We look forward to continuing our collaboration in improving stroke care.
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This week I was reading a January 2012 TRENDWATCH from the American Hospital Association entitled “Bringing Behavioral Health into the Care Continuum: Opportunities to Improve, Costs and Outcomes.” While I work with and around the problem every day it makes me pause whenever I see some of the numbers.
….among children mental health conditions were the 4th most common reason for admission.
….27% of Americans will suffer from a substance abuse disorder in their lifetime.
….in 2009, more than 2 million discharges from community hospitals had a primary mental health diagnosis
….in the past year, 34 million adults had comorbid mental health and medical conditions
Here is what it means:
Patients with comorbid mental health and medical conditions experience higher healthcare costs, with much of it attributable to higher medical, not mental health, expenditures. Individuals with comorbid conditions are at a heightened risk of returning to the hospital after discharge.
There is a critical shortage of behavioral healthcare treatment capacity. According to the report, 55% of US counties have no practicing psychiatrists, psychologists, or social workers. Only 27% of community hospitals have an organized inpatient psychiatric unit, while state and county hospitals are closing to financial constraints. Emergency department visits and resulting problems like boarding are on the rise.
With health care parity for mental health, healthcare technology advances, and public and government pressure to reform and recreate healthcare delivery, telepsychiatry is quickly becoming a solution. It allows the too small pool of psychiatrists, who are not evenly geographicly distributed, to meet the growing national mental health challenges. We see the armed forces, the Veterans Administration, rural counties, managed care and many entities using telepsychiatry to reach no, low or special needs access areas. Specialists in substance abuse, child psychiatry, mental retardation, and geriatrics can reach dispersed patient populations in need of a higher level of specialization.
Increasingly we are seeing hospitals, who previously did not have or could not maintain sufficient on demand coverage, identify and take advantage of the improved quality, cost, and outcomes that telepsychiatry offers. The new questions become:
-What is the benefit to the care of the co-morbid patient when the hospitalist has a Psychiatrist to consult?
-What is the benefit to the hospital that has no mental health services but has patients whose primary diagnosis is a mental health condition being brought to the Emergency Department and admitted to the hospital?
-What is the benefit of being able to diagnose, stabilize, manage, and direct to appropriate treatment the patient who is undiagnosed, untreated, or suffering from exacerbated mental health symptoms?
-What is the benefit when a child, elderly person, substance abuser comes to the hospital with an acute mental health problem and a specialist in that field is there to help?
-What is the savings when a psychiatrist is almost instantly available to determine capacity, treat emergent and urgent cases, and provide specialized recommendations?
Increasingly, as telepsychiatry is being used in the hospital setting, outcome studies all show that with early intervention, assessment, and treatment there is reduced cost of care, LOS, readmissions, staff burden and risk; and there is increased quality, services, and satisfaction.
My work deals with the problems of how to address the mental health challenges that our hospitals and their communities are facing. Every day I show hospitals that telepsychiatry is a tool to decompress ED’s, provide needed specialty treatment, and reduce the costs hospitals bear while trying to meet the needs of the people they serve. Can we afford not to address this growing problem? There is still a ways to go in improving the national landscape for telepsychiatry (new prescribing laws and national licensing, reimbursement and medicare coverage, and so on…), but in your community the answer may already be here.
Two weeks ago I had the pleasure of attending the Society of Interventional Radiologist CLOTS training course in Dallas TX. The course is staged as a comprehensive five-day training course is composed of in-depth multidisciplinary lectures emphasizing the entire spectrum of stroke diagnosis and management.
The conference was centered around the minimally invasive approach to advanced ischemic stroke intervention and all of the management considerations, along with this, there was a full suite training course on the various techniques and medical device technology-from imaging to the catheter based solutions to intervention.
There were many presentations at the meeting, presenting many findings from some of the luminary interventional programs in the U.S. and Europe.
Several presentations focused specifically on the overall process in which acute ischemic stroke is identified, triaged, processed, and managed on a systemic level. This approach is generally considered a “Hub and Spoke” a model of developing a transfer pattern with in a defined geography where institutions that do not have in-house interventional capabilities can efficiently refer the appropriate cases to the “hub” for the advanced procedure that would not be able to be performed in-house at the originating site. This model is particularly attractive to the interventional team as the number of in-house cases that present are generally not in sufficient numbers to fully support and justify the cost burden of a full swing interventional program.
