Teaching hospitals with neurologists specializing in stroke are creating programs to help clinicians in smaller community hospitals diagnose and treat the condition. And as these telestroke programs get off the ground, CIOs are providing support and facilitation, using clinical IT, videoconferencing technology, and other communication devices to make it all happen.
One factor that has played a critical role in the evolution of stroke treatment is the emergence of tissue plasminogen activator (tPA), a clot-busting drug that can save brain function during the early onset of an ischemic stroke - but only if a patient is correctly diagnosed within a narrow window of time.
“I'd get a call from a general physician who would be asking whether he or she should give their patient tPA. And I would say to the referring doctor, ‘If I could see the patient, I could make a determination.’”
The drug, approved for stroke care in 1996 by the FDA (tPA had already been in use for heart attack treatment), must be administered within three hours after the onset of stroke symptoms. But, prior to the establishment of telestroke programs, many patients were being rushed to community hospital EDs or into rural hospitals that were situated too far from neurologists who could approve the administration of tPA.
Now, hospitals like Massachusetts General and Brigham and Women's in Boston, Swedish Medical Center in Seattle, and the UCLA Health System in Los Angeles, are addressing this problem, with the assistance of IT.
One of the earliest innovators in this area has been Massachusetts General Hospital, a 900-bed academic medical center that is a part of the multi-hospital Partners HealthCare system, and whose sister institution, Brigham and Women's Hospital, is a partner in its telestroke program.
At Mass General, Lee Schwamm, M.D., vice chairman of the department of Neurology, and director of TeleStroke and Acute Stroke Services, established the telestroke program in 2000 (it began as a pilot in 1998). Schwamm says it became clear, upon the FDA's approval of tPA for ischemic stroke care, that a stumbling block to its use was connecting patients with experts in brain imaging and brain function in a timely way.
“I'd get a call from a general physician who would be asking whether he or she should give their patient tPA. And I would say to the referring doctor, if I could see the patient, I could make a determination,” says Schwamm.
Initially, he created a QuickCam setup that allowed him to remotely view patients and their referring physicians, and through which he did “some very primitive consults,” he says.
But Schwamm soon realized he needed help, and reached out to Jim Noga, Mass General's vice president and CIO. “I sat down with Jim and an informaticist and developed a browser-based system for evaluating brain function,” he says.
By 2000, Schwamm, Noga, and their colleagues had set up a pilot with Martha's Vineyard Hospital (Oaks Bluff, Mass.). Four years later, Mass General became a formal stroke center.
As a result, neurologists on call at Mass General can connect online from anywhere to view patients and their caregivers at referring hospitals. They can also remotely manipulate the video camera to view patient function and symptoms and, at the same time, view digital diagnostic images that have been produced at the referring hospital.
Since the program first began, it has steadily expanded. “We now serve 26 hospitals in Massachusetts, southern Maine, and southern New Hampshire, and we've become a model for programs across the country,” Schwamm says.
Noga says, in terms of IT support for a telestroke program, there are a few critical components. “One is really having a robust videoconferencing infrastructure, as well as the ability to externalize that to other sites. And when you do that for telestroke, it obviously has to be reliable and available 24/7, because you never know when one of these patients in the ED might need to be evaluated for stroke.” This, he says, means expanding service into specialists' homes.
And Mass General hopes to grow the program further, according to Noga, who says the hospital now acts as a software-as-a-service provider to other hospitals looking to establish a telestroke program.
In Seattle, Swedish Medical Center's program, which operates out of the multi-hospital system's Cherry Hill campus (where its team of neurologists is based), runs on a similar platform of medical and technical supports. As at Mass General, on-call neurologists are remotely available to ED physicians at referring hospitals that participate in the program.
“From a technical perspective, we wanted to be able to create network connectivity with the referring hospitals in a more easily replicated fashion.”