Telestroke and Teleneurology

Lawrence R. Wechsler, M.D.

Chairman, Department of Neurology Vice President, Telemedicine

University of Pittsburgh Medical Center

Outline

Telestroke Teleneurology Challenges Compensation

Estimated Demand for Neurology 2025

Dall et al. Neurology 2013

Demand for Vascular Neurology

Number of new strokes per year in US 795,000

Number of vascular neurologists 1100

Primary stroke centers 1092

Comprehensive stroke centers 110

Stroke Fellowship programs (2016) 74

Stroke fellowship positions 123

% Fellowship positions unfilled 34%

Culebras A. Neurology Today 2015

Teleneurology

IP over Internet Remote control of PTZ camera – Hx, PE

History, exam, recommendations, documentation

Imaging

Consult

Teleneurology Anywhere

International Teleneurology

Advantages of Teleneurology

Direct history by neurological provider

Observe critical elements of examination

Order specific tests – done locally Review results Speak directly to patient regarding

assessment and plan Team based care

Why Teleneurology in an Academic Dept?

Better care for patients Protect referral relationships Endovascular transfers Income for faculty Alternative work models Research potential Clinical trials

Components of Teleneurology Program

Bidirectional real time video and audio

Protocols / order sets In service training Stroke/neurology team Community education EMS awareness

Reliability of Telestroke Exam - NIHSS

Craig J Telemed Telecare

1999

Shafqat Stroke 1999

Meyer Neurology

2005

Anderson JSCVD 2011

Wang Stroke 2003

Handschu Stroke 2003

Lamonte JSCVD 2004

Pts 17 20 25 20 20 41 2 actor pts / 12 scenarios

Setting General Neuro exam Non-acute

stroke Non-acute

stroke Non-acute

stroke Acute stroke

Acute stroke Ambulance

Comparison ISDN v. bedside ISDN v. bedside

Web based v. bedside

iPhone 4 v. bedside

Web based v. bedside

Web based v. bedside

Ambulance v. NIHSS training

Result Kappa r=.21-1.00 Kappa r=.97

Kappa r=.94

Corr coef r=.98

Pearson r=.95

Kappa r=.85-.92

Kappa r >.5

Teleneurology Examination - Limitations

Visual fields Strength gradation Tone / rigidity Sensory examination Reflexes Stethoscope Ophthalmoscope

Teleneurology – IT and technology

Purchased services REACH InTouch $$$

Self supported Vidyo Polycom 24/7 coverage Response time $

Why Telestroke?

Only 2-8% of stroke patients receive IV tPA

Many hospitals don’t have stroke protocols and have never treated a patient with tPA

64% of hospitals in US did not give IV tPA *

Lack of available stroke specialist in rural hospitals major impediment to emergent treatment

* Kleindorfer et al Stroke 2009

UPMC Telestroke

0

100

200

300

400

500

600

ME PS WS SM MK JR MV BV NW HR JM AR EA CR WM LT UN MG BD FR

Consults - 3525 tPA -1078

• 23 hospitals – 12 UPMC, 11 non-UPMC • tPA treatment rate: 31% • Transfers: 24% • 6 hospitals teleneurology coverage

Telestroke Before and After: All UPMC Hospitals

2.9%

5.5%5.4%

7.2%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

% strokes Rx with tPA % strokes within 3 hrs

Before

After

1235 Pts Before 2175 Pts After

Telestroke v. SC Patients Treated with IV tPA 90 day Outcomes

90-Day Clinical Outcomes

8.9

17.1

14.3

21.1

14.3

4

8.9

11.8

14.3

7.9

8.9

6.6

30.4

31.6

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

STROKE CENTER(N=56)

TELESTROKE (N=76)

90 Day Modified Rankin Scores

mRS 0 mRS 1 mRS 2 mRS 3 mRS 4 mRS 5 mRS 6

Zaidi et al. Stroke 2011

Telestroke: Post tPA care tPA Treated Pts – Hub v. Spoke

Hub Drip and ship Drip and stay P value

Patients 272 73 134

Median NIHSS 11 11 8 >0.001

Mean age 72 71 76 0.008

Onset to needle 156 min 134 148 min 0.072

Door to needle 72 min 75 77 min 0.151

Sx ICH 5% 7% 2% 0.79

LVO 36% 33% 12% >0.001

LOS (days) 6.2 4,6 7.2 0.56

Pneumonia 14% 10% 8% 0.077

Intubation 19% 19% 2% >0.001

In-hosp death 11% 11% 10% 0.859

Heffner et al. Stroke 2015

Reorganization of System Stroke Care

Stroke neurology evaluation by telemedicine: Initial hospital evaluation 2 day follow-up Hospital pre-discharge visit Outpatient follow-up

