Winning the Battle Against Brain Attacks: Fighting Back with Telehealth

Andrew M. Southerland, MD, MScDepartment of Neurology

University of Virginia Health System

DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

Conflicts of Interest

U.S. Provisional Patent Application Serial No. 61/867,477Research Support

• HRSA GO1RH27869-01-00 (Solenski)• Virginia Alliance of Emergency Medicine Research (Chapman)• UVA Neuroscience Center of Excellence• American Academy of Neurology, American Board of Psychiatry and Neurology

Additional

• Deputy Editor, Neurology Podcast®• Legal expert review

© HIMSS 2015

Learning Objectives

• Discuss how telehealth technology can be leveraged to optimize stroke management

• Describe how telehealth can be used to achieve cost and quality goals

• Outline how telehealth can be used to improve both patient and provider satisfaction

The Burden of Acute Stroke…Time is Brain

• Stroke is a leading cause of death and long term disability worldwide

– 15 million new strokes/year:• 5 million deaths• 5 million permanently disabled

• The efficacy/safety of life saving reperfusion therapy is TIME DEPENDENDENT

• Every minute a large vessel ischemic stroke is untreated, the average patient loses

– 2 million neurons– 14 billion synapses– 12 km (7 miles) of axonal fibers

WHO statistics, Saver JAMA 2013

Prehospital Stroke Care – No Time to Wait

• Numerous international initiatives have called for innovative approaches to prehospital stroke care to improve time-to-treatment

– American Heart Association/American Stroke Association (AHA/ASA) Target:Stroke

• Patients living in rural and underserved areas suffer a geographic disparity of distance to primary stroke centers and access to neurological expertise

• In the acute stroke setting, this geographic disparity includes prolonged EMS transport times

Avg time to UVA ED arrival 2012: 2 hr, 45 min

Mullen Stroke 2013, Lin Circulation 2012, Garnett Int J Stroke 2010 www.sitsinternational.org

UVA’s first mobile cardiac unit – 1971

• Richard Crampton, UVA cardiologist, develops one of first mobile coronary care units in U.S.

– Equipped with ECG, defibrillator, oxygen, and cardiac treatments during transport

• Deployed to treat President LBJ during a visit to Charlottesville in 1972

UVA Center for Telehealth

• Director, Karen Rheuban, MD• Began in 1994• Over 125 site telehealth network

Quick Metrics: data through Dec 2014• Total TMED Services, 1995-2014: 44,551• Total VA Travel Saved for Patients: 15,787,298 mi• Total Carbon Emissions Saved: 6,678 tons of CO2

UVA Telemedicine Partner Network (139) sites)

CharlottesvilleCharlottesvilleCharlottesvilleCharlottesvilleCharlottesvilleCharlottesvilleCharlottesvilleCharlottesvilleCharlottesville

Scale LegendMile(s)

0 20 40

CharlottesvilleCharlottesvilleCharlottesvilleCharlottesvilleCharlottesvilleCharlottesvilleCharlottesvilleCharlottesvilleCharlottesville

Scale LegendMile(s)

0 20 40

* Includes emergency preparedness only sites.

Community HospitalsHealth SystemsRural Clinics (FQHCs, Free Clinics)Virginia Department of HealthVirginia Department of CorrectionsCommunity Service BoardsSchool HealthNursing Facilities (2014 USDA grant)Dialysis Facilities (2014 USDA grant)PACE programsHome Telehealth

Stroke Telemedicine and Tele-education Program (STAT)

Va Senate Bill 675: April 2010

§ 38.2-3418.16. Coverage for telemedicine services.

Thinking outside the box?...

Cellular Biology

• The first mobile telephone call was made on June 17, 1946 from St. Louis using Bell System's Mobile Telephone Service

• Phones were composed of vacuum tubes and relays, and weighed over 80 pounds (36 kg)

• Cost $15/month = ~$200/month 2015 dollars• 1978: AT&T conducted first FCC cellular field trials• 1993: Engel and Frenkiel receive National Medal of

Technology and Innovation for pioneering work in cellular

Blodget H www.businessinsider.comaccessed 8-21-14

• Mobile devices have far surpassed desktop computers worldwide 2009-13

• 2014: 58% of the U.S. population own a smartphone and 42% own a tablet device

• 2009: 35% and 8% respectively

Going Mobile

• Searching “Neurology” at app store returns 256 results• “Cardiac” = 338 results• “Stroke” = 1,047?

Neurology® Podcast

14

• Produced over 400 weekly Neurology podcasts since 2007• Surpassed 6 million total downloads in 2014 (30,000/episode)• 2,000 hours of podcast-related CME each year• Timely topics:

– Concussions (former NFL player and advocate Ben Utecht)– Medical marijuana for neurological disease– Medicare payments to Neurologists

– Coming soon…Emerging Subspecialties in Neurology: Tele-stroke & tele-neurology

Mobile Telestroke

• Integrating telestroke model with mHealth technology

• Purpose: facilitate mobile videoconferencing between a stroke physician, patient and transporting EMS provider:

– Improve accuracy of prehospital stroke diagnosis– Facilitate appropriate patient triage– Reduce stroke onset-to-treatment time– Assist in prehospital stroke research

• Mobile telestroke feasibility studies– Telebat – LaMonte et al 2004– Europe - Aachen (Bergrath), Berlin (Liman), and Brussels (Van Hooff) – Wu et al. UT Houston 2014 (InTouch Health)

Schwamm et al. 2009

iTREATImproving Treatment with Rapid Evaluation of Acute stroke via mobile Telemedicine