SOC attended this course in order to bring attention to one of the key issues that hinders these programs from realizing their growth potential-Acute Emergency Neurological consultation in the ED. All interventional programs depend on the neurology staff of any given institution to identify candidates for both IV lytics, medical management, and in most cases, those that would benefit from advanced intervention in a bi-plane suite. Many community level hospitals do not have 24/7/365 neurology to cover ED stroke call. Even those that do, do not have the ability to respond to stroke codes within the “window” that stroke cases require to capture the opportunity for either lytics administration or intervention. Hence the emphasis on how to create a network of hospitals that can feed an interventional practice. This window is often lost due to the response times from the local specialists. The lytics window is up to 4.5 hours for IV, and 8-12 for endovascular therapy. The SOC specialists are guaranteed to respond in 15 minutes or less, thereby shortening the time that is lost waiting for a specialist to give an opinion on the case.
Many Interventional programs lack the depth of call and expertise to provide such rapid response to neurological emergencies in the community setting. With that said, many of the institutions that develop partnerships as “hub and spoke” lose momentum as the neurological consulting staff is not deep enough to provide 24/7/365 call coverage in a consistent and rapid fashion-burn out ensues and the network loses its effectiveness. As a result, many of the partners lose confidence in calling for consultation and revert back to just sending all cases to the tertiary center. This is neither good for the patient nor the receiving hospital, as the vast majority of cases are ones that can stay at the originating hospital and need not be transferred away from the community. The receiving hospital is then using resources to manage patients that could have been kept at the partner site and not using the resources for advanced care.
SOC had Dr. Heather Linn present on the history of SOC, the methods and value that having the availability of rapid response from a top level neurologist. She articulated to the audience how 15 minute response time, along with the correct information has allowed SOC doctors to deliver more front line acute stroke care than any other neurological practice in the U.S. Because SOC physicians are all fellowship trained and also well versed on the available interventional treatments available in most tertiary centers, SOC is uniquely able to assist both hubs and partner hospitals in tending to the extremely time sensitive nature of acute ischemic and hemorrhagic strokes. With that said, there was considerable interest from the interventional field in how SOC can partner in assisting the flow and triage of patients that are appropriate candidates for advanced neuroendovascular procedures. The body of specialists I spoke to were blown away with the volume of cases that the SOC physician staff has responded to, on average over 10,000 a year. Further, they were also impressed with the ability to appropriately manage and in many cases recommend treatment for these critically ill patients.
I very much enjoyed the presentations I attended and want to thank everyone that stopped by the booth and asked questions or for more information. It is clear that there is high value in utilizing the SOC solution as a key component in an advanced neuro-rapid response outreach program. I look forward to seeing more partnerships with SOC as an integral part of advanced Neuroscience initiatives.
1 in 6 men and 1 in 5 women will experience a stroke in their lifetime; Every two seconds, someone in the world suffers a stroke; Every six seconds, someone dies of a stroke; Every six seconds, someone’s quality of life will forever be changed – they will permanently be physically disabled due to stroke.
Today is World Stroke Day, a day dedicated to promoting stroke awareness. SOC is proud to be one of the companies helping to fight this epidemic. There are 800,000 strokes a year in the USA; approximately one of every 50 is evaluated by a SOC physician.
In honor of World Stroke Day we want to remind you of the tremendous work we do made possible because of the amazing employees, partners, hospital partners, and physicians we work with. Consider that, with your help, SOC:
- Provides 24/7/365 on-call emergency teleneurology coverage for 225+ hospitals in 23 states
- Delivers over 2,000 emergency teleneurology consultations each month
- Has conducted more than 55,000 emergency teleneurology consultations in less than 6 years – more than any bricks and mortar medical facility in the country
- Delivered 13,000+ stroke consults per year
- Oversaw the administration of t-PA 900+ YTD 2012
Knowing the warning signs and getting someone who may be suffering a stroke to the hospital quickly allows them to be assessed for the clot-busting drug t-PA, which may reduce disability or death from stroke. An easy way to recognize the sudden signs of stroke is to remember FAST:
F – Face - can the person smile?
