AcuteCare Telemedicine Blog


Study Reveals Telemedicine Improves Patient Outcomes

Researchers at UC Davis Children’s Hospital have found that telemedicine consults improved pediatric patient outcomes for patients treated in rural pediatric emergency departments that lack pediatric specialists.  They also found a physician was more likely to adjust the patient’s diagnosis and course of treatment after a face-to-face video conference with a specialist.   Madan Dharmar, an assistant research professor in UC Davis’s pediatric telemedicine program and the study’s lead author said, “The shortage of physicians in rural communities isn’t going to be solved by increasing the number of physicians, but by increasing the number of physicians available over telemedicine.”  “Telemedicine is going to be the future.”

Researchers examined data collected from five rural California pediatric emergency departments from 2003 to 2007. The EDs were equipped with uniform telemedicine technology, which was met with some resistance at first.  “Some of the rural doctors [who] were old-school at first resisted using the technology but when their objections were overcome they used it and liked it.  To aid the adoption process, UC Davis doctors conducted periodic test calls to check in and help the rural doctors adjust to the technology.

The face-to-face communication was responsible for improved outcomes, according to James Marcin, director of the UC Davis Children’s Hospital Pediatric Telemedicine Program and the study’s senior author. “More time is spent on a video consult than a phone consult. Rural doctors asked more questions and UC doctors provided more recommendations when video conferencing. “The technology is readily available,” Marcin said. “There’s no excuse why it shouldn’t be used.”

Only 3% of pediatric critical care specialists live in rural areas, serving the 21% of U.S. children who live in those areas.  Expanding the availability of specialized care to these children should be a priority for all communities and healthcare providers. The benefits of telehealth are increasingly being recognized all around the country. A bill recently sponsored by state senator Arthenia Joyner will make Florida the 20th state to require private insurers to cover telehealth services.



Mobile Healthcare and Monitoring on the Brink of Revolution

Wireless in-home health monitoring is expected to increase six-fold in the next four years. A recent study by InMedica indicates that 308,000 patients were remotely monitored by their healthcare provider for congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes, hypertension, and mental health conditions worldwide in 2012. While congestive heart failure accounts for the majority of remote monitoring, it is expected that diabetes will supplant COPD with the second largest share of telehealth patients by 2017.  It is predicted that more than 1.8 million people worldwide will utilize mobile monitoring in the next four years.

Telemedicine is seen as a significant tool among healthcare providers for reducing hospital readmission rates, track patients chronic disease progression or provide advanced specialized medical treatment to patients in remote areas.  Four main factors are driving the demand for increased use of telemedicine and telehealth; Federal Readmission penalties introduced by the U.S. Center for Medicare and Medicaid Services (CMS);  healthcare providers desires to increase ties to patients and improve quality of care; insurance providers who are looking to increase their competitiveness and reduce in-patient pay-outs by working directly with telehealth suppliers to monitor their patient base; and an anticipation for future increased demand for telehealth services by patients.

Of the billions of dollars spent on health care each year, 75% to 80% of it goes for patients with chronic illnesses such as diabetes, heart disease, asthma and Alzheimer’s disease.  With rising costs and the anticipated shortage of physicians and healthcare providers over the next decade, utilizing the telemedicine technologies is becoming increasingly important to the routine delivery of medical services and monitoring of chronic diseases.

Even telepsychiatry, the use of secure Web-based video conferencing technology, and ambulatory patients, those who have been diagnosed with a disease at an ambulatory care facility but have not been hospitalized are expected to experience significant increased utilization of telemedicine among healthcare professionals in the next four years.  A plethora of emerging mobile technology, such as wearable wireless monitors to smartphone attachments will offer consumers the ability to track everything from core vital signs to impending heart attacks by discovering problems with heart tissue are on the horizon, offering a revolution in digital medical technology.

Speaking to those resisting the new mobile technology, Dr. Eric Topol, a professor of genomics at the Scripps Research Institute, recently encouraged the medical community to end paternal medicine, where only the physician has access to healthcare information, and to embark on a new beginning where patients own their data.  Dr. Topol compared the new mobile technology to the Gutenberg press and the way it revolutionized the way information was shared throughout the world.

We are embarking into a new era where patients have the mobile tools to better enable them to participate in their own medical diagnoses and treatment.



Check Your Head

In the wake of countless notable events including the deaths of several professional athletes in the past 5 years, new light has been shed on an epidemic which we are beginning to learn may be far more widespread than initially thought.

Researchers at Boston University recently published the largest study of chronic traumatic encephalopathy (CTE) to date. CTE, a progressive degenerative brain disease thought to stem from concussive trauma to the head, has been known to affect boxers since the 1920s, but only recently has gained notoriety as a serious concern for athletes of all ages across many sports. In these latest findings, 68 of 85 donated brains from deceased veterans and athletes with histories of head trauma showed visible evidence of the disease, including a staggering 34 of the 35 brains from former professional football players.

CTE

The greatest concerns sparked by our growing understanding of CTE’s causes and pathology are without a doubt related to the protection of younger children participating in sports and other activities where risk of injury to the brain is involved. The work of the BU researchers has led to drastically improved protective equipment and restructuring of rules and regulations to minimize the number and force of hits to the head, but it is nearly impossible to remove the potential for these injuries from sports at any level.

Thus, the best possible measures that can be taken are to prevent any repeat injury of the brain. Taking the lead, the NFL has instituted mandatory on-field concussion screening following hard hits. The NHL has also ordered that players with potential head injuries spend time in a ‘quiet room’ off the ice. Youth leagues are particularly concerned with preventing any participant who may have sustained an injury from getting back into the game and facing further danger.

