Two million neurons die per every minute that a stroke goes untreated, making rapid diagnosis and treatment crucial for the best outcomes. However, 45 percent of Americans live more than 60 minutes away from a primary stroke center. Enter telemedicine: telestroke networks have sprung up across the U.S., and are rapidly expanding, delivering revenue gains and improving patient outcomes.

Two years into a five-year business plan, the Mayo Clinic telestroke network serves 10 hospitals in Arizona, one in Missouri, one in Florida and is in the process of being offered in Minnesota and surrounding states. It has also piloted international care in Canada, Mexico, Spain, India and Bhutan. "We've experienced tremendous growth," says Bart Demaerschalk, MD, director of the network based at the hub hospital of Mayo Clinic Hospital in Phoenix. The plan is designed to accommodate nearly 40 spoke hospitals in Arizona alone.

The hub-and-spoke model consists of one hub hospital—a primary stroke center—that provides stroke services to several smaller spoke hospitals. A hub-based stroke specialist observes the patient through a cart-mounted computer screen, or robot, and communicates with the patient and caregivers at the spoke site, similar to videoconferencing.

Because there are two kinds of stroke, ischemic and hemorrhagic, rapid imaging, diagnosis and evaluation is crucial to the best possible outcome. Treatments are very different so quick access to knowledgeable, experienced clinicians is vital. And, every delay in treatment requires more imaging to assess progress of the disease. In Demaerschalk's network, both the spoke hospital radiologist and the Mayo Clinic telestrokologist interpret the CT brain scan. For patients with a complex stroke, such as a ruptured intracranial aneurysm causing a subarachnoid hemorrhage, the Mayo Clinic telestrokologist is joined by the Mayo Clinic teleneuroradiologist, tele-endovascular surgical neuroradiologist and teleneurosurgeon to conduct a collaborative assessment, establish a diagnosis and embark on an emergency management plan.

Radiology and informatics infrastructure are just part of the equation for a stroke network. To successfully participate in a network, a spoke hospital needs clinical and administrative leadership that recognize a deficiency of clinical neurology expertise and is open to telemedicine.

"What we've done is taken a small critical access hospital in a very isolated area and given it a medical capacity it never had," says James Dickson, CEO of Copper Queen Community Hospital (CQCH), a 14-bed hospital and part of the Mayo Clinic Telestroke network. Since becoming a spoke hospital in 2009, CQCH has transferred 35 fewer patients and seen an increase in its patient census of 5 to 6 percent, which directly translates to increased revenue.

Dickson says the telestroke program requires a significant amount of preparation, including training and certifying nurses in stroke care, learning to use new pharmaceuticals—specifically Tissue Plasminogen Activator (tPA)—and expanding rehabilitation services. tPA, the only thrombolytic agent approved by the FDA for treating acute ischemic stroke, offers a 30 to 50 percent better chance of cure from stroke disability as long as treatment begins within a 4.5-hour window.

Network-wide, Mayo Clinic has reduced patient transfers from 90 percent to 30 percent, Demaerschalk says. By keeping most patients in community hospitals, those facilities experience revenue gains. The network also has increased the opportunities for treatment with tPA, which means an increase in reimbursement since Medicare pays a much higher rate for increased complexity—approximately $6,000 per case. Mayo's spoke hospitals increased tPA use from a baseline of 2 percent of stroke patients prior to the program to up to 25 percent after joining the network.

Another measured outcome is accuracy of diagnosis. After completing nearly 700 telestroke consultations, Demaerschalk found 96 percent accuracy in diagnosing stroke, compared with 83 percent accuracy for phone-only consultations.
 

Where's the money?

Dwight Channer, Mayo Clinic‘s telestroke program manager, demonstrates a telestroke workstation.

Despite these benefits, telestroke programs are hampered by the overhead. From 2007 to 2010, the Mayo Clinic Telestroke network was completely funded by the Arizona Department of Health Services. A $1.5 million state grant funded the design and implementation of a telestroke program, Stroke Telemedicine for Arizona Rural Residents, with an understanding that the seed money would not continue.

"Fundamentally, we are constrained by a lack of sufficient reimbursement for the professional services rendered by the teleneurologists. Any model we created had to overcome that deficiency," says Demaerschalk. The network introduced the concept of a modest annual subscription to offset the lack of professional fee reimbursement. Mayo Clinic completely covers the cost of the network and the spoke hospitals pay an annual fee as low as $10,000, depending on utilization.

While a simple telemedicine platform cost about $25,000 in 2007, the same platform in 2011 costs between $10,000 and $15,000, Demaerschalk explains. And, the best of spoke hospitals, like CQCH, are growing their telemedicine service line to telecardiology and teledermatology, among others.

Questionable reimbursement didn't hold back Wake Forest Baptist Medical Center in Winston-Salem, N.C., which established a telestroke network in 2009, "even realizing that for some of these folks we wouldn't be able to charge anything," says Charles H. Tegeler IV, MD, director of Wake Forest Baptist's telestroke services.  

Unlike in Arizona, many payors in North Carolina reimburse for telemedicine. As far as the Centers for Medicare & Medicaid Services (CMS) is concerned, it's a matter of rules about rural vs. metropolitan settings, explains Tegeler. Rural facilities can bill for telemedicine, but metropolitan facilities cannot. "Virtually all our network hospitals are in rural areas, but if we are really going to make this available for everyone, then some of those will be in metropolitan areas. We're hoping the American Telemedicine Association can help lead the fight to change some of those rules," he says.

