Telestroke: extending stroke expertise into underserved areas.
ABSTRACT Telestroke systems offer the opportunity to extend stroke-care expertise into rural and underserved areas. These systems are being used to give alteplase to patients with stroke in previously underserved areas safely, effectively, and rapidly. Telestroke will probably play a large part in improving the quality of stroke care and in enrolling patients into clinical trials in rural and community hospitals. One such telestroke system, REACH (remote evaluation of acute ischaemic stroke), is a low-cost, web-based system that allows the consultant to access the system from work, home, or on the road. REACH is presently being used to give alteplase and guide acute stroke care in eight rural community hospitals in Georgia.
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ABSTRACT: Telemedicine provides a new approach to improve stroke care in community settings, delivering acute stroke expertise to hospitals in rural areas. Given the controversies in many aspects of the treatment of intracerebral hemorrhage (ICH) and the lack of guidelines, a prompt neurosurgical second opinion may facilitate the treatment of patients with ICH. Here, the authors' 8-year experience with the use of telemedicine in the management of ICH is reported. The medical records of patients with ICH treated through a telemedicine system in the district of Messina, Italy, between June 2003 and June 2011 were retrospectively reviewed. Neuroradiological and clinical data for patients were transmitted through a high-technology "hub-and-spoke" telemedicine network. Neurosurgical teleconsulting (at the hub) was available for 7 peripheral hospitals (spokes) serving about 700,000 people. The authors analyzed 1) the time between peripheral hospital admission and the specialized second opinion consultation, 2) primary and secondary transfers to the authors' neurosurgery department, and 3) the treatments (surgical or medical) of patients transferred to the hub. The telemedicine network was used to treat more than 2800 patients, 733 with ICH. A neurosurgical consultation was provided in 38 minutes versus 160 minutes for a consultation without telemedicine. One hundred seventy-six (24%) of 733 patients were primarily transferred to the hub. Ninety-five patients (13%) underwent surgical treatment. The remaining 81 patients (11%) underwent neurointensive care. Eight (1.4%) of 557 patients treated at the spokes needed a secondary transfer for surgical treatment because of a worsening clinical condition and/or CT findings. Considering secondary and inappropriate transfers, the interpretation of data was correct in 96.5% of cases. Telemedicine allowed rapid visualization of neuroradiological and clinical data, providing neurosurgical expertise to community hospitals on demand and within minutes. It allowed the treatment of patients at peripheral hospitals and optimized resources. A small percentage of patients treated at the peripheral hospitals had secondary deterioration. Telemedicine allowed fast patient transfer when necessary and provided improved accuracy in patient care.Neurosurgical FOCUS 04/2012; 32(4):E6. · 2.49 Impact Factor
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ABSTRACT: Abstract Introduction: Many veterans live in rural areas distant from Veterans Affairs Medical Centers (VAMCs) and receive primary medical care from community-based outpatient clinics (CBOCs). These veterans often must travel great distances to the nearest VAMC for neuropsychological evaluations, resulting in poor access to care, travel reimbursement costs, fee-basis evaluations of uncontrolled quality, and driving safety concerns. Return trips for feedback compound complications. Accordingly, we initiated a pilot trial of neuropsychological evaluation and feedback via telemedicine (i.e., clinical videoconferencing). Subjects and Methods: Participants were veterans referred for neuropsychological evaluation from a rural CBOC 115 miles from the regional VAMC. All veterans were given the choice to undergo evaluation at the CBOC via telemedicine or in-person at the VAMC. Telemedicine equipment allowed presentation of digitized material with simultaneous patient observation. Testing materials were organized in numbered folders and given to veterans by CBOC clerks immediately prior to evaluation. Clerks returned completed materials via facsimile. Results: Fifteen veterans from the rural CBOC were seen for neuropsychological evaluation. Eight chose telemedicine evaluation. Groups based on evaluation modality appeared similar on demographics, referral basis, resulting neuropsychiatric diagnoses, and follow-through on recommendations. No significant technical or clinical difficulties were encountered, and veterans reported satisfaction with telemedicine. All veterans requested feedback via telemedicine. Conclusions: Neuropsychological evaluation via telemedicine is feasible and appears comparable to in-person evaluation. Experiences are encouraging and consistent with the broader literature on the acceptance of and satisfaction with clinical videoconferencing. Future studies will assess possible psychometric issues in clinical populations.Telemedicine and e-Health 10/2012; · 1.40 Impact Factor
