Telemedicine touted for stroke patients, adoption obstacles remain
Telemedicine provides access to neurologists with expertise in stroke care. Photo source:
A new policy statement from the American Heart Association (AHA) advocates that healthcare facilities to use high-quality video conferencing systems to connect expert neurologists for rapid, remote examination and treatment of patients undergoing suspected strokes. Commentary, published in the July 1 issue of the Journal of the American Medical Association, notes that reimbursement obstacles and the necessity of establishing "stroke systems of care" for effective assessment and treatment remain.

The policy statement is meant to spur the stroke-care community to overcome barriers limiting the use of technology--telemedicine or telestroke--and provide optimal treatment to patients having strokes in underserved areas, according to lead author Lee H. Schwamm, MD, vice chairman of neurology at Massachusetts General Hospital in Boston.

"The advantage of telemedicine is you get a stroke expert at the bedside, whereas in the community, you might get someone who has treated some stroke patients in the past, but for whom it is not an area of expertise," Schwamm said.

According to the AHA statement: "Whenever local or onsite acute-stroke expertise or resources are insufficient to provide around-the-clock coverage for a health care facility, telestroke systems should be deployed to supplement resources at participating sites." The statement also recommended that patients and families be made aware that telestroke consultation will occur and that they should grant permission for the consultation.

"It is important to adopt these recommendations because right now, far too many patients with stroke never see a neurologist and do not have access to urgent treatment," Schwamm said. "It has been estimated that less than 50 percent of patients who are admitted with a stroke ever see a neurologist while they are in the hospital."

Bolstering the AHA's policy statement was the simultaneous release of a scientific statement by the AHA and the American Stroke Association (ASA) providing evidence-based recommendations for uses of telemedicine for stroke care, ranging from neurological assessment and primary prevention of stroke to acute-stroke treatment and rehabilitation. The joint statement defined telemedicine as the use of dedicated, high-quality, interactive, bidirectional audiovisual systems coupled with teleradiology for remote review of brain images.

However, the JAMA commentary, written by Mike Mitka, noted that obstacles stand in the way of widespread adoption of telemedicine for stroke treatment.

"The overriding barrier is acceptance of this new form of care delivery," Schwamm said.

Other obstacles include a Medicare reimbursement policy that allows payment for telemedicine only in the treatment of patients in specially designated rural counties; a reluctance by some payors to reimburse for telemedicine services; licensing by state medical boards that restricts the out-of-state use of the technology; and liability concerns.

To combat the regulators' resistance, the American Telemedicine Association (ATA) is pressing Congress and the White House to change Medicare rules and allow for payment beyond the designated counties, Gary Capistrant, the ATA's senior director of public policy told JAMA.

"About 83 percent of people live in metropolitan areas, so it is critical that these telehealth services be in urban areas," he said.

Also, Rep. Mike Thompson, D-Calif., introduced a House bill this April (the Medicare Telehealth Enhancement Act), which would provide $30 million to help healthcare facilities pay for telemedicine equipment and expand Medicare reimbursement to urban and suburban areas.

Capistrant noted that liberalizing licensure is a more difficult task because reform battles must be waged on a state-by-state basis.

"If Medicare covered urban telehealth, there could be enough clamor for the state licensing agencies and insurers to change," he said.

Also, the recommendations in the AHA policy statement are based on the stroke association's "stroke systems of care" model (Schwamm et al Stroke 2005;36[3]:690-703), which emphasizes linkages rather than silos in the chain of stroke assessment, treatment and rehabilitation. To aid in this linking, the model recommends using telemedicine and aeromedical transport to assist health workers caring for patients in underserved areas.

The goal of the stroke systems of care model is to create a team of health workers involved with stroke, starting with public health advocacy to reduce stroke risk and continuing all the way to outpatient rehabilitation.

The AHA policy statement uses evidence gathered from hub-and-spoke telemedicine networks, in which nonprofit academic medical centers or tertiary-care hospitals serve as centralized specialty care stroke centers to a network of rural or community hospitals that lack readily available stroke expertise throughout the day. Other telemedicine models also have emerged, including partnerships among individual campuses of a single hospital system and stand-alone vendors not affiliated with larger institutions.

Any debate about the benefits of telemedicine or which model of care delivery works best should center around the patient, according to Schwamm.

"Telemedicine is just another enabling technology that allows us to do a better job of treating patients with an acute stroke," he stated.