To date, Wake Forest's improved outcomes center around the use of tPA. "If the robot consult is activated," Tegeler says, "we administer tPA in 23 percent of cases." Before the network, some hospitals did not even offer tPA because clinicians were not comfortable prescribing such a potentially risky therapy. Now, more than half the time, the patients are able to remain at the network hospital. "One of our goals is to avoid unnecessary transfers."

Wake Forest also is tracking discharge disposition, and 70 to 75 percent of consults end up going home or to rehabilitation or assisted living—"what we consider a good outcome," says Tegeler. The facility is working on metrics for other factors such as quality assurance and time to consultation.
 

Savings at every level

Despite newer regulations, financial reimbursement is still questionable and continues to be a challenge for clinicians practicing in a remote place, says Bruce Silverman, DO, director of the stroke unit of St. John Providence Health System (SJPHS) in Farmington Hills, Mich., and director of its telestroke network.

Potential savings spurred SJPHS to launch the network. "Significant savings can occur when you can keep patients in their own facilities," Silverman says. These include savings for patients who don't have to travel hours to see a specialist, savings when the patient has the greatest risk of relapsing in the first six weeks after a stroke and savings for rehabilitation. "This field is clearly in its infancy and we'll see more of this to come because there are cost savings on every level."

He says neurologists in Michigan can bill for telestroke services, but frequently won't get paid. Stroke, however, is one of the organization's mandates of excellence, so the prestige of that expertise can help the bottom line in other ways. "There's downstream revenue that comes from being a center of excellence. You may not make your dollars on remote stroke patients, but the notoriety you'll develop will be your calling card for others to come to your institution for care."

Reaping telestroke rewards isn't easy. "Every step of the way there have been tremendous obstacles," says Demaerschalk. Telemedicine affects everything from technology to clinical training to legal issues and interinstitutional relationships. One of the biggest hurdles is credentialing and privileging. The eight vascular neurologists in the Mayo Clinic telestroke network, for instance, must hold privileges in each of the 10 hospitals it services. "It's a laborious process to prepare its application package, initially and with annual renewal." Fortunately, a new CMS rule went into effect in July allowing spoke hospitals to utilize the credentialing and privileging information housed at the hub hospital.
 

Bright future?

Mayo Clinic's telestroke network now has a wealth of experience in telemedicine, including a formula to guide a new spoke hospital into the network, says Demaerschalk. "We remain optimistic that we are gradually and systematically identifying and overcoming the most major obstacles across the U.S."

Despite enthusiasm among patients and physicians, telestroke remains hampered by reimbursement. Compared with the time and energy required, telestroke reimbursement is not very successful, says Silverman. "The government doesn't understand how to deal with it, but there's only so long you can continue to do things without reimbursement." No matter how much the patients appreciate the system, "doctors and institutions will lose interest," he predicts.

"I remain encouraged that state by state and payor by payor, gradually reimbursement opportunities are improving for this much-needed treatment," Demaerschalk counters. In some cases, the state legislature has required insurers to reimburse telemedicine consults. Sometimes insurance companies recognize the clinical value and cost effectiveness. "Progress, to date, has been slow, but the future is bright," sums Demaerschalk.
 

iPhones Power Stroke Networks

J. Ross Mitchell, PhD, of the imaging informatics laboratory at the University of Calgary shows ResolutionMD. © Trudie Lee Photography Smartphones can be a valuable tool for telestroke networks. Using them to diagnose stroke is just as accurate as hospital workstations, according to a study published in Journal of Medical Internet Research in May. The study focused on iPhones, iPads, Android smartphones and web browsers. Researchers used an application called ResolutionMD to examine stroke images from the Calgary Stroke Program database and compared the results with diagnoses made in hospital reading rooms. ResolutionMD was between 94 and 100 percent accurate. The study results are "quite surprising," says the study's lead author J. Ross Mitchell, PhD, of the imaging informatics laboratory at the University of Calgary in Canada. With ResolutionMD, a server does all of the computing work and streams images to display on a smartphone in real time. Only the images are on the phone while firewalls protect patient data. ResolutionMD allows users to scroll through 2D images and render complex 3D images, such as oblique cuts and multiplanar reformatting. "The interactivity is good enough that it feels like you're sitting at a workstation," he says. If widespread adoption of the app occurs within the next five years, as he predicts, "Why have a workstation at all?" The application can be used wherever there is a CT scanner. ER physicians at small, rural facilities often have little stroke expertise and usually transfer stroke patients. The time that takes dramatically reduces the chances of a good outcome. "Every 15-minute delay halves the ability to get a good result," Mitchell says. He says anyone trying to run a stroke network needs this kind of easy-image-access technology or "someone else may take your business away." In Canada, one out of every eight patients treated with Tissue Plasminogen Activator (tPA) walks out of the hospital within four to five days and returns to a normal life. "If a patient goes to long-term care, however, the first year costs about $100,000 just for the bed." When compared with the $1,500 cost of tPA and $10,000 to $20,000 in imaging costs, the economic rationale for rapid imaging, diagnosis and tPA is clear. In addition, when a patient is transferred, clinicians immediately order another CT or MRI because the disease has progressed. The ability to avoid that cost makes stroke "the low-hanging fruit of telemedicine [and ripe for handheld-enabled image review]," sums Mitchell.