Treating Time-Sensitive Stroke Patients With Digital Video Medicine

Colin T. McDonald, MD, specialized in neuro-critical care at Massachusetts General Hospital (Mass General), Harvard Medical School in Boston in 1998, when the father of an emergency room physician at an affiliated hospital became one of his patients. One morning, the father experienced symptoms of stroke, which the son immediately recognized. Doing something about those symptoms, however, was complicated; the father and son were on Martha's Vineyard, where the local hospital was not equipped for emergency neurology care."They contacted me at Mass General because we had one of the early video connections from their hospital to the Mass General neuro-intensive care unit," McDonald told Applied Neurology. "I was able to see the CT scan. I was able to evaluate the patient, and then, in talking to the son, we were able to agree that a clot-busting medicine, tPA [tissue plasminogen activator], was appropriate for 'Dad.' We delivered that medicine and we transported him by Coast Guard to Mass General."Administering tPA to the patient was clearly the appropriate decision, McDonald said. "When I saw him 4 months later, he was walking with the slightest limp, talking, perfectly alert, and independent in all aspects of day-to-day living." That was the first real demonstration for McDonald that telemedicine technology could be beneficial in a community like the one that depended on a small local hospital."I didn't know how useful it was going to be in community hospitals at large," McDonald said, adding that he was under the naive assumption that "most community hospitals in relatively big urban or suburban areas would have neurologists come to the bedside 24/7." It was a few years later, when McDonald went to South Shore Hospital in Weymouth, Massachusetts, to organize a stroke program, that he realized how much of a shortage of around-the-clock emergency neurology care exists in the United States. "There aren't enough specialists that are either available, experienced enough, or interested enough to want to do emergency neurology," McDonald said. For an emergency room to have 24-hour neurology coverage, a hospital would have to pay the salaries of 4 or 5 neurologists, and "that just goes against hospital economics," he said.EXTENDING THE PATHThe use of telemedicine to treat stroke has been well documented by a number of university-based and academic medical center programs.1-3 In addition to the Mass General program, the Medical College of Georgia and the University of California at San Diego have programs as well. Now McDonald is a founder, CEO, and medical director of a privately funded Massachusetts company that is expanding the concept and extending stroke care across state lines. Brain Saving Technologies (BST), which has its headquarters in Wellesley, took its first teleneurology network live last year in a collaborative program with the University of Massachusetts Memorial Medical Center (UMass Memorial) in Worcester. This spring, it began operating a second network in cooperation with Virtua Health, a health care system serving southern New Jersey with headquarters in Marlton.Most communities lack health care services with personnel who have expertise in delivering agents such as tPA or who even have the expertise to evaluate and treat patients who are having or are in immediate threat of having a stroke, McDonald said. Furthermore, he added, they don't have the pathways in place to prevent patients from having a second stroke.BST named its particular form of telemedicine "digital video medicine," or DVM, after the technical equipment used by the treating doctors and community hospitals. The setup is centered around the Tandberg TeleMD video conferencing system, which connects hospitals with doctors through a dedicated T1 Internet line managed by Global Crossing, an international telecommunications service provider.When a patient who may be having a stroke arrives at the community hospital, a physician at one of BST's neuro-critical care centers will view a CT scan on one screen and the patient on another screen. The patient will view the attending neurologist on a high-definition video screen. BST provides a turnkey system for hospitals for a set-up fee of about $40,000.In the DVM program at the UMass Memorial, 5 community hospitals, representing about 400 inpatient beds, are participating, said Stuart Bernstein, president and COO of BST. The company has set up 3 neuro-critical care centers in Massachusetts: one at its headquarters, another at UMass Memorial, and a third at South Shore Neurology in Weymouth. Tele-physicians PC, a sister company of BST, contracts with doctors to be on call for the centers.In March, BST had 15 doctors under contract, Bernstein said. In addition