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ABSTRACT: Stroke is a leading cause of death and disability, and recombinant tissue plasminogen activator (rtPA) can significantly reduce the long-term impact of acute ischemic stroke (AIS) if given within 3 h of symptom onset. South Carolina is located in the "stroke belt" and has a high rate of stroke and stroke mortality. Many small rural SC hospitals do not maintain the expertise needed to treat AIS patients with rtPA. MUSC is an academic medical center using REACH MUSC telemedicine to deliver stroke care to 15 hospitals in the state, increasing the likelihood of timely treatment with rtPA. The purpose of this study is to determine the increase in access to rtPA through the use of telemedicine for AIS in the general population and in specific segments of the population based on age, gender, race, ethnicity, education, urban/rural residence, poverty, and stroke mortality. We used a retrospective cross-sectional design examining Census data from 2000 and geographic information systems analysis to identify South Carolina residents that live within 30 or 60 min of a primary stroke center (PSC) or a REACH MUSC site. We include all South Carolina citizens in our analysis and specifically examine the population's age, gender, race, ethnicity, education, urban/rural residence, poverty, and stroke mortality. Our sample includes 4,012,012 South Carolinians. The main measure is access to expert stroke care at a PSC or a REACH MUSC hospital within 30 or 60 min. We find that without REACH MUSC, only 38% of the population has potential access to expert stroke care in SC within 60 min given that most PSCs will maintain expert stroke coverage. REACH MUSC allows 76% of the population to be within 60 min of expert stroke care, and 43% of the population to be within 30 min drive time of expert stroke care. These increases in access are especially significant for groups that have faced disparities in care and high rates of AIS. The use of telemedicine can greatly increase access to care for residents throughout South Carolina.Frontiers in Neurology 01/2012; 3:44.
A 62-year-old woman with a history of paroxysmal atrial
fibrillation suddenly develops weakness of her left arm
and left leg and falls when getting out of her car on her
way to an exercise class. During the fall, she sustains
trauma to her left orbit. She is taken to the local 56-bed
rural hospital in Washington, Georgia, and arrives in the
emergency department within 30 min. The emergency-
room physician activates a REACH (remote evaluation of
acute ischaemic stroke) telestroke consultation with the
Medical College of Georgia, 61 miles away in Augusta,
During examination over remote video, the patient
shows severe neglect and a dense left hemiparesis. Her
National Institute of Health Stroke Score (NIHSS) is 16.
She has swelling over the left eye making it difficult for
her to open her eyelid. The CT scan of brain—viewed
remotely by a personal access communications system
built into REACH—is normal without any evidence of
haemorrhage or early infarct signs. The consultant
advises alteplase and the REACH system calculates a
weight-based dose. Recommendations, including dose
of alteplase, are printed out at the local rural hospital.
90 mg of alteplase is started intravenously at 1 h and
50 min from the time of symptom onset. The patient is
transferred by helicopter to the Medical College of
On arrival, the patient still has neglect and left-arm
weakness but she is now moving her left leg against
gravity and her NIHSS is 13. Transcranial doppler
shows absence of flow in the right middle cerebral
artery. After examination of her left orbit by the
ophthalmology department she is taken to the
neurointerventional suite where the angiogram shows
occlusions in the proximal superior and a few branches
of the inferior division of the right middle cerebral
artery. She receives a total of 7 mg of intra-arterial
alteplase with complete recanalisation at 7·5 h after
symptom onset. She slowly improves and is discharged
to a rehabilitation hospital 9 days later on warfarin with
an NIHSS of 8. After 3 months she is able to take care of
most of her daily activities but has residual mild left arm
This case shows the obstacles of delivering stroke care
in rural communities and a solution. Alteplase remains
the only treatment for ischaemic stroke approved by the
Food and Drug Administration. According to the
Coverdell Stroke Registry, only 3·0–8·5% of patients with
ischaemic stroke in the USA receive alteplase.1,2The 3 h
time window continues to be one obstacle to more
widespread use of the drug.3Moreover, delays in
emergency departments resulting in long door-to-needle
times are still commonplace. Many physicians are
reluctant to use alteplase, because of the fear of
complication of intracranial haemorrhage. This fear is
not unfounded; poor compliance with alteplase treatment
guidelines can lead to high rates of symptomatic
intracranial haemorrhage and complications.4
unavailability of neurologists and special stroke expertise
has generated controversy and has led the Society for
Academic Emergency Medicine to resist alteplase as a
standard of care for stroke.5
In rural communities, the use of thromboylsis for
stroke is not common.6–8Stroke care in community
hospitals and in rural areas does not commonly adhere
to published practice guidelines.7There are many
reasons that contribute to the uncommon use of
alteplase in rural hospitals: the lack of on-site stroke-care
expertise, concern over the risks of intracranial
haemorrhage, and lack of neuroradiologists or trained
specialists to interpret rapidly a CT scan of the brain.
This situation has led to a “rural penalty” for stroke care.