Hypotheses: Mobile telestroke using wireless connectivity and tablet-based teleconferencing is -

1. Feasible to perform prehospital telestroke consultations determined by adequate EMS transport time and qualitative, reproducible AV connectivity;

2. Reliable to perform acute stroke assessments during patient transport determined by accuracy of stroke diagnosis and interrater reliability of NIHSS;

3. Efficacious to reduce stroke onset-to-treatment times measured by absolute reduction in median door-to-needle time compared to baseline.

iTREAT System

• Apple iPad® with retina display

• Cisco Jabber (Movi)™ video conferencing application (HIPAA compliant)

• 4G LTE CradlePoint© modem

• External magnetic-mount antennae

• Portable tablet mounting apparatus

• Verizon Wireless© 4G Mini SIM card

• Durable Pelican case

Connectivity Mapping – Feasibility Aim 1

Verizon© Map

Connectivity Map

Lippman, Chapman et al. ISC, AAN 2014

iTREAT – Feasibility Results

• 93% of all runs achieved at least 9 minutes of continuous connectivity between all raters

– Mean: 18 minutes

• Good AV quality without technical interruption

• Excellent correlation of neurological examination compared to face to face encounters (0.98)

• Next steps include a Phase II clinical trial to evaluate diagnostic accuracy and time-to-treatment in live patient encounters

– Virginia, St. Louis, San Francisco

Stroke Mobile Ambulance

http://www.youtube.com/watch?v=gIHJNBlwNXk

http://www.youtube.com/watch?v=OvXNUYBczhw

Audebert et al., Int J Stroke 2012, Neurology 2012

Median call-to-needle: 62 vs 98 min

What’s next…Mobile CT?

Leon-Carrion Brain Inj 2010, Bressan Child Nerv Sys 2014

What’s next…Handheld Diagnostics

http://infrascan.agencystudy.com

http://tricorder.xprize.org

What’s next…Wearable Platforms?

NEUROEGG STUDY:• Neurology Resident Evaluation using Google Glass

• 2-year feasibility study of remote evaluation and supervision of neurology residents and patient examinations in the ambulatory and inpatient settings

*Sponsored by the AAN and ABPN

Remote Patient Monitoring/Home TelehealthUVA-BroadAxe Care Coordination Center (“C3”)

• Launched in 2013 to address readmissions challenges• Enrolled 680 patients with CHF, COPD, AMI, Pneumonia, • Monitored 60 days• Reduced hospital readmissions by 41%• Opportunities to support chronic disease, palliative care• Just began enrolling patients discharged with stroke

What’s next…Home Monitoring

Courtesy Karen Rheuban

• Reimbursement • Funding of telehealth (Stark, Anti-kickback)• Informed consent• Ensure privacy and confidentiality (HIPAA)• Credentialing and privileging – CMS, JCHAO• Licensure• Malpractice • Practice guidelines and technical standards• Telecommunications venue/costs• Integration with EMR/HIE• Interagency mal-alignment related to policies

Telehealth Challenges?

Courtesy Karen Rheuban

• Medicaid expansion opportunity>40 state Medicaid programs currently cover telehealth

Most state programs pay for transportation

• Private pay mandates (22 states plus DC)

• Boards of Medicine: No prior in-person requirement– Addressing “telephone-only” direct-to-consumer models

– Considering FSMB licensure compact

• Correctional telehealth opportunities

• State health information exchanges

Policy Opportunities

Courtesy Karen Rheuban

• Medicare reimbursement of telehealth services remains low• 2013: Medicare reported <$12 million dollars in reimbursement

nationwide• Rural requirement for originating site; the home is not eligible • Rural definition poorly aligned with specialty workforce shortages,

limits sustainability models and access to care for our seniors• ACO regulations limit telehealth to rural only

• 2012 Institute of Medicine Workshop

• “21st Century Cures” Legislation

Improve Federal Payment Mechanisms

Courtesy Karen Rheuban

How do we cross the divide?

Urban Area under Medicare

1. Expand the evidence base for telemedicine– HRSA Evidence-based Tele-emergency Network Grants Program

2. Be part of the solution– Incorporate telehealth into new shared savings models (ACOs)– Provide data and demonstrations to government agencies

• Center for Medicare and Medicaid Innovation (CMMI)• Federal Communications Commission (FCC)• Congressional and State legislators

3. Collaboration with professional societies, state medical boards, consumers and industry (technology, telecoms, payers)4. Advance entrepreneurship and innovation5. True integration into mainstream healthcare

5 Things for the Future of Telehealth

Courtesy Karen Rheuban

Telecorps?Medical education must parallel the tele-revolution in healthcare

Medical students, residents/fellows,

faculty

Nurses, technicians, home health

EMS

Administration, policy makers,

industry

UVA Global Telemedicine Program

STROKE…on the horizon

1 33

Howard 2014

Thank you

“Nothing is troublesome that we do willingly.” - Thomas Jefferson

Questions?Contact: Andrew M. Southerlandas5ef@virginia.edu@asouth01

UVA Stroke TeamSherita Chapman Smith

Nina SolenskiBrad Worrall

Heather TurnerTimothy McMurry

Jack CoteMax Padrick

Jason Lippman

UVA Center for Telehealth– Karen Rheuban– David Cattell-Gordon– Brian Gunnell– Virginia Burke– Kathy Wibberly– Lara Otkay

UVA Emergency Medicine– Debra Perina– Donna Burns– TJEMS Council

Business Partners– Verizon Wireless©– Cisco systems ©

UCSF– Prasanthi Govindajaran

Sponsors:- HRSA- NINDS CTMC- VAEMR