Clinical Telemedicine Blog

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

Teleneurology as a Model for Telemedicine Growth: Part 1

By Amy Levitt

Emergency teleneurology and telestroke care—the importation of stroke and emergency neurology specialists to the patient’s bedside using videoconferencing technologies—is growing steadily in magnitude, impact and validation. Early in the decade some hundreds of patients each year were connected to specialists by video conferencing; in 2010 literally thousands of acute stroke patients will have a distant specialty neurologist involved in the critical phases of their care. The typical associated conclusion is that the evolution of technology has allowed the growth of telemedicine in general, and specifically teleneurology and telestroke. Nothing could be further from the truth, and it’s time the word gets out that the breakthroughs driving the successful growth of this one dimension of telemedicine are financial, not technical.

Today, both university-based and private telemedicine efforts bring good neurology to the bedside of the patients who most need the benefits of evidence-based best practices. Patient acceptance has proven to be high, technology supportive of good clinical results, and distance-based practice capable of great, measureable clinical impact. Increasingly, local physicians are realizing that telemedicine can be used to enhance, and not burden, their practices, and in the case of on-call coverage, can help them focus upon their core practice and prevent burnout while actually expanding their patient population. The successful evolution of teleneurology is providing an operational model for the effective distribution of other specialty services by telemedicine. And it’s all due to the fact that hospitals who lack effective neurology call coverage are financially worse off, and at a competitive disadvantage to those hospitals that have good call coverage.

The model for hospital-supported teleneurology has been relatively easy to define because about 70% of emergency neurology cases referred to expert neurologists by telemedicine are acute strokes and other neurovascular events. In this narrow collection of diagnoses, it’s been possible to build a reasonable predictive model for hospital returns-on-investment against the costs of imported specialty neurologists. And on that basis, telestroke and teleneurology services have grown, and are demonstrating the values that telemedicine has always seemed to promise but never deliver: efficiency, distribution of talent free of geographic restraints, and real benefits for patients and hospitals.

Not all specialties lend themselves to the financial model that supports teleneurology and telestroke care…But all telemedicine strategies that deliver combined efficiency and quality will eventually find support from a party at-risk for the costs of poor care, and this will spark the attention of telemedicine providers ready to deliver clinical care at a distance. And there will, of course, be technology involved; it will be less expensive than today’s technology; and its reliability will be critical to the effective use of the system, but it will not have started the next push in telemedicine. Finances will drive that. As a model for care, teleneurology has explored interesting ground that will serve as a foundation for other telemedicine specialties. It too has lent some new lessons, and reinforced the importance of some that are old.

Topics: Stroke, teleneurology, Physicians, Patients, neurologists, Efficiency