AcuteCare Telemedicine Blog

Regional Solutions Are Best for a National Health Care Problem

Stroke affects every community in the United States. However, the risk varies by region (consider the “Stroke Belt” of the southeastern US), and the resources available for treatment have historically been unevenly distributed. Much of the disparity is cultural, but some is political. In the 18th and 19th centuries, where a river or mountain range limited travel, state boundaries were created. At the time, those natural boundaries impeded communication, but 21st century technology breaks those barriers with ease.  The federal government’s recent institution of 12 new telehealth regions takes into account the latest technological advances while maintaining regional autonomy. New broad-band internet availability in rural parts of the country now allows telehealth to provide high quality medical care in areas where geographical obstacles once prohibited.

Rapid stroke-specific care can be accomplished at any local hospital within a telehealth region. No longer does a zip code determine the quality of healthcare available to its residents. Fortunately, regionalism, an inherent aspect of human nature, is preserved, and for good reason when providing healthcare. Each region, unlike some individual hospitals, has all the specialty services needed, but still provides a manageable focus for organizing and monitoring quality of care. Compared to national approaches, regional telemedicine providers have knowledge of and experience with regional medical care and resources, making it easier to understand each region’s specific needs.

The Federal Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services (HHS), created the Office for the Advancement of Telehealth (OAT) to promote the use of telehealth technologies for health care delivery, education, and health information services. Each region is managed by a regional Telehealth Resource Center (TRC). OAT provides a list of the current TRCs on their website as well as a map of their catchment areas.

The Georgia Partnership for Telehealth is a leader in the Southeastern Telehealth Resource Center, providing reliable and cost effective high speed internet service to medical sites in Georgia, Alabama and South Carolina, all of which are located in the aforementioned “Stroke Belt,” where incidence of stroke is highest. Linking a region’s medical resources to maximize patient care is a race against the clock (which in the case of stroke is a race towards saving brain), and telemedicine consultations now take just minutes. Simply put, an internet connection traveling the speed of light is a significantly more efficient means of linking these resources than an ambulance driving at full speed or a helicopter flying at 120 miles per hour. This is the power of 21st century technology.


Advances in Telemedicine and Technology Call for Changes in Standardization

Rudimentary forms of health care standardization in the United States can be traced back more than a century. The Joint Commission, for example, began its evolution with an elementary inception in 1910, when Dr. Ernest Codman proposed the “end result system of hospital standardization”. This system was designed to track patient care and outcomes to determine whether treatment was effective. In cases where treatment was unsuccessful, attempts were made to improve patient care. Three years later, the American College of Surgeons (ACS) was formed to promote this standards system, and in 1917, it developed the Minimum Standard for Hospitals. The following, year the ACS began on site hospital inspections, and of the 692 hospitals surveyed, only 89 met the standards set forth by the one page document. After the introduction of an 18 page manual in 1918, hospitals had increased incentive to meet these standards, and by 1950 standard of care had improved tremendously, with more than 3,200 hospitals approved by the ACS.

Needless to say, over the next 60 years, with countless advances in medicine and technology, there have been many changes to the ACA and its manual. The committee now known as The Joint Commission has expanded and upgraded standards in an effort to ensure that health care organizations are providing quality patient care. Although the Joint Commission is one of the most recognized and sought after accreditation programs, several other organizations such as Leapfrog, HealthGrades and Get With The Guidelines have also been formed in an attempt to foster improvement in quality of care throughout health care systems. The decision to seek accreditation by The Joint Commission or any other organization has always been voluntary, but because of its link to Medicare and Medicaid, Joint Commission accreditation has essentially become a default requirement. Because reputation, reimbursement and, most importantly, patient care may at minimum be presumed to be compromised without certification, a health care organization’s failure to achieve accreditation by the Joint Commission may be adversely perceived.

In 2003 The Joint Commission, in collaboration with the American Stroke Association, developed a Primary Stroke Center (PSC) Certification Program. This program was developed to recognize health care centers “that make exceptional efforts to foster better outcomes for stroke care”.  According to The Joint Commission, a PSC “is the best signal to your community that the quality care you provide is effectively managed to meet the unique and specialized care of stroke patients.” Demonstrating compliance with these national standards may help a facility obtain contracts from employers and purchasers concerned with controlling costs and improving productivity. Becoming a PSC has been shown, in one published study, to have increased the administration of IV- TPA to eligible patients 7 fold.

Unfortunately for many hospitals, this level of achievement in stroke care is not possible due to lack of availability of 24/7 neurology coverage. The reality is particularly challenging for smaller, rural hospitals. However, in 2011, the Brain Attack Coalition updated recommendations for PSCs, acknowledging the use of telemedicine as a means to provide remote diagnosis of acute stroke in facilities where this capability would otherwise be unavailable. Hospitals that do not have current PSC certification could use telemedicine services along with physicians that provide 24/7 expert care in acute stroke to become PSC certified or either transfer eligible patients to the closest PSC for IV- TPA administration. The Brain Attack Coalition has also recommended that EMS transport acute stroke patients to the nearest PSC facility, thereby potentially improving patient outcomes and increasing revenue at certified hospitals.

In 1997, The Joint Commission launched “ORYX: The Next Evolution in Accreditation” which incorporated the use of performance measures into the accreditation process. Under this initiative, hospitals had the flexibility to choose which performance measures they would submit for accreditation. This system posed problems in that there were no standard measurements across health care organizations. The Joint Commission has since put in place core measurement sets for which specific, standard accountability measures must be met in order to obtain and maintain accreditation. The initial core measurement sets were designated in 2003 and included Acute MI, Heart Failure and Community Acquired Pneumonia. As of 2011, Stroke has been added to the core measurement sets, giving facilities even more incentive to become Primary Stroke Centers.

Undoubtedly, the standards that have been initiated by the Joint Commission and other accreditation programs have lead to changes and improvement in health care outcomes for all specialties of medicine. Reaching a perfect level of standardization will always be a work in progress, particularly with the rapid advances in technology that have helped medicine evolve more quickly in recent years. As the landscape of medicine and technology continues to change and expand in the future, particularly regarding the management of acute stroke care, it is our expectation that hospitals will continue to strive to adapt to these changes in order to achieve the highest quality of patient care.