by Lawrence R. Wechsler, MD
Director, University of Pittsburgh Medical Center Stroke Institute
The term "telestroke" was first used by Levine and Gorman in 1999 to refer to the use of telemedicine for evaluation of a patient with stroke.1 At that time, most telemedicine used ISDN connections with limited bandwidth and flexibility. Recent advances in technology and broadband communication networks have dramatically enhanced the ability to evaluate patients remotely and increased the use of telemedicine.
Despite the evidence that intravenous tissue plasminogen activator (IV tPA) is effective in improving outcomes in patients within three hours of stroke onset, only two to three percent of stroke patients receive this treatment.2 Although there are many reasons for this low treatment rate, the lack of availability of acute stroke expertise in emergency departments is one of the limiting factors. Neurologists often cover several hospitals and have busy office practices, making it difficult for them to evaluate acute stroke patients emergently. Emergency physicians may not have the experience to make decisions about thrombolytic therapy without the backup of a vascular neurologist.
Telestroke offers an alternative source for emergent evaluation in the emergency department by a vascular neurologist. A community hospital emergency department may be connected to a stroke center by audio-video conferencing equipment or by web-based video conferencing systems. In most cases, the connection is made via the Internet. The neurologist at the stroke center is able to control the camera at the remote site, allowing the neurologist to focus on specific elements of the examination pertinent to the stroke evaluation. This includes the usual elements of the NIH stroke scale (NIHSS), and important details of the patient's history, including time of onset and blood pressure. In addition, the neurologist can remotely view the CT scan and evaluate laboratory test results. Once all the information is obtained, the neurologist determines whether the patient is a candidate for IV tPA, obtains consent, and gives the order to administer tPA. In most cases, the relationship between the stroke center and community hospital also includes arrangements to transfer the patient to the stroke center, if needed, for additional interventional therapy.
Comparisons of stroke assessments by telemedicine and at the bedside have established the reliability of telestroke evaluations. Several studies compared the results of NIHSS obtained by telemedicine with similar evaluations performed at the bedside.3-5 The correlation was excellent both in non-acute stroke patients and those undergoing evaluation for thrombolytic therapy. A report from the telestroke network in Bavaria, Germany comparing 90-day outcomes of patients treated by telestroke with those treated in person at their stroke center showed a similar rate of good outcomes.6
While telestroke goes a long way to treat stroke patients, the procedure adds additional expense to remote evaluations, including the cost of audio-video conferencing equipment and the availability of vascular neurology expertise 24/7 at the stroke center. A possibly more cost-effective approach is to communicate with community hospitals by telephone rather than telemedicine. Meyer et al. recently reported the results of a randomized trial of telemedicine vs. telephone evaluation of acute stroke patients by a single hub hospital servicing four remote sites.7 The correctness of decisions regarding eligibility for IV tPA was reviewed retrospectively by an expert panel blinded to the evaluation method. Telemedicine was significantly superior to telephone in leading to the correct decision about delivering IV tPA. Telephone evaluation more frequently led to incorrectly judging the patient to be ineligible for IV tPA when the expert panel thought IV tPA should have been given. The difference was even greater in favor of telemedicine when only those patients receiving IV tPA were considered.
Many challenges exist for telemedicine, impeding the growth of this promising technology. Reimbursement for services delivered by telemedicine, including acute stroke consults, is limited. Many insurers do not reimburse any telemedicine services and CMS reimburses consults only when the patient is in a rural or non-metropolitan statistical area. Critical care codes, commonly used for acute stroke patient encounters in which tPA is given, are not eligible for reimbursement by telemedicine. Physicians performing remote consults must be licensed in the state where the patient resides. This creates an enormous burden for telemedicine networks involving multiple states. Few precedents exist for determining liability for treatment decisions made by telemedicine. Acceptance of telemedicine by patients, families, and local physicians may require education and experience.
In summary, telemedicine is a practical and feasible method of providing stroke expertise to community hospitals with limited or no neurology coverage. Available evidence indicates that remote stroke evaluations are comparable to in-person examinations, and good outcomes are the same as those achieved in patients treated at stroke centers. It is likely telestroke will continue to expand as the need for stroke expertise grows at hospitals throughout the country.
Within the past 24 months, Dr. Wechsler received personal compensation for work performed as a consultant for NMT Medical, Abbott Vascular, Concentric, and Nuvelo. In that period, he also served as editor-in-chief of the Journal of Neuroimaging. Additionally, he held stock options greater than five percent in the company Neurointerventional Therapeutics. Within the past five years, Dr. Wechsler received research support from NMT Medical, Nuvelo, Astra-Zeneca, Boehringer-Ingelheim, NovoNordisk, and Boston Scientific.