A – Arm - Can the person raise both arms?
S – Speech - Can the person speak clearly and understand what you say?
T – Time - Act FAST!
By simply educating yourselves and your families on the signs and symptoms of stroke and seeking immediate treatment, together we can make a profound improvement in the care of stroke patients across the country!
Joe Peterson, MD
Last week I had the privilege of attending this 1st annual symposium which had over 225 people in attendance. To say this inaugural event was a success would be a gross understatement! I personally spoke with folks from as far away as Texas and many other states including Mississippi, Georgia, Louisiana, Kentucky, Florida and more. Dr. Stephen Suggs, Specialists On Call Teleneurologist, presented a very well received session that highlighted 5 Impacts of Telemedicine to Prattville Baptist Hospital (you can get the executive summary here.)
I was also able to attend other sessions including those by Ron Sparks, Senator Taylor, Dr. Carl Taylor, APT COO Dr. Jeffery Kesler, and Executive Director of Connecting Alabama Jessica Dent. There is a lot of commitment to bring the GPT model to Alabama and to get telehealth reimbursed for all payers. The overall messages resonated with SOC’s focus on patient care – connecting patients with the right doctor when they need it.
My goals for attending the conference were to learn everything I could about the APT initiative, hear from thought leaders in Alabama, and meet some of our SOC partners. I also wanted to let the other attendees know that SOC is the leader in telehealth and that we have a local representative. I feel like I accomplished it all!
Thanks to everyone that came by the SOC booth and especially to those that were singing the SOC praises loud and proud! I look forward to attending again next year!
Author: Joe Peterson, M.D.
In every service area there are new incentives for large and small hospitals—plus outpatient facilities, home health agencies and community practices—to work in greater harmony than ever before. Some of those incentives are based on the Accountable Care Organization (ACO) paradigm, which is steadily gaining ground as a collaborative, patient-centered standard of care.
The ACO model is intently focused on collaboration to improve patient outcomes, and telemedicine is already playing a key role in the transition. Telemedicine lets large hospitals begin building relationships with smaller hospitals and health organizations in the community, and it can dramatically improve outcomes—from initial diagnosis to long-range results.
Take, for example, the treatment of strokes. Here’s a hypothetical scenario that illustrates how telemedicine can build ACO-style relationships:
A patient goes to the emergency room at Northern Hospital of Surry County or Davis Regional Medical Center in North Carolina suffering stroke-like symptoms. The small community hospital doesn’t have a staff neurologist, but it can rapidly set up a telemedicine consultation with a top neurologist from SOC, obtain expert diagnosis and treat the patient quickly with the clot-busting drug tPA if needed or if necessary, send the patient for a higher level of care and possible intervention at Forsyth Medical Center.
To use a well-worn phrase, it’s a classic win/win/win scenario for both the smaller community hospital, the medical center and the patient. It’s a matter of leveraging telemedicine to provide clinical expertise to smaller facilities, ensuring that each part of an ACO is able to offer patients the optimum care available.
The benefits are even greater when telemedicine is combined with EHR technology. In most healthcare settings today, stroke therapists don’t communicate well with each other. The hospital therapist’s clinical notes are rarely shared with the home health staff. And when a stroke patient has recovered enough to go to an outpatient facility, therapists there make a brand-new assessment. Yet each provider at every stage is required to have the neurologist’s approval for a plan of care. And in the ACO model, they’re all accountable for the desired patient outcome.
Clearly, telemedicine can foster the teamwork needed for success as ACOs coalesce in each community. Many large hospitals are looking for a way to “break the ice” with potential ACO partners in their areas—and telemedicine provides the perfect entrée. By putting these partnerships in place now, hospitals both large and small will soon enjoy the benefits: greater quality of care and the financial results that accompany it.
Most televised reunions are gimmicky and superficial, but there was nothing trivial about the reunion of Sandra Bowden and Todd Samuels, M.D., at this year’s American Telemedicine Association (ATA) annual meeting in Tampa.
