Most people have heard of telemedicine, and an increasing number of Americans have used it.
Technology has been used to connect doctors and patients for decades. But in the past it was often limited to one doctor phoning another, or one facility faxing lab results to a specialist for consultation. Secure broadband technology has significantly expanded what telemedicine can accomplish.
Formerly limited to mostly remote rural areas, telemedicine is everywhere now. After all, it doesn’t matter if an elderly patient lives two blocks or 200 miles from their doctor: if they don’t have access to transportation, they can’t get to their appointments. Telemedicine is increasingly being used in situations where distance isn’t the problem, but time or access is.
When someone experiences a stroke, prompt diagnosis and treatment are critical for the best odds of recovery. Medical centers around the world are learning the value of telemedicine for ensuring stroke patients receive help as quickly as possible so they can experience the best possible outcome.
Visual Elements of Neurological Exam Can Be Critical
Rural or isolated emergency departments have long called upon neurologists from bigger facilities when someone comes in with symptoms of a stroke and there’s no neurologist on call. This advice can be extremely helpful, but many neurologists rely on visual cues to help them diagnose stroke.
Today, with secure video conference technology, a neurologist hundreds of miles away can see and examine a patient with the help of emergency department nurses and doctors. Harrisburg Medical Center in Illinois recently added this technology to allow high quality visual access to stroke patients.
Doctors say it’s very much like being in the room with a patient. Equipment even allows neurologists to zoom in on a patient’s pupils for evaluation. The consulting neurologist simply carries a laptop with the secure conferencing technology on it and can use it wherever he or she happens to be located as long as there is broadband access. What once required hundreds of miles of travel, now only requires a few minutes of time.
The Acute Stroke Advancing Program in China
In China, the use of “clot busting” drugs (tissue plasminogen activator, or TPA) on stroke patients is extremely low. But a study called the Acute Stroke Advancing Program, which commenced in 2014, is designed to determine whether telemedicine may increase the rate of use of these drugs and improve the quality of stroke care in local Chinese hospitals.
This multi-center controlled study will evaluate approximately 300 participants divided into two groups. China’s telestroke network consists of one hub hospital and 14 “spoke” hospitals in regions of China that are underserved by medical professionals. The “control” for the project will be data on the usual stroke care in spoke hospitals that did not have guidance from the hub hospital.
The telemedicine consultation uses video conferencing technology on portable devices used by the consulting neurologist at the hub hospital and clinicians at the spoke hospitals. Outcomes to be measured include the percentage of patients treated with TPA within four-and-a-half hours of stroke onset for both the telestroke-treated group and patients who receive traditional stroke care in spoke hospitals.
Swedish Medical Center Helps Patients in Colorado, Surrounding States
Swedish Medical Center in Colorado is another example of how telemedicine can benefit stroke patients. The hospital now offers telemedicine stroke care to communities within Colorado, and also in Kansas, Wyoming, and Nebraska. Outside metropolitan areas, many hospitals don’t have neurologists available on-site. But the CO-DOC stroke telemedicine program lets neurologists examine patients with stroke symptoms from hundreds of miles away.
Neurologists in CO-DOC use laptop computers to examine patients visually, and use high-definition video to look at signs and symptoms like subtle eye movements that can help with diagnosis. Neurologists also have access to vital signs from bedside computers and can talk in real time with patients, hospital personnel, and the patient’s family members.
Because time is so critical to successful outcomes with stroke, CO-DOC’s immediate consultation with a stroke neurologist allows neurologists to instantly overcome geographic obstacles and evaluate a patient similarly to a traditional, in-person visit. The time that is saved can make the difference between life and death for some patients.
Telemedicine to Enroll Stroke Patients in Clinical Trials
One of the biggest problems with clinical trials for acute stroke is that enrollment of patients is highly inefficient. For many trials, access to medical centers where trials are conducted is limited, and transfers from smaller community health facilities simply aren’t practical for many patients. Many stroke trials involve testing therapies alongside standard-of-care treatment within a very small window of time of symptom onset. For example, TPA must be administered within a certain amount of time of symptom onset to be effective.
To evaluate the use of telemedicine in enrolling stroke patients in clinical trials, the University of Texas Health Science Center in Houston was designated as a hub hospital. It has used telemedicine since 2005 to serve 14 rural and community hospitals in Southwest Texas. The telemedicine setup allows two-way live audiovisual communication as well as access to CT images.
Two “spoke” hospitals, Baptist Beaumont and Memorial Hermann-Southwest hospitals, were already accredited primary stroke centers and had the infrastructure necessary for enrolling patients in acute stroke clinical trials. Eligible patients were identified, randomized, and received therapy or placebo at the spoke hospitals under the direction of trial researchers at the hub hospital via telemedicine. No study procedure delays, safety events, or protocol violations occurred with this enrollment setup, leading researchers to conclude that telemedicine can be valuable in enrolling stroke patients into acute clinical trials, saving time and money.
Realistic Expectations for Telemedicine
Telemedicine for stroke treatment is designed to determine whether or not a patient is experiencing a stroke. If a neurologist concludes that a patient is not experiencing a stroke, further medical tests have to be done to determine what is causing a patient’s symptoms. Some patients have the misconception that being diagnosed as “not having a stroke” by a telemedicine neurologist means telemedicine “doesn’t work,” but in fact, that’s how telemedicine is supposed to work: a neurologist who otherwise may never see a patient becomes available, performs tests, and renders a diagnosis.
To counter misconceptions that a telemedicine consult with a neurologist always ends with a definitive diagnosis, hospitals may want to adjust informed consent protocols to more clearly spell out what is and is not possible with various types of telemedicine services. Nonetheless, telemedicine has a bright future in treatment of stroke patients and enrollment of stroke patients in clinical trials, because in cases of stroke, time is critical, and saving time by eliminating geographic distance saves lives.
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