to stroke treatment, BST physicians can provide consultations on other neuro-critical care issues, such as traumatic brain injury. The company was recently approved for accreditation as a provider of real-time DVM service by the Joint Commission for Accreditation of Healthcare Organizations.More doctors were being brought on board for the 4 New Jersey-based Virtua Health hospitals, which represent about 1000 inpatient beds. Some of these were being cross-licensed and cross-credentialed in New Jersey and Massachusetts so that they could treat patients in either state. BST was treating 15 to 25 patients a month in Massachusetts, but that number was expected to rise rapidly when the New Jersey hospitals went live in April, Bernstein said.Part of the reason for BST's expansion is that state laws, such as those in Massachusetts and New Jersey, require hospitals to provide emergency stroke care or else they require ambulances to bypass those hospitals that do not provide such services. The obvious reason for this is the time sensitivity in treating stroke patients-most patients are not candidates for tPA because they do not arrive for treatment within 3 hours of symptom onset.4FOR EMERGENCIES NOW, RESEARCH IN FUTUREMcDonald said the focus of BST is emergency care for patients experiencing stroke, threatened stroke, or transient ischemic attack. After the emergency is resolved, BST recommends that patients be referred to local neurologists for management. "Many neurologists do not really like to leave a busy outpatient day to go to their community hospital emergency department to see a stroke patient who may or may not be a tPA candidate," McDonald said. "The fact that we are there 24/7 to see stroke patients allows [these physicians] to get through their office day. They also know that a physician who has seen that patient by using digital video medicine is highly trained and has provided evidence-based treatment."I have not seen a better solution for treating such a time-sensitive disease as stroke," McDonald continued. "The technology is there now, and it's safe and effective. The question is whether we can craft a successful business. We're feeling pretty comfortable about that."Tele-physicians PC physicians are paid normal consulting fees of $300 by the hospitals in Massachusetts and New Jersey, where telemedicine treatment of stroke is not reimbursable by Medicare. However, plans to expand the program include states where telemedicine procedures are reimbursable by Medicare and by private insurers. McDonald sees the company operating in 4 or 5 states as early as next year.RESEARCH APPLICABILITYOne of his biggest hopes-other than to provide emergency treatment for stroke to as many patients as possible-is to be able to participate in clinical trials for potential stroke treatments.5 "While I believe in tPA, we need better medicines to treat patients, and I know that most patients begin their journey in community hospitals," McDonald said. "Telemedicine allows us to identify those patients much earlier than they would have been in an academic medical center because we're seeing them right on arrival. What I hope is that we would be able to screen these patients in community hospitals and decide which of several different clinical trials they might be appropriate for."He added that BST has been developing in stages. The first stage was to prove that the business model could deliver state-of-the-art stroke care in community hospitals in the Massachusetts network. Second, beginning with the New Jersey network, they had to prove that the same level of care could be distributed across hundreds of miles. Then, he added, "Let's see if this distributed system, which provides state-of-the-art stroke care, also can become a research tool by allowing certain appropriate patients to become part of clinical research trials. That is my ultimate goal: patient care first and foremost, but also forwarding medical knowledge by participating in research, a close second."REFERENCES1. Schwamm LH, Rosenthal ES, Hirshberg A, et al. Virtual TeleStroke support for the emergency department evaluation of acute stroke. Acad Emerg Med. 2004;11:1193-1197.2. Hess DC, Wang S, Gross H, et al. Telestroke: extending stroke expertise into underserved areas. Lancet Neurol. 2006;5:275-278.3. Meyer BC, Lyden PD, Al-Khoury L, et al. Prospective reliability of the STRokE DOC wireless/site independent telemedicine system. Neurology. 2005;64:1058-1060.4. Deng YZ, Reeves MJ, Jacobs BS, et al. IV tissue plasminogen activator use in acute stroke: experience from a statewide registry. Neurology. 2006;66:306-312.5. Fisher M. Developing and implementing future stroke therapies: the potential of telemedicine. Ann Neurol. 2005;58:666-671.LARRY HAND is the former editor of Applied Neurology.