What the “Human Touch of Telemedicine” conference video crew captured that day was a vision of our medical future: a teleneurology advocate and stroke patient from Texarkana, Texas, getting to meet the neurologist who assessed her from his office in Baltimore, Maryland—and helped improve her outcome and recovery time. Here, in her own words, is Sandra Bowden’s account of her very personal introduction to the benefits of teleneurology.
Telemedicine Made Personal
There are many ironic moments in life, but few that compare to my stroke assessment last year.
I am director of medical post-surgical services at Christus St. Michael Health System in Texarkana, Texas—a city perhaps best known for being the hometown of one-time presidential candidate Ross Perot. Although our facility includes a 312-bed acute care hospital, Texarkana is still a fairly small city—ranking 288th in the latest U.S. census. We don’t have as many local neurologists to call as do hospitals in Boston or Los Angeles. For that reason, teleneurology has played a key role in our hospital’s campaign to become a certified stroke center.
In 2010, during an early morning meeting with the Christus stroke team, I began to feel a tingling sensation in my ear and face. It spread down my left arm, and a colleague noticed that the left side of my face was starting to droop. She quickly escorted me to the ER, where the doctor ordered a CT scan. By the time I returned to the ER, Specialists On Call, our recently implemented teleneurology provider, had been notified and neurologist Todd Samuels was speaking with my physician.
With the help of the attending nurse, Dr. Samuels began a complete neurological assessment. Throughout the entire consultation, I was the center of his attention. He answered all the questions my husband and I had, and made us both feel comfortable during a very difficult time.
Dr. Samuels told me that he believed I was having a stroke that would respond well to the clot-busting drug called tPA. He also explained the risks and benefits of the therapy. I assumed he would order the drug and be done, but he stayed and checked in on me. In a short time, I started having resolution of my symptoms—and Dr. Samuels seemed very pleased with the outcome.
I was soon transferred to the ICU, where my condition steadily improved. The left side of my face continued to droop for a few days, and I had some minor issues with gait and balance. But physical therapy resolved those conditions, and today I live a normal life with no deficits.
So when I attended the ATA annual meeting earlier this year, I had no idea that I would be meeting Dr. Samuels in person. It was a complete surprise to me. I knew I’d never forget his face, and it was wonderful to express in person how grateful I was. I couldn’t have asked for higher quality care.
I have long been a teleneurology advocate, but it wasn’t until I was the recipient of this innovative approach to care that I completely understood its importance. This is the way that medicine is going. We already have far too few specialists to meet the growing needs of people in areas of the country like mine. But I’ve experienced first-hand how teleneurology can help solve the specialist shortage and offer wonderful, life-saving care. After my encounter with SOC, I more firmly than ever see telemedicine as the wave of the future.
--Sandra Bowden, RN-BC, MSN
A relatively recent European study
documented the high cost of psychiatric misdiagnoses in emergency departments (EDs). What it found: misdiagnosed panic attacks were costing hospitals a small fortune.
Because they’re not psychiatric specialists, ED physicians often were baffled by patients’ symptoms, unable to tell if they were having bad reactions to illicit drugs or having a problem requiring immediate psychiatric intervention. In many cases, on-call cardiologists and endocrinologists were summoned—and both time and money were lost.
The problem is arguably even worse in the U.S., where most psychiatric practices haven’t implemented electronic health record (EHR) systems. Remember that meaningful use incentives
weren’t extended to behavioral healthcare in the original HITECH legislation; as a result, psychiatry lacks some of the financial incentive driving other specialties toward EHRs. Since there’s very little interoperability between most hospitals and nearby psychiatric practices, the case for telepsychiatry is a compelling one.
In the case of panic attacks, for instance, hospitals can waste precious hours and countless resources investigating a patient’s cardiac and glandular health. A wide cross-section of people experience these attacks, including celebrities like Johnny Depp, Barbra Streisand, and football Hall of Famer Earl Campbell. Yet most EDs don’t have rapid access to highly trained, board-certified psychiatrists who can quickly identify mental problems masquerading as physical ones.