Telemedicine offers the potential for significant further contribution to these efforts. With the help of technology, expert neurologists can always be on hand to examine potential head injuries, and monitor patients in the aftermath of an injury, aiding the recovery process. Thanks to telemedicine’s advances, logistics and associated costs are no longer obstacles to immediate and accurate concussion diagnosis and treatment.

The fight against CTE and other trauma-induced brain disease starts long before the first injury happens, but when it cannot be entirely prevented, telemedicine could play a role in ensuring fewer players incur more severe consequences later in life.



Stroke Mimics in the Emergency Setting

The role of the neurologist in treatment of acute stroke often focuses on the decision to use clot busting medication (tissue plasminogen activator; tPA), recommending care setting (e.g. ICU vs routine admission) based on patient deficits and prognosis, and of course, patient education in the midst of this emotionally charged experience. However, an often overlooked mandate for the neurologist is the proper recognition of stroke itself. Dr. J. Stephen Huff, Associate Professor of Neurology at the University of Virginia, provides a clear and comprehensive review of what are termed stroke “mimics” – disorders which may appear to be a stroke, but are not.

Stroke, broadly defined, is any prolonged disruption of focal neurologic function due to decreased blood flow from blood clotting in a specific region of brain. If that disruption is transient or intermittent it is typically referred to as a transient ischemic attack (TIA). If brain function is disrupted by a cause other than a blood clot, treatment with tPA may not only lack benefit but expose the patient to unnecessary harm. Recognition of “stroke syndromes” that result from specific artery involvement is the bread and butter of neurology. The abrupt onset of aphasia (language deficit) and right sided weakness almost certainly indicates a patient has blocked their left middle cerebral artery. Blocking this same artery on the right results in the classic presentation of left sided weakness and “neglect,” an inability to recognize one’s own physical deficits. In either case, the immediate administration of tPA can be life-saving.

Other disorders may cause brain dysfunction unrelated to a blood clot. This is the case in approximately 13-20% of patients presenting with presumed stroke. If the duration of symptoms is unclear, this number may even be as high as 30%. The most common mimic is seizure. Excessive electrical and chemical brain activity may result in focal weakness (Todd’s paralysis) and other deficits. If the seizure was not witnessed (especially in patients with previous stroke as the cause of seizures), excluding an acute stroke can be difficult. Focal neurologic injury from brain tumor, inflammation (e.g. multiple sclerosis), or even peripheral nerve palsy may be mistaken for stroke.

Stroke can be mimicked without direct injury to the brain. The most common mimic in this category is a complex migraine in which visual disturbance, weakness, numbness and even aphasia can occur. Hypoglycemia or, less often, hyperglycemia (low and high blood sugar) can cause general symptoms of lethargy or coma, but focal brain dysfunction (particularly weakness) often occurs and can outlast normalization of blood glucose. Finally, 30% of patients presenting with psychiatric causes of physical illness (i.e. conversion disorder) exhibit neurologic deficits, typically weakness.

Determining the cause of a patient’s deficits can sometimes be accomplished in an emergency setting through the use of CT imaging and appropriate diagnostic tests. Often the results of serial examinations, detailed history and, increasingly, advances in MR imaging can eventually lead to the correct diagnosis. However, certain diagnoses, notably migraine and conversion, are diagnoses of exclusion, so repeated events and extensive negative testing may be required for confirmation.

Among patients presenting with neurologic deficits, emergency department physicians correctly identify stroke before applying diagnostic studies in about 75% of cases. This means as many as 1 in 4 cases are incorrectly diagnosed. It is the role of stroke experts, like those of AcuteCare Telemedicine, to quickly and accurately determine the likely cause of neurologic deficits, the risks and benefits of multiple treatment options and convey a plan of action simply yet fully to the patient and loved ones. It is a difficult but rewarding task.



Acutecare Telemedicine CEO Featured Speaker For American Heart Association’s Stroke Webinar Series

Dr. Matthews Gwynn, CEO of AcuteCare Telemedicine (ACT), appeared as the featured speaker for a webinar series produced by the southeast affiliate of the American Heart Association. The presentation, entitled “Extending Stroke Care through Telemedicine,” was delivered to several hundred hospital administrators and medical staff throughout the southeast and other areas of the U.S.

Dr. Gwynn’s webinar presentation, hosted by Mary Robicheaux, Vice-President of Quality Improvement for the American Heart Association southeast affiliate, focused on the advancement of teleneurology in the treatment of acute stroke patients. Dr. Gwynn discussed the positive effects that teleneurology continues to have on advancing stroke treatment, such as the increased use of the clot-disolving medication tPA (tissue plasminogen activator), as well more advanced neuro-interventional procedures known as thrombectomies, performed by neuro-interventionalists at such world-class facilities like Grady Hospital’s Marcus Stroke and Neuroscience Center in Atlanta, GA.

“Advanced treatments for acute stroke cases are becoming more and more prevalent with the advent of greater technology and treatment procedures,” stated Dr. Gwynn.  “The medical community observed this within the cardiology field over the past couple of decades, and now we are starting to see similar advancements in stroke care via neurocritical care and interventional neuroradiology.

In a continued effort to expand teleneurology in the southeast, Dr. Gwynn and the other neurologists of ACT serve as critical evaluators at partner hospitals of stroke cases that may require advanced interventions such as those discussed in the webinar.

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.