Clinical Telemedicine Blog

SOC Teleneurology Team Thanks EMS Personnel

By Amy Levitt

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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. Specialists On Call is the largest provider of teleneurology care in the world, with over 4,000 patients treated every month and more than 200,000 consultations performed to date. 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.

Contact us to learn more about how we can help improve stroke care in your hospital.

Topics: telemedicine, Stroke, neurology, teleneurology, emergency neurology, stroke awareness, Emergency Medicine, Neurologic Emergency, Neurologic Emergencies, SOC, emergency departments

Telepsychiatry, The Right Time But Not Yet In Enough Places

By Chris Pick

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.

Topics: telemedicine, healthcare, Emergency Medicine, Physicians, telemedicine solutions, Specialists On Call, SOC, hospitals, telepsychiatry, emergency departments, emergency department, On Call Coverage, Telepresence, Specialty Physician Shortage, Patients, Emergency Psychiatry, telehealth, psychiatry

Teleneurology Provides Rapid Response from a Top Level Neurologist

By Jeff Simer

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.

Topics: telemedicine, Stroke, neurology, teleneurology, emergency neurology, healthcare, Emergency Medicine, Neurologic Emergency, Physicians, Neurologic Emergencies, telemedicine solutions, Specialists On Call, SOC, hospitals, emergency departments, emergency department, On Call Coverage, Telepresence, Patients, telehealth, neurologists, telestroke, Efficiency, CLOTS, Society of Interventional Radiologist

The High Cost of Psychiatric Misdiagnoses

By Amy Levitt

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.

Topics: telepsychiatry, emergency departments, Uncategorized, psychiatric misdiagnoses, panic attacks