For example, depression often appears to present as a sleep disorder—which means an ED patient could be sent home with medications that can deepen depression. With a telepsychiatrist as the ED’s first line of defense, these kinds of critical misdiagnoses can be prevented.
There are other advantages to on-call telepsychiatry as well. Beyond panic attacks and depression, an ED is often required to handle a myriad of psychiatric evaluations to address suicide attempts, substance abuse, physical abuse, mental illness, and psychiatric medication issues. Further complicating an ED’s ability to treat patients are the complexities of state psychiatric systems—often something in which an ED physician is not fully versed. A highly qualified telepsychiatrist can ensure complete compliance with state mental health regulations. Rapid response time is another huge plus. Many communities have a shortage of psychiatrists, especially those willing to be on-call throughout the night.
This can be especially problematic when a patient has been placed on a psychiatric hold. Without the proper assessment from a psychiatrist, the patient must remain in the hospital, but often times given the proper medical attention it becomes evident that the patient can be released early. The hospital can then free up a bed space and lessen overcrowding in the ED.
Sigmund Freud had a lifelong struggle with panic attacks. It’s fitting that the profession he launched can now accurately pinpoint the condition far better than most generalists in today’s emergency departments. And in the case of telepsychiatrists, far faster, too.
Medicine, like most human endeavors, is all about collaboration. The EHR is one tool currently being touted as a way to aid collaboration by making patient data more accessible. But how does the data benefit a patient if the right specialist isn’t available to use it to guide care? EHR technology and data management are helpful only when they speed and simplify the collaborative process.
To illustrate the point, let’s take an example from the movie business. There’s a process called “looping” in movie post-production. It’s a way to add dialogue after the film has been shot. Thanks to technology, a movie director in Los Angeles can communicate with an actor in New York and a sound editor in Chicago. They watch a scene together, and the actor adds dialogue that might have gotten muddied during filming. It’s a perfect example of long-distance collaboration aided by technology.
But that type of seamless collaboration is in short supply in modern medicine, according to Ken Congdon, editor-in-chief of Healthcare Technology Online. In a recent article, he notes that the U.S. has spent some $32 billion on EHR technology, but has done little to solve an underlying problem: shortages (and uneven distribution) of health professionals. Congdon’s point is that the finest EHR system in the world achieves nothing if it doesn’t bring health professionals closer together in genuine collaboration.
Without universal access to specialists, for instance, a gap in care still exists.
This is particularly true in America’s emergency departments – and not just in remote places like Coldfoot, Alaska. In a recent survey of California hospital CEOs, more than
half are finding it difficult to obtain enough on-call specialists to meet the state’s legal requirements.
That’s why Congdon is so enthusiastic about the benefits of teleconsultations, which let ED professionals and on-call specialists transcend the most daunting geographic and financial barriers. An ED at a small critical access hospital in Idaho, for example, might find it difficult and costly to attract a full-time, on-call neurologist. Why should it have to shoulder that burden, when its physicians could speedily collaborate with a top-quality neurologist who happens to be in Boston?
Teleconsultations make sense financially and they’re achieving better outcomes as well. In one study reported in Archives of Internal Medicine, teleconsultations reduced ICU deaths by 20% and shortened the average length of stay in the ICU by more than a day.
In a wide range of industries, tele-collaboration is crucial to success. If Steven Spielberg can collaborate long-distance with his colleagues to improve something as non-essential as a movie, why shouldn’t the medical community start doing the same to close existing gaps in care and better our nation’s health?
The 2011 ISC in Los Angeles marked the first time that SOC data has been highlighted at international meeting and the first time that our vast collection of data has been mined and presented in poster form and submitted for publication. Latish Ali and colleagues from UCLA and SOC presented a poster entitled, A National US Telestroke Delivery System: Patient Characteristics and Frequency of Thrombolytic Therapy Delivery
. All SOC hospitals in 2009, were plotted on a map and the population within 30 minute driving time was calculated. Over 34 million people had access to our teleneurology hospitals, representing 12% or the US population. This number is only growing as we continue to contract with more hospitals in multiple states. It's amazing to realize that when I'm on call for SOC that, from my home office, I could potentially provide emergency Neurology care to over 12% of the US population!