AcuteCare Telemedicine Blog


Acutecare Telemedicine Discusses The Benefits Of Telestroke Services In Georgia At Kiwanis Club Of Northside Atlanta

Michael Woodcock, Sales Executive for AcuteCare Telemedicine (ACT), spoke at the Kiwanis Club of Northside Atlanta on April 13th  discussing the benefits of ACT’s teleneurology services for residents of rural Georgia who lack access to emergency neurological expertise. The presentation was delivered to the membership of the Club, a civic organization comprised of business leaders in the metro Atlanta area.

Woodcock’s presentation, sponsored by Club President Daniel Shorr and Vice-President Joel Isenberg, was entitled “Telestroke in Rural Georgia: Bridging the Gap Between Doctor and Patient”.

The presentation presented the statistics for stroke mortality in the U.S., focusing specifically on the “Stroke Belt” of the Southeast, which includes the state of Georgia.  Georgia’s mortality rates for stroke are among the highest in the nation, and providing expert stroke care to rural Georgians via telemedicine can be a key factor in reducing those mortality rates over time. Woodcock discussed the importance of promoting stroke awareness among the general public, and how crucial it is for individuals to recognize the warning signs for stroke (Face/Arms/Speech/Time).

“It is a well-known adage within the neurology community that “Time is Brain”, and that granting patients immediate access to expert care is crucial to preventing potentially severe disability or even death.” said Woodcock. “AcuteCare Telemedicine can provide that expertise to hospitals that enables them to better care for stroke patients in areas of Georgia that are traditionally underserved.”

For more information about AcuteCare Telemedicine, visit www.acutecaretelemed.com



RLS in Four Easy Questions

Restless Leg Syndrome (RLS) is an often undiagnosed or misdiagnosed, yet relatively common, sensorimotor disorder, with a prevalence rate of 7.2% in the United States and Western Europe (a prevalence rate as high as 29% has also been reported). The effect of RLS on one’s quality of life can be significant. Furthermore, RLS can be a harbinger of other disease processes and therefore prompt and accurate diagnosis is essential.

Diagnosis of RLS is based on four clinical findings; an often indescribable sensation in the legs (or arms) causing an urge to move, an increase in symptoms with rest, symptom relief with movement, and symptom worsening at night. It is more prevalent in women than men (2:1) and although RLS can be genetic, the etiology in many cases is unknown. Research has suggested that the cause of RLS may be due to the brain’s inability to correctly utilize dopamine and or iron. Although causative effects are not clear, RLS is often seen in patients with chronic disorders such as diabetes mellitus, uremia, autoimmune disorders, thyroid disease and iron deficiency. Thorough laboratory evaluation in adult patients, especially with recent symptom onset should be pursued. In particular, ferritin levels should be checked in all men and post-menopausal women as iron deficiency is present in about 20% of those with RLS. Iron deficiency in this population can be the result of occult bleeding, which can be a sign of an underlying malignancy, such as colon cancer.

In 2005, the Restless Legs Syndrome Prevalence and Impact General Population study was published in the Archives of Internal Medicine. Of the 416 study participants found to have a clinical diagnosis consistent with RLS, 81% had discussed their symptoms with a primary care physician and 74% of these received a diagnosis. However, RLS was actually the second least common diagnosis comprising only 6.2% of all diagnoses. The most common diagnosis was “poor circulation” comprising 18.3% of the diagnoses. Other diagnoses in descending percentages included arthritis, back/spinal injury, varicose veins, depression/anxiety, and nerve entrapment. Although these may have been accurate, “secondary” diagnoses, in approximately 94% of patients, the diagnosis of RLS was not made. Unfortunately, the treatment of most of the above conditions would not effectively alleviate symptoms of RLS and in some cases may exacerbate them. (ie antidepressants).

Given reported prevalence rates, RLS it is not a rare disorder. The potential negative impact upon the lives of those with RLS has been found to be as high as in those with diabetes and clinical depression. Because the symptoms of RLS are more prevalent in the evenings, it can have a significant impact upon sleep onset and sleep maintenance. This in turn can lead to complaints of insomnia, daytime sleepiness and fatigue, cognitive dysfunction and poor daytime performance, all of which tend to lower quality of life. If not diagnosed and treated effectively, the cumulative impact of untreated RLS may lead to an increased economic burden due to work absenteeism and increased health care utilization.