Outcomes to be monitored Mortality Readmissions LOS Patient Transfers

19

Telestroke Workflow

Portal for calls from originating site Receiving calls and response time Time of onset, stroke severity, tPA exclusions Telephone discussion and triage Activation of video Confirmation of history NIHSS exam Consent tPA orders Transfer decision CTA

Teleneurology

Stroke TIA Seizures Confusion Dizziness

General Neurology

Follow-ups

Inpatient Daily

rounds Acute Care

Stroke

Teleneurology Issues EMR access Immediate v. scheduled Imaging review Documentation Guidelines for acute stroke calls Telepresenter Follow-up: new v. same problem Communication with originating

team Transfer agreements

(stroke, non-stroke)

Staffing Models

On call physician Dedicated physician Stroke v. general neuro Triage by fellow/NP Call center Urgent v. Non urgent Backup and surge coverage

Imaging Access

Direct spoke PACS signin Push imaging studies to central

hub PACS Push imaging to teleneurology

software 3rd party cloud based imaging

solutions

http://www.bing.com/images/search?q=nuro+surgery&view=detailv2&&id=2014701C9BEE3BE4A2738B2C9E6D573AFE865B2D&selectedIndex=97&ccid=bC4Muifm&simid=608011754808017629&thid=OIP.M6c2e0cba27e6b40f9484fd56f42d6afeo0

Reimbursement for Teleneurology

E&M codes with GT modifier

Most require real time video conferencing

Medicare – rural areas only Medicaid – state mandates

with variable definitions National insurers - limited Other private insurers 32 states with parity laws

States with Parity Laws

Billing Models

Flat monthly fee – unlimited consults

Tokens Monthly fee plus per case fee Tiered charges based on ED

volume Who pays for equipment and

software Hub hospital support

Compensation

Physician Salary Per case fee Coverage fee per day,

per night or per shift Combinations

Reporting: Process Measures 849 tPA Treatments

0 20 40 60 80 100 120 140 160

Sx Hem

OTT < 90 Min

OTT < 2 Hrs

DTN < 60 Min

Door to Rx

Onset to Rx

Mean NIHSS 12

140 min

77 min

37%

11%

4%

62% (2015)

Reporting: 90 Day Outcomes 711 tPA Treatments

0 10 20 30 40 50 60

Sx Hem

Asx Hem

mRS 0-2

mRS 0-1

Mean NIHSS

UPMC NINDS (benchmark)

11 14

39% 39%

47% 48%

6% 5%

4% 6%

ROI of Teleneurology: Hub and Spoke

Hub Hospital Spoke Hospital Societal

+ Neurology transfers + Avoid transfers + Improved outcomes: tPA

+ Endovascular and surgery + No EMS bypass + Reduced disability

- Network support + High quality patient care + Return to work

- Neurology support - Greater cost of care + Less caregiver burden

- IT costs - Quality monitoring - Higher upfront costs

Summary Telestroke and teleneurology

bring expertise to areas without stroke and neurology coverage

Network models vary and several technologies available

Staffing and compensation are challenging issues

Insurance reimbursement limited

Telemedicine now routine component of systems of care

http://www.bing.com/images/search?q=telemedicine+challenges+&view=detailv2&&id=25AF58734E65B857C85479267466D483CA841CC2&selectedIndex=32&ccid=8ciCIV77&simid=608005655959111334&thid=OIP.Mf1c882215efbac1f5e3ac0e7d208f9c4o0

Telestroke and Teleneurology��Lawrence R. Wechsler, M.D.�Chairman, Department of Neurology�Vice President, Telemedicine�University of Pittsburgh Medical CenterOutlineEstimated Demand for Neurology 2025Demand for Vascular NeurologyTeleneurologyTeleneurology AnywhereInternational TeleneurologyAdvantages of TeleneurologyWhy Teleneurology in an Academic Dept?Components of Teleneurology ProgramReliability of Telestroke Exam - NIHSSTeleneurology Examination - LimitationsTeleneurology – IT and technologyWhy Telestroke?UPMC TelestrokeTelestroke Before and After:� All UPMC HospitalsTelestroke v. SC Patients Treated with IV tPA �90 day OutcomesTelestroke: Post tPA care�tPA Treated Pts – Hub v. SpokeReorganization of System Stroke CareTelestroke WorkflowTeleneurologyTeleneurology IssuesStaffing ModelsImaging AccessReimbursement for TeleneurologyBilling ModelsCompensationReporting: Process Measures�849 tPA TreatmentsReporting: 90 Day Outcomes�711 tPA TreatmentsROI of Teleneurology: Hub and SpokeSummary