Stroke-care delivery systems
Present systems that deliver acute stroke care and
thrombolysis rely upon one or a combination of the
following models: the consultant physically travels to the
stroke patient in community hospitals (the “Cincinnati”
model); the patient is transferred to the regional stroke
centre for treatment;9,10“drip and ship” protocols where
the recommendation to give alteplase is made over the
telephone;11,12or remote assessment systems using
telemedicine such as REACH and similar systems.13–17
Travel to the small hospital is labour-intensive for the
consultant and is only a viable option in metropolitan
areas where traffic patterns allow travel time to be kept to
Lancet Neurol2006; 5: 275–78
Department of Neurology
(DCHess MD, S Wang MS,
HGross MD, F T Nichols MD,
CEHall MD, R J Adams MD)and
Department of Emergency
Medicine (H Gross)Medical
College of Georgia, Augusta,
GA 30912, USA
Dr David C Hess
http://neurology.thelancet.com Vol 5 March 2006 275
David C Hess, Samuel Wang, Hartmut Gross, Fenwick T Nichols, Christiana E Hall, Robert J Adams
Telestroke systems offer the opportunity to extend stroke-care expertise into rural and underserved areas. These
systems are being used to give alteplase to patients with stroke in previously underserved areas safely, effectively, and
rapidly. Telestroke will probably play a large part in improving the quality of stroke care and in enrolling patients into
clinical trials in rural and community hospitals. One such telestroke system, REACH (remote evaluation of acute
ischaemic stroke), is a low-cost, web-based system that allows the consultant to access the system from work, home,
or on the road. REACH is presently being used to give alteplase and guide acute stroke care in eight rural community
hospitals in Georgia.
Telestroke: extending stroke expertise into underserved
a minimum. The transfer of patients from smaller
community hospitals to regional hospitals by helicopter
and ground transportation is an option, but this is
expensive and critical time can be lost in the process.9
Recent analyses show that the shorter the onset to
treatment time, the better the functional outcome. If the
onset to treatment time is 90 min or less, the odds ratio
(OR) for a favourable outcome at 3 months is 2·8 but
drops to 1·4 if the patient is treated between 90 min and
3 h.18Time lost in transfer can be brain lost. Telephone-
directed stroke care has been used to increase the use of
However, the lack of reliable
information from the remote site has made many stroke
specialists reluctant to advise alteplase treatment over
Telestroke is a method to rapidly bring neurological and
stroke specialist expertise to a hospital irrespective of
geographic barriers.20Although many hospitals might not
have the on-site resources to provide a stroke team
throughout the day, everyday, to guide the use of
alteplase, these resources can be delivered via
telemedicine. The drug can be given safely with telestroke
systems.13,15,16,21The advantages of telestroke systems over
telephone include the visualisation of patients in
emergency departments, the ability to obtain a valid
baseline NIHSS score,22,23the ability to view the CT scan
in real time,13,14,22,24and the use of a graphical interface that
includes the printing out of alteplase orders and other
evidence-based recommendations.21,24Haemorrhages can
be detected reliably in patients with stroke on CT scans by
stroke consultants using teleradiology.25Therefore, both
accurate rating of stroke severity as measured by the
NIHSS score and exclusion of haemorrhage on CT scan
can be assessed via telestroke systems. Studies
comparing telestroke systems with the telephone in
therapeutic decision-making are in progress. Telestroke
systems might avoid unnecessary transfers of patients
and the cost of helicopter and ground transfer, but cost-
effectiveness studies are lacking.
Telemedicine systems are of two general types. In the
fixed-site model, the consultant is either at or travels to
the hub hospital when called to do the consultation.13,16
This system uses dedicated integrated services digital
network (ISDN) lines transmitting 30 frames per
second, two-way full motion, video and audio
teleconferencing with the remote site encrypted via
virtual private networks. ISDN lines transmit digital
telephony and data transmission between two fixed
points via existing telephone wires. By contrast, in the
site-independent or web-based
consultant accesses a web application on the public
internet via any computer using wireless (WiFi) or wired
broadband. Access to patients’ data is password
protected, and data transferred between the hub, rural
sites, and the consultant’s home or other remote
computer access site are encrypted. One of the
advantages of this model is that time can be saved by
avoiding travel to fixed sites and therefore shortening the
onset to treatment time. Moreover, the stroke consultant
can take a “call” anywhere; from home, a hotel, or
anywhere with broadband internet access, without being
tied to a fixed site (figure 1).
One web-based telestroke tool is our REACH
system.21,22,24This system includes custom-built software
integrating video conferencing, CT imaging, and
patients’ data into an integrated screen. This system
presently links eight community rural “spoke” hospitals
(bed size 10–72) in east central Georgia to a tertiary care
hub hospital, the Medical College of Georgia (figure 2).