Once RLS is diagnosed, there are several effective treatment options available, including behavior modification, discontinuation of offending agents, and medications such as dopamine agonists, gabapentin enacarbil, and iron supplementation.

To diagnose RLS is quick, easy, and done without the cost of diagnostic studies or procedures. Hopefully, increased healthcare provider and patient awareness will lead to fewer undiagnosed or misdiagnosed cases of RLS. It takes only four easy questions to diagnose a patient with RLS; a seemingly but not so benign disorder.



Yes America, Time IS Brain

“Time is brain” is such a frequently repeated mantra of stroke neurologists that it seems almost to have become cliché. For more than a decade, fliers, lectures and even billboards have been admonishing us to get to the hospital immediately when we develop symptoms of stroke such as speech trouble or weakness. The longer a stroke victim goes without treatment, the more brain damage accrues and the greater the likelihood of permanent disability or death. Using the latest methods to restore flow to blocked arteries, neurologists can improve the outcomes of stroke victims beyond anything imagined before the “Decade of the Brain.” 

It was distressing to be called recently to see Sam, a 55 year old, via teleneurology consultation. Sam had fallen at home around midnight. When his wife noticed his complete paralysis on the left side, she wanted to call the EMS. However, he refused to let her do so and dragged himself to bed. When he was no better by the morning, they came to the ER more than 12 hours after the stroke started. Sam’s arrival to the hospital was far too late; the damage was complete. He was unable to even wiggle his toes or fingers on the left side, and was suffering severe left facial weakness.

Unless clot busting medicine is given or a clot is physically removed from a blocked artery within a window of just a few hours, brain cells die without exception. The struggle against time to save brain capacity is an uphill battle. Rather than facing a prospect for a good recovery and being able to walk or dance again, Sam is now likely to remain under nursing care for years to come.

Contrast Sam’s story with that of Britt, a young college student who suddenly found himself unable to move or speak while at home. His family also immediately recognized the signs of stroke, but unlike Sam, Britt was brought to the ER quickly. A study of his brain revealed the blocked artery and Britt soon underwent a procedure to open it. Within a day’s time, he was back to normal, his brain cells recovering when oxygenated blood returned after the artery was opened.

Today, Britt can look forward to decades of normal living. Sam? His fateful decision to ignore serious symptoms and go back to bed has cost him his freedom. Regardless of clichés, Time is Brain. The urgency of timely diagnosis and treatment in cases of stroke cannot be understated.



Looking Backwards to See Ahead – Part 5: Contracts & Technology

This is the final blog in a series chronicling the development of AcuteCare Telemedicine (ACT). Much of this reflection involves lessons learned at a past Annual Meeting of the American Telemedicine Association (ATA). What follows is an amalgam of facts, experience and opinions culled from that fantastic symposium and honed by hindsight. Today’s blog will focus on legal and technology issues.

As stated in Part 4 of this series, Running the Business, there are a myriad of issues confronting physician-entrepreneurs when establishing a telemedicine service. Physicians are trained to provide medical care, yet this is a technology business. Therefore, an overview of contracts and technology is paramount.

Contracts have to be written to fit the specific needs of each client. However, it is appropriate to have a boilerplate document that addresses both general contract features (e.g. non-malfeasance, non-compete, etc) as well as telemedicine specific features (e.g. the type of encounters covered, the times covered if not 24/7, etc). The contract should stipulate that the telemedicine provider will determine appropriate use of telepresence. If used for routine consults, a maximum number of encounters to be provided per time period can be stipulated in lieu of a sliding fee schedule. It is probably good practice to make it the obligation of the client hospital to maintain HIPAA compliance (e.g. not having the patient in an ED hallway) and assure patient identity prior to consultation (requiring the RN to show you the patient’s wristband ID [never thought of that, did you?]). The contract should also clearly state who is responsible for technical support (see technology below).

A few more legal issues bear mentioning. CMS may allow the originating site (i.e. telemedicine corporation) to do one time M.D. credentialing versus repeating at every client hospital. While CMS doesn’t apparently distinguish between corporations and health care centers, this credentialing allowance is likely in deference to university hospitals proving remote presence. It would ultimately be up to the client hospital to accept the remote provider’s credentialing process in lieu of their own.  Every business partner who has access to patient related data must have a HIPAA oriented contract. A written statement should be obtained from one’s malpractice provider documenting coverage for each state in which treating physicians are licensed.

There are ever expanding options for remote presence technology. Purchase or leasing of proprietary hardware by the client hospital has been the standard. This is attractive because the telemedicine provider makes more money and the hospital experiences lower upfront costs. In the long run, this is actually more expensive for the hospital, and obscures whether the service is providing medical care or simply technology. There are less expensive alternatives, including subscribiptions to web-based software for use with the clients preexisting resources (i.e. PC, webcam, ethernet, hospital IT department). However, choosing this technology will affect reliability; IT departments may not have dealt with the paradigm of providing 24 hour, secure, immediate, unfaltering access for physicians from remote sites.

The better alternative is the purchase of hardware and software from vendors dedicated to telemedicine technology and IT support. It has been demonstrated that client hospitals with a financial investment in the technology are more likely to use it. This leads to more encounters and a reinforcement of the value of the entire endeavor. The technology available varies from fairly fixed COWs (Computers On Wheels) to fully autonomous robots that can move independently between and within rooms, with one-time costs ranging from $25-60,000. Hospitals may then choose the technology based on budget, IT support, software and value added features (e.g. stethoscopes, government grant subsidies, etc). Hardware should undergo scheduled replacement (i.e. laptops every 3 years). Either a dedicated T1 line or reliable Wi-Fi are mandatory. Regardless of the technology employed, patient interaction should be standardized across sites by a telemedicine provider. This normalizes the decision process and improves remote partner (RN, MD) facilitation of exam at the bedside. A written protocol (e.g. NIHSS) is also useful. Finally, as technology continues to proliferate, the future holds great potential for interoperability of these systems with electronic health records, further revolutionizing patient care through telemedicine solutions.

Establishing a telemedicine service is a challenging yet extremely rewarding endeavor that will ultimately contribute to an overall higher standard of patient care. Armed with new insights culled from these experiences, AcuteCare Telemedicine is moving towards the future with consideration for the procedures and mechanics that are obligatory for success, yet not part of standard medical school curricula. 



Checking in From the 2012 ATA Conference

AcuteCare Telemedicine (ACT) Sales Executive Michael Woodcock attended the 2012 American Telehealth Association Conference, the world’s largest telemedicine, telehealth, and mHealth event in San Jose, California.

Greetings from San Jose!

The 2012 ATA Conference has been very impressive. This year’s conference has drawn a record number of attendees (4,500) and more than 175 vendor exhibits. The exposition features several booths with groundbreaking new products and services. Attendees have been encouraged to share news and notes and interact with the conference on social media platforms, which is demonstrative of the kind of technical innovation on display here.

In addition to the exhibitions, there have been a large number of interesting presentations and discussions on a wide variety of topics relating to telehealth and telemedicine. I have attended highly informative Industry Executive Panels on growth sectors in telemedicine, reimbursement issues facing the industry, and perspectives on the state of mobile applications and their compliance with HIPAA as they relate to telemedicine.

Some of the highlight sessions included Model Telemed Programs (a Georgia Partnership for Telehealth presentation from Paula Guy), a feature presentation on Telemedicine and its profitability, and a keynote address by Apple co-founder and tech advocate Steve Wozniak. There are too many presentation topics to list, but suffice it to say the conference is a comprehensive, in-depth look at all facets of the industry. It is exciting to see the growing influence of telemedicine as a potent solution to many pressing healthcare issues.

A link to the full conference program can be found here.



A Lens to View Technological Innovation in Healthcare

Keeping up with new technology feels like a sisyphean task. One way to think about technological innovation in healthcare is considering whether the innovation brings services to the patient or requires that the patient be brought to it. The former distributes care, while the latter centralizes it. Both have advantages; by distributing care, it is possible for many resources to contribute to care, and by centralizing care, treatment is focused at one site. Recognizing this technological dichotomy allows savvy hospitals to maximize their return on investment.

Dramatic improvements in radiology over the last 35 years exemplify centralizing care. New MRI and CT scanners dramatically improve our ability to diagnose complex conditions, but the machines’ bulk and expense mean that patients must be brought to them. The same rings true for the latest catheter-based therapies for heart and brain disease, requiring that the patient be brought to the specialized providers.

By contrast, telecommunications innovations distribute care, leading to improved patient outcomes regardless of locality. Translation services are a shining example: in the past, finding someone to translate a language like Amharic or Hmong was daunting, and in an emergency situation, it was simply unavailable. Thanks to new standards set by the Joint Commission, more attention will be paid to proper translation services. The Joint Commission standards reflect federal nondiscrimination laws regarding care of patients with limited English proficiency and recommend that patients be addressed in their preferred language. Now, thanks to successful providers such as CyraCom, dual handset phones can be brought to the bedside and certified translators in hundreds of languages are available in seconds

Telemedicine provides the best example of the power of distributive technological innovation. In stroke care, having experienced stroke neurologists readily available via telemedicine means that stroke patients have unlimited access to state of the art care. Being able to remotely conduct a video interview with the patient and family, examine the patient, and review the brain CT scan equates to faster and better care. AcuteCare Telemedicine’s stroke neurology experts, based in Atlanta, GA, contract with hospitals that need this type of coverage. By distributing care, these hospitals successfully avail their patients with top notch care and reduce treatment times, all while conserving a vital resource: the fossil fuel needed to physically bring the neurologist to the hospital.

 



A Timely Solution

In the few minutes it takes to read this post, two or more people will have suffered a stroke in the United States. In the Southeast, in what has become known as the ‘Stroke Belt,’ the rate of frequency is at its highest. The need to attack stroke from both a preventative as well as a curative perspective is critical if a  decrease in the incidence and the morbidity/mortality of stroke is to occur.

Over the course of the past few decades, several initiatives to lower the incidence of stroke throughout the nation and particularly in the Stroke Belt have been developed and implemented. Increased education, improved  blood pressure and glucose control,  advised dietary changes etc, have led to a decrease in incidences. What remains concerning, however, is the lack of acute stroke care treatment in many rural areas in states such as Georgia and Alabama. This deficiency is primarily due to excessive travel time necessary to gain access to physicians. Several rural counties in Alabama are altogether without hospitals. “Lack of access to health care is a reported problem in some areas of the state. Some counties have no physician in the entire county. It is difficult for poor rural areas to attract doctors

According to a report in 2010, 44 of 67 counties (in Alabama) did not have a single neurologist. “Some stroke victims have to travel across three counties to access a neurologist for care.” Stroke is the third leading cause of death in Alabama, with nearly 3000 Alabamians dying from stroke each year.

In 2010, only 2 hospitals in the entire state were certified by Joint Commission as Primary Stroke Centers. That number has since doubled, but still remains insufficient, as an overwhelming percentage of the population remains underserved. Although with preventitive measures and education in place, the incidence of stroke should continue to decrease, there will theoretically be no significant change in stroke related morbidity and mortality without timely and appropriate healthcare.

Unfortunately, poor quality health care is deeply and chronically rooted in the infrastructure, or lack thereof, of many of these rural communities. More than 30% of Alabama’s population is situated in these areas lacking equivalent government representation. Fundamental changes in, or the development of new infrastructures within these communities are requisite to create permanent changes in healthcare delivery.

Although not a solution to all of the health care concerns facing states like Alabama, telemedicine does offer an avenue by which cost effective, high quality care can be delivered to residents of rural communities. As pointed out earlier, there is a specific need for neurologic care, given the significant paucity in this area of the country. The implementation of teleneurology programs in these areas would lead to timely neurological consultations and care that would otherwise not be available. Where time equals brain cells in the case an acute stroke, expeditious treatment via teleneurology can literally be life saving. Teleneurology would help to improve not only quality of health in rural communities, but also quality of life. When a healthcare facility earns primary stroke certification (an initiative for which teleneurology programs can offer assistance), it typically sees a growth in ER volume and admissions, subsequently increasing revenue. Jobs can be created as a result of this growth, which in turn can help jumpstart  local economies.

Telemedicine alone will not solve all of the health care issues in rural Alabama and other similar regions in the stroke belt. However, these solutions can immediately fill a desperately missed need. Remember the two people in the United States who will have had a stroke in the time it took to read this article. The question is, will a neurologist have been able to reach them?