Recent statistics say that stroke is the third leading cause of death in the U.S.; more than 140,000 people die from stroke each year in the country. Undoubtedly, it is urgent to seek emergency care at the first sign of a stroke, as early treatment saves many lives and reduces the effects of stroke.
Oftentimes, however, patients in rural areas don’t have access to this much-needed care. Columbus, Ohio is not one of those rural areas, but that’s the home of OhioHealth, a 17-hospital health system servicing a 40-county area. Inside the health system is the Ohio Health Stroke Network, designed to work in the manner of a "hub and spoke" model, which connects several smaller spoke hospitals to one or more hub hospitals via formal agreements to engage in telemedicine consultation. The idea is to maximize efficiency in stroke care, while minimizing the need to transfer a stroke patient elsewhere for specialized care. In this specific network, there are two hospitals or “hubs” in Columbus—Riverside Methodist Hospital and Grant Medical Center—and 19 partner hospitals or “spokes.”
When a stroke victim is brought to a partner hospital's emergency department, the emergency medical team provides direct treatment on-site, while collaborating with OhioHealth's emergency stroke team, using real-time technology from a mobile cart, explains Steve Hickenbottom, the system business relationship manager at OhioHealth Stroke Network. This mobile cart, equipped with a two-way camera and audio connection powered by the Alpharetta, Ga.-based REACH Health technology, is located in the partner hospital's emergency department and connects to OhioHealth's electronic intensive care unit (eICU).
The advanced technology allows OhioHealth stroke specialists, who are on-call, to actually see the patient. They can evaluate the patient's condition; view test results; confer with the community hospital's physicians; and help determine the correct course of action immediately. After initial evaluations and tests are completed, the OhioHealth stroke team can help determine whether or not the patient should remain at the local hospital or be transferred to an OhioHealth certified stroke center, Hickenbottom says.
How a Telestroke Network Came About
In 2009, the concept of a telestroke network emerged in Ohio when leaders at OhioHealth began to realize that when a patient in a remote hospital had the signs or symptoms of a stroke, it was necessary that the patient needed to be looked at by a stroke neurologist. The neurologist would determine if that patient was a candidate for the clot-busting drug tissue plasminogen activator (t-PA) or other procedures that could benefit that patient immediately, Hickenbottom explains.
“The problem was that these smaller hospitals didn’t have a neurologist on staff or didn’t have one available 24 hours a day,” Hickenbottom says. “So the only option was to put that patient in a helicopter and fly him or her to a larger facility where a neurologist would be available. As we know, time is brain and the quicker and sooner we could diagnose and get treatment to the patient, the more brain cells we could save,” he says.
As such, leaders at the health system started to look at how telemedicine could solve this issue. During the early stages of this process, they started off by putting together their own homegrown system using in-house technology and video conferencing tools that were already in place. But a good mechanism for capturing the clinical information was missing, notes Hickenbottom. In 2010, he says, REACH’s clinical documentation tool was put in place, and eventually, the vendor’s fully-integrated platform with the clinical documentation tool as well as the video conferencing tool was implemented, putting everything in one application. “What we had before was clunky and difficult for physicians to use, as they had multiple applications open at the same time,” Hickenbottom says. “There was a bandwidth issue with our partner hospitals, so we struggled with having a reliable platform. But we have been able to solve those Internet issues,” he says.
A Game-Changing Program
In OhioHealth’s eICU, critical care nurses sit in front of monitors and oversee the critical care beds in all of the health system’s facilities. As Hickenbottom puts it, this serves as an “extra set of eyes and ears.” He adds, “It’s been a way for us to utilize technology and add another layer on top of our bedside nursing. We have been able to improve outcomes because of it. eICU is a triage point for our stroke network,” he says.
When a patient shows up in one of the rural hospitals, the nurses in the ER pull a mobile cart into the room and kick off the process, notes Hickenbottom. “We encourage our hospitals to register any patient that comes in that might be a stroke candidate of any kind. Our eICU nurses will then help to triage those patients,” he says. Between the EICU nurses and the physician at the hospital, if a decision is made to bring on a neurologist, the EICU nurse will get the neurologist to join the consult, Hickenbottom explains. “Our stoke neurologists all carry laptops with 4G cards embedded in them so they can log in from anywhere—from their office, home, their kid’s basketball game, or even pulling over on side of road. We’ve seen all of these happen,” he says.
Hickenbottom recalls a situation in which a 58-year old female patient with stroke symptoms came into the ER at one of the northern Ohio facilities. Based on the NIH Stroke Scale (NIHSS) a tool from the National Institutes of Health used by healthcare providers to objectively quantify the impairment caused by a stroke, the patient had a score of 7 on the 0-44 scale (0 is best, 44 is most severe). “We fired up the mobile cart, and the neurologist was on the screen within a few minutes,” Hickenbottom says. “The patient was given t-PA, but she got worse rather than better. The neurologist recommended that she should be flown to our hub hospital in Riverside for more careful evaluation. There, the clot was pulled out of her brain mechanically, and blood flow was restored. She walked out of the hospital two days later with no deficits. If not for this telemedicine program, the deficits would likely have been far greater.”
Fighting Through Challenges
In today’s healthcare, of course, not all telehealth costs are reimbursed. According to Hickenbottom, there is not good legislation on the books in several states, including Ohio, when it comes to telemedicine reimbursement. “Currently there are strict rules around what is considered a rural area—there are many caveats involved,” he says. “So for us to be able to determine which hospitals we would be able to bill for these consults and which ones we wouldn’t, coupled with the amount of reimbursement, which only comes out to $30 or $40 for one, it’s not worth it to us considering the overhead costs,” he explains. He adds that legislation in the state is being considered to force third-party payers to reimburse for telemedicine. “But that is not happening currently, so it’s a struggle, and I know Ohio is not alone with that struggle.”
Considering this reimbursement challenge, another stumbling block presents itself in the form of getting attending physicians to buy in to the value of telemedicine. “It’s been difficult to convince the ER physicians in the local hospitals that it’s better for the patients to put them on the telemedicine cart and have a neurologist take a look at them,” Hickenbottom says. “It’s difficult to change that mindset, because many of the physicians just want to get the patient out of their ER as quick as possible. The telemedicine cart slows that down.” Hickenbottom notes that since the neurologists get a stipend for these calls, they’re more on board with the program. “But it’s not just the stipend,” he attests. “They have seen and thus believe that telemedicine leads to better outcomes.”