The rural hospital activates the system by making a toll
free call to the emergency communication centre at the
hub hospital, which then contacts the stroke specialist
on call (DCH, RJA, FTN, HG, CH). All consultants have
telestroke privileges at all the eight hospitals. The stroke
consultant then logs onto the REACH website via any
workstation with broadband internet access (with a
minimum 512 kilobits/s downstream connection) and
does the consultation. The stroke specialist at our unit
interviews and examines the patient over real-time video,
gets an NIHSS score, reviews the CT scans transmitted
via DICOM (the digital imaging and communications in
medicine system) from the rural hospital, and
communicates with local staff from the emergency
http://neurology.thelancet.com Vol 5 March 2006
(or other third site)
Figure 1:The REACH system
A cart with a video camera and computer workstation is in the rural hospital. The rural hospital contacts the
tertiary care hospital, which contacts the stroke consultant on call. The consultant logs onto www.reachmcg.com
and does the consultation from any point with broadband internet access. Live patient video, CT scan images, and
other patient data from the rural site is incorporated into one screen using custom-built software. The consultant
records the NIHSS score with a drop down-menu and indicates the decision “for” or “against ” treatment with
alteplase by clicking on the screen. The CT scan shows a patient with a subarachnoid haemorrhage.
department with a graphical interface. Finally, a
recommendation to treat or not to treat with alteplase is
given. Recommendations for diagnostic assessment and
therapy are given as well as arrangements for transfer to
our unit. The requirements for the local hospital are few:
broadband access to the internet, a CT scanner capable
of transmitting DICOM images over transport control
protocols or internet protocols, and equipment costs
under US$10 000.
Telestroke systems provide rural or urban underserved
hospitals with a 24-h stroke team and some of the critical
elements to fulfil the criteria for a primary stroke
centre.26As in the case presented, patients can be
initially assessed and treated with intravenous alteplase
at spoke hospitals and then transferred to the tertiary
hub for closer observation in a dedicated stroke unit and
possible intra-arterial treatment. In the future, telestroke
systems will offer the opportunity to enrol patients with
stroke from rural and community sites into clinical
trials.20To date, trials have not been able to enrol patients
from rural or stroke-underserved areas.
One of the most important issues for the success of
telestroke systems in the USA will be reimbursement.
Presently, Medicare only reimburses facilities and
physicians for interactive telemedicine consultations
that include two-way video and audio and where the
hospital initiating the consultation is in a “rural health
professional shortage area” or a “county not classified as
a metropolitan statistical area”.27
hospitals that are not in these geographic zones are
“stroke-undeserved” and would benefit from a remote
stroke consultation. These issues will need to be
addressed. Medicare has been responsive to stroke care
issues recently and has created a new diagnostic related
group (DRG 559) for treatment of acute ischaemic stroke
with thrombolytics.28The new group will increase
payment to hospitals for a patient with stroke treated
with alteplase; this will encourage hospitals to provide
the infrastructure to treat appropriately selected patients.
Regulatory initiatives to improve stroke care
Stroke care is fragmented in the USA and there is an
urgent need to develop systems of stroke care.29
The Joint Commission of Hospital Accreditation now
certifies primary stroke centres with a key requirement
being the capability to deliver alteplase treatment.
Several states have needed hospitals to meet a minimum
standard of stroke care in order to have emergency
medicine systems transport stroke patients to their
facilities. The Massachusetts Department of Public
Health has enacted a licensure of primary stroke centres
that requires a 24 h, 7-days-a-week ability to diagnose
and treat patients with stroke. Beginning July 1, 2005,
emergency medicine systems began routing patients
with stroke to these licensed primary stroke centres. The
New York State Department of Health has collected data
supporting stroke centre designation.30The Florida
Stroke Act (2004-325) establishes primary stroke centres
with planned routing of stroke patients to these.
However, many hospitals and communities will struggle
with the requirement to staff a stroke team all day,
everyday. Telestroke systems, by bringing the stroke
specialist rapidly to the hospital without geographic
barrier, offer a solution to the problem of providing
stroke care 24 hours a day.
The authors would like to acknowledge Michael Jensen, medical
illustrator, Medical College of Georgia, for the creation of the figures.
We also acknowledge the dedication of nurses, physicians, and staff
from the eight community hospitals that have been part of the REACH
DCH took primary responsibility for writing the article and helped
develop the REACH system. SW was primarily responsible for the
technical development of the REACH system and participated in writing
the article. HG, FTN, CEH, and RJA all participated in REACH
development and assisted in writing and reviewing the article.
Conflicts of interest
CEH, SW, FTN, and RJA have a patent pending of the REACH
telestroke system. DCH is on the Speaker’s Bureau for Boehringer
Ingelheim and has served as a consultant for AstraZeneca
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Figure 2:Map of the “hub and spoke” REACH network in Georgia
All spoke hospitals have between ten and